You're listening to the PT Pinecast,
where smart people in healthcare come to
make noise.
Here's your host, Jimmy McKay.
I'm pretty much just living live today
here at Graham Sessions,
the top APTA's headquarters,
live streaming during Graham Sessions.
And I'm telling people Graham Sessions is
this annual event called the Cool Kids
Lunch Table, super secret.
But you know all these people.
If you're rubbing elbows in the
profession,
you've
met or heard of or at least you
know know asymmetrically through linkedin
a lot of these people alex benderski but
i'm gonna show a bunch of times is
this your how many gram sessions my number
one is your first one it's my first
one i'm grand session virgin really this
is great we get purity uh so my
big picture question would be uh what is
something so far that's made you someone
who thinks writes talks acts in this
profession and we'll get to what you do
but what's something that
surprised you or excited you?
Let's go with positive first.
I think the panel sessions,
the panel structure is actually very good.
It's a good format to get different
voices.
Go topic-wise.
Anything that either is on the docket for
later today or tomorrow or already that's
made you go?
okay cool uh the the strength of numbers
talk is is definitely pertinent uh there's
a laws of scale that can't long lever
arm yeah the levers and the arms and
the leverage talking about i mean and
again the rule that the rule about gram
sessions is you can't say who said what
right let's talk about the idea and the
idea there is uh can you find ways
to connect with colleagues or other
businesses without
being bought formally, right?
And then how can you use those economies
of scale to get things that are better,
either better,
higher payment or lower cost?
I mean, think of the European Union,
right?
You retain your autonomy,
you retain your borders,
but you open them up so that you
can have a collective bargaining,
you can have collective currency,
like just use that as a narrative for
physical therapy practice.
So you keep your autonomy and agency,
but you are able to share some of
the risk, able to share your borders.
able to share some of their common
expenses.
So it's logical.
Certainly there's movement in the right
direction.
It's not the only organization that's
uniting.
Hopefully there's going to be more of a
grassroots movement around the country to
do this,
but
It's still a fractured ecosystem.
And so by majority,
we either lose private practices because
they sell or we lose them because they
close.
What is something, my second question,
what is something that isn't on the
docket?
You're the guy who reads the instructions,
is my guess on you.
What's something that you were reading and
going, why are we not talking about this?
I think the theme of diamonds under
pressure.
That's the theme this year, yeah.
I don't know if it's closely related to
the actual topics that are being
discussed.
I think it was just the theme, yeah.
It's a nice theme.
It sounds good.
It certainly gets a buy-in.
It's like, yeah, we're hurting.
Let's see how we can get better.
Teaching resilience is a skill.
I think to teach resilience,
you have to have topics that actually
empower you.
to withstand some of that stress under
pressure.
And if you're going to turn this coal
into a diamond, teach people how.
Don't give them ten thousand years until
they actually turn into that.
We forgot to add that.
It is pressure that turns coal into
diamonds.
It is also a long time.
Yeah, for sure.
It takes millennia.
And if you want to expedite the process,
you have to have an external source.
You have to have that pressure source from
somewhere else.
So, yeah.
If you were to talk next year,
what would you say this needs to be
on the docket, idea-wise?
No, that's a terrific question.
I think next year on the docket,
you need to have a greater voice of
other professions that are presented here.
You need digital health providers to be
present.
That's interesting.
Half of the economic equity in physical
therapy is digital health,
and they're not present.
PTAs need to be here.
PTAs are the troops on the ground.
They're the ones delivering care.
I don't see them represented in any
panels.
So if you're going to have someone
delivering care for you,
they should have voice.
Yeah, PTAs,
and I'm not the policy politics part of
PT.
I like the fact that some other people
do it,
but PTAs were just getting basic rights in
a PTA environment.
mean still working for basic for sure
right of course it was like why don't
the ptas show up i'm like would you
no exactly but how do you expect it
economically to give them a bigger burden
of delivery care process without giving
them representation and giving them voice
so i would love to see a broader
representation we can maintain this
exclusive pt only club yeah and still
expect equity yeah
uh what's something that not a lot of
people have on their bingo card right now
as we record in january that will become
a thing in the next twelve months like
something that people are not gonna see
we'll say most people aren't gonna see
coming in his issue there's a lot of
policy changes law
And maybe they're like, well,
I saw the law change,
but I haven't felt that yet.
What's something in the next twelve months
that people are sleeping on that they're
going to be affected by?
So not to be a bearer of bad
news,
but your bread and butter of outpatient
physical therapy business,
your post-operative cases are going to
start to disappear.
Why is that?
Your risk-based contracts,
your hospitals become stakeholders in your
risk.
And when the hospital is a stakeholder in
the risk,
they will retain most of their delivery
processes.
So your mom and pop shop that is
now taking care of your ACL high school
population,
which is great because it's like six
months of guaranteed utilization.
Once that disappears,
what are you going to do to occupy
your therapist time?
So be aware of these models that are
emerging.
These are tenure models.
And the reason why they're tenure models
is they're not expected to be fully live
until twenty, twenty seven, twenty,
twenty eight.
But they're here.
So your team, your access,
your wiser models, they're here.
They're a ten-year roadmap.
They have a runway.
And right now, you're just taking off.
So are you ready to deliver care?
Are you ready to collect outcomes?
Do you have the infrastructure?
Do you have the technology?
So yeah, I think that's... All right,
well, someone who's like, you said,
I hate to be the bearer of bad
news, but you were.
What should someone be doing, reading?
Where should they be skating to?
I think one positive effect of CMS is
there's full transparency about it.
Right, they put it in writing.
It's a lot of writing, but it's there.
It's a lot of writing,
but we live in a day and age
where you have Chet GPT.
Right, right, right, right.
Ask it to summarize it for you,
and you become an educated consumer.
I learned logical fallacies on the drive
down here.
I was like,
I know they were a thing,
but I'm like, teach this to me,
then give me an example,
then give me a multiple choice quiz.
And I learned it in two hours.
So it's democratization of information.
It's wild.
We are living in an age where knowledge
is democratized.
It's free, almost free.
you just have to be a smart consumer
so go to see a master website download
those documents and ask chad gpt to
summarize it for you step one step two
look into your existing infrastructure are
you ready to create a checklist create
like go through the same chad gpt
conversation and say what do i need to
do exactly what i run an outpatient
physical therapy practice in arkansas
what are my steps to participate in these
risk-based models?
Give me a checklist.
Now you are an educated consumer.
Now you're prepared.
And then start checking off those boxes.
The last part is really important too,
checking off the boxes.
Oh, for sure.
We always want the brochure.
Give me the checklist.
I now feel safe.
still need to act on it yeah i
need you we need you to act on
it you remember those days when dating was
a thing right i remember that like i've
been married for too long so my memory
is very faint but uh you if you
wanted uh somebody to respond to your
phone call you have to make a phone
call
um so you you have to be the
one taking the initiative and you have to
be prepared so if you're gonna want to
future proof yourself then start
acknowledging that where your shortcomings
are and protect yourself from them yeah uh
what do you think of the room uh
in terms of who's in it being this
your first uh gram sessions and it's hard
to see everybody right we're just seeing
people walk around um but there's business
There's academia.
There's small clinic owners.
There's large clinic owners.
There's product companies.
Who else?
You mentioned PTAs.
You mentioned digital health.
Who else needs to be in that room?
I mean, peers need to be here.
Why would they come?
We're assuming that peers is one
homogenous system.
It's a heterogeneous system.
There's parts of peer ecosystem,
there's parts of their ecology that is
interested in what we're doing.
Really?
They're just getting this information
through a secondary resources and tertiary
resources.
Why not be here?
Why not extend the invitation and see what
will come?
We don't extend the invitation.
That's what Lincoln would do.
We're looking at the Lincoln Monument over
there, right over the hill.
That's what Lincoln would do.
Extend the invitation.
There's no enemies here, right?
We're looking at the same picture from
different vantage points and expecting
different results.
It's not going to happen.
So, yeah, start the conversation.
Start the conversation that's not haggling
over prices,
because that's already step three.
You're haggling over prices,
but you haven't established ground truths.
Get them here to establish ground truths.
Get somebody who has knowledge of payer
sources.
Right now,
we're talking about payer sources from a
consumer side only.
So are you really getting an equal
representation here?
Yeah.
The thing that frustrated me sometimes
with people is we're very people-y.
My first Grime Sessions was ten years ago.
And then I went back a year.
So I did it in twenty sixteen,
twenty seventeen, or twenty seven,
twenty eighteen, whatever it was.
And the problem was we were talking about
the same thing the second time.
And I don't have patience.
You and I are right now in the
hallway while the talk is going on.
You and I are like, got it.
I'm going to be outside.
I need to walk around.
I need to touch some grass.
um why do we fail to do that
sometimes well jimmy i i've been a
physical therapist for i've been talking
about the value we've been talking about
identity this is not a new conversation
it's funny because i come in and i
go this is all so new and then
yeah three six nine years later i'm like
oh same thing yeah it's it it is
the same thing there's it's almost
ridiculous how reproducible this is and i
fully expect in twenty twenty six twenty
twenty seven uh nothing changes when
nothing changes so and and we're in that
same perpetual cycle of nothing changing
yeah so and then we have agents of
change so we have people calling for
change but just calling for change without
actually that's what it felt like it felt
like what do we want change when do
we want it now how will we get
it someone else or i already did my
part i said what should be changed but
people are people are out there in clinics
or satisfying right like you we want to
maximize because ideally we want it all
right but it's not a binary it's a
spectral
thing so you you have to satisfy so
you have to accept suboptimal change but
change is gonna come regardless whether
you want it or not you can just
drive the direction of change to a certain
degree yeah do you remember that simpsons
episode when uh homer or the mayor mayor
was running for re-election and he came in
the balcony and he said like all right
people of springfield uh abortions for all
and people were like boo and then he's
like all right people never mind them
abortions for none and they're like boo
abortions for some yeah everything's man
Yeah, it is, it is.
You just expect,
if you want to be the agent of
change,
you have to be the active ingredient.
You have to drive energy into it.
I've got a social experiment going on that
I thought would have some reaction,
and it turned out having no reaction.
I'll talk to you about it.
What I needed to do was go further
with this, and I will.
So I dropped this in a Facebook group
that, are you in Tony's Facebook group?
I'll get you in there.
It's meant to be a bunch of people
looking to create content,
alternative revenue streams for
practitioners.
What it's turned into,
a bunch of people trying to solve problems
different ways, which I like.
Tony Meritato,
my normal co-host on our livestream,
he tries to solve a thing a thousand
different ways tony tries to fail as fast
as possible which is good so i dropped
this little social experiment i'm calling
ninety nine problems pt edition and the
idea was um
We can't usually change the big thing
first, right?
Knock down a small domino,
it'll loop to a second, third,
then you get bigger.
So my thing was,
this came from an idea,
I saw a guy talking in his community
about medium problems.
Medium problems are,
first we need to describe large and small
problems.
Small problems are,
you come out of your house and someone
just left a bag of trash there.
I just throw it away.
I don't call the cops.
I'll solve it.
It's stupid.
It's rude, but I'll just solve it.
Big problems are someone drives a dumb
truck through City Hall.
That's big.
The town is going to take care of
that.
The medium-sized problems are like it's
too big for one person,
but not big enough to ever hit the
number one list on the town.
So he gave an example of how they
solved medium problems.
And he's like,
I'm giving you an example that you should
take to other places.
So the medium example was there were parts
of the city infrastructure like sidewalks
in neighborhoods that were just overgrown.
It's not really big enough.
It's not causing a fire.
It's not causing a flood.
So the town's not going to take care
of it.
But uncovering a sidewalk.
is like a pain in the ass for
one person.
So he's like,
we got a group of three people,
and the three people all brought a friend,
and now it's six.
And then we did it,
and while we were doing it,
we shot a video,
and then ten people were like,
where's your next one?
Next thing you know,
you've got thirty people.
So that was one problem.
So the idea is, you've now got experience,
you've got people who are like,
that wasn't that hard,
and there's more than one person,
and now you've got cred.
So this is one of the things he
was talking about,
the important aspects of what maybe talk
about this was now you're like,
we solve problems.
So the next time you go to solve
a problem, you're like,
I have a resume of problems solved.
I solved this little one,
then a bigger one, then a bigger one.
So I said,
could we take this to PT?
What are the ninety nine problems?
Let's rank them small to big.
And then who wants to help me help
me solve the smallest one?
And we don't move on until we solve
the smallest one.
And then.
We solved the next biggest one.
But along the way,
we picked up three or four more people
who were like, I'll solve that problem.
And now you've got a team who are
now skilled at problem solving.
They have a variety of skill sets and
experience.
The problem was, Alex,
I put this post in.
I said, help me figure out the problems.
Nobody suggested one problem.
So you have to remember,
there's a couple of...
problems with your problem.
Okay.
I can't figure out what it is because
I thought it was cool.
A problem with your problem is that
there's a selection bias.
People who will react to that post are
the people that are already problem
solvers.
You're probably right.
Yes, yes.
So you're not asking,
like the problem solvers are the ones that
will get a reaction out of it and
the ones that actually do need to be
the ones for solving problems are not the
ones that are reacting.
Yeah, I felt that trap.
right right so the second one is like
you're discussing thresholds right the
threshold for change there's a really good
book it's called cascades uh and the
gentleman is a journalist and a uh i
think political scientist but uh the point
is he looks into the these environmental
cascades that that are agents for change
so essentially it's not linear uh change
right and he talks about the eastern
europe when the soviet bloc fell through
and it didn't happen right away but
initially there was a little protest and
it was people who left then there was
a little bit bigger protest and then the
police instead of just letting people
protest started reacting which caused even
bigger changes so the cascade is that
non-linear amplification of a response
like a hockey stick until the certain and
the threshold is past a certain threshold
the cascade turns into change so what is
the better question would be here is what
is the threshold of stress on the system
for the change to occur.
When is our community going to be right
at that point?
We're going to be like, that's it.
We have to do something different.
We're not there yet.
Right now,
we're still talking about problems.
We're not talking about solutions because
we're not at that threshold of change.
It's not scary enough?
It's not pressing enough?
It could be scary,
but we're okay with scaries, right?
Scary is not actionable.
Actionable is when I actually don't have
Brad to feed my family.
Then it becomes actionable.
So when you,
there was scary that was actionable was in
two thousand two when Medicare came up
with a cap and fifty percent of physical
therapists lost their jobs.
All of a sudden that was scary because
you are not employable.
You have your student loans and you have
to pay for them.
That is actually actionable.
That's when change occurred.
If you look at the fundamental change in
our profession early two thousands was
good.
Like we made a lot of positive change
and then become complacent.
Right.
Then we have bread on the table.
Right.
I'm not hungry anymore.
So.
Oh, the line like,
hard times create hard men,
hard men create easy times,
easy times create easy men.
Now it's a cycle.
That fable, right?
Like it went to war, like came back.
There's an entire Chinese fable that goes
into that.
Like each step of the cycle,
there's a positive and a negative.
But yeah, we're not there yet.
So we're still just discussing this
change.
And we have been for years.
Yeah.
i foresee that the way the government is
looking at our utilization matrix is
they're going to try to cap our
environment and we have a potential of
becoming a very niche fringe industry
unless we change and part of it is
what we discussed about this risk-based
contracts but part of it is
just identifying that what you're doing is
not good enough yet like it's it's good
enough for you to satisfy the bare minimum
now yeah when that changes you're in
trouble unless you're prepared but the
threshold of failure is based on your
ability to handle the stress right like
your your business resilience is dependent
not on your execution right now it's
dependent on how tolerant are you to when
you fifty percent of your patient volume
disappears
can you still keep the doors open right
or if the peers are going to turn
away and say that you know we're just
going to discount you another fifty
percent and you're accepting these
payments can you maintain that well and i
think you can still operationalize it but
are you ready i do you have these
uh contingency plans and you're and you're
prepared to until you're not and then you
might not know what that point is but
you'll know it when you get there the
known unknowns and the unknown yeah like
yeah so these are known unknowns but you
have to protect yourself from unknown
unknowns you have to have enough of a
buffer
That allows you to be more resilient to
these changes.
Yeah.
All right.
We're doing quick live streams.
And every episode we have,
we do something called the parting shot.
This is the parting shot.
One last mic drop moment.
No pressure.
Just your legacy on the line.
All right.
Parting shot.
What do you want to leave with people?
What's what's either words of scary or
words of encouragement?
Which way are we going to go?
Oh, this is a huge opportunity.
It has been a huge opportunity.
I think now we just have to seize
that opportunity.
We have a chance that there's still
probably fifty percent of the market has
not been captured by anyone.
Digital health providers came in and
captured some parts of that market and now
they have billion dollar valuation.
and that's not even half of the market
that's available if you look at the
overall economic cost of musculoskeletal
problems in a society it's a trillion
dollar venture and we're capturing sixty
five billion of it right uh so so
the people who risk or the people who
do the work who follow the last step
give me the help me understand give me
the checklist and follow the checklist
will be the people who people there were
the people are going to capture the other
one billion dollars or one trillion
dollars
wow that is like it's it's just an
immense financial and economic opportunity
for those that are prepared yeah all right
alex live from uh graham sessions
appreciate your time thanks for doing this
on your very first graham sessions amen
thanks for being
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And legally, none of this was advice.
It's for entertainment purposes only.
Bullshit!
See, Keith?
We read the script.
Happy now?