How To Fight Decreasing Reimbursements: Kristin Fox

Hey.

Well, guys, welcome. We're so excited to have our town hall take a stand for PTO TSLP meeting today. We have a very special guest today and yeah, what a, what a wonderful time of year. We're just talking before this call about the crazy winter we've all been having. And so last month we talked about how to drop your, your lowest paying insurance and we talked a lot about Steve Edwards and how he went through this journey to find a more profitable way of doing business. So moving forward, what we decided to start looking at were individuals who were either organizing or part of an organization that was taking a successful stand against insurance declines, as well as any other suppressive force, if you will, over anything that's going on in the physical therapy private practice space. So I am really excited to introduce today's guest speaker, Kristin Fox. I've had the great privilege of knowing and working with Kristen over the last year. And she is a very powerful leader in South Dakota in private practice. And what makes her so powerful is her, her way of leadership. She's got a charming personality coupled with a real hard worth work ethic. Someone who's very concerned about her team but also concerned about the industry. And I think that's hard to do when we're knees deep in alligators. In private practice, it's really hard to take a stand for the greater good for all. But this is an individual who totally does that. So she was born in Arlington, South Dakota and graduated from Northern State University in 2004 with a Bachelor's in biology. Then she went to graduate from the University of Nebraska Medical center in 2007 with her doctorate in PT. She holds multiple certifications and is extensively trained in pelvic health and lymphedema. She also loves working in neurological disorders and anyone suffering from pain, injury that's limiting them to fulfill their life, which is most PT owners to some degree. But she has a very specific niche in her private practice around that as a very passionate individual. She's one that is constantly looking to create value for all. And she currently serves as a reimbursement committee chairperson as well as the president elect for the South Dakota chapter of the American Physical Therapy Association. And of course, outside of work, she loves spending time with her family, South Dakota, huge outdoor person, loves fishing, hunting, gardening and is has been married to her husband, Troy and has two beautiful children, Ellie and Wyatt. So without further ado, please welcome Kristen Fox. Kristen, thank you so much for being with us tonight.

Yeah, thanks, Bill. Thank you for having me.

I appreciate that Did I miss anything in the intro?

No, not at all.

So, okay, Very cool. I probably went a little bit further than you felt comfortable. If I know you, you're an individual who doesn't like to take center stage on those things. But the reason we've got you on the call today is to talk a little bit about your efforts in South Dakota. One of the cool things I've seen you do is that you guys have had some successes around fighting insurances and doing different things. But can you give me a little background? I remember there's something really unique about South Dakota's APTA situation there. It's a little bit different, isn't it? Yeah.

Yep. So I guess maybe not so much the APTA situation, but our ability to reach out to our licensed providers across the state. Really, our only point of access is through our state association and not much. Unlike a lot of other states, we have a fairly low, I guess, participation per our number of licensed professionals. We're probably 25, 30% of our licensed professionals are actually members of our association, which is a battle we fight. But the bigger battle is the fact that that's really our only means of active communication or easy communication about our profession, whether it's at local level, state level, national level things. And so. And part of that is because we're one of three states that are licensed by a board that we have no representation on. So in South Dakota, we're actually licensed by the medical board.

And just in the growth of the PT profession in general, we were placed under the medical board in 1955. We've actually had direct access available for physical therapy since 1986 in South Dakota, but we've continued to be licensed under the medical board. And with the growth of the practice and the transition to the doctorate level professionals, that's been a real struggle, you know, for us here in the few recent years, just with different legislative issues, some scope of practice issues, and things like that. So. So we are unable to attain like an email list or a good way of communicating with our licensed professionals in the state, which we see as a problem. So we're actually in the process of bringing legislation to form our own licensing board. We're almost through that process, but not quite yet. Our governor has not signed off on the bill yet. So we're hoping for her positive support. We had great support in both chambers of our legislature, but still waiting for the final. Final yes on that.

So, my gosh, that is so interesting. So tell me a little bit about your journey in. In the American Physical Therapy association as well. What kind of, what kind of things have you guys done that help private practice and like, maybe even talk specifically if you've ever had any successes around fighting insurance declines in reimbursement or anything like that?

Yeah, for sure. I think, I think the two most prominent things I can speak to and I have to fully admit I was, you know, I've been a practitioner for 16 years. I've not always been the most active member. Definitely when you become a private practice owner, that changes things in your motivation levels towards, I think, being a little bit more involved. But it's also, like you said, hard to be involved when you're fighting for your team and just trying to keep your practice and your doors open. So one thing, we've had kind of two big wins in the last year, I would say, here in South Dakota. First of all, we've. We do biannual payer meetings. So this is kind of as our reimbursement committee pay chair. I've sat on that committee for several years and became the paychair a year and a half ago. And we've had continual meetings with all of our local payers, with their provider relations reps and things like that. But we've also been meeting with our state Medicaid, and we've had great conversations with them. And we really kind of brought to their attention about, and say about a year, year and a half ago, we basically just brought them a presentation. We put together the numbers, we gave the state Medicaid rates for all of our commonly billed codes for PT and put it against, like, all of our neighboring states, all the regional states around us. And we're at, you know, bottom of the barrel. We were basically getting paid, I want to say, 14 to $15 a unit across the board. Whether it was ultrasound or neuroret or their activity didn't matter. So extremely low rates. And basically you were doing a community service anytime you took on a Medicaid patient. And in our more rural and underserved areas, that's also, which is a lot of South Dakota was also a huge problem for private practice owners that typically serve those areas. The other part was they had a 55.0percent PTA differential in place as well.

What does that mean?

It means like you're, you know, you're, you're paying Medicaid to allow a PTA to see a patient. You couldn't, you couldn't utilize a PTA and, and keep your practice.

If you used a PTA that your reimbursement was decreased by 50%.

Yeah. So the PTA differential, instead of like, oh, my God, we're seeing right now, was 50. So prior a few years ago, they wouldn't even let a PTA treat a Medicaid patient. Then they allowed PTA to treat them, but at a 50% reduction. So. So we kind of brought that information up, shared with them, even that, the Medicare, even that is an effective, like, 12%, you know, differential. And we just presented the information honestly and just kind of kept conversations going.

And did some negotiation, and they. They came back to us and, you know, without any legislative acts having to be passed to do it, you know, they were actually able to increase those rates pretty substantially not to where we want them to be, obviously to a place that it's at least feasible to. To do business and break even or maybe make a very small profit. We were able to successfully reduce that pta differential from 50 down to 10%.

Okay.

Which was huge.

Yeah. 40% improvement in reimbursement with PTAs.

Yeah. And in general, a lot of our codes, the reimbursements increase anywhere from 25 to even 60, 70% or more. So. So in general, it made it. So we were making.

More 20, $25 a unit or something roughly in there. And they actually differentiated the codes based on the skilled capacity or component of it, which was not the case before. It was just almost like a flat rate across all codes. So that was really a huge win for us. We felt like. And in the meantime, in those conversations, we also were able to open a conversation with them about becoming a direct access provider. South Dakota. Medicaid has some kind of.

Cumbersome referral rules that has to go through their PCP that's listed with Medicaid and things like that, which results in a lot of denials and a lot of extra administrative burden on the billing side of things, fighting some of that, like, if they have an orthopedic surgery, you know, if the orthopedic surgeon writes the order, we cannot use that as a referring provider. We have to go back and get the referral signed off by the PCP that, you know, might be a mental health practitioner in one, you know, in a particular case. So. So we've. We've had conversations with them on that. We're currently in the process of forming kind of a test group to look at, you know, things that might be more appropriate of when PT should be utilized prior to other interventions, you know, before they can approve maybe imaging or something like that. And we also open that conversation for becoming just a direct access provider for musculoskeletal conditions. So we've got some work, but that could also help reduce some of the provider burden in general in our state. So we're excited about that.

Well, it's amazing to me to hear that, because, you know, when you talk to private practice owners, especially if they're not members of the apta, they'll oftentimes complain about the lack of action that goes on. But at your state level, you guys were very successful in fighting some reimbursement with Medicaid directly. And I have so many questions on that that probably aren't even appropriate for this conversation because I'm like, how do they even know? I mean, I, I really am like, maybe one of the, one of those people leading this conversation who knows the least about it? Because in my mind, I'm like, how do you even know to talk to in the state Medicaid world? Like, who, who are those people that are making the decision? Is it one individual? Is it a committee? And then how do you get in front of them? And then, you know, like, you, what you did talk about was how you used research in the area to dictate, like, listen, this is what we get paid. Otherwise, the hard thing about that, Kristen, is that, like, reimbursement stand across the board. So even though that was successful, I am sure that the other places that you used as research weren't as strong as maybe they used to be kind of a thing. So it's, it's a, it's a powerful step in the right direction. And I don't mean to take anything away from that. It's just a reflection of, like, man, how hard this uphill struggle is.

Right. You know, And I think for us, you know, in just looking and talking with people in similar positions in neighboring states, you know, our reimbursement was, was very poor, but we don't have some of the layers of administrative burden or third party, you know, administrators and things like that currently. And I guess my biggest concern for us was that as a state and, and then there was even a little pushback, like on our committee, like, is this really worth fighting? Like, these are not the patients that we're trying to, like, bring in our doors necessarily from like a financial standpoint, which is true. But I said, know, this is like our bottom of the barrel, right? But we're all going to take it because, you know, we feel the need, this is important to us, right? To make sure that we're providing service to this population. Of patients. But at the end of the day, we don't want them looking for alternative solutions either. You know, if they're needing to save money in an area, we want to make sure they know our value, our worth, and they can see. Know that we can help. You know, our Medicaid program to me is a lot like direct to employer type of programming where our goals align. You know, they're trying to keep their bottom line in check and so it's easy to work with them and they're willing to work with you and they're willing to have conversations. And so I think that's what I found refreshing and good is that, is that, you know, our, our goals actually align in that we're trying to help provide a service that can help save them. You know, there's, there's immense value, but it also can help save them on their bottom line and keep them from searching out other alternative solutions to meeting their budget that might sound effective, but maybe really aren't.

Yeah, I love that. And so I'm just curious, like, when you guys were able to do that, what was that like for you personally?

It felt really good. I mean, like you say, like there's always that, you know, wish it could be more. Yeah, but, but no, I mean it, it felt really good to present them with information. In fact, there was a little bit of like, was it really that easy?

You know, no one's even tried before. Like, it's just one of those things where like, by doing it, you were successful. You're like, what?

Yeah, it's like, we should talk to these guys more often. No, I mean, and it took a lot of work. There was a lot of people, you know, even before my time, you know, in these meetings and having these conversations. And like I said, just keeping up a consistent relationship was really important. And we, we met strictly with the actual director of the South Dakota Medicaid program or. And then the deputy director is kind of our points of contact. And you know, it's a three hour drive out there, but I made the trip, you know, you, I like to do those meetings in person. I love the virtual aspect, but I think that there's something to be said when you're trying to build a relationship to actually sit down face to face and, and have some of those meetings is important as well. And in the end, even since that time. So our reimbursements went up last July and they didn't just. We presented them with PT data. They actually went across all therapy codes, PTOT and speech and Increased reimbursement for all three services, which was huge. Like if you own a rehab agency or you're a hospital based system with all three services, I mean, that was a huge, huge win that they didn't even have to, you know, invest anything in. So it was a big deal. And the one thing I feel like we probably need to do a better job of, which we don't necessarily do a good job of in our profession is, is marketing or sharing that news of what actually got done and how we did it. I think that that's actually really important so people know, you know, how, how these things happen.

Well, and I, you know, I love that you said that. That was a beautiful promotion of what we're doing here because that was the whole point of like, let's get as many PT owners as we can together, or PTs in general, and share these success stories. So for this month, next month, and the following month, we're having people like yourself who have been leaders in the industry who've, you've made successful changes. I don't think there's any, I mean, from my world, until I started coaching, I never heard about stuff like this. And you know, it really does blow my mind, Kristen, that like, all you guys did was sat down and go, hey, please stop doing this. They're like, oh, thanks. Sorry, we didn't know. And then what you guys did was raise the tide. And then OT and SLP came right up with you guys. It's really powerful. And it makes me wonder, like, what would it look like if we were really organized and we're more of a squeaky wheel that was just kind of like in their ear all the time? I don't know, like from that experience, where do you think? At least in South Dakota, what do you think is potentially capable of happening? If, if enough PT owners came together and were organized, what do you think would, would be the outcome of that?

Yeah, I mean, I think with.

You know, outside of the Medicaid program, I mean, just in general with our, our commercial payers and things, I just think there's a lot that can be done. I mean, we especially, we have some very large health systems in our state which are, are wonderful and serve a lot of different areas, especially some of our more metropolitan areas. But when you get into like more of the rural small communities and things like that, it's a lot of people like myself with one or two clinics and five to ten practitioners or whatever. And you know, I think if we all just as a profession started having a little Bit different of a mindset of letting people know what the issues are and owning our. Our worth and showing our value. I think that that could be extremely impactful. And that's why I love. I love jumping on your town halls and these conversations, because.

I think there's a lot we need to do for a little bit of a mindset shift from a professional standpoint and getting on the same page and working together.

You know, I've always said too, you know, in. In private practice, especially somebody small like me. You know, it's like you feel like you're competing against the hospital down the street or the hospital 40 miles down the road or whatever. And at the end of the day, I'm like, I'm not. No. If we actually got together and worked to get all of the people to physical therapy that belong in physical therapy, there'd be plenty of pie for all of us. We don't have to fight over the small pieces of what we are right now. And so I'm on board, and I want more people to have that mindset of, let's work together. We're a profession, and we all have the same goals.

Well, I think that's inspiring. And I love how you said earlier, Kristen, this thing about we have a PR problem. I think it's like the main problem we have outside of how we. How we. How we experience ourselves as leaders. PT owners are the most notorious ones to say right out of the gate, well, I'm not really a business person, like, right out of the gate. Right. And. And it's so funny, because what is a business person? It's someone who's trying to successfully own a business. So you'll meet people who've owned businesses for decades successfully at a good profit, but because they are typically tied to the service directly and they've never learned how to get out of it, they just minimize their power. And I think that's the number one problem. But when you talked about the PR problem, I think that would be just kind of brainstorming a little bit. I just think it'd be really cool. What if we all pooled, you know, not just, like, united in a American Physical Therapy association kind of way, but what is. What if the entrepreneurs really got together? It's started leveraging, you know, communication across their patient lists. You know, there's nothing wrong with you emailing your pa, your past patients about anything that you're doing. That's actually an encouraged practice to keep that relationship tight and to do these things. What if we created some sort of United Message that would promote the industry in terms of educating them on what we do, but also like helping them help us take a stand against their insurance companies at or, you know, there's not. Right now there's 250,000 physical therapists in the country. There's only about 25,000 PT owners in the country. But between all of our email lists, we have like tens of millions of people that we could be engaging with if we were better organized. And again, it's always going to be the entrepreneurs that are going to do this. Everyone else are very important and needed in the industry, but it's only the men and women like you who are standing up for the profession in their own communities to make that happen. So like, when you, you know, it must be hard for you to balance. I mean, as a side note, how. What is that like? I guess I'm putting words in your mouth, but is that difficult for you to balance your APTA work and your family and your practice? I mean, I used to have a practice. I remember how crazy that was. What's that challenge like for you?

Yeah, it is. And that's something I've, I've really tried to start to, to work on and make sure that I'm keeping some balance and stuff here in the last year or so as well.

And you know, this was a. Before I accepted like our president elect position, it was a conversation my husband and I, he owns his own couple of companies and that, you know, I said, I'm like, I, I feel really passionate about this, but I'm a, I'm an entrepreneur and I'm a very idea shiny object person. So I said, I want to make sure that this fits, you know, for our family and things like that first. And, and he kind of threw the same thing back in my face that I said to him when he was going to open his first company, which was, I'd rather you do it and, and say you, you know, we did it might not be easy, but we're going to make it work and versus not do it and be a few years down the road or 10 years down the road and, and regretting that you didn't do something. And he's like, you know, we're both kind of the type of people that we're not going to sit around and complain about something and not try to make a change or at least give it our best effort. So luckily, with his support, that was huge for us and our kids and things like that. But yeah, it's not easy balancing I Think my biggest concern sometimes is I fear that my. I have a great team of people, they've allowed me to be away here in the recent months, like to go do this legislative stuff that's been important for our profession. And at the end of the day, I hope that they see the value and the worth. I think that they do in, in our conversations. And they're, they're here showing up every day, providing great care so that I can step away and do some of those things. My fear is that if we don't do some of those things, practices like mine will cease to exist. And that's important to me that, that, that doesn't happen.

Yeah, I, absolutely, I don't, I don't even think that's a strong opinion. I think that's a fact. If we don't do something, individual practices in 10, 20 years, time won't even exist. I mean, just look at the math. It all comes back to numbers. So it's, it's. Again, I think what's interesting too is that when, when I see people like you doing the right thing, despite the difficulty of doing it, I, I also can see from a distance how that actually grows your practice. I can only imagine what those team members think about you when you're out there fighting the fight the way that you're doing, like, for them to see you gone. Fighting is like when they're treating the patients at your company. They're like, well, I'm here doing this to do what's right for the patient. She's out there doing that to help us all. And that must create a culture. And I think the more you do that, the more you're going to draw these amazing people which will grow your practice and increase your profits, which, again, is the point of owning a business.

I said this once to a class of students, and the teacher pulled me aside to talk to me privately about her concerns. But I just said, hey, guys, I want you guys to make as much money as possible as a physical therapist. And they all just looked at me like I had just swore up and down. And I said, guys, I'm talking about ethically, but I am definitely talking about the importance of being a part of these things. So as I, you know, I'm with you and I hear what you're doing, I'm super inspired. You talked about support, like how your husband gave you support to do this. What does your movement in South Dakota need in terms of support? Like, you're, you're going to be the president of this thing if you could go into the brain of every physical therapist and PTA in the state of South Dakota and program them to act or do something. What would those actions look like?

Oh boy, that's a big question.

You know, I think the biggest thing is.

Uniting around what we all feel is right, but being open minded enough to, to realize that.

Some of the ways we've been doing it for a long time maybe aren't the right, I don't want to say the right ways, but you know, that, that the, the climate has changed and if we want to continue to exist and, and do what we love to do that brought us to this profession, like we have to get off our butts. We have to be willing to give of our time and of our money, which we all feel like we don't have enough of.

And, and really rally together and, and go fight this thing and, and, and not, I mean in South Dakota, but across the country. I mean this is a, it's a epidemic if you will, of, I mean like you say, it's a, it's a math problem and we are not winning the problem. And unless we get together and start shifting our mindset that it's okay to make money and that we're in this to make money and that we're good people that are going to do good things with the money we make and we're going to continue to grow and serve people the way we want to. That's, that's what it's all about.

You know, with our licensing stuff, there's a fee cap in our legislation that the licensing fees may go up to a certain amount and they're going to have to increase in order for us to successfully run our own board. But not outside of what other doctoring professionals in our state pay for a license on an annual basis or what other pts in surrounding states pay for their annual license.

And legislators and people are up and down and all over about this cap and whatever and what this fee might increase be. And I mean we're talking it's going to go from probably 50 bucks a year to renew to maybe 70 or 100 at most, right? The cap is 300. And I just looked at, I kind of broke down five minutes. It's like if you're willing, like if you're not willing to pay enough for your annual license more as much as you would pay for a Netflix subscription, then we have a problem. If you don't believe in what you do enough to, to pay $300 a year for your license to practice As a doctor of physical therapy. And what are we doing? Like, it's a mindset. It's a mindset issue.

Like, yeah, I love that. That was very articulate. I think if there's going to be a tagline if you're not willing to pay more than your Netflix account. I just thought that was brilliant. But it's true. And it's. So what's funny is that, like, we think about the problem of fighting for our profession and taking a stand for what we do as like this multi layered, complex thing. And I know this is an oversimplification of it, but there's only one outcome that changes all of this, right? And that's we get paid more for what we do. That's. That's it. Like, you know, we have a problem right now with PTs who've been making the same ranges for 30 years now. You know, they're coming out. Maybe not. Maybe 30 is a little bit generous. But I came out in 2002 and my starting salary was 65,000. That's not very different than what people are making now. And so 20 plus years later, the income that PTs are making is, is minimal. And, and inflation has occurred as, you know, and all these things. And the reimbursement has stayed the same. Or dropped. Yeah, and dropped. So like, for us, it's like, how can we ever make the impact on our patients unless we get paid more for what we do? And so thank you so much for sharing your story about how you guys were able to successfully do that. Do you have plans in the future for doing other things? Like, are there any specific, like, initiatives that you have underway with any. I don't know if you can even talk about it, but like, do you have anything in the future that you're working on?

Yeah, we have a couple things we have, you know, from the. Just our conversations with our state Medicaid, like I said, we've opened some conversations for direct access, which it's not going to be like an immediate thing, but I really see that as being something that continues to grow that partnership and prove our value as professionals and then thus continue to increase reimbursement. In our. Our director has, you know, said, I mean, I think. I think there's definitely still continued room for growth with that. So we're not done in our work there. The next one, you know, our state association, we're just really trying to sit down and we've got some new motivated people we're starting to recruit some younger people that are a little bit more tech savvy and motivated to get involved. And I think that that's really good. I think if we can start tapping into that younger generation of professional professionals and getting them involved, I think that we could really have a big win there in, in growing that. And we're looking at maybe implementing like, or creating an insurers forum. I think it's something we've done in South Dakota in years past. It's been quite a while. I know they've done this at like the national level. I kind of envisioned it at first as like more of a payer workshop where they come in and talk to us and we answer questions on like billing issues and whatever. But what we're really kind of evolving with is more of an actual.

Forum where we bring in payer representatives and we educate them. We educate them about the profession and things like that. And you know, I have some. A lot to learn and, you know, to work out with that. But I think that there could be some real value of doing that either within South Dakota or even regionally. So we're kind of looking at trying to do something along those lines.

Okay, well, it sounds like you're going to have a fun year as president. I am really going to be hoping and praying for you because I think that you in that role is going to be a powerful piece and I hope you get the support you need. You know, I do have a question for, for someone else in this meeting. I think that is going to be our guest speaker next month about how I don't, I don't want to like have him talk too much into what he's doing, but I am like legitimately looking for a way for us to connect these efforts. You know, this, this is a sounding board where we can do this. And for me, I. Let me, let me do this first. What would you say to a new physical therapist about what you would advice you'd give them to help them like join these efforts? Like, what would you tell them to do?

Me?

Yeah, sorry, you.

Oh, that's.

Yeah. Well, I'm going to go talk to a whole bunch of new physical therapists here in about a month. And.

I think it's just the power of getting involved. You know, again, like uniting.

Your approach and getting involved and the power of that. I mean, like I said, I haven't been that deeply involved for that long. And since we've been involved, the things we've gotten accomplished and then looking back and seeing the other people involved have gotten accomplished is great. And just getting involved, whether it's at your state association or like you say, in groups like this. And I think we need to do more of this as professionals, entrepreneurs. We all know that it's kind of where the light and the fire is. And just I, I wish, I think if I could get every PT student to think like an entrepreneur, even if they never want to become one, that could change.

The heart of what we do.

Well, I almost feel like we need to end right now on that. That was so articulate. You were so articulate. You're gonna be a great president. Hey, Seth. So, so Seth. Seth is our next, our guest speaker next month. So he's been a member of another group that's not APTA based. It's an independent group that he created with some others a number of decades ago now, right? Yes, yes, they are. They are independently just taking a stand with entrepreneurs in the state of Arkansas to make a big difference. Seth, I don't want to go too far into your. I actually don't want to get into your story because next month we're going to dive into it. I think we're going to end a little early here, but I do want to seed your discussion. What, like, do you. Is there a way that we can connect these efforts? Like, is there a possibility with like, what Kristen's doing? I mean, and she's in that formal group of the apta, like what you're doing in Arkansas in terms of its product, it's very comparable, right? Or am I missing something in that?

No, I would agree. It is very comparable. And one of the things that we've been able to do with rehabnet of Arkansas is to be leaders in the association. I'm the immediate past president of APTA Arkansas, and our current president is a RehabNet member and the president before me was a Rehab Net member. So we've been able to make some changes and do some things there that I think dovetail in very nicely. And if we can get the entrepreneurial mindset in a leadership position, I think, Christian, you'll be way down the road toward doing some good things.

I mean, I was intrigued that you're, you're potentially going to get your new board. I was actually a member of the examining committee when we were under the medical board back in the late 80s and was on the board when we were established as a new board in 91. And I would be more than happy to visit with you directly about some of the challenges and the, and the things that we dealt with back in the 1990s establishing a new Board, Independent board. And I'm excited for you.

Yeah, I would greatly appreciate that because we've all kind of said, okay, if this thing actually gets signed, what next? You know, what do we do next? So. And I know we have, we have processes in place and things like that, but I, Yeah, I would welcome that conversation. So thank you. Sure.

Yeah. I'm excited, Seth, for next month, when you talk about your organization because it's an independent group, you know, one thing I'm noticing too, and I don't know much about this, I'm embarrassed to say, but do a lot of state board presidents, American Physical Therapy association presidents, Are those usually entrepreneurs? I mean, I. Are those usually private practice owners that are stepping into leadership in that, or is that a mix?

Well, for, for Arkansas.

Thank you, Kelly.

The longest time the APTA was led by the university professors. That was the big part of that. So once, once Rehab Net got going, we have actually have changed that dramatically. But our APTA numbers are similar to South Dakotas as well. It just, it's. We're not, as a, as a collective group of professionals. We don't organize ourselves well enough and we don't pat ourselves on the back and scream from the rooftops how good we are with what we do and the differences that we can make in our community and, and in our state.

So the reason I said that was because, like, when Kristen and you guys were talking, I thought, man, that'd be so cool if we. To grow the movement in a more national way. Because there's, there's gold in these calls. There's gold when, when, when entrepreneur like Kristen talks about how she helped the, the state board or the state, excuse me, American Physical Therapy Association. I use those interchangeably. I know they're different. But like, when she was talking about how she fought, and then you'll talk next month about how your independent group fought. It's just like for me, it's, it's like, what if we invited all the presidents across the different states to meet? You would assume that there's some sort of meeting that they have on a regular basis with each other, but I'm willing to bet they don't. But even then again, I'm, I'm not saying I'm closed off to educators. Being in the group, I think they're incredibly valuable. I just don't experience the change coming from them. I think it's going to be the entrepreneurs like Chris and beautifully articulated. If every physical therapy student thought like an entrepreneur, regardless of opening a practice, everything would change. Yeah. And Kelly's been dropping value from a distance here. She's saying in her state they don't have entrepreneurs on that, on in that group and they are too removed from the reimbursement side. There's like this mindset with, with the educators typically. And I'm not trying to bag on them. I'm just saying, like the different in mindset is educators are usually saying things like your license is your livelihood and you know, don't get, don't go to jail there. You know, which is, which is really good advice, but it's not. We have so far gone down that road that our actions are fear based to a crippling degree. Our educators, they're really going to serve. People would say join the organizations that are making changes to promote physical therapy, like chiropractors and everyone else. They put money into their organizations. Kristin?

Yeah, the thing I think something I struggle with, I think there, it's like a.

We have to get educators involved because we need them.

Bought in and supporting this message.

How we do that, I'm not sure. But you're exactly right. They have no problem helping their students know what their value is on interviews and what we should be making. But yet we're teaching CMS billing as the bible and not anything else.

No cash pay, none of that stuff.

None of that. None. And nothing on marketing. How do we. Even if you're working within a system or within any like marketing or services, selling yourself and, and everybody, you know, I, I'm no different. Right. I was an entrepreneur's daughter. My parents, you know, were entrepreneurs. My sister was an entrepreneur. I went into the medical profession thinking I was different. You know, I'm not a salesperson and I don't sell. You know, my sister could sell boats. I don't sell. Yeah, I do. I sell every day. You sell to every single patient. You sell to higher staff. You were selling what we do. We're not selling a bad product. We're not, we're not like shady salesmen. But you have to be able to sell. And I don't think we teach that skill enough. I don't think we promote that skill enough. And that's why we suck at our PR and we just, we have to start if we want all the other stuff. It's like we want our cake and we want to eat it too. We want to be the nice guys that don't say anything. But we want all the money and all the good stuff that comes with it. You have to get off your butt and do Something. And you have to show people people aren't. People don't just intuitively know what we do. And I think that's been across the board as a practice owner, as a professional working in the legislature. Legislators don't know what we do. They don't know that. They don't know that we have a doctorate degree. They don't know that you can walk into my clinic and be treated, you know, with your insurance versus having to go see my doctor. And oh, I thought I only did that after a total knee or, you know, they don't know. People don't know. And if we don't tell them, what they're going to find out or know about us is not going to be what we want them to know.

So I love it. Well, I appreciate your time today, Kristen. That was incredibly valuable. I am really hoping you'll be able to attend the next meeting. I think we'll do it on a different night so that it's easier. But I, I just think it's one of those things where, like, I, this is the part of the discussion I really want to have. I don't know if it's as attractive to the general population of busy entrepreneurs who are struggling for to catch their breath from time to time. So super kudos to those of you who are here and those of you who are going to listen later. I just know that this is the thing. Like, I don't know, man, there's, there's so much potential. I honestly believe that we're waking up. I can feel it. Like as an industry, people like us are starting to talk. And it's not, it's not like I talk to people and they have no concept of this. Everyone I've ever talked to in entrepreneurial world, they know about it and they have their own opinions and they're strong. There's just no organization around it. And then like, you know, even the educator piece we just talked about, this new rising group of educators are different. They're, they are way more entrepreneurial. I know because I'm talking to their students all the time. I sat on the plane going to CSM two weeks ago next to the director of a PT school in Arizona, and she was incredibly entrepreneurial. So it's not all educators, but it's traditionally has been those that need better guidance to help them prepare this generation. And then I think on the entrepreneurial level, what we need to be busy in action doing is taking action. I, you know, when I first had my first call back in October, we had this Bra Raw meeting where everyone's like, it was kind of like the Graham Sessions. People were like, yeah, this is silly and we gotta change how we say discharge and all these things. And it was true. But then I got all these emails like, yeah, but are we gonna do something about this? And I'm like, that's a really good point. Like, I don't think we need the rah rah to educate. I think what we need is the organization to execute and that's what I am hoping we'll figure out. Again, I don't think I'm going to figure it out, but I have a strong feeling. Kristen and Seth with some other people, will and I think this could be an incredible opportunity for us to unite our efforts and make some lasting change. It'd be really cool. In my mind, the vision of this meeting would be to have thousands of entrepreneurs on call and one person saying, in my state, here's my problem, how do I fix it? And then people are just like, well, this is what I did and this is what you can do. And they get the support. But at some point it's gonna, it's gonna take some money. I don't know how that plays into it. But like right now people don't wanna give it to the APTA for a few reasons.

And anyway, that's a whole different discussion for another day. But Kristin, thank you so much for your time. Thank you all for attending tonight's call. What a wonderful meeting. We will do our meeting. I'll announce that early next week in terms of when the incredible Seth Coulter will be talking to us about this organization that he built as a legacy to help change. And it does all, every day, it's making change. And I was very privileged to go speak to that group last month. So I'm going to have. We'll talk, we'll continue this discussion that Kristen started so articulately with Seth. And then in May we have a wonderful speaker who is an OT who organized her own group with include lobbyists and all to stand for pt, OT and slp. And she has done some amazing work. And so yeah, thank you guys for being on the call. Chris and especially again want to give you a special thanks for reorganizing your night, your night to be with us tonight. And we'll see you guys next time.

Thank you, Will.