Keystone Reset: The Future of Preventive Physical Therapy with Dr. Chad Nowlin

In this episode, Ben and Todd sit down with Dr. Chad Nowlin, a Doctor of Physical Therapy and founder of Energy Physio. Dr. Chad shares his journey out of the traditional corporate physical therapy model and unveils his cash-pay approach focused on root cause pain relief. He opens up about the limitations of diagnosis-based care, the power of preventative MSK strategies for employers, and his discovery of the Keystone Reset, arguing that better outcomes are achieved by changing the way people move, not just how they feel.

Main Talking Points

• Dr. Chad's path from a high-volume corporate physical therapist to a cash-pay entrepreneur.
• The critical differences between insurance-based and cash-pay physical therapy models.
• The philosophy behind the Keystone Reset and treating the whole body (ankles, hips, shoulders) to solve local pain (e.g., low back).
• Why pain is a "lagging indicator" and the focus should be on leading indicators like movement quality.
• The huge opportunity for preventative MSK screening for employers and its ROI.
• A new model for triaging care using virtual assessments and navigating patients to high-quality local cash practitioners.
• How this preventative framework can drastically reduce employer work comp and health plan claims by addressing issues before they require surgery, injections, or excessive medication.

Transcript

Meet Dr. Chad And His Mission

SPEAKER_01 0:00

You're listening to Risk and Resolve. And now for your host, Ben Kid Hufford.

SPEAKER_02 0:09

Welcome back to another episode of Risk and Resolve. I'm your co-host, Ben Connor, alongside Todd Hufford. Today's special guest is Dr. Chad Nolan. Dr. Chad is a doctor of physiotherapy who started his own clinical practice in 2018 with a focus on root-cause pain relief through holistic care, focusing on full body movement and mobility. His commitment to treating comprehensively led him to discover the Keystone Reset, which I'm looking forward to diving into, which corrects one key body asymmetry that creates increased mobility and decreased pain throughout the body within just a few minutes. This approach to musculoskeletal care, also called MSK care, has paved the way for a true preventive framework for employers to minimize MSK health and work comp claims. He's gone off to work with some of the state's largest corporations, helping them implement strategies to improve employee health and wellness and continues to speak and educate on simple strategies to improve musculoskeletal health and longevity. Dr. Chad is on a mission to deliver pain freedom to as many people as possible by reshaping the way employers and their employees interface with MSK-related health care. The driving force behind his mission and purpose is deeply rooted in faith and primary role as a husband and father of three. What a mission to be on, Chad. Thanks for being with us today. Awesome. Appreciate it. Well, Chad, um you know, we met gosh, like three or four years ago. And um what I learned in a that quit that first meeting, which was probably 30 minutes, is um man, you're forced to be reckoned with on things can be done differently in healthcare, and um just your vision is was just it was palpable. But before we dive into that, give us a little bit of your background and kind of what got you here.

From High-Volume Clinics To Cash Pay

SPEAKER_00 2:18

Sure. Uh so uh like to mention before, doctor of physical therapy by trade, and kind of had my got my feet wet in the corporate scene. I'm originally from Texas, and so my first job was there, spent a couple of years at a clinic that he was two locations, uh just one city apart. And I quickly became kind of the lead therapist on uh for the university there. And so I had my full caseload, and then uh, you know, once or twice a week, a bus full of athletes would uh walk in all at the same time. So, you know, I carried a caseload of you know 14 or 15 patients per day, and then a couple of days a week that would spike to 24 or five within a single hour. And uh so, you know, just got a got a good dose of of how the system was gonna work really quickly. Uh when we moved to Indiana in 2016, uh, I went to work for Athletico, and it was largely the same. And so the corporate environment was a great opportunity to get get a lot of reps in, uh, doing certain things just with the nature of high-volume clinics. And uh that's ultimately what kind of drove me out, which was I just had this gnawing inside that man, I I just think if I had more time with people, I could do something different, I could do something better. Uh, you know, just the cognitive dissonance eventually just forced me out of the corporate setting into my own business, uh, which was energy physio. And uh, but there was kind of this interim moment that I think it had really is really what paved the way for what I'm doing now, which is, and I was too chicken to just quit and start my own business. So I took a part-time job and looking back, you know, I kind of regret not just going all in on myself. But at the same time, had I done that, I would have never seen a facet of healthcare that I didn't know existed, which was employer-based healthcare. I actually went to work for a company that had me stationed as the on-site therapist for a Kohl's distribution center, which was right in my backyard. I mean, literally two minutes from where I live. So it was great. And uh just kind of opened my eyes to kind of a different vehicle of delivery for physical therapy. And so I kind of had this part-time job over here delivering inside the employer-based model. And then over here, I was starting my practice working with CrossFit athletes. So they seem like they're worlds apart. Uh and in a in a sense, they kind of are. The demographics that we get with with employer groups are are definitely different than the CrossFit athlete, but that is what taught me everything that became super relevant and important for preventative models, treatment care models that are efficient for our employer groups, because I was seeing people who are using their bodies in a different way. And I was uh checking every joint on every person every time, regardless of their pain location. And ultimately, that's where we just started to pick up on these patterns that would uh become some of our primary frameworks for how we work with anybody. And so that's that's kind of what led me here, you know. I couldn't handle the corporate gig anymore, and uh just kind of opened my eyes to some new opportunities. And I knew as soon as I saw the employer-based healthcare model that that was something I was gonna have to figure out for myself as I continued on.

Insurance Limits Versus Outcome-Driven Care

SPEAKER_02 5:59

So you've kind of set aside this dichotomy, if you will, of traditional physical therapy and the traditional physical therapy practice of someone that's injured that comes in that needs and hopes that they can feel better so they don't have to have surgery. And you've the the the other side of this is you mentioned checking every joint, preventive, those sorts of things. Can we dive into like how are what what are what is what are those two separate worlds? What is the different offering?

Movement Over Pain: New Success Metrics

SPEAKER_00 6:35

Yeah, uh, you know, I knew when I left the corporate scene, there were a couple of of commitments I made early on. And one of those was I'm not taking insurance. So the that was uh the the thing that I perceived as the biggest barrier between the type of care I wanted to provide and uh not being able to do that. And of course, you know, you you know the drill. Once insurance gets involved, uh there's so many layers of complexity that exist for any type of clinical setting when it comes down to support staff and billing, uh claims denials and all these types of things. Ultimately the reimbursement rates for therapy were very low, which is why we had like such high productivity metrics we were chasing after. And once you add in the complexity of billing and claims denials, and and then you have to uh pay people to do that as their full-time job. Uh, you know, so I knew I could go into business for myself and take insurance and probably get up to speed pretty quickly. But in terms of being scalable, I had already seen what that looks like at Athletico and at the other clinic I worked at. And that wasn't a model that I wanted to reproduce because I knew ultimately it was going to end the same way, which is if I was ever going to grow a business, step out of fulfillment into running a business, uh it was just gonna be a high volume scenario. And ultimately all roads lead back to the same type of treatment model. I didn't want to do that, so I committed early. Hey, I am uh cash pay. Okay, we took, you know, we can take HSA and those types of things. Uh, I I was gonna be very focused around a specific clientele, at least getting started, and that was what we did. I worked with CrossFit for two years until I could really, you know, afford to start branching out into some other lanes through online marketing. And that was the the biggest probably separator in the two worlds in terms of just delivering physical therapy. Not that doesn't even include uh like an employer contract, which which functions largely the same as cash pay because it's direct. But you know, that that commitment early was huge. Um, working one-on-one was also another big one. Very difficult to do that in the insurance-based setting, just due to the nature of volume, the volume you need to produce a margin in that setting. Once you grow beyond a certain point, uh it just becomes difficult to do. I think you know, a lot of solo practices uh can do really well, make a lot of money, provide great care, uh, but you can only grow so far. And so, you know, I always had a bigger vision than being a uh one kind of a one clinic guy and treating forever. I was I was thinking a little more long-term than that. And so the cash pay model is what allowed me to learn a lot of things that I would not have learned otherwise, like the Keystone Reset, which you talked about earlier. And so, you know, some of these things that I just decided early on for other reasons are ultimately what led to the track we're on now, the things I've learned about the human body and and how we kind of integrate that into this end-to-end type of musculoskeletal effort, which which really includes, yeah, how how can we pick up on problems before they start and have a legitimate prevention program that that goes far beyond just stretch more or do do this series of stretches at your workstation before you start, all the way out to what does it look like to return somebody uh to work, maybe post-surgical or post-injury, with less likelihood of recurrence, repeating the same problem over and over again. And uh, you know, I don't know if that answered all of your question or if I chase.

SPEAKER_02 10:48

I mean, can what you're doing now be done in a traditional setting?

SPEAKER_00 10:52

Absolutely not. Insurance won't pay for it. Um that that some of the nature of insurance is that you have to produce a diagnosis code and treatment has to follow with that code. And to truly solve somebody's problem, and that we're talking about medically necessary care here. I I think uh, you know, like a traditional physical therapy clinic, to have people pay for a preventative type model, it's you you can't you can't sell people a solution to a problem for a problem people don't think they have. That's just really hard to do. Um a little different with employers because there's an ROI attached to that. Regular people can't can't think in terms of like, oh, well, if I just never have that problem, then I'll save a lot of money. So it's a different environment. But due to the nature of diagnosis codes, you know, if you have, let's say, low back pain, which comes with you know a couple of different diagnosis codes, documentation has to follow suit with that diagnosis code. And if you have a secondary diagnosis code, here's what's really goofy is you can't treat this two different diagnosis codes in the same treatment or even on the same day. And so let's say somebody has a knee episode and a low back episode, and you want you know them to go two times a week for eight weeks. For both of them, they have to go four times a week for eight weeks. You have to work the knee one day, you have to work the low back another day. Now, maybe some of this has changed in the last five or six years. I'm largely unplugged from that. So there could have been some changes that have happened since I've stepped out. I doubt it. Uh, you know, changes in healthcare don't happen quickly or often. Uh and so though that was just a real negative because my perception of how the body works was if we have if we're gonna solve a problem in the low back, we have to solve these other hidden problems in the ankles, the knees, the hips, the shoulders. And so then it just it kind of created this ethical mess of like, okay, well, the right thing to do is what's right for the patient. But ethically, I can't bill for that. But it was time that we spent. And so then I have to document it and chart it because I did it. Uh, but then we can't bill for it. And then now you then you got somebody, you know, higher up the chain breathing down your neck about why you did a bunch of stuff and didn't bill for it. And it's it's just convoluted mess once you get into that. And stepping out into cash cash pay removes all of those barriers. You know, I mean, essentially do what you want. You know, you you now you are now um, you know, in the insurance-based setting, it's such a such an interesting dynamic because the patient is the patient, but they're not your client. The insurance company is your client because you have to do what satisfies them to get paid. Once you remove that relationship, and now it's a direct exchange of money for result or service or outcome. Now you're really free to do what's best for the client. Uh, and sometimes that includes just what do they want, and not what do you think they want or what they should want, but it's it's really the the relationship that is more like all other businesses function, which is we are going to exchange dollars for what it is that you want, and that's a great relationship to have. And it functions much better, everybody's happier, results are better. There's just a lot of positives that came with that.

SPEAKER_02 14:32

So, what I heard is in the setting you're in before, you have a patient that comes in, they present as a condition that you're trying to solve for, and you need to do an activity to get paid, and there's only a certain activities that you can do to get paid, and that's it. And so you have a condition and activity, and an outcome is somewhat a thing that's not paid for, which there's value-based care and that kind of thing, but it's really not how the model is made for that, right?

Building True Prevention For Employers

SPEAKER_00 15:08

Yeah, physical therapy, I don't think uh fits that. Like, you know, value-based care and like primary care functions a little different. Right. You flip over into physical therapy, it's things can get kind of weird.

SPEAKER_02 15:23

But now you have a model where it's look you're talking about the goal you have a patient that has a condition and the desired outcome prescribes the activity. Yes. Right. It's not the diagnosis. Condition and outcome produce the activity rather than what the payment source is, or if you will be paid because you're dealing with the person who wants the outcome, because that's what's ultimately important. That's it.

Why Many Surgeries Aren’t Necessary

SPEAKER_00 15:53

That's it. Uh and outcomes are outcomes are the most important uh for obvious reasons. But I I think um what's been really nice about the the shift in payment model is that now we can more more clearly define what the appropriate outcome is, because pain relief is not the appropriate outcome. Like chasing pain relief is is what leads people down a rabbit hole of quick fixes uh and solutions that don't lead to a real root cause management of a problem. And that even goes, that even gets down to the diagnosis code level, where when the primary metric you're measuring is pain, and you can only isolate your treatment down to this area associated with the diagnosis code, then it's very difficult to attach other objective measurements to show improvement outside of that area. So, you know, the ankles are a huge problem for most people. Uh, if somebody has low back pain, they've probably got stiff and asymmetric ankles. I've seen that enough at this point. And um a good a good illustration is like uh dieting. So if your only focus is calories and you're not losing weight, then the tendency is, oh, I'm just going to eat less calories. Well, eventually that gets to a point where you're eating less and less, but you're still not losing weight. People don't ever eat so little that it's impossible not to lose weight, uh, but they never eat the correct amount of things to systematize the weight loss. And you end up with only one trackable metric, which is weight loss. And then you have no ways to really show your progress outside of scale up or down. Uh, versus you can track your protein, you can track your total calories, you can track your fat intake and your carbohydrate intake. Now we have uh four metrics to show progress. Okay, I hit the I hit the protein, I hit the carbs, I hit the calories, I hit the fat. Now we have all these other metrics, and then you can tie in softer metrics like uh waste measurement or progress pick daily, and we can start seeing other elements of progress, even if the scale's a flat line. And it's the same with physical therapy. It's like, yeah, pain might be the same for a period of time while we're implementing certain treatments and strategies. But if we reframe the outcome as not pain relief, and we reframe it as movement quality is increased, joint mobility is increased, uh, then pain is a natural reduction off of those things. Like uh one of our common mantras is if you don't change the way you move, you won't change the way you feel. And so much about diagnosis-based treatment is designed to change the way people feel and not change the way they move, which is the root cause of most people's pain, is they they don't move very well. And there are a lot of reasons for that. But once once you step outside of diagnosis-based care into how can we make this person feel better and also not focus completely on how they feel, uh, turns out progress is much faster and it's much easier to objectify and show progress, which is important for patients. It's like, hey, look, yeah, we haven't moved the needle a lot on your pain, but look, your movement's better, uh, your mobility's better, uh, you're able to work longer before you have pain. When the pain starts, it's not uh as bad as it was. There's so many different ways and angles to look at progress once you step outside of you know, a zero to ten pain scale.

SPEAKER_02 19:50

Um so with this model and going out on your own, what um what's the future of really appropriate pain management and the opportunity for preventive physical therapy to impact the rest of a population or for the future of a person?

SPEAKER_00 20:18

Yeah, that's a really good question. And I got some I got some big ideas around that. Uh as far as I am aware, there are not very many preventative services currently. Um musculoskeletal health as it relates to employer-sponsored health care really is synonymous with physical therapy, which is too late. Uh, medically necessary care is is very important, but there is a huge, huge play to be made in the preventative space. And it it wouldn't look that much different than primary care, which is hey, let's go get your blood testing, let's get your biometric screening done and just get a baseline. Uh and I estimate, and this is just based on, I don't know, common sense, maybe total guess, but I would estimate that probably 80% of an employee population has pain. There's not doing anything about it. And then you can take whatever fraction of people that actually have claims related to musculoskeletal health is a much smaller percentage of that. But the truth is uh there's a big problem lurking just beneath the surface of all claims for an employer, because a lot of their employees have pain and they just think it's normal. And you know, I had another birthday, so that's why my knee hurts. And it's simply not true. But because we know that movement is the root cause of pain, it's very easy to screen for. Uh, and these are some of the huge positives that came out of working with CrossFitters and also checking full body all the time, is because when I started doing that, it was very, very quickly that that I started noticing the patterns that people have. Where I mean the human frame outside of rare anomalies is the same for everybody. And and so it only makes sense that when things go wrong, they can only go wrong in so many ways. And so what we see very, very consistently is when somebody has low back pain, uh, their squat looks a certain way, the way they bend over and pick stuff up looks a certain way, the way they lift things over their head looks a certain way, and those movements always default into the same negative patterns because the body always follows the path of least resistance. And so it's just going around a restriction, and ultimately that's what leads to breakdown of tissues. The body, the body is a machine, it's a it's an organic machine. And when you start uh taking parts that should be carrying load and then they don't, it shifts the load somewhere else. This is how machines break down, it's how the body breaks down. And so after seeing all the patterns of how movement leads to certain pain conditions, it's very easy to quickly screen somebody's movement and have an understanding of what joints are not moving well that creates that pattern of movement. And then what are the things we need to implement early and quickly to change the mobility so we can change the movement pattern very simply. You can screen somebody's movement in three minutes. You know, it doesn't take very long. And build prevention programs based on that. It's like, hey, look, the people aren't seeking medically necessary care yet, but waiting for them to seek care, we know that's too late because once somebody has pain, that means they've been ignoring the problem for a long time. And pain's the last thing to show up. It's a lagging indicator, not a leading indicator. So all we do is we go in and look at the leading indicators and just say, hey, look, I mean, you do that long enough with enough weight, enough repetitions, these are the types of problems you're gonna have. We just solve for X before X becomes, I need to go to physical therapy, I need to see the doc, I need to have medication injection, advanced imaging. Definitely not trying to let people slide down the slope to surgery, uh, especially with most of the research indicating that it's not necessary.

SPEAKER_02 24:25

So double-click into that. He said research says that it's not necessary. Why would surgery not be necessary?

SPEAKER_00 24:33

Um unless preface that with surgery is sometimes necessary. Uh, I think just the way the system is designed, it's it's easy to assume that it's necessary when it's not. Uh, most people get to a surgical procedure with a lot of stones left to turn over uh in in their care track. And I think starting with a preventative model will allow you to educate people on what those stones are before you really need to consider surgery and create a lot of wedges in between certain other stepping stones to at least slow the process down. Surgery is a very, very valuable service, uh especially when it's done the right person at the right time for the right reason. But it can also become a swift nightmare when people have surgery and then they think they're better because they're forced to take rest, and then they resume their normal life, and then not long after that, here comes the same pain they had before. And their physical therapy is not the right model. Uh, like the current therapy that exists is not the correct model necessarily to prevent surgery because there's still more things that need to be addressed if if we're going to really impact those numbers in the biggest way.

Virtual Triage And 24-Hour Access

SPEAKER_01 26:09

You talked about how um your cash pay system, which is not uncommon on the healthcare side, thinking through work comp, how do you serve an injured worker who's in the work comp system where it's just naturally tied to an insurance company? And you it's really hard to break that out. How does that work in your world?

SPEAKER_00 26:31

I I mean, honestly, when we're on site with an employer, it's just a reroute.

SPEAKER_01 26:36

Um and who and who pays it?

SPEAKER_00 26:43

Uh you know, that's uh that almost extends uh further than my pay grade goes. Uh I can tell you, I can tell you what I know. I'll never never tell you anything. I don't know. Uh when we're on site with an employer and they have somebody come into, let's say, HR, they're like, hey, I was working, I hurt my back. They say go to the health clinic, yeah, and we just start right there. Uh because it doesn't have to become something bigger than it is if we can just start it in the right place. Uh I do believe that a lot of musculoskeletal-based health problems, whether it be a health plan or work comp, escalate into higher cost services simply because people start in the wrong place. They they they have a musculoskeletal health problem and they start in primary care. And primary care is not well suited to handle musculoskeletal issues. They have very little training, uh, they have very little knowledge of the types of strategies that need to be put in place for somebody who has a physical, like a musculoskeletal health problem. And it almost always walks away with prescription. Uh it can very quickly escalate to uh imaging. Once you get on those stepping stones, injections are just right around the corner. And if you go to physical therapy that's ineffective and you've already stacked up an image, an injection, physical therapy that didn't work, and medications are ineffective. I mean, what's the next step? You know what I mean? By all accounts, it looks like, yeah, we need to address that little anatomy thing on your image through surgery. And so when it comes to work comp, I think the biggest play to be made there is in the prevention space because most work comp is not traumatic. It's exacerbation at work. And people, you know, I ex last year I explored the idea of well, no other insurance on the planet will insure a pre-existing condition. So is there any play that we can make to just prove that these conditions are pre-existing and just make sure it doesn't funnel into work comp because they already had the problem. That was a quick and hard no because exacerbation at work falls under the purview of work comp. So the idea is like, okay, well, we already know they have the problem. They have pain when they came to work today. That's a problem. We can easily identify that and just say, hey, well, how about we not get worse at work today and we just solve some of these problems before that happens? Uh, we can quickly screen their movement and understand the dynamic between their movement pattern and the nature of the work they're doing, and say, oh, yeah, well, if if you do this type of work with that movement pattern, of course your body's gonna hurt worse and just solve that quickly. So probably one of the uh easier things to do would be drop work comp claims uh from exacerbation at work. I think that would even be easier than health plan claims. The solutions are all the same. I mean, it's we're still dealing with a human body and human movement. And so the screening looks the same. The understanding of how the movement patterns play out inside of their workstation, those are that's the same. And and then largely how you take that information and build it into a prevention program or some type of treatment strategy, still the same. It just funnels into different buckets versus health plan and work comp.

Direct Contracts And Cash PT Networks

SPEAKER_01 30:24

Yeah, I guess I guess what I was looking for was, you know, most employers do not have a clinic on site. They're working with an off-site, you know, commercial clinic like some of the ones you've worked for or ones that provide even broader services beyond just physical therapy. Do you have a model built today where you know a client, a customer, an employer essentially, can buy into your services? And if the injured worker is presenting with these five or six different areas of pain, rather than going to your main concentra or whatever clinic that might address a lot of different things that might eventually refer you to physical therapy, that do you have either a mobile individual or some kind of setup where the H the trained HR could say, you know, let's go here first. And maybe that employer pays it out of pocket and doesn't it doesn't try to get the carrier, the work comp carrier to pay that claim. They just triage it, but they don't triage it internally, they triage it externally through your organization. Do you have that model built? Are you thinking in that direction?

MSK Audits, Targeted Outreach, ROI

SPEAKER_00 31:31

Yes, 100%. And this is this is where virtual is so high value. When you understand how pain presents and why, solving problems virtually is much easier. And we have a system of techniques where we actually teach people very effectively how to self-mobilize the joints that we know are gonna be problematic in their pain condition. We also know uh through the Keystone Reset that if you don't address this thing first, the chances you're gonna have the uh best effort on the other things uh and go way, way down. And so most people can solve most problems with very, very, very little effort. And I think people are trying to replace in-person physical therapy with virtual physical therapy, uh, which I think is the wrong play. I think they both have their place. One is access. Like somebody has an injury at work, they they need to be speaking to a clinician inside of 24 hours. Uh and there's a there's a lot of reasons for that. One, if we're just gonna take good care of people, we need to see them quickly and get them started on something that's gonna move them in a positive direction very quickly. The other thing is, and and this leans towards the skeptical side and human nature a little bit, but the longer somebody has pain who got hurt at work, the longer their brain has the time to formulate this idea that they can not work and get paid. Because if they go down the work comp route, they're going to get paid to not work. And you don't want to leave an employee there for a very long time. We want to get these people feeling better and back to work ASAP before they can ever have the thought of how long can I milk this thing and get paid to not work? And getting connected with somebody within 24 hours is a huge play. And definitely connecting them with legitimate strategies to solve their problem uh is first and foremost. Then it just frees you up to understand, okay, we installed some of the things that are most likely to help this person. You give yourself a little bit of breathing room to say, okay, if we have to triage this to the next level, when and where and how are we going to do that? Because there's a local, there's somebody locally that can help solve that problem. Uh, you can't discount the value of seeing somebody in person. The the when you have the right clinician in person, you can't beat that. It is it is unbeatable. Uh and this goes for any industry. If you have the wrong clinician in person, it sucks. Just like anything else. They're they're really good people, really great at what they do. And then there's a lot of mediocrity. And this is this is in every environment. It's I just think it's more detrimental in healthcare because somebody's foot in the bill that's not the clinician. And so when they're very average and they provide a very uh sub-optimal result, there's dollars and cents attached to that that's either going to hurt the patient or uh the employer, whoever's whoever's footing the bill for that. And so using virtual as a means to weed out people who don't need in-person care and weed in people that do, giving yourself the breathing room to vet out the highest quality service that somebody could access in an area uh to solve that problem to the highest degree in a great way for the patient and the employer. Uh because I also think there's another, another great play to be made, just with more cash pay clinicians popping up in every city and every state. There's a lot of opportunity to serve smaller employers just through better triage and care navigation outside of the normal networks of physical therapy and health systems. Because these cash pay clinicians, they're the best at what they do. If they weren't, they they can't exist because they have to provide uh legitimate value for thousands of dollars. And the ones who can't do that, they don't hang around very long. But they're obscure. Nobody knows about them because they're in some little niche market, you know, doing word-of-mouth services. But these are some of the greatest clinicians you're gonna find on the entire planet, and they're all over the place. People just don't know about them. And so part of part of my you know, future big mission is how can we become a central hub that helps people solve problems digitally and virtually, especially for small employers who can't necessarily put somebody on site, uh, but then triage care out more intelligently to a legitimate cash practice who can organize a direct contract relationship fee for per visit that everybody agrees to, uh and ideally with a cap. Like, hey, look, you know what I mean? Like, we're never gonna charge you more than this, like per episode, um, just to create kind of some protective mechanisms for everybody. But I I think I think how physical therapy is starting to get more cash pay traction um it is gonna create some opportunity in the healthcare space for employers, especially the smaller ones, because you know, even you know, Batesville out in the middle of nowhere, there's a there's probably a cash practitioner somewhere close over there. Uh, you know, they're they're becoming less and less uh spread out and starting to pop up in all these different places.

SPEAKER_02 37:32

So what I'm hearing is almost this idea of the movement of direct primary care, that moving over to physical therapy, where you can empower uh you know direct relationships with employers, and the best triage mechanism is intake virtually and then deployment to where you know you have the biggest area of need. So you're more efficient with your with everyone's time. So if it is a minor situation that you can coach to, hey, let's let's start with this, this, and this, and let's circle back and see how that's going, versus someone you're like, hey, I you need to come in. Like, I need to we need to do some work because we we have to you know send this the other direction uh with what you're experiencing. Is that is that is that right?

Pelvis First: The Keystone Reset

SPEAKER_00 38:28

Yeah, and I I think that works for any model, honestly. So take a uh take a large manufacturing employer who has several thousand people on site uh across all shifts. This is this is the best opportunity to have on-site physical therapy. Uh, but at the same time, it's like why why would we not run uh like MSK audits and screening upfront? Let's get prevention programs installed based on true need and legitimate problems people have, not some arbitrary stretch stretching program. And then as we start to triage in medically necessary care, we should be weeding out people who don't need to be seen in person so that the schedule is open for people that actually do. And this this saves room for people who need legitimate, hands-on in-person care. It saves room on the schedule for like some emergent work comp stuff, like, hey, this just happened. Can we get in? And you can the I think the triage mechanism works in all scenarios. I just think there's a more unique benefit for smaller employers who could not afford on-site care because now we can serve them in largely the same way. And then when it just gets to a point of navigation where it's like, okay, we have a partner who we've vetted out, they provide great care. Let's organize a direct relationship in a contract. And so when they do need hands-on, they're going here and they're gonna get a better model of care versus like you know, athleticos and ATIs and selects, they've got great clinicians in there, but they're still strapped by the model that they're in. You can't you cannot get around that. It doesn't matter how good the the clinician is, they are still going to be a product of the environment that they're in at a certain level. And so just triaging somebody to in-person care for a direct, like contracted rate with the an insurance-based clinic, it might be more easily accessible and available, but they're still going to get the same model. And that's the problem with physical therapy. It's the model, it's it's the delivery system and the environment that they're in that limits the type of care they can get. And so by shifting over here to solo practitioners, cash pay practices, it's not that you're just getting someone that takes cash already, it's that you're getting a better delivery system attached to that, which always leads to a better result on the other end. And for a company of 100, that's huge. Like a company of 100 is never gonna have an on-site physical therapist. As I see it, maybe I'm wrong, but like to go somewhere for a full day for like 100 people, it's hard to hire people for one day a week. Like to staff a clinician somewhere one day a week, you would really need like six or seven of those in the same city so that one clinician could serve the whole group. This, like, more like the near site model, right? And so you start getting into especially like 50 plus, where you know we have to provide insurance now. But I mean, what's the bottom threshold? It's a good question for you. Uh, because a lot's changed in the last probably five years. What's the bottom threshold for uh self-funded?

SPEAKER_02 42:05

Oh, well, I'm glad you asked that. Um, our plan, so we're self-funded, Connor Insurance Plan, and we have 30 people on our plan.

SPEAKER_00 42:13

Okay, yeah, so that's great.

SPEAKER_02 42:15

You it's the same fundamental dilemma that you mentioned is that if you're going to have if you're going to do something differently and have success, you can't deploy the same metrics. So for our health plan, people will be like, oh my gosh, it's too small to be self-funded with 30 on the plan. It's like, well, it is too small if you do it the same way as Anthem Fully Insured does it. You have to have a different delivery system and a different business model to accomplish success and be able to manage a health plan that way. So um, similar deal. Um you know, I was thinking as you were talking about um just you know, we think we're narrowing in on physical therapy and pain, but you mentioned a lot of things that's in that immediate uh chain of events when it comes to medications. Um and, you know, to say the quiet part out loud, that could be also pain medications, which is a whole different animal in and of itself, right? And then, you know, you have ineffective potential physical therapy, um injections, and you have this circle of I'm doing all of these things, but nothing's changing, but we're gonna continue to do all these things. Um so that's what's the table stakes for this, and employers rethinking how they're uh introducing, how they're encouraging their employees to consider their pain element, right? What what what else is missing? What are some of the unintended consequences in that that we haven't talked about?

Beyond Mechanics: Nutrition And Hormones

SPEAKER_00 44:09

Of people just dealing with pain and doing the same things over and over again, outside of spending a lot of money. Uh I I don't know, man. It's just a self, it's a self-perpetuating cycle. You know what I mean? If if if you're doing that, you're never getting out of it. And it as long as you're turning over employees and continuing to run a business, that's you might as well just say, hey, we're committed to uh losing a lot of money every year because of how we think about health care. And it doesn't have to be that way. Uh I think one of the big problems with like how care is delivered is care, care happens in a lot of ways, and people get value in a lot of ways that's not just at the point of contact. And like when I was at um, you know, the the on-site therapist for the distribution center, it was kind of this, hey, if we build it, they'll come mentality. Where it's like we're here, and so why aren't you coming? Because we're here. You know, you got a captive audience of 2,000 people and we don't reach out to any of them. It's like, man, what a waste. You know what I mean? Uh I think there's such a huge opportunity for information, education, content. You you could literally solve an employee's problem with one good piece of content, you do you would just never know about it. And that's okay. Uh if I had to choose between solving people's problem and never knowing about it, and only solving people's problems that I could objectively measure, I would, I would choose the other because you're going to affect a lot more people. You know, if you can provide high quality content that people will take action on, uh not only could you prevent something ahead of time, but let's just let's just play it out by marketing metrics, where you've got uh you know, you've got your triangle, the tip of the triangle is your top 3%. These people will engage with whatever is available because that's just what they do. Then you have 17% below that that are solution aware. They know they have a problem, they are looking for a solution. You're probably gonna get these people in your clinic. And then you've got 20% below that who are problem aware, but they're not looking for anything. These are the people that need to be seeing your content over and over and over and over because it takes somebody seeing 12 pieces of your content before they will make a decision to do anything with that. Uh, these are just these are standard marketing metrics across all industries. Like it's a low trust era. People just need to see a lot of stuff before they're gonna choose to do anything. And then you've got the 60% below that that don't have a problem, or at least they don't, uh they're not aware of the problem. These people need to see your content so that as soon as they become problem aware, they go look for your solution because they know it exists already. This this is the environment that employers could create with their partners. Is like, hey, look, yeah, we got a thousand people here. We don't know anything about what you're doing. Let's just create a content scheme that puts good information in front of people nonstop. Because in healthcare, you're not just we're not just uh fighting for patience uh with like other healthcare, right? Where you're fighting for the attention of people who need what you have, and you're fighting against Instagram and Snapchat and Netflix and YouTube and all the other distractions and all the other spam emails. I think daily is probably not enough to send content to people because they're probably not gonna see it. You know what I mean? Like my inbox is so full of stuff. It it'll take me a solid day to filter through stuff just to find the one email I actually need to look at. And you just have to assume that employees are the same, like especially if they're not seeking a solution and you're sending them info once a week, they're they probably don't see it. They might get one a year, and they might see one email that you sent per year. Uh, and so you know, I just think there's a huge play to be made for employers on education that can extend well beyond just care that can be both helpful and hopeful for people to see it.

SPEAKER_02 49:03

There's certainly a lot of noise, and it's hard to be top of mind because usually when someone has a healthcare event, they're like, what do I do? And they don't know what that next step is. But um, with that, you know, we have our listeners that, you know, 200 employees to 300 employees that run manufacturing organizations or nonprofits or um whatever the business is, they're like, hey, Dr. Chad, like I I agree, the model is broken. Our people are in this in this sick care system that is perpetual. What's your advice of like, how do we get out of this? Like, what's the best way for us to get into a preventive PT, pain management, movement management, whatever it may be, circumstance? Like, what's what's the pathway out? What is what is the perfect plan look like?

Risks Taken And The End-To-End Vision

SPEAKER_00 49:58

Yeah, you know, I think it I think it starts with just understanding the true nature of the problem you have. So just collect the data on it, you know, and as employers, we like to make data-driven decisions. So let's let's just understand the scope of what's actually going on. Uh I think a great way to do this is like an MSK audit, uh, where we will actually pair up a little bit of subjective, like self-report information on what's going on, how long has it been going on, uh, what you know, what have you been doing, and then actually do a physical movement screen. Uh, we can do about all employees, or what does that look like? You know, I I think the more the merrier, for sure. But at the same time, I think you could do like your most high-risk site or your most high-risk individuals and then extrapolate the information out to the organization. Right. Obviously, like let's say you've got a manufacturing company, they've got 500 employees, and maybe 80 of those are office staff. Now, we're not excluding office staff, they have pain just like anybody else, so you just have it for different reasons. And they are curled over or whatever it may be. Yeah, same, same pain, same problems, just different uh different reason why they have it. But in in reality, they are a lower risk population than your labor force, right? So, hey, let's let's whittle down our screening event to your labor force. And even if we can get 150 of those, we can extrapolate the data out to the other 250. Uh, or if you want to get all of them in there, that's always best because now we have accuracy. And when we do this, it allows us to understand a couple of things. One, who needs what? Now we have a risk profile per individual, and we know exactly what their problems are. So when we build like a custom prevention-based package, it is based on that individual, not based on, oh, the company has a problem. We install this for the company. Uh, and so you can easily pick up on who's really high risk. If we're gonna prevent, what does that prevention program look like for these people? How do we how do we direct them into that? Number two, if we're going to roll into some like annual plan for on-site care, who do we target early? Uh, who are our highest risk individuals that are gonna most likely be in exacerbation at work and could potentially become a work comp claim? Uh, who is furthest along in their healthcare journey and not getting results is most likely to become a high cost claim? And how do we we bring them into the fold quickly and early? So then we can get we can get ROI early. Like, hey, look, these are high-risk people. Let's get them in, let's solve their problem, and let's start moving the needle back in the other direction. And then all the while, you know, we we still it's still open access to the company, but you need to promote and you need to engage and you need to be specific with what you communicate to your population. Uh, one of the most fascinating things I found over the last couple of years has been if you send out a message and let's just for simplicity say, if you have pain, you need to go over here and see this guy. And it's very low engagement. But if you say, if you have knee pain, go see this guy. Immediate uptick. And it's simply because you called out the specific pain that somebody has, and you can do that for every pain point and get automatic uptick in people coming in. Uh, we see we see this with our current corporate clients. It's like we just send out a broad general, hey, if if your body hurts, you know, you need to come over here. Flat line. But if it's like, hey, you got neck pain, the the following week that we go in there, there's a schedule full of neck pain. You know what I mean? And so it's it's just really interesting how speaking directly to a problem is so much more valuable than just speaking about a problem that we know people have. And so those are those are probably the biggest things. It's like just understand your population. Uh, how but how bad is the problem? How many people have pain? You know, how and and then how can we use that information to create legitimate prevention programs? And then instead of shooting for 100% engagement, which never gonna happen, uh, how can we have targeted engagement that that improves the financial metrics early versus you know, waiting to see how things play out over 12, 18, 24 months when we can just know who should we be talking to, and still not be exclusive, still not exclude anybody who needs medically necessary care. Uh, but I think that comes on the tails of better messaging, marketing for lack of better term, to the captive audience called your employees, uh helping them better understand what's going on, why is it like this, and here's how you can access the benefit we've created for you, whether that be virtual or on-site, whatever the case may be.

Closing Reflections And Takeaways

SPEAKER_02 55:12

You know, I think this is uh important conversation. And because if you're if you're thinking about this, this is a topic that and you mentioned you you alluded to this earlier. This is a topic that um can really put someone on the sidelines. Um, you mentioned like if someone's injured and we don't get to them, you know, the thought goes into maybe I can get paid and not work. And the worst thing for a human is to be put on the sidelines and remove activity and you know, because what work is delivering to us, to all of us, because I believe that work is actually God ordained, you know, uh, and it gives us dignity. And if we can help people provide for their families, if we can help people feel well in doing that, so when they go home, they're not hurting, but they're healthy to then contribute to their family, that's the highest human good that we can do is to get someone out of that cycle or that pattern of pain, or you know, the slippery slope to what a what an unnecessary surgery or even a negative surgical experience can provide. And we mentioned, you know, there's you know, painkillers and all these other things that are just really uh big opportunities for big problems that can occur in this journey as you navigate. So I love it. I mean, this idea of more or less a a concierge movement coach, if you will, and uh someone that comes along to say, Hey, are you okay? Like, is there anything that needs to be taken care of? That's uh that's such a value I think employers can add that um really does well for their employees, but also does have return for the business for sure.

SPEAKER_00 57:12

Dope, no doubt, no doubt. And you know, maybe uh you know, I kind of like concierge movement coach, it's a little sexier than physical therapy, I think.

SPEAKER_02 57:23

But what you're doing is uh it's it's proactive, it's it's ahead of, you know, people pay for, you know, a life coach or a, you know, whatever it is, a uh a health coach or whatever. If we're starting if our goal is for someone not to become injured and this start this backslide, then we are on the front end doing a coaching element and ensuring that there's longevity and that people can be their best selves at work.

SPEAKER_00 58:02

And oh, for sure. And and that's part of our you know, our bigger mission and values is how does someone's life change when their body doesn't hurt all the time? Uh there's so many different ways that can go. And you know, over the years, I've gotten to have really unique conversations um just with people on you know the faith component of what it means to wrestle with pain and move past that and do what you need to be doing, take care of your family. But, you know, I I think the thing you mentioned that stands out the most is when like we're we deliver the same thing, whether somebody has pain or they don't, because the solutions are the same. The same things that rehab you out of a problem are the same things that prevent the problem in the first place. Uh it's just a matter of restoring the body back to whole, restoring it back to normal. And if you just restore it back to normal before you have pain, uh you're just one step ahead because you got to do the work and your body didn't hurt while you did it. But the secret is, and this is like with health coaches and life coaches and any other good coach, sports coaches, it doesn't matter. What they do for people is they make the unseen seem. They show somebody something they couldn't see in themselves, either because they didn't know or they were blind to it or whatever, and then they show them the pathway forwards to correct that. And that's all we do is we make the unseen seem. People's ankles don't hurt. So people don't think about them, but ankles are a big problem. People's shoulders might not hurt, but it's why their back hurts, because their work requires more out of their shoulder than they have, and the way that they go around that is with their back. And and once you have a good understanding of how movement patterns are knit together with joint mobility and limitations, it's just it's not rocket science anymore. Like we don't need a diagnosis to create a treatment pathway because our treatment pathway, our diagnosis is. Your body doesn't move right. That's your diagnosis. Our medical diagnosis is you move bad. And so, what do we need to do to make you move good? And just create clear pathways for here's how you do that in 15 minutes a day or less.

SPEAKER_02 1:00:14

Well, in your example, does it circle back to the beginning conversation? If someone has shoulder pain, or they have back pain because of their shoulder issue, and their back is compensating for whatever's going on with their shoulder. If they have a diagnosis code of a back pain, a back pain, and you work on their shoulder, in a traditional model, is the physical therapist isn't getting paid.

SPEAKER_00 1:00:40

Yeah, I don't know how they're I don't know how they're going to justify it. Maybe they yeah.

SPEAKER_02 1:00:45

So then you're really not working on the thing that actually is causing the back pain. Sure.

unknown 1:00:49

Sure.

SPEAKER_02 1:00:50

Or if you do, you're not getting paid for it.

SPEAKER_00 1:00:52

Yeah, yeah. And you know, it it can it can be kind of convoluted because you know, notes can be very vague, and then you're just sending off billing codes. But you know, if somebody ever comes back and audits that, and it's like, yeah, well, what exactly did you do here?

SPEAKER_02 1:01:07

You know, yeah, right. Um, and talking about dealing with pain, is the model, it's like an engine in your car. You're the light comes on on your dash to say you have an an engine problem. And the curr the question is, is you are are you actually going to go and fix the engine problem, or is or is the approach that you want to turn the light off?

SPEAKER_00 1:01:38

Yeah, I did.

SPEAKER_02 1:01:39

In the traditional model, it's well, let's clip the wire so that the light turns off. Yeah. Because the the that's the problem.

SPEAKER_03 1:01:46

Yeah, and those are non non-solution solutions.

SPEAKER_00 1:01:51

And it kind of wraps us back to the keystone, which which we didn't talk about, but you know, the the pelvis has become such a an interesting uh component of the engine, uh, where it spins off so many problems into the rest of the body that you have to start there. I'm I'm I'm fixed on that. You you will not convince me otherwise. If somebody has pain in their shoulder and you find a pelvis asymmetry, you have to correct that, or you will not have a good result in the shoulder. You just won't. Because I've seen it a million times at this point where somebody's missing shoulder motion and they have pain in the shoulder. We correct the pelvis and they have better motion and less pain in their shoulder. We didn't even touch their shoulder. And so this goes back to like, okay, well, how can we justify that in the traditional model? That's hard. Uh and but it also created the foundation for hey, look, we can solve a lot of problems real quick, just starting here. It's the foundation of prevention programs. So let's test this and correct it and then branch out from there. And but that's the unseen. You know what I mean? It's you got you gotta uncover things that nobody else is uncovering. Those are all the stones. Even even taking pain relief into nutrition, uh, hormone balance, and um the there are several other plays to make that can be very orthopedic, very musculoskeletal, and have nothing to do with your mechanical system. But 98% of the time, the mechanical system is the easiest place to start. There's a lot of things going wrong with it that are easy to address, but then it gives us a series of like green lights. Like, okay, we sorted out the mechanical pieces, we sorted out your movement patterns. They look ideal, your mobility is ideal, and we still have pain. So, what other rocks can we turn over? Okay, well, let's talk about your diet. Uh, well, I eat only things out of a wrapper. Okay, well, uh, let's not do that and see how your body feels. Let's have some whole foods. Uh, okay. I drink zero ounces of water a day. Let's just take that to like 30 and see how you feel. You know what I mean? Uh, I've worked with a lot of men and women who uh they get 99% there, but they're still just, man, they can't get right over the hump. They go get tested, their hormones are way off. They they roll on to a supplement, feel 100%. You know, so there are just there are a lot of things that that really extends outside of uh I think the employer spectrum. Uh that's gonna, I think that's gonna take three or four decades to integrate that stuff into employer groups, probably, if ever. But a lot of personal choice in that.

SPEAKER_02 1:04:40

That yeah, although it really is in the best interest of the employee, it's you know, it's personal choice. But yeah, anyway, Chad, thanks for the thanks thanks for the conversation today and your insight into really how how that concierge movement coach is the redefinition of the status quo of physical therapy and your mission to solve for that. So we um we ask our guests two questions uh at the end of every show that we want to ask you. Uh, the first one is what is a risk that you have taken that has changed your life?

SPEAKER_00 1:05:18

Starting the business, for sure. That was uh that was a big one. Uh very risky at the time, also. Uh, you know, my decision to do that was against uh lots of other people's decisions. You know, you got a good job, you got the stable money, we just don't understand why you would do it. And so it not only came with the inherent risks of starting a business, but a lot of relational turmoil from a couple of different angles uh until it kind of proved itself out. So I don't know that there's been anything more life-changing, both financially, spiritually, uh, just the wisdom you gain, the personal development from running a business, you know the drill. Uh, so so many net positives. Even when it seems like you're getting kicked in the face over and over again, uh, there's there's probably nothing better than business.

SPEAKER_01 1:06:11

And Chad, the second and final question is what is left yet unfinished that you have the resolve to complete?

SPEAKER_00 1:06:18

Oh, that's a big one. Um my biggest mission summed up very quickly is changing the way that employees interface with musculoskeletal healthcare. And there's a lot packed into that. Uh, and really, I think if if I get to see my mission all the way through, it will be the legitimate creation of an A-Z musculoskeletal health service, which helps employers navigate prevention, medically necessary care, pre-surgical intervention, post-surgical intervention, and return to work. That this is the musculoskeletal health journey. It right now it's just physical therapy. There's there's so much we can do to help people. Like we we talk about employers and we talk about employees. These are people, and and people are getting underserved because the systems aren't built for them to have success. And so, my goal is in my in my little neck of the woods to build that system that makes sure people have the best success in their musculoskeletal health journey. We're just leveraging the opportunity that employers provide for us to do that because it's beneficial to their employees, beneficial to me, and it is beneficial to back to the employer. It's a pretty sweet spot to be in.

SPEAKER_01 1:07:49

Well, it sounds like you're looking to build an end-to-end practice, but along the way, you might uh accidentally build a whole industry.

SPEAKER_00 1:07:57

Well, wouldn't that be something?

SPEAKER_01 1:07:58

Yeah, we'll take that.

SPEAKER_02 1:08:00

Well, Chad, thanks again for joining us today. And thanks to our listeners for joining us on another episode of Risk and Resolve. We'll catch you next time. Thanks for tuning in to Risk and Resolve. See you next time.