You're listening to the PT Pinecast,
where smart people in healthcare come to
make noise.
Here's your host, Jimmy McKay.
All right.
What happens when someone spends an entire
career refusing to wait for someone else
to fix the problem?
It's probably a good thing.
When reimbursement drops,
when regulations pile up,
when every year it feels like physical
therapy is just asked to do more for
less.
Some clinicians complain about the system
a lot.
Others start working to change it,
and it's not easy.
But today's guest has spent more than
three decades treating patients,
building a private practice,
raising a family,
and quietly working behind the scenes to
reshape how physical therapy is recognized
and paid for.
From pushing for a primary care
designation for PT to advancing fair copay
legislation to expanding the Utah Practice
Act.
He's part of a group of clinicians who
decided to do something radical.
Stop waiting for change and start fixing
the profession where they are.
Oh,
and when he's not doing any of that,
he's probably bass fishing with the boys.
Today on the show,
we're joined by Howard Quackenbush.
Howard, welcome to the show.
Hey, thank you, Jimmy.
It's a pleasure to be with you.
excited you i like people uh who just
say well if no one's gonna fix it
i'm just gonna do it myself it's never
glamorous it's never ever i can imagine
easy uh it's never quick nothing good
usually is but i would i would assume
someone like you would say doing it is
worth it well you know like you said
um
It's always a challenge.
You know,
I've been doing this since nineteen ninety
four when I graduated from Wash U and
as an athletic trainer before and even as
an athletic trainer, the student,
you know, everybody is like, well,
let's ponder this.
Let's think about this.
Let's see if the National Association is
going to do.
And then we got in,
we have physical therapy and I've,
you know,
I built a practice and finally said I
want to get involved.
I got involved with the APTA Utah.
and in some, you know, minor little roles.
And then they put me in as chief
delegate.
And then once I got out there with
National APTA,
I realized that they're trying awful hard,
but they're doing a lot of policy stuff.
And it's like,
this is not working for us.
It's like, you know,
we have a lot of concerns.
We want to say we want to mandate
APTA to do this.
APTA doesn't have the ability to do a
lot of things.
They're a policymaking position.
They represent us.
They're fabulous in that.
But we got to do it ourselves.
Right.
They're good at what they're good at.
But you can't be, I mean,
I haven't figured it out yet,
how to be good at all the things.
Even if you just looked at how APTA
is structured.
And again, I don't work for APTA,
but I'm a member of APTA.
APTA is a national organization.
It's also a local organization times fifty
one state chapters.
I want to make sure people from D.C.
don't throw stones at me.
I'm not from D.C.
But if you want things changed because we
live in this country where things are
different,
as soon as you cross sort of an
imaginary line from one state to another,
you have to understand what the
differences are,
where you live and where you practice.
And that's step one.
Step two,
if there's something you don't like about
it, Howard would probably say this.
I agree.
Nobody's coming to look around.
If nobody's working on that problem,
guess what?
You just nominated yourself to be part of
the team to work on that problem.
Quick little story, my Fillmore,
Utah clinic,
a physician and I own the building
together.
And so he has his physician's practice,
it's Revere Health on one half,
we have physical therapy on the other.
One day his secretary came up to me
just mad, said, you know,
the cleaning person is not cleaning the
toilets well enough.
And I said, fine, go do it.
If you don't like it, go fix it.
Oh, she got mad.
She marched off to Dr. Groves and says,
Howard,
I told him the toilets were getting
cleaned well enough.
And Dr. Groves laughs.
He says,
I know exactly what he told you.
He says, what did he tell me?
He told you to go do it yourself.
And she just got mad.
She quit.
She quit like three days later.
But ultimately, that's what has to happen.
If you don't like your situation
personally, you do something else.
If you don't like that the bass fish
aren't biting a jerkbait,
you go to a tube.
You gotta change something.
And if you wait for somebody else to
do it,
somebody probably will sooner or later.
But if you really wanna do it,
you gotta step up and do it yourself.
And I'd say there's a problem with that
too,
which is if you wait for someone else
to do it,
they might not do it exactly how you
think it should be done.
If it's somebody else from a different
profession,
they're never going to do it with as
much enthusiasm,
with as much inside knowledge,
as fast as you probably think.
I mean, I'm sorry to tell you,
but if the bass aren't biting,
you got to change the bait.
You could scream at the bass all you
want.
Right?
It's so true.
Yeah.
So you've been working on getting PT
designated as primary care providers in
Utah.
When most PTs hear that phrase,
they're probably not really sure what that
means.
So let's walk through it real slow and
real clear.
What does it mean?
What does primary care providers mean?
pts primary care providers mean and then
what changes when that happens okay so
before we get into what primary care
really means we've got to you know clarify
what direct access is okay good because i
think sometimes we conflate those two
things yeah
I agree a hundred percent.
So again,
back in my student days and I was
in St.
Louis out there at Wash U and this,
the Missouri rule was I could not even
talk to a person at the grocery store
about physical therapy without having a
doctor script in my hand telling me that
I could do ultrasound massage and heat.
You know,
you couldn't even speak to someone about
it.
Couldn't you speak to them?
No,
it was illegal to even talk to them
about physical therapy without a physician
script.
And so over the years,
each state got some sort of considered
direct access, which basically just said,
yes, you're a physical therapist,
you have a professional degree,
you have a skill, yes,
you can talk to them and they can
come talk to you also.
And so everybody kind of termed that, oh,
we have direct access to the patient and
then the insurance company is going to pay
us because they come and get there.
But we all did the same song and
dance of, yeah,
you can come and see me directly,
but check with your insurance to see if
you need a physician's description.
And so it may be termed direct access,
but we have a barrier in place and
it was insurers.
Yeah, it was directly indirect.
Yeah.
Yeah,
directly indirect is a great way to put
it.
And so as we pondered this,
and now every state in the nation has
some form of direct access,
and a lot of people think, well,
we've arrived,
but then we're still not getting paid,
we're still struggling with insurers,
we have regulations, overburden,
we're bitching and moaning about all this
stuff,
and we really gotta step up
and say okay what do we do and
so we did in utah um and it
was fascinating because it was our
executive director her name is katie
manziel she's not a clinician but she is
fabulous and she just said you know what
what if we
you know,
got everybody together and brainstormed
about this.
And so we called up the six biggest
private practice groups in the state that
are all competitors.
They each were, you know,
turf battling and everything else.
We said, okay, guys,
come to a meeting sponsored by APTA Utah.
And let's talk about what we could do
to try to promote physical therapy.
We got everybody in the same room.
And as you'd expect,
it was pleasantly formal.
You know, hey, how you doing?
I'm going to sit on my side with
my guy.
You sit on the side with your guy.
And we got talking.
It became pretty clear pretty fast that we
all had the same concerns.
Why can't we get the patients to come
and see us?
And why do we have this barrier with
physical therapy?
the insurance companies.
And so we said, okay,
what would it take for us to be
considered primary care?
And in Utah,
we got digging around and we found that
the primary care designation was not in
practice acts,
was not in the medical code.
It was actually in the insurance code.
And so we looked and said, okay,
how's it termed?
They said,
primary care is considered physician,
nurse practitioner, dentist, and DOs.
And we said,
what if we ran a legislation that says,
and PT?
And so we said, let's try it.
And we said, okay, if we do this,
talk to our,
every component and association has a
lobbyist, talk to our lobbyist.
And he said,
it might take you three years to push
something like that through.
We said, well, let's try.
So we called up all the lobbyists.
private practices that, okay,
ask each one of your people to donate
one hour's worth of their pay to a
lobbying thing.
So whatever your salary is,
whatever you make per hour,
donate one hour.
And we actually had a great response.
We raised some basic funds.
We said, I default this legislation.
Next thing we said was,
let's just see how it goes.
We put it out there and immediately the
Utah Medical Association lost their minds
and the insurers went,
what are you all trying to do?
We thought, let's keep trying.
And so we started,
we picked a senator to sponsor the bill
for us and we floated it.
And then, you know,
we were learning as we went,
it went to the Senate committee.
So immediately we identified all the
Senate committee members and we just
reached out to, again,
all the private practice people said,
here's the list of the senators who are
on this committee.
Which one of you do you know?
Who knows who?
And it was amazing.
Every single one of those senators had
their PT,
had their their guy or their gal.
And so we reached out and said, hey,
reach out and, you know, and see how,
you know,
what their their aspect of how they feel
and tell them physical therapy is.
saves the system money.
Direct, you know,
direct access is a wonderful thing,
but we have barriers that can increase
patient access to care.
And then we can get the patients better
without opioids,
without unnecessary diagnostics.
If they do,
we're trained in triage and screening.
If they do have stuff that's not in
the physical therapy scope of practice,
we'll send them on to the appropriate
person,
just like any other primary care
know provider does and that was their
concerns they a lot of the concerns came
back for well the medical association got
up and said if they do this what
if they miss cancer you know what if
the person's having a stroke it's like
we've had direct access we've been doing
it forever and and we're we're perfectly
trained and capable and most of us have
you know look at our syllabus we've got
that covered don't worry about that good
we got it
yeah we got it and so we got
started going through and so they started
the uh medical association sure started
coming out hard but we went to the
first committee meeting and uh in that
committee meeting um they the senator
proposed the bill um i uh my colleague
chad tenney
physical therapist, he got up there.
He did a beautiful job.
He said, look,
physical therapy is this bike lane on the
highway of healthcare.
We're staying in our bike lane.
We don't want to be physicians.
We are smart enough.
We could be if we wanted to.
We didn't want to do the on-call stuff
in the hospital.
He was great.
He just said, we're going to stay here.
We know what our role is,
but we want to have patient access for
that role.
And they liked it.
And they asked for public comments.
So I got to speak and I kind
of followed suit, you know,
explaining the cost savings and the
importance.
And then the insurers and everybody else
came through, you know,
telling us why the sky will fall,
cats will start living with dogs if,
you know, this happens, you know.
Slippery slope.
It's going to be awful.
And the comments from the senators were
amazing.
They say, well, we understand this.
And I have to ask this question because
one of my donors is asking this.
And then they'd all finish up with,
but my physical therapist takes care of my
family.
And my physical therapist did.
We passed that Senate committee with one
hundred percent unanimous support.
Wow.
Went back to the Senate floor and got
a hundred percent vote there also in the
positive.
So then it goes to the House and
we did the same thing with the House
committee.
We had therapists for every House member
and they had the exact same thing.
We passed the House committee at a hundred
percent and then we didn't pass the House
Senate with a hundred percent.
We only had one nay vote because they
were, you know,
they were just being obstinate.
And so, so then it'd be,
so we came primary care.
Then everybody said, who cares?
You know, you have it, big deal.
And that's,
in some ways it's kind of true,
but what it did was it started our
ball rolling.
So now we, with this past year,
we are promoting the aspect that we're
primary care.
So now we can see the patient directly.
We can become referral sources, Utah.
And I got more,
I got some news as of yesterday for
you.
It's hot off the press for you.
But we could do x-ray and MRI in
Utah.
We could do several other things.
So now we can actually go to the
x-ray facilities.
You can accept our referrals because we're
primary care.
We can receive our patients because we're
primary care.
We can do this.
So over the past year,
Since we had the project, we said,
what's the next step?
And the next step, we decided to, well,
we had two things going on.
The Occupational Professional Licensure
Review Board,
it was our ten-year annual review.
And so they were working on that last
year.
And they came up and said, well,
we want to expand the practice act for
physical therapy to give them all imaging
abilities.
We want to clarify dry needling.
We want to change the supervision
requirements.
They gave us this whole laundry list of
stuff, offered laboratory tests.
And all the stuff that would fit our
primary care designation was good timing
because we were primary care designated
when the OPLA review came along.
And so they said, oh,
since you're primary care,
you should be able to do these other
services because you're trained in them in
school.
You have the education.
Let's allow you to do that.
As you'd imagine,
then it goes back to the legislative
process.
So that's the first bill.
The second bill we said, well,
let's go after fair co-pays.
If we're primary care,
we should have a primary care co-pay.
In Utah,
most of the commercial insurers co-pay is
twenty five bucks right now.
Physical therapy is ranging anywhere
between fifty.
I have one company that's ninety five
bucks for a co-pay on a plan.
Patients aren't going to complete them.
First of all, they're not going to come.
If they do,
they're not going to complete their course
of care.
And if I had the choice of go
to my doctor and get a pill or
go to physical therapy,
pay more and have to do exercise and
do things and maybe get better.
What's my first choice going to be?
I'm going to get the pill.
And we're sitting there whining about,
you know,
the opioid epidemic or medical
complications from, you know,
medication complications.
We have all those issues.
So we said,
let's run a fair co-pay spell.
So we started doing that one and just
the same thing.
The Opler bill was done by the state
and we expected that one to go through.
The only thing we lost in that one
was laboratory tests.
And here's my pushback on our own
profession.
Most of the time,
we're our own worst enemies.
The senator that was sponsoring the Opler
bill, Senator Evan Vickers,
he's actually my senator from Cedar City,
Utah,
he went to several of his physical
therapists in the area and said,
here's Opler,
here's what they're suggesting,
what do you guys say?
And we had all,
we had several therapists tell him, oh,
we'd never need laboratory tests.
but they're in the outpatient clinic.
Well, what about our acute care?
What about our nursing facilities?
What about our primary care?
If we really are gonna do Instacare
physical therapy stuff,
why wouldn't we wanna know if it's a
UTI versus confusion versus dizziness?
Why couldn't we?
Anyway,
so they ended up pulling it out because
the therapist said, oh,
we'd never use it without thinking.
Pelvic health is a big issue,
big area in physical therapy.
I am never going to do that.
I'm an old dude,
I don't want to do that.
But I'm not going to go tell the
Senator, we don't need,
we don't public health because I'm never
going to do it.
You speak on behalf of the profession and
one of our strengths and one of our
weaknesses is we are wide.
We do everywhere.
There is a large spectrum.
Yeah.
So anyway, so long story short,
that one got pulled out.
So we went on to the legislative thing.
The Offler bill, you know,
kind of went up and down,
struggled through.
They actually had more.
They bumped us in with nurse
practitioners, PAs, occupational therapy,
athletic trainers.
And so we were under the radar.
Our stuff all went through.
But the fair co-pays was a battle.
I bet.
The money comes out, the claws come out.
Oh, and again,
the medical association started out with –
I got to be the point this time
on the committees.
We did the same thing.
We knew which committee we were going to
be in.
And fortunately, we were in this initial,
the Senate committee,
we were in the same one as we
were last year with primary care.
And so we already had the therapist,
everybody identified.
So we went into that one and the
Utah Medical Association president got up
and just got mad at me after I
presented.
And she said,
you should know orthopedic surgeons are
primary care and they do physical therapy
in their offices all the time.
And sadly, I was disrespectful.
I laughed.
I said, first of all,
they're not going to want my little CPT
code when they do a surgical code.
And no, they are not primary care.
They're specialists.
And thirdly,
they don't do physical therapy in their
offices.
They may have some ancillary.
There might be a couple that have some
incident two stuff, but no,
they don't do that.
And so she got mad and she left.
insurance companies came up and were like,
oh, again, the sky will fall.
It'll be awful.
Everybody's costs will go up.
And I just answered and said,
when was the last time your annual
premiums went down?
No answer.
And so we got through that one because
we did it.
So then we went to the Senate floor,
and our Senator Mike McKell was fabulous.
He pushed it through the Senate floor for
us.
There were a few more nay votes because
the insurance is the second largest lobby
in Utah behind the utilities.
And of course they spend an awful lot
of time and effort in the summer for
campaign donations and things to have
influence.
So it wasn't unexpected.
We got through the summer,
went to the house and
we ended up,
the insurance company got ahead of us,
and so we were able to get in
a different committee from the year
before,
and we were able to identify a lot
of the, again,
therapists for their representatives,
and they all had the same response, like,
oh, I love my therapist, they do this,
and the best part was it was on
a Friday afternoon, we only have,
tomorrow's the last day of the legislative
session, and this was last Friday,
and it was Friday afternoon at
five-thirty, they were done,
they'd already had a heated battle about
immigration and different things in the
discussions, so they were tired,
and the committee chairman was not having
it.
He let us present, let me speak,
and then he just kept going, okay,
we're done, we're done, we're done.
They voted,
we got out of committee with a vote
of six to one, which was favorable,
and then we went to the House floor,
but our lobbyists and our House sponsor
the folks that don't make this committee a
representation of what you think the house
is gonna be.
So you're in for a battle,
because the insurance companies are not
wanting to change this,
because they think if you change physical
therapy's co-pay to primary care,
Every specialty is gonna wanna do it.
And we said, we're not a specialty.
We are primary care in Utah,
and we are a first line of access.
Even though we have specialty training
inside of physical therapy,
the physical therapy umbrella coming out
of school is really quite generalist.
And so that argument worked really pretty
well.
We got to the main house and our
people went to work.
We had got the grassroots campaigns
rolling and we passed sixty to nine on
the House floor.
And so as of yesterday morning,
about ten o'clock,
Utah now has primary care co-pays to go
into effect January first to twenty seven.
So there was a set.
So we start with primary care.
primary care co-pays, we have access,
now we've reduced the barrier for patients
to get to physical therapy.
And then insurance, in the back rooms,
we were having discussions with the
insurance companies in the back rooms
anyway, and they all said,
physical therapy saves us a ton of money.
We know it's a great thing.
They're just worried about,
where it will go,
what everybody else is going to do.
It's the same thing.
It's a business thing for them.
It always is, right?
It always is.
And I don't fault them one bit for
bad one.
They should.
That's what they should do.
Yeah, sure.
Yeah.
but we're gonna save them money.
And so it went through, that's our steps.
And now we're looking,
where's the next step?
The next step is now gonna be, oh,
part of the deal we made with the
insurance companies to let this go through
was they're gonna let us visit with the
insurance plans purchasers about the
importance of physical therapy and how we
can save their company's money by getting
physical therapy first.
And so it's this snowball.
And so primary care, eh,
it's a little bit better than direct
access.
Primary care plus co-pays,
quite a bit better than that.
Primary care plus co-pays plus access to
insurance buyers.
Then the buyers of the plans will say,
no,
I want better payment for physical
therapy, so my people will go there.
WCF,
it used to be known as the Workers'
Compensation Fund of Utah.
They changed it to WCF because they now
insure more than just workers' comp.
Love this.
They came to us earlier this year and
said, bill us directly.
You don't have to go through anybody,
and we're going to pay a better rate
because we're saving some of the
administration.
Circular thing, going to the doctor,
so rates are improving.
This tide will lift all boats.
And now the big goal,
and I've mentioned this before,
if we can get...
Twenty-six states that have some sort of
primary care,
and then we're the fifth state for
co-pays, fair co-pays.
If we can get twenty-six of everybody
where we're the majority,
now APTA has a talking point with the
feds of let's change the federal stuff.
Because now you have more than half the
country.
Yeah,
you got half the country and we're a
republic.
And so let's – we have the majority.
Let's go that way.
Until then, it's just like, hey,
give us more money.
Like, oh, we can't.
It's the budget.
We've got to spend it here.
We've got to spend it there.
We can start changing fee schedules.
This is not my area, policy.
So I was trying to keep notes because
you just told a story that started with
an awkward meeting.
of a bunch of people who were aligned
against each other.
Once they got in the room,
they realized they pulled a page out of
The Art of War, Sun Tzu.
The enemy of my enemy is my friend.
Like, well, hang on a second.
We're actually not enemies here.
We have a common enemy.
It's the opposite of that.
So being in the room with the five
families, right,
to go to the gangster meeting,
let's get the five families together and
figure out what are we actually,
what is limiting us?
Is it each other or is it something
else?
This is also a masterstroke that I
highlighted and wanted to say again.
You didn't ask for a hundred dollars.
You didn't ask for a thousand dollars.
You didn't ask for a business to give
ten thousand dollars.
You put it...
This is very subtle but very powerful.
You asked for something...
that everybody could picture,
I would be willing to do that for
this.
If you had said,
everybody should give a hundred dollars,
I can picture a hundred dollars coming out
of my pocket, that doesn't feel good.
You didn't say that.
You said, what if tomorrow,
one of the eight hours you work tomorrow,
you worked not for free,
but you donated that hour of time
To this cause,
you don't have to do the work.
Your work is doing one hour and donating
that money that you'd earned for the hour
to this cause.
I'm Howard.
We got people.
We're going to go do the work,
but we need you.
One hour, one hour, one hour, one hour.
And an hour is different for everybody,
but it evens us up.
Now I feel like I'm, hey, listen,
I don't make as much money as that
guy over there,
but I'm still having proportionately the
same skin in the game.
The person who makes more, I get it.
But the rising tide, as you said,
lifts all boats.
You then highlighted,
you paid attention to the people you were
talking to,
which as a communications person,
you know your audience.
Step one, know who you're talking to,
know what they value,
know where they live, what food they eat,
what they like.
And you did one step further.
You found out they all had a PT.
Now we're not talking to an audience who
doesn't know any.
You all have your own.
Can you picture what would happen if your
PT... And that is not small.
That is powerful.
All these things are lining up.
This is not an accident.
You don't knock the big domino down unless
you knock the small domino,
the medium domino, the next big domino.
And then you went small to big.
You did exactly that.
If you had gone for the grand slam,
you're going to miss.
But it sounds like you guys looked and
you're like, how do we hit...
How do we draw a walk today?
How do we hit a double tomorrow?
Could we hit three doubles?
Three doubles scores two runs.
That's not bad.
I'll take that.
So it sounds like this is the blueprint,
right?
I mean, you said five states, right?
We want to learn from each other.
So is Howard,
are you doing a road show now?
What's Howard,
are you traveling from state to state and
going, I'll show you how to do it?
Or what happens next?
Well,
the first thing is the idea of the
dollar per hour.
Brilliant idea.
Was Brad Powell's idea,
Foundation for Physical Therapy.
Beautiful.
And then-
I've merged my Delta Fillmore Physical
Therapy with Mountainlands Physical
Therapy,
and they have clinics in Idaho and
Montana.
So our goal is we're going there.
And guess who?
Montana doesn't have a legislative session
this year, but Idaho does.
And guess who's introduced House Bill?
I think it's a five forty seven is
primary care access for physical
therapists in Idaho.
Here we go.
And then I've known that Arizona is kind
of looking at things.
Colorado is pondering it.
Maine is pondering it.
When we go to the primary care SIG,
I decided to go to that just for
fun.
And it was amazing because it's federal.
The feds have had primary care forever.
Just for the audience,
explain what the primary care SIG and
where it is.
It's under the federal section of APTA?
Yeah.
federal section of APTA,
and it was new to me.
But they've had primary care,
so they kind of just had a little
roadshow clinic.
It'll be in Utah this coming fall in
September.
We've offered to do it here,
so it's going to be here.
Yeah, great bunch.
And in pretty low key,
but it was interesting that a lot of
federal people are trying to give
education on primary care issues or what
you do and things.
But once we were all in the same
room, everybody's like,
what are you doing?
How did you do it?
You're Utah.
How did you pull this off?
It wasn't the information.
It quite literally is an information
transmission problem.
It was like, hey, we figured it out.
But unless you make it clear, consistent,
and concise,
someone who could benefit from that
information in Maine might never know it
exists.
Yeah.
And of course,
every state's going to be a little
different.
Our primary care just happened to be in
the assurance code and Idaho's is really
similar.
So that's going to be pretty easy for
us to dovetail with that.
Other states,
it'll be a much heavier lift.
They're all different.
Right, right, right.
But we just got to identify where is
it?
And once you know where it is,
then you make a plan, you know, and,
and what was fascinating going back to our
first story,
we pulled the five different clinics into
the room.
It was,
Yesterday's, you know,
texting list of all of us, you know,
it was high five and all around.
All these competitors are like, you know,
they're still working, but we realized,
oh,
there's so much more than our clinicians.
There's more therapy than any of us can
do.
It brought us all together.
And not only that,
each clinician or each CEO or president
or, you know,
whatever their title is in each company
brought a skillset.
Mine just happens to be,
I'm pretty good with legislative stuff.
Brad Pals was pretty good at fundraising.
Rick Libert was really good at bringing
numbers of people to go after legislators.
Everybody brought a skillset and it'd be
tough to replicate,
but I'm sure everybody can.
You just gotta look.
And once we brought those skillsets
together,
I just happened to go along for the
ride and it was a hoot.
I mean, the answer is always people.
We started this by saying,
if you're waiting for someone else to
solve your problem,
you're going to wait a long time,
and the solution might not...
That toilet might not be cleaned as well
as you want.
So it's solved,
but it's not solved as well as I
want.
The answer is always people.
And...
The goal is to find the right people
who can bring their natural skill and
help.
In isolation,
one of you wouldn't have gotten this done
because you would have not had...
It's like the A-team, right?
You needed somebody with a little bit of
this, a little bit of that,
a little bit of this.
It's Ocean's Eleven.
You needed this kind of person who's good
at that or else everything else doesn't
work.
It's very simple to say.
It's not easy,
but as Hannibal used to say,
I love it when a plan comes together.
So what advice would you give to another
chapter who's sitting there listening
going, whew,
sounded like a long walk there.
What's their first tactical thing that
you'd have?
If someone's sitting there listening in
APTA,
Kentucky or New York or New Hampshire or
Idaho or North Dakota, what's step one?
Because if we give them fifty steps,
it's too much overload.
Right.
It's why we give patients like two or
three exercises.
What's step one?
What would you have them do?
My first step,
and I've neglected to probably give a big
shout out to Justin Carrier,
who's our president of APTA Utah right
now,
because he's an educator in the physical
therapy assistant program at Slick.
Somebody had to say,
let's just do this.
Someone just has to have the idea.
And then people will coalesce around that.
It was the private practice people that
really pushed it.
When we tried to pull bigger hospital
system therapy groups,
they didn't want to because they have
legislative challenges.
So the first step
I really think is for the state
associations to say, we want to do this.
Now, in Utah, we're pretty good.
We've got a fairly high percentage of
members.
A lot of states,
they struggle with membership.
Idaho really struggles with membership.
But the first thing is,
you've got to have something that people
want to go to.
And if the association says,
we're going to be the voice,
and we're going to represent all
therapists,
whether you're a member of the association
or not,
and we're going to go do this,
come jump on my energy bus,
come get with me.
Um, they're going to do that.
So it's really going to have to be
the, the association just saying,
we want to do this.
This is the target.
Yep.
And as soon as you have a goal,
um,
so I don't know if you've seen this
or not, uh, for the fans out there,
there's a YouTube video from years ago
called the Sasquatch music festival
dancing guy.
I will be Googling that soon,
but keep going.
It is awesome.
So this, you know,
this is Hillside and there's open music
festival.
Oh, yes.
I know this one.
Yes.
And then one person joins him and two
people join him.
The next thing else, everybody's going,
you know, that's what you got.
You've got to not be scared as an
association to be the dancing guy.
To be the first dancing guy.
And don't worry if everybody thinks you're
stupid.
And don't worry if everybody's making fun
of you because it was fascinating to watch
that music festival.
There'd be a couple of girls that kind
of on the side,
I want to be part of this,
but I'm not so sure.
You know,
then as soon as a couple got in,
more people got in.
And that's what we found.
Last year with primary care,
We were begging,
please call your representative.
You know, we've got these things.
Everybody's got it.
Please, please, please.
This year it was like, hey,
so we did last year.
We're going to knock this out.
If we had more.
Okay.
And whatever we choose to do next year,
we're hoping we'll have even more.
Because you have social,
you have public social proof.
this is why on Amazon there's a star
system that shows you how many times it's
been bought in the last month we are
big dumb animals in a good way we're
sort of predictable I know we're all
individual snowflakes we're all different
but there's an operating system that says
I don't want to be an outcast from
the group that guy's doing something weird
but if I watch three people do it
I want to do it and next thing
you know fifty people are doing it and
it's a movement it starts I mean as
Linkin Park would say it starts with one
And, you know,
so we thought maybe if Utah did this,
you know, we're going to dance it.
And we got, it was so funny.
We went out to House of Delegates.
I'm the chief delegate for Utah.
And we got, what are you all doing?
Oh,
I was more than happy to stand in
there and tell, you know, Speaker McGee.
In Utah, we did this.
In Utah.
And finally, he got fed up with it.
He goes,
thank you for your shameless plug, Utah.
Yeah.
And then all of a sudden,
people are like, well, how are you doing?
So we've got Idaho trying,
we've got others trying.
And of course, with the Fair Copays,
we're the fifth.
We kind of did the same thing.
Hey, Virginia, Dakotas, they did it.
How about, we can do that too.
Well, it starts to become a reality,
right?
It's the Roger Bannister story.
The four-minute mile was impossible to
break.
Roger Bannister breaks the four-minute
mile.
And I forget what the statistic was,
but within a year of Roger Bannister
breaking the four-minute mile,
I don't know what it was,
ten or fifteen other people broke it.
Suddenly, it wasn't impossible.
It's probable.
Wow, I guess we can.
Okay.
There was one example I saw recently.
it was a track and field competition and
like crazy numbers of PRs and records were
set and they couldn't figure out why it
was.
I think it was even an indoor match.
They're like, wind is out of the equation.
The clock was wrong.
They thought they were running slower due
to this.
The clock was telling them your split is
slower.
So everyone ran faster.
Cause they're like,
I'm behind what I normally am.
And then when they did the math at
the end, they were like, Oh no,
you were crazy fast.
Yeah.
So it's sort of like when I want
to make sure I'm on time,
I set my clock ahead.
So when you do it, you know,
it doesn't work without knowing it worked.
Yeah.
So that's what we need.
We need social proof.
We're big, dumb animals.
But if we know how our operating systems
work.
You have five dominoes that have fallen.
Well, that's not fifty, but it's not zero.
And if three more happen in the next
year,
it's like now we're now we're eight and
eight's pretty heavy and eight goes to
twelve and twelve's half.
You know,
it's a quarter of the country now.
I like how that feels now.
I don't mind jumping in and being a
Sasquatch and just dancing on the
hillside.
Yeah.
My thought, too, is here next month,
I'm going to go out to the day
on the hill.
I'm going to be there.
I think I'm going to be there in
April.
Let's hang.
All right.
But because, yeah,
the national stuff is a really heavy lift.
We're getting it on the state side.
But if we are priming this over here,
once we get there,
we might as well start trying to rock
that domino while we're getting all the
momentum coming.
Right.
It's inertia.
Yeah.
So, you know, the states, you know,
some of the state associations say we want
to.
I think the second step then is go
after private practice.
Why private practice?
They have probably the most to gain,
you know, from that.
Biggest biggest win.
You've probably got some more resources
than the average single person.
Right.
But you're saying if we win this,
you win this, too.
So come along.
Yeah.
So go after the private practice because
they have resources.
They're willing to bet on them.
They're usually risk takers because going
to business,
it's not just doing physical therapy to
have a business.
You got to run payroll.
You got to do taxes.
You got to have attorneys.
You kind of have learned the game.
But you understand that to get an outcome,
sometimes the answer is I have to spend
something.
But I'm going to monitor that spend.
And here's the best part.
If you're in...
Idaho or New York or New Hampshire,
you can be like, well,
they spent X and they got Y in
Utah.
I wouldn't mind spending X because I'd
love Y.
So how do we spread that spend across
our state?
I think you're right.
Just in my experience, too,
when you work with a super large
organization like a hospital system,
you got to get fifty yeses.
It'll take three years.
They're aircraft carriers.
It would be great to have one of
their help.
Except those boats don't turn as quick.
You need more of a destroyer.
You need enough firepower.
Fifty destroyers might be better than one
aircraft carrier because they can turn on
a dime and you can organize them,
and there's more of them.
Yeah, so get them going,
and then they will know who the other
players are.
Correct.
They'll be able to pull that key therapist
from the hospital.
They'll be able to pull that key therapist
from the rehab bunch that has influence.
They already know who people are.
It's the same model as the movie Ocean's
Eleven.
The target is we're robbing this casino
vault.
Okay, that's the end.
What do we need if we start going
backwards?
Well,
we need a guy who's good at this.
We got to get a guy who's good
at that.
Okay, well,
you start with what Stephen Covey said,
right?
You start with the end in mind and
you work backwards.
If you didn't have the person who knew
how to fundraise,
that was Elliot Gould's character.
He was the bankroll, right?
Mm-hmm.
Without it,
you don't have the toys for the explosives
guy and the tech guy.
And then everybody plays their part.
Mm-hmm.
Yeah.
And that's where I would start.
You know, those three steps, want to,
get a good group behind you,
and then let that group bring their skill
set.
Then you can do about anything you want
to do.
And, you know,
some states will be a tough battle.
Sure.
And others will be a slam dunk.
But we've tipped that first snowflake on
the top of that avalanche,
and we got a snowball that's starting.
You know,
I think we got a great thing ahead
of us.
A lot of analogies today,
and that's right in my world.
I love that.
And then you got to stand up on
stage with a bunch of our colleagues at
CSM just a couple of weeks ago,
and you got to get handed an award.
Talk to me about what that award really
meant to you.
What was it about?
You know, it was certainly flattering.
It was very kind.
When I got the first email that says,
hey,
you're going to be receiving this reward,
this award, I said, why?
You know, what did I do, you know?
And then, of course,
I walked right into it.
One of my colleagues, Jamie Christensen,
said, hey, I just got this.
And I said, do you know about this?
Oh, yeah, I wrote a really good letter.
You're a dog, man.
So that's the academic leadership and
innovation,
which I still think flies under the radar.
Oh, because it's not clear.
It's not ortho.
That's pretty clear.
It's not geriatrics.
It's not education.
I call it and they don't like this
analogy, but I do.
I call it it's sort of the junk
drawer.
that's not a negative term because if you
think about it the junk drawer is the
drawer you can't let anything go you're
like no no that's very specialized i you
cannot get rid of that weird shaped
screwdriver because that's for eyeglasses
or the random things it is this thing
that it's you're not sure what fits there
And once you start looking around,
you're like, oh, damn,
this has a lot of different.
But it's not clear.
It's not one thing.
It's many.
That's probably their weakness.
But their strength is it's not one thing.
It's many.
Yeah.
And then the second thought I had with
the award was that, you know,
being flattered and surprised,
it was like, it was not mine.
You know, this was all a Utah.
This was the Utah Association.
This was all those private practices that
stepped in.
It's everyone that wrote a letter.
You know, I just happened to, you know,
receive the pretty thing.
But it was certainly nice to be recognized
because, again, we did something.
Somebody else is, you know, great.
you know, association said, Hey,
that was cool.
Right.
And now, now, you know, other people,
other people are going to be able to
see it and they'll say, Hey,
maybe we can too.
So I'm just hoping that it moves on,
but I certainly flattered.
It's so awesome.
I was so grateful, you know,
for the fun night we had and all
the good people that were there and
everything they're doing.
But it,
but it wasn't me that this was all
our association and stuff.
You, you just got to be George Clooney.
You got to be Danny Ocean and you
can't give the award, you know,
you couldn't give the award to everybody.
Maybe they weren't at CSM, but.
You know, like Hannibal Smith, you know,
it's just love it when a plan comes
together and that was the embodiment of
it.
Well, that's fantastic.
Well, congratulations to you,
the rest of your team,
the next state that does it.
I want them to be proud of doing
that.
And if you're thinking about it,
this is the, the,
at least the first few steps, uh, Howard,
we have a tradition on the show.
It's called the parting shot.
This is The Parting Shot.
One last mic drop moment.
No pressure.
Just your legacy on the line.
No pressure.
Just your legacy.
I'm a lot.
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All right, Howard, parting shot.
What's the idea, the sentiment, something,
whatever you want to leave the audience
with as we wrap up?
My boys, I've got six kids,
I've got seven grandkids,
but I have two trailers.
My two youngest,
twelve years younger than their older
siblings and stuff.
One's a senior, one's a junior.
My seniors,
we are members of Church of Jesus Christ
of Latter-day Saints.
He's got a mission call to Belgium this
summer, you know, and he's super excited.
But they get sick and tired of me
teaching them the same thing.
phrase all over the place.
I tell them that everything in life is
about relationships,
your relationship with God,
with your spouse, with your employer,
with everybody,
and that you will never have influence on
anybody that you don't have a relationship
with.
And so I tell them to build relationships
and guard those relationships because
they're important.
That's how things get done.
And that's how you grow as a person
because I learn from others.
I take the best things from others.
I put them in me.
I try to emulate good qualities.
But the best thing we can do is
develop and keep relationships.
We're in a society of hyperbole.
We like to be angry about everything.
We like to scream and yell.
We got to guard relationships because
that's what's most important.
That's the Quackenbush philosophy.
I mean,
if you could sum up a parting shot
that goes exactly with the topic of
today's discussion,
the thing that you did is every little,
every,
nothing in that story happened without the
relationships and how those relationships
were interconnected.
That's a perfect parting shot.
Howard, appreciate your time.
Thanks for doing this and congrats on the
award again.
Thanks, Jimmy.
It's a pleasure to speak with you.
This will be fun.
I look forward to seeing you out in
D.C.
Sounds great.
That's it for this one,
but we're just getting warmed up.
Smash follow, send it to a friend,
or crank up the next episode.
Want to go deeper?
Hit us at pgpintcast.com or find us on
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And legally, none of this was advice.
It's for entertainment purposes only.
See, Keith?
We read the script.
Happy now?