Richard Leaver, PT
In this episode of Agile&Me, we discuss predictions for 2022 and beyond for physical therapy.
So welcome back to agile and me a PT podcast series for physical therapy leaders. I'm really excited to speak to John Colucci in this episode about 2021 and more importantly, looking forward to 2022.
So welcome John. You probably need no introduction, but perhaps those that don't know you I'd love If you could perhaps introduce yourself to the readers and listeners.
Richard, thank you so much for the opportunity today. Very excited to speak with you. I am the CEO, president and founder of JAG one physical therapy which is a multi-site physical therapy company throughout New York, New Jersey and Pennsylvania offering physical therapy, occupational therapy, hand services, and athletic training services. We're actually the largest athletic training service business in New York. New Jersey provides. Athletes from clubs, high schools, pro sports semi-pro sports provision of care through our athletic training providers. And we're very excited, which gives the athletes an opportunity to get care. First, as the injury occurs, and then we help them navigate the healthcare business and get them into the appropriate physicians and then of course, rehabilitation in our clinic. So we're excited about those services. I'm a physical therapist and an athletic trainer with a global licensed dual degree. I've had the honor for the last 30 years to work in both professions in multiple settings in pro sports now for about 26, 27 years at an opportunity to work very early in my career with Mike Saunders from New York. As a part-time associate with him years ago, learning pro-business, but I've had the opportunity to be at NYU Columbia. The Metro stars, which became red bull. And for the last 16 years, I've had the honor of working with our chief medical officer and our commissioner of major league soccer, helping navigate quality care for major league soccer players throughout the country. So very excited to be here today, Richard, and I appreciate the opportunity to be with you.
Thank you. You did all that before the age of 40, so kudos to you.
Well, I wish I'm definitely on the other side. There's not a day that goes by. I'm not happy with what I'm doing. The most important thing is to go to work every day and to be happy. And, I've had that opportunity over and over.
That's impressive and also you know, thank you for your work for the profession in general. So is your philanthropic work, because you seem to have done a lot for helping others, not only within therapy, but in a wider audience for healthcare as well.
Thank you Richard. We've had a great opportunity, me as an individual and us as a company. To really get involved in the advocacy for physical therapy, the collaborative understanding of, of multiple musculoskeletal injuries, the rationale and importance of physical therapy services at a very early entry port for those musculoskeletal injuries. I love where our profession is currently going and we have so much opportunity over the next five to 10. As a physical therapist.
Before we talk about the opportunities, there are definitely some challenges as well, but certainly opportunities love to know how you and your team have done in 2021. It's been a strange year. There's definitely been ongoing challenges through COVID and reimbursement challenges. We've had our best year. I sometimes kind of struggle getting my head around both ends of the spectrum. Has that been similar for you or have you had a different take on 2021?
So we've been very fortunate coming out of 2020 COVID years, so to speak and all of our budgets being decimated through the year and, and navigating the quality of healthcare with the ups and downs of Physical therapy and the closing and openings of clinics as you can imagine, New York and New Jersey Pennsylvania was hit very hard in March, April and May of 2020.
But we did start to see cause people wanted care. As we got into May, June, July, a really big uptick in people coming back and we've had a steady flow right into 2021, we built, as you can imagine at the end of the day we're providers, but we are a business that has to be fiscally reasonable. And we built a ramp budget throughout the year, and we're very proud to say that we were very lucky throughout the year and we're able to hit our marks. We've also been able to grow our footprint. Our footprint in Pennsylvania is larger now at eight facilities growing into bucks, county and Philadelphia. With goals of going into Montgomery county, we were able to fill in some catchment areas in the five boroughs and Rocklin county and where I started the business in New Jersey, our collaborative efforts with our healthcare partners, such as the payers, we've been able to do some great data collection programs with them and really find locations of eat and utilization for in network providers with outcome based care and evidence based. So we've been very fortunate, 2021, as you can imagine, as a CEO, wasn't easy navigating, but only had it wins. And definitely had its roller coaster rides, but I think we're, we're getting to the other side of it. We're very fortunate and, and I think what's starting to come out, especially in the research, the importance of the utilization of physical therapy, but musculoskeletal injuries. I definitely think as we go into 2022 to 2023. We can really advocate for ourselves, especially with the federal payers and then really move forward with the commercial payers and the workman's comp parents. So I think we have an opportunity in front of us. I think we are becoming a primary care provider, which is very important. I do think, and please hopefully you don't strike this. I do think the American physical therapy association needs to catch up a little bit to the profession. And we can talk a little bit about vision 2020 and where are we on? And what we did, which was great, but the problems that we will actually cause for ourselves, but we can go down that tangent.
Absolutely. The reason I love talking to you, John, is because you're definitely a glass half full and fyour glass, probably three quarters, you know, 80% full. And it's refreshing in a way because when we're in the trenches every day, trying to navigate the challenges, I kind of look at you and your insight really. To Understand and appreciate that, you know, things are good, aren't they going forwards? And you know, I think that's important that we don't kind of lose sight of the big picture sometimes isn't it, as we're fighting off the various challenges.
I agree. And, you know, I was very honored to have a grandfather that taught me at a very young age that when you wake up and you're on the green side of the grass, that the day is beautiful. Try to enjoy every minute before you put your head to rest at night. So I think we have great opportunities as a profession, but I think we have great opportunities as an American healthcare system too, to really take the physical therapy profession and put it where it needs to be in the treatment and care of the Americans. It's very important here in the United States, just based on. Direct access based on the treatment of musculoskeletal injuries, helping payers mitigate costs that should be eliminated for the simplicity of soft tissue. So I think we've got some great opportunities. But again, I want everybody to understand every single business has its ups and downs. Every single provider has its ups and downs. Every person has their ups and downs, but at the end of the day, if you're on the green side of the grass, we should be very happy and just work through.
When we think of the short term obviously you mentioned federal payers and then we'd definitely have the. Payment or reduction for PTA is providing care compared to PTs. I've done a separate podcast addressing this issue and how we might manage it from an operational perspective. But do you see it as a major impact or just really just kind of another road bump that we just have to navigate and manage around.
I think I'm going to answer that in two ways. I definitely think it's a road bump, but I definitely think our advocacy from the APTA to the APTQI and individual physical therapists in each individual state needs to continue to advocate to the politicians. And I think as long as the politicians start to really understand the profession of physical therapy, the need for physical therapy, the importance of physical therapy. That our profession will actually start to see an increase in federal reimbursement, as long as we keep the narrative in that way of evidence-based and research-based physical therapy care. I think, as we've seen, based on the advocacies of our, of our colleagues and what's been done from our colleagues navigating and educating the politicians, you've really seen the opportunity to make. I think that we put a little bit of the cart before the horse with the vision of 2020, because we marketed during those periods of time, the importance of physical therapy, we market it, that we are the musculoskeletal healthcare. We marketed that we are direct access. We marketed that we're a doctorate profession, but what we forgot to do was get our education process geared up for the influx and opportunities of increased patients.
I know myself and the group at web PT are trying to get in front of education. The academic world and make them understand the importance of increasing their graduates because as we know when we've seen the statistics, we're going to have close to a 25,000 physical therapist shortage by 2025, because we did a great job with vision 2020, but we didn't do a great job increasing the level of increasing the number of graduates. I think we need to get the academics we need to get in front of the presidents of the schools, the program directors cavity, and really start to understand that vision 2020 was to make us the provider of musculoskeletal. And now we need to answer the bell and make sure we have the providers to do that.
You bring up a really good point there. I know we're jumping around a little bit, but I'd like to, to look at this, provide rush. I always say that there are winners and losers. Therapy will be dependent upon three things. One is patient experience. Secondly is the adoption of technology. And third is those that can recruit and retain and you bring up a very good point. There is a shortage and I believe the shortage is going to get worse because of the, you know, one you've mentioned the vision 2020, but also going forward. We hope to launch as a profession, the hashtag gets PT at time. With the concept and idea of increasing demand significantly over the next five, 10 years now, how do we manage this to increase, be able to see more people within the century, less clinicians and also maintain financial viability.
I suppose we could probably dedicate a couple of hours to this as a topic in itself, but I do have concerns. There's a fundamental structural issue with clinicians just or lack thereof my belief is in part it's because of the cost of training, the limited training places relative to demand. As a, perhaps a graduate looking to enter healthcare, the cost of becoming a PT relative to the salary doesn't necessarily make it as attractive as say for instance, becoming a PA or a physician or some other provider. A lot to unpack in that, but I'd love your thoughts. So again, I think that based on entities that are advocating such as the APTA and the APTQI, as we know, we've had a great partner with web PP and other services out there that are trying to help us gain the research, gain the data, gain the information to get not only federal payers, but national and local payers and of course workman's comp payers just in Texas recently. We had the opportunity to see a great presentation of PT first for musculoskeletal cases. I think that we need to make sure again, getting in front of the academics. Getting in front of looking at their qualifications to actually develop programs and also look at the institutions that have programs to be able to grow their class sizes, but still be able to put out quality. I think the other concern I mean, when you and I graduated from physical therapy school, we graduated on day one and we were able to treat, we graduated on day one and we were ready to go and take on a patient. The way the therapists are coming out of school now, although they are doctors of physical therapy, we see an issue of truly hands-on patient care, where most of us are having to teach and mentor these physical therapists that have their doctors. Pass the didactic board exam to protect the consumer, but are they truly ready on day one?
To treat patients and we are putting dollars now in the first year of any new physical therapist who now mentors Veatch, and that's becoming an expectation as opposed to you've studied, you've had your clinical. You've been mentored. You sat for your boards, you should be able to come into a company and be able to treat a patient load. Some of our colleagues disagree with me on that because they feel every healthcare component is a provision of practice, the physical therapy practice and the more you practice the better. But you, and I both know from when we graduated, we walked out into the clinic and we were able to take a patient load, be able to navigate and progress that patient with therapeutic exercise, hands-on treatment progression with modalities to reduce symptoms. Now we find ourselves with entry-level graduates with a doctorate degree that we're spending a lot of time and money to educate. I really think that you might see. A bunch of our colleagues really need to get in front of the academics to make sure that they understand that we're putting ourselves a little bit behind in terms of graduating. Even if we graduate new graduates, we need to make sure they're prepared to treat on day one. There is nothing wrong with practice and learning from mentors, but it's become a costly component on day one. And you and I both know that navigating what's called. I think the other way is that we can navigate as well, and it truly works within the confines of each individual demographic. So as you know, my density is quite difficult being in a very dense population of New York, New Jersey, Pennsylvania, one of the most populated densities in the country, if not the world. What we've been able to do is navigate our demographics and catchment area. Actually, if you remember back in the eighties, it was all about 2000 to 2,500. Square foot foot clinic that caused us a lot of money in rent versus a lot of money in space. Now we've been able to navigate with 1,015 hundred square foot clinics, be able to put one or two providers to truly get into the market and help that area that may have the difficulty. I definitely think we have a great opportunity.I just think we, as the leaders of physical therapy, need to really start to get in front of the academics and Kathy to make them understand the issues that are faced in the United States of America, when it comes to the utilization of physical therapy and quite interesting. The payers are starting to realize the importance of physical therapy here in the Northeast. Some of your largest payers are truly working opportunities based on data collection and the importance of that data collection to see how important physical therapy is in getting people back to full-function also getting people back in less pain quicker also of course, as you can imagine, there is a business making sure that we're mitigating costs that should not be spent for the simplicity though I don't think you and I are going to solve all these problems today in our podcast together, but I definitely think we have an opportunity collaboratively. And as you know, we sit with a group of 17 to 18 professionals nationally that are operating some of the largest physical therapy companies. I think we should start to really talk about that collaborative effort in our meetings and really talk about getting in front of the academics.
Personally, I've been in front of four to five program directors. I know Heidi from web BT, one of four or five program directors and presidents and having the conversation. And they're starting to listen. I think we all need to have this talk to have. Because we've proved ourselves. We are the musculoskeletal injury profession and illness profession.
We are here to get people moving. We are here to get people better. We're here to get them motivated and get. Back as we like to say in the game of life at JAG one physical therapy, but we all, as physical therapists know the importance of that, and we need to really start to collaborate with the academics and a PTA and AP DQI to get that message out as soon as possible.
Yeah, it's interesting. You bring up academia because I think we sing the same song and there's definitely, I believe, a disconnect between academia and clinical practice here with their gods to not own it well, in many respects with regards to what is taught and reality. I also think perhaps clinicians whilst they're trained in a very different way. I don't know if it's better or worse. I wouldn't say that, but write differently. What I mean by that when I trained, there was a minimum of 2000 clinical hours, whereas now I think it's around a thousand hours. I remember saying to many graduates, recent graduates, when they say, what are the expectations. I would say just, you know, just don't kill anyone or hurt anyone and they kind of look at me and discuss with their guards. Do you know how dare you question my clinical judgment and skills, but my attitude was, really the school gave you a very basic understanding and to achieve true clinical competence probably requires between five and 10 years of, of further education and, and, you know including Pete, what I call patient mileage and further hands-on training.
I just feel that we need to do a better job and perhaps be teaching somewhat, slightly different skill set or, you know, additional training. But I also appreciate the cost associated with that. Again. I think you hit definitely hit the nail on the head about the clinical component, but there, the academics have a philosophy. That we're going to give didactic information for a consumer national exam. And as you know, we removed the hands-on portion of our examination. We removed the clinical thought process from not just physical therapy, but also from athletic training to, to really focus on the, the, the consumer didactic exam of 200 questions. I definitely think the school. I need to understand that the so-called three, 12 week rotations or two, eight week in a 12 week rotation is what is expected during that time and what you should be, especially when you're in a third year, you should be walking in and handling your own patient load. And you and I both know when we went to school that was accepted. That was what was expected when we walked in. Because you were about to graduate and go and treat the consumer and you needed to understand time management, you needed to understand hands-on skills. You need to understand how to progress patients and ultimately in the last 10 years, although we have some graduates that work hard to be able to do that, I would say the majority of graduates need that whole extra year in employment. Which is costing us a lot of money, but we now have to designate another clinician as a mentor. We all had to develop mentorship programs. We all had to develop. Hands-on exercise progression programs, because think about the current exercise progression education they're getting in a PT school. It's literally three to four month class And you, and I both know if you don't move it you'll lose it. So how could we not be spending more time on the progression of movement on the philosophy of biomechanics? I had a great opportunity. So not only did I go to school, not only was I an athletic trainer, I had functional physical therapists that were my mentors. Remember, as you know, I've been in clinics for some 13 years old, which is an anomaly. I had the passion to be a physical thing. At 13 and had the opportunity to between 13 and 24 to work with people like Dr. Art Nelson from NYU Dr. Richard data who was the New York Rangers physical therapist for years. Catherine McWilliams who started the physical therapy musculoskeletal program at Lenox hill hall. These were my mentors and there was not a day that they didn't say you have to work with patients. Communicate patients, teach patients, be hands-on with patients and make sure they understand the biomechanics and movement because that's how you get patients. I think we've lost that a little bit. I'm not saying all programs, but I think we lost that a little bit and I really think people like you and I Heidi definitely other people in our profession that can get into the schools and work with the students and give them the expectations on graduation. I think it's very important. It's a teamwork approach. And I think what we've learned, Richard, you and I, as CEOs And the last 22 months with COvid, we've learned to collaborate. We've learned to work as a team. We have such a bright opportunity right now to really work collaboratively, to continue to get the profession exactly where it has been,
Sort of moving on a little bit. I want to, I,p totally agree that we are moving and we should be moving and recognized as the primary provider of MSK, obviously with direct tax, this law laws improving and, I think insurance companies are beginning to understand that not only are we Cost-effective but actually clinically effective in managing muscular cyclicals in in the primary and acute setting.
But When we look at that in relation to staffing, do you believe that we need to perhaps utilize and accept that we will need other types of providers to assist us? Because there just aren't enough licensed PTs? Or do you think that we'll be able to adjust how we treat and manage patients to be able to see more patients in the same amount of time? What's your thoughts?
I think as we, as we look at our profession of physical therapist and we look at physical therapy assistance, and then as you, and I both know the concept of the aid and, and really most of your age where people would an interest in a path of becoming a physical therapist or a physical therapy assistant, I think we have the opportunity based on the licensed professions, such as a physical therapy assistant and a physical therapist. I think that we need to change the narrative. Especially at the federal level of the importance of physical therapy assistance and how important they are to MSK just as a physical therapist is as you know, I am dual licensed and dual degreed as an athletic trainer. I think there's an opportunity, especially on a biomechanic component to work collaboratively with athletic teams. Throughout the communities to again, be able to get people care quicker. As I said, I have a business that's in the community each and every day. And when you sustain a musculoskeletal injury in New York, New Jersey, Pennsylvania, you're getting care within minutes. And that care model immediately gives access to everything that you need. Let it be if it's an emergency, getting you seen as quickly as possible. When an ed I need the fast track program, but musculoskeletal injuries, which we've developed through the three states here with certain partners, we've definitely done evidence-based education. Physiatrists orthopedics primary care to make them understand the importance in getting research in front of them collaboratively, to make sure they understand that a sprained ankle should not be booted before weeks.
And I'm using that as an example, or someone with a low back pain should not be embedded on medication for two and three weeks. I think we're changing that narrative and I think we need to get the education and the research in front of the federal payers to import and make sure that they understand the importance of physical therapy assistance collaborating with physical therapists. I think we've seen the component of an overseer or a supervising physical therapist, and we've worked very, very well for years. I think that you need to understand that the patient is still getting the same quality of outcome. With a physical therapy assistant supervised by a physical therapist. So why should there be a decrease in reimbursement? Why would a federal payer ever think that if they have a patient that is getting better, they should decrease it based on a supervising physical therapist, over a PTA. I think that's something we need to start to educate the federal government on and the local. I've had great opportunities over the last two years to work with the New Jersey and New York politicians, both at a local level And now at a national level, I've been in front of a few Congressman, a few senators, just giving them education. I don't know if you know what's happening here in New Jersey with the dry needling bill, but we added an opportunity two weeks ago to get the Senate floor to pass the bill to move on to the assembly. And ultimately when, when, when the APTT and Jay looked at that presentation for dry needling, they realized that the narrator was incorrect because it was being negated by another profession. As soon as I, and they got in front of about 10 to 12 senators, they were true research proof facts of our clinical education. All of a sudden that bill was passed. I think out of all of the centers of New Jersey. 2 voted against a bill that thinks about how we change that outcome. I'm telling you we had 12 to 15 and only two to three didn't vote for the bill because we advocated and educated. And I think that's very important when it comes to the utilization of physical therapy assistance, especially based on the shortage. We may see, I think we can navigate around the shortage by getting in front of the academics. I understand that Northwestern is now doing three cohorts for the graduating students three times a year. I know Dominican college here in New York has increased the volume of their class. I believe Columbia and NYU were doing the same thing, but we can still navigate the way from the shortage, but we need to get in front of the academics and make them understand.
Absolutely. Yeah. I obviously trained in, or not obviously, but I trained in England, you know, a few decades ago, shall we say? And I won't hold that again. And what was interesting in England? They had direct taxes since 1972 and, you know, Therapists in England as a result of that further forwards. And there was the clinical evidence to show that it worked in the management of MSK you know, just look at the surgery rates being significantly less as one example. But I think the evidence. Clinical evidence has been there for a long time, but I think it's really the, when you talk about education, I think it's educating the other stakeholders, isn't it? And primarily it's the insurance companies and legislators. And I think we've really only just started doing it effectively. I remember being asked by the states, a PTA group regularly for donations. So they could go on golf outings, but I don't think that was necessarily effective. Perhaps it was, I don't know, perhaps I'm being unfair there, but it's really at the moment educating primary. Payers at, in order to change how they treat therapists in the, in the grand scheme of things, isn't it. And I think a good example of traction is a waiving of copays, but I think there's a lot more that can be done. You know, thoughts on that. So that's, you know, that's a great point. And as you know, companies similar to yours and mine, Can can change the narrator healthcare companies, such as major healthcare systems can change the narrative just based on the research. So what we've done at Jaguar physical therapy as a self-insured program for our employees is that our employees have of course direct access to physical therapy because they work for a physical therapy company. Their families have direct access as well, just based on, based on the laws of the state. But what we've done is there's no copay, there's no co-insurance and there's no limits of physical therapy in a year's time that you can get. I think that's what we all need to start to do to get that out. I know that there's certain workman's pump companies that have realized that workman's comp payers realize that if they increase access to physical, And save money. And ultimately they're starting to move away from any type of limits of visits per year. They are moving away from any type of copay or coinsurance. Also, if we look at a component of healthcare systems, Are truly looking at the research. So here in New York, New Jersey, as you know, you have NYU, you have New York Presbyterian, you have locked well, you have RWJ BH, you have Meridian hacks Hackensack. If you look at those hospital systems alone, I just gave you six PS 60 hospitals. And they're starting to realize what their employee is. If they get access to physical therapy quicker, they can get them back on the job. And they're saving money. So they're starting to look into their self-insured programs as well. So we need to start to get in front of blue, cross blue shields, the United healthcare's, the signatures. I know we've done a very good job with Cigna but the editors educate them that putting restrictions on is ultimately going to cost them more money to treat the simplicity of certain musculoskeletal injuries. Now you, and I understand, and this, this is again, only because we're the same age. How silly is it that an insurance company or a payer basically tells a physician that they could do an ACL surgery and we will pay for the ACL surgery or a rotator cuff surgery. And we will pay for the rotator cuff surgery, but Hey, we're not going to pay for the full gamut. Research-based evidence. Physical therapy care, which is the most important factor to that surgery, getting that success. And you, and I know in the eighties and nineties, and that was the big joke, but we had to get on, on a peer to peer review and 95% of the time when you got off, it wasn't a peer to peer review that was not in the MSK space. As soon as we educated them on research, all of a sudden the patient was able to get the physical therapy. Why is that still around? We've got the research, we've got the proof and we need to get it in front of the payers to make them understand that if you're approving the surgery how could you not approve the care needed? Post-operatively and I think that's another battle. Again, I'm throwing a lot of battles out there. Ultimately it's another battle. That's very easy to prove. Very easy to advocate. Because we have the research for the last 30 years based on the outcomes of simplistic musculoskeletal injuries. I find that I'm entertained and I hope this doesn't irritate anybody that we literally have a total joint surgeon that say, after I give you a new joint, you are good to go, just walk around the new. So let's talk about biomechanics of somebody that needs a total joint for the year to two years before they had the total joint, the competence, Tory patterns, they went into the problems that they had with their musculoskeletal system. Of course, the joint wasn't functioning and a surgeon is going to do surgery on somebody and say, you don't need physical therapy. That's totally against all the research of biomechanics movement functionality. Plus you're cutting into tissue and you're never restoring the tissue. Now. I'm sure there's some joint surgeons out there that will get mad at me, but there are some joint surgeons out there that love to send their patients to physical therapy, because their outcomes are better. And the insurance companies don't want the patient to be readmitted. So of course, physical therapy is important.
I find it bizarre, you know, they are beginning to understand the ones side. That therapy is a cost-effective solution for everyone. But on the other side, they keep driving down in actual relative terms, reimbursement. It just drives me nuts. You know, it's as if they're giving you in one hand and taking away in the other and they don't know quite how to perceive outpatient therapy. do you get the same feeling?
I'm in agreement with 150%. Agreement a hundred percent. Yeah. You know, how can you sustain an injury or illness and have biomechanical deviations, muscular deviations, and, and not be able to have an appropriate gait pattern"