Richard Leaver, PT
In this podcast titled, The Future of Virtual Physical Therapy, we speak to Ben Keeton. Ben currently serves as Director of Clinical Operations at The Jackson Clinics, a leader in outpatient physical therapy in Virginia.
"Richard: Welcome back to the Agile&Me. A podcast for physical therapy leadership. Today's title is the future of virtual physical therapy, and I'd like to welcome Ben Keaton, he is the director of clinical operations for Jackson clinics. Welcome.
Ben: Thank you for having me
Richard: Most welcome. Before we talk about virtual PT, I would love to have you introduce yourself to the guests.
Ben: I'm a physical therapist I have been treating since 2006, I have my specialty in orthopedics and my MBA. As you mentioned, I'm director of operations for a 19 clinic practice in Northern Virginia, and we focus on sports and orthopedics.
Richard: What I want to talk about today is the adoption of virtual PT and the future. I think there's a lot of therapists out there that dismisses it. I think there's some that embrace it. What's been your experience as it pertains to delivering physical therapy virtually up to this point.
Ben: That's a great question. I was one of those who fully embraced it from early on and was actually looking at telehealth and virtual PT as a mechanism to deliver care pre COVID and actually spent some time in the past few private practice section meetings and combined sections meetings researching and meeting with people who had done it before and was interested in trying to get it off the ground pre COVID. I'm glad that I did because then COVID happened and it turned out to be a lifeline for our business for months and months when patients were uncomfortable coming in. So it was a big help to us. Since COVID has established itself in our area a bit more and patients are a bit more comfortable coming in. It's definitely dwindled quite a bit. But as you said it still has a place in our practice.
Richard: Did you find that many patients were able to be transitioned to the virtual environment during the COVID waves? What we found varied somewhat between clinicians and clinics and geography. I was quite surprised actually, personally, how many patients could actually be transitioned and successfully managed? Was that your experience?
Ben: I think it was interesting. Our initial hope was that all patients who wanted to be, could be transitioned over. We live in Northern Virginia, which is a very technologically connected area for sure. But we did find that there was a bit of an equity gap and there were people that we were caring for, who didn't have great internet connection, or didn't feel like they had a great setup, but we found a mechanism to make it work. Some regulations that were loosened a bit during COVID to allow alternative mechanisms of virtual PT that probably won't be allowed later on that were a little bit less secure, but patients were a bit more familiar with or comfortable with. So we found for everyone who really needed it and wanted to do it, we were able to find a way.
Richard: It's interesting. You mentioned that you were looking at telehealth as a medium to provide care before COVID and likewise, we were as well at Alliance physical therapy. We had discussions with a med bridge back in 2019 as they were developing there tele-health platform. I saw this as being on the horizon, but COVID was actually the catalyst, wasn't it, I believe to really bring it to the forefront or at least bring it into mainstream therapy. Is that what you found?
Ben: Yeah it was a massive acceleration where we were still in the ideation phase and trying to lay down frameworks and foundations. Then all of a sudden we were forced into a brand new model and I was excited. There were some challenges that came along with it, but I'm glad for virtual PT and for telehealth that we have the opportunity to try it. At scale as a profession
Richard: I believe COVID acted as the catalyst. I think personally the circumstances, everything aligned, what I mean by that is every state now has the ability for therapy to be legally provided using tele-health modules. The compat rules allow therapists to see patients over a larger number of states or makes it easier. And then lastly, the parity by the insurance payers for virtual care. So it was really that alignment, I believe that that really allowed it to occur. Would you agree with that?
Ben: I remember in all the presentations at CSM and PPS that those were big barriers. Those were things that were standing in the way. So I agree with you to have many of those get easier, certainly not removed all the way necessarily, but those items getting easier has really made. Made the opportunity for telehealth and virtual PT to expand a bit. So it's very exciting. The compact in particular, for us being so close to three or four other states in a very small area has made it much easier for us to care for patients with virtual PT.
Richard: A lot of PT companies or therapists see virtual PT as a complimentary to the bricks and mortar. So helping manage their existing patients very often, what would be a hybrid manner where there. Where there's a combination of in-person visits and, and virtual visits. But I look at it much bigger than that. You know, when we set up agile virtual PT as a national company, I saw it as a standalone and virtual PT being able to manage a proportion of the population that are suitable for physical therapy. How have you used it? Have you used it as a hybrid or have you used it as a standalone way of treating patients?
Ben: A little bit of both. I think our original vision was to. have at least a start with the brick and mortar hybrid, where we would evaluate patients on site, we would get hands-on and build that initial therapeutic Alliance, but then use it for at least in our area. It's difficult. Sometimes because of traffic and being time poor and work obligations and other things, it can be difficult to get into the clinic, the frequency that the therapist may desire or prescribe. So this is, was, or would be an opportunity for us to capture that second or third visit that week. The other way we were looking at it was if there were some weather incident or, or other events prevented someone from comfortably coming to therapy that we could provide that as an adjunct. But during COVID we had to, we were forced to perform evaluations via telehealth and complete the entire plan of, and continuum of care that way and found it remarkably satisfying for the therapist and for the patient. Again, since COVID has established itself. Patients and consumers are a bit more confident coming. At least to medical facilities. We've seen them prefer in person more, but we still have, you know, a percentage of patients who really like and prefer tele-health. It's comfortable to do it from their home and it seems to be getting good results.
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Richard: Virtual PT will always be the minority of patients or traditional type of patients that would attend bricks and mortar, but I see it as potentially opening up a much larger audience. So what do I mean by that? If you believe the 90% problem, which essentially says that 90% of the people who could benefit from therapy never actually attend therapy. I believe that virtual therapy can provide care to a significant proportion of those. So it's not necessarily taking away patients from the bricks and mortar, but offering services in a manner that captures more patients and gives cat to a wider audience. Is that something you've thought about?
Ben: It is, I think there's in every value proposition, there are barriers to entry and. To take time off of work and come into a brick and mortar. And especially if they don't really know what physical therapy is and we haven't established that value to them yet, virtual PT gives us an opportunity in a low barrier to entry way, at least for the patient to try us out the challenge. I think I see there is a tendency we've had, I think at least as a profession, to rely heavily on the touch aspect and the hands-on aspect to establish that rapport and the therapeutic Alliance and there's a challenge now to establish a similar rapport in therapeutic Alliance with communication only, and with education on exercise and with expert queuing. and that can be, that can be a new challenge. I've seen with our providers some discomfort there where they are really skilled, manually, and can connect with someone that way and show them that they can get them better. Now they have to do that communication and exercise. So it's a bit of a shift in routine, which I think is, was initially difficult for some of us, especially our expert providers on the manual side, but they found a way to do it and have gotten more comfortable.
Richard: I think. Perhaps it's the manual therapist. If I want to use that term, I don't necessarily want to differentiate PTs by whether they're manual or exercise orientated because PT obviously combines both components, but I believe those that are very manually focused are probably those that certainly in the beginning and probably remain the most skeptical as it pertains to providing PT care virtually. Has that been your experience and have you seen clinicians that were in the beginning extremely skeptical come around as time has moved on?
Ben: All of the therapists in our practice were initially a little skeptical and had a little trepidation, at least to some degree, anything new, I think is going to be a little scary and we've spent so much time and energy and effort honing our craft and educating ourselves on how to provide the best care in the most efficient. So there was a lot of trepidation initially for most of our providers, but you're right. I mean, when, when you're forced to adapt and as a profession, I would say physical therapists are very smart, very adaptable people. They were able to, and they did come around really. They had no other choice during COVID, which again, I think is a silver lining to this whole thing was for them to really see. With some durable medical equipment and excellent queuing and demonstration and communication, they were able to get reasonable outcomes and in an efficient way, and in a way that the patient was comfortable with. So it took a little bit to come around, but I would say where we had 50/50. On the skeptics versus adopters side, it's now maybe 95 adopters and 5% skeptics on our team. And those who are still skeptical, I think it's just the pain of change that's driving that more than anything else.
Richard: As a therapist myself, I was trained in various manual therapy philosophies Maitland McKenzie, CREX Mulligan. I think what helped me perhaps understand or feel that virtual therapy could be performed successfully for a significant number of patients was the McKenzie approach, which is really education and self directed forces to begin with up to. If that doesn't work, then you transition to a therapist generated force. So a lot of patients I believe can be managed very successfully through virtual means. Now what I don't understand and love your insight is why do we think that there is a very low volume of PT patients seen virtually, because I think that there's a mismatch between those that could benefit virtually versus those that are seeking their care virtually. Now, as I said, it will never be the predominant number of patients, but I believe that it's a lot more than the very low percentage that we are currently seeing.
Ben: Yeah, I think that's a great point and one that I've ruminated on quite a bit, you know, and to support your patients. There's a lot of amazing research out right now on self-efficacy and how critical that is to someone's outcome and even other determinants of health. In some ways the social, environmental, cognitive emotional aspects are the predominant determinants of outcome based on some great research by Chad cook and others. So I agree with you a lot of what we probably should be doing is instilling self-efficacy and encouraging patients through exercise and education and, you know, targeted mobilizations, you know, even without our hands on to accomplish the things that we know that they need. So to your question now of why aren't they seeking virtual PT at a higher rate? I think it's, again, changed. There's this change cycle and this expectation. Where someone, where a patient initially perceived value is in the manual exchange, where if we gave them the opportunity, most patients would come just for the manual portion of therapy and not stay for the cardio or the core or the stabilization exercise or any of the stuff that we know really does a majority of the work on establishing their outcome. Human nature, I think would be, let me just lay there and be passively cared for. It's harder to get them to really appreciate and understand that active therapy is really what the secret sauce is. The manual therapy, I think, establishes rapport. It builds therapeutic alliances. I'm not diminishing at all the therapeutic value. It helps in restoring mobility and many other things, but where they really stay better, I think, is through the core and the cardio and the stabilization. Even now, even in person, patients would much prefer not to do that. If they can get out of jail and not have to do that, they'll do it nine times out of 10. So I think to have an exclusive education and exercise focused treatment. Doesn't really match with the patient's perception of value yet. That's a task, I think, for our profession to show them that that can have benefits.
Richard: Well, that's the final words of wisdom if there ever was one, but we're not there yet.
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Richard: I feel that the virtual PT is where let's say Teladoc was 15 years ago. Teladoc 15 years ago, had a minimal number of users. It was seen as an ability to access a doctor perhaps out of normal hours. So it was seen as an alternative convenient, but not necessarily the primary means of seeking care. It took a long time to convince the consumer that virtual medical care was effective and actually provided great outcomes and patient satisfaction. But it was really explaining to the consumer the value proposition of providing it through. Tele-health medium. I believe that we're in a similar position as therapy, trying to explain to the consumer, the patient, the value proposition of therapy through virtual care rather than differentiating. So when the conversation is about, Hey, we can help you through virtual care rather than, Hey, you can choose agile virtual care, or you can choose the Jackson clinics. Do you feel the same way?
Ben: Yeah. I think it was a great analogy. You know the medical profession, as you said, was established as in some case way back when house calls and this in-person connection. So that of course transitioned to going to offices and you know, all the, all the normal routine. So to switch to digital is a big shift. If you can't be touched by the provider initially the consumer doesn't necessarily feel they're receiving the same value, what they hope. I think what medicine has done a good job off, cause they've had a head start of course is saying, well, no, no, it's the clinical reasoning of the provider. It's the brain. It's the thought process that really is where the value lies. They're going to be able to establish quickly whether you need to have a hands-on assessment or an additional medical imaging or something. I think that's what we could do as a profession as well is to really, you know, if, if there's a patient who is a skeptic, you can start with a sort of a triage sort of session evaluation that establishes for the patient. Hey, it's a very clear pattern. It's something that we know we can fix and we can do it virtually if you'd like to come in so we can get to it, but I think what Excel will do. The adoption of virtual PT is the fact that patients are now people, our communities are now used to doing a lot more from home than they used to do. The convenience of that I think is starting to add value to the consumer.
Richard: The genie's out of the bottle, I say whilst there probably will be some backpedaling by certain payers, perhaps based on parity of payment. I definitely believe that the state laws, as it pertains to providing tele-health for PTs and the direct taxes and contract rules probably they're not going to go backwards. Are they
Ben: Let's hope not. I think, you know, we've got a good one. A good advocacy side of our profession. And for those who don't donate, I think we definitely should be involved as professionals to make sure that we advocate for things like that. Cause all those payer rules and legal issues are under our control to some degree with the amount that we advocate on our behalf.
Richard: Now what surprised me about virtual care was when we looked at the data and did a case study with agile virtual PT, and med bridge, last year, and that was presented at PPS. It clearly showed cost efficiencies for the patient and equally. Good patient satisfaction and functional improvement, which surprised me in some respects, perhaps in other ways it didn't, but have you found the types of outcomes that you've achieved and the cost saving for patients that we have seen.
Ben: Yes to some degree. Yeah. I think, you know, we constantly are challenged with interpreting things like patient satisfaction and even to some degree outcomes. It's been a weighted discussion in our residency and fellowship programs and we've got a lot of smart people on our team and, and elsewhere. Kind of debating that, I think from the patient's perspective, they, by the end of it, perceive value and they feel better. I guess that's really what it comes down to. Do. We have happy consumers. Who got better and hopefully will stay better. I'd love to be able to measure that with things like downstream costs of care and total episodic costs of care and things like that. Just getting that data has been a bit tricky, but yeah, I think so.
Richard: We found that the average length of care was about two thirds of. Normal bricks and mortar. And we did the comparison and our net promoter scores were 89 for those that were virtual. And we average 94, our bricks and mortar patients. So on the pain scale there was a reduction in pain and yes, functional improvement. That's always a tricky one, perhaps isn't it, but certainly looking at our data and if you look at if you believe the data that is published by the likes of Kaia sword hinge I think they're all saying a similar thing which is interesting. It's great in one way for the consumer, but perhaps worrying as well in some respects because it might actually. Go the polar opposite way where people think, well, everything can be managed virtually and it will save money. Which, which isn't true either. Is it?
Ben: Yeah, I think we have to be careful not to play that tune. You know, where we can get you better in six visits instead of eight visits. I think that the trick is from my perspective, at least is keeping someone better. It's using the opportunity of care to not only manage the patient identified problem, the reason they hired you, but also prevent it from returning and prevent other, you know, very predictable issues from returning as well. And considering those environmental contextual, cognitive, emotional factors that are driving their long term outcome and, you know, being an active participant in population health. So, you know, I like the fact that we can. Maybe manage the patient identified problem very quickly and efficiently. I, at least my personal philosophy and the philosophy of our organization is we want to be thorough and give the patient the full breadth of care. I think, you know, as long as we avoid that temptation to go, Hey, your pain is starting to get better. Let's end this episode of care and we really look more broadly and say, let's do it. Downstream cost of care, let's prevent imaging and injections and surgeries and opiates and prevent recurrence and prevent anticipated problems. Then I think we're in a much better space where we're really providing long-term value for the patient and not taking the short-term win and saying, Hey, look how great we did.
Richard: Yeah. I wonder whether a reason why virtual PT can give good outcomes in part is because of self-selection by patients. So I believe that those patients that tend to gravitate towards virtual PT rather than bricks and mortar perhaps those that are naturally motivated to be active and engaged in their care. Earlier you said a lot of patients would like to just come and have a massage and you know, a little bit of manual therapy or whatever, and be passive receivers and those we know with the, the external locus of control and passive recipients of care, don't have such great outcomes compared to those that have an internal locus control and actively engage in their care. So I wonder. If there is some self-selection what do you think?
Ben: Yeah, I think that's a reasonable point. Certainly those who continue a virtual plan of care are those who are comfortable with being in control themselves and being the ones, providing their own intervention and who are able to establish that self-efficacy and follow along with the exercise. So I think it's a reasonable point and one that makes sense to me.
Richard: I thought incorrectly, I believe now that the type of conditions that could be managed virtually were relatively small. So it would be the hyper acute ankle sprain, for instance, or perhaps a management of a frozen shoulder at certain stages in the in the. The certain stages of points of care. But what we have seen is over time, there's been quite a diversity of diagnoses and demographics that are actually suitable to respond to virtual care. Did you have that Fetty myopic perspective in the beginning? Also what have you changed your thinking on who might benefit.
Ben: Again, the catalyst of COVID really shattered a number of preconceived notions that we had at a practice where you're right. I think the more education focused conditions, the more exercise based traditional exercise-based conditions, those made a bit more sense to us initially, but you're right. I mean, necessity is the mother of invention and we really quickly learned that with modifications to the way that we approach certain patient conditions and patient types, we were able to be effective with virtual PT, where initially that would have been much more manual heavy, or, you know, neuromuscular reeducation with manual queuing sort of approach. We didn't have that opportunity. So we, and we still needed to care for them during the day. The thick of COVID, at least when most patients were coming in. And so, yeah, I think we were very surprised with the breadth of conditions that we were able to meet.
Richard: I think not only were clinicians surprised, I think actually patients were surprised, I believe as well in regards to, Hey, yes, this can be done remotely. And actually I do enjoy it because I don't have to commute for 40 minutes to get to therapy out of my day. I can be for the exercises that can be facilitated just as well by a good therapy.
Ben: Yeah and it's surprising for sure, across the board.
Richard: Now, a lot of PT, traditional bricks and mortar PT companies, I think have sat on the sideline. I believe that they are waiting to see what happens. Personally, I think that's short-sighted. The world continues to change around them. But I think they feel that this is perhaps a wet fish in regards to, it's just a passing fad. Now we'll talk about different types of competitors that are coming into the marketplace a little bit later, but yeah. I personally believe that virtual PT will be here in the future and we'll grow. If you had a crystal ball, what do you think was going to happen?
Ben: Yeah, I think it's here to stay, as you said, the fitness industry, which we would have thought is forever in person, the group classes. How can you be in a group class from a Peloton? From YouTube. I mean, things that we thought would never become digital at least have a market share in the digital world are decisively established. So I think you're right. I think we have the opportunity to, you know, help embrace and direct that future or. To passively receive it. And when that happens, it's not necessarily on your terms. So we've taken that same approach of, Hey, let's embrace it. Let's try to influence it. Let's hopefully have control over the direction that it goes so that we're happy with where it ends up when, when it finally gets.
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Richard: I personally believe that as technology continues to develop and improve, the virtual experience will also be enhanced further. Now I. I don't necessarily want to get into debate about wearable devices, but I'm just thinking about, for instance, the quality of video, even. So the likes of these online wellness classes, they almost have a 3d images in real time. Their instructors. So it becomes much more of a natural experience rather than very artificial in 2d. So I think as technology improves, I think the patient engagement and quality of, of experience will probably improve as
Ben: well. I agree. I think the technology is already there, In many industries, even, you know, very close industries to healthcare. It's just that we tend to lag a bit behind and haven't really figured out the payment side of it, you know, in some cases, at least for that higher level technology. But yeah, I think it's here now,
Richard: I agree, I believe the technology is here as well. And what else is here are companies that are. Saying that they're providing physical therapy. And I don't necessarily believe that a lot of it should be called physical therapy personally, but, you know, that's you know, that's probably a podcast in itself, but such entities, as I mentioned earlier they are all setting themselves. As the virtual MSK solution, they're making some very bold claims. And as a therapist, I feel it personally a little bit insulting, but they have huge amounts of financial investment. So for instance, hinges are valued at $3 billion, which is twice the valuation of PT, a publicly listed outpatient therapy company. And they raised $300 million in investment earlier. Yeah. W which is remarkable. So. I worry about the existing PT profession and how we stay relevant and compete against such entities. Have you had these and these alternative entities on your radar? Or what, what are your thoughts and feelings?
Ben: Yeah, I mean, it's important to have your eyes on the horizon and listen to what's happening that could disrupt your space. Story after story, after story in business, literature of establishments that dismiss the newcomer Honda, as an example, came in and, you know, destroyed the auto industry is the wrong word, but took over the auto industry and flew under the radar and were kind of dismissed the entire way. And As I mentioned infinite, other stories of disruptors that came in, ultimately from my perspective, it comes down to the value proposition. What is it that the consumer is looking for? They're looking for education. They're looking for the ability to be in control of their own health. They're looking for clarity for what is an extremely complex mechanical system, the human body, and how to solve common problems. And there are a number of providers out there vying for that attention and that audience we've, I think, complained as a profession for many years about athletic trainers and chiropractors and acupuncturists and massage therapists and you know, all the others. You know, people who are also trying to serve patients with pain, especially musculoskeletal pain. And now we have really sophisticated technology and really high level, you know, personal trainers and athletic trainers and physical therapists and others who are putting out content that people like that you can't ignore. That I think that's important for us to pay attention to. And I think it would be smart of us as a profession too. Not hold them necessarily at arms length to, to learn more about what they're doing, why they're so effective to have physical therapy owned platforms that try to innovate as well. One of my, one of my favorite physical therapists, his name is Kelly star at, and he was an innovator in Crocs. Is the owner of San Francisco. CrossFit wrote multiple books that many of our professional, you know, higher ups in the profession dismissed him as, you know, someone who's kind of gone against our profession and in my head, he's, he's really done a lot to bring awareness to the field. So I, I dunno, I think I am not one who I think, I don't think the sky is falling.I'm not worried about that. Our profession is becoming irrelevant, but we're going to have to make space because if people are delivering better value than we are, or they're embracing technology in a way that consumers like better then. The consumer gets to choose. So we should pay attention. I think we should collaborate. I think we should learn. I think we should encourage physical therapists to build platforms that are competitive and, you know, Ride the wave because change is inevitable. It's coming.
Richard: Yeah. I get the feeling you know, I've been a therapist for 30 years now and the change that has occurred in therapy, certainly in the US in the last 20 years I've been here, has been very much incremental. So just be nibbling at the edges, be that adoption of technology be that changes in payer relations or the way payment is received. I really believe at this point, there has to be a paradigm shift because not only are changes occurring, but it seems to be changing at a faster rate all the time. And I think in order to maintain relevance and truly be common and be. The primary provider of musculoskeletal, I think we've got to really move forwards. And the analogy I use is the blockbuster and Netflix analogy. I feel the traditional outpatient therapy is the blockbuster and it doesn't matter how much you optimize your service. The concept of delivery. If I believe in borrowed time, that's not to say blocked outpatient therapy clinics will become obsolete. They won't, but we have to acknowledge that there is an alternative provider for blockbuster. It was obviously Netflix for us. I believe it's online businesses. And unless we, as you say, embrace, adopt a similar technology and do it quickly, I think there are very. Heavy storms ahead personally.
Ben: Yeah, that's an aggressive analogy, I think, with the blockbuster and Netflix, but one that is a cautionary tale that interestingly blockbuster was offered the chance to buy Netflix years and years and years ago and turned them down. They laughed at the asking price, which I think was something like $30 million. I think it's a cautionary tale for sure. I agree with you that again, I don't think the sky is falling necessarily. I don't think that we will become obsolete. Like, a blockbuster had a value proposition. There was a consumer movie, a consumer movie for us. It's different. A different value proposition for sure. And I think brick and mortar will always have a space. However, there is, you know, given the opportunity for blockbuster to buy a Netflix. Now they would have taken it. And are there platforms and are there. Groups that are doing a really spectacular job that we could add our own, you know, that, that our profession could embrace and our profession could adopt and, you know, add the, the additional expertise to, and I think there are, and I think those are the sorts of opportunities where as long as to use that analogy, as long as we as blockbuster, don't dismiss Netflix altogether, and yeah and miss the opportunity to collaborate in a case by it. Well then as long as we avoid that pitfall, I think, I think we've got a chance to really use the technology, to accelerate our profession rather than to be. Frustrated by it.
Richard: Perhaps given my 30 years I may, cynicism is perhaps a little too extreme, but I, I don't see. I, once I see that storms, I, I definitely believe that we can compete in the, in the another analogy I use is the fact that yes, the likes of Hinz sword and a martyr, et cetera, the Netflix. You know, there is now competition between Netflix and Hulu and Amazon and Disney plus. I think we have to change to be able to be that, Hulu, Amazon, or Disney plus and we're capable of it. We have the technology, we have the resources, it's just more than anything. I think it's, you know, do we, do we have the commitment to embrace that change."