Ramping Up And The Future Of PT Post-COVID-19 With Dr. Dimitrios Kostopoulos

What will the future of physical therapy look like going forward after we gradually recover from COVID-19? What should owners be doing as we walk into that future? Nathan Shields is joined by board-certified Clinical Electrophysiology Specialist Dr. Dimitrios Kostopoulos to talk about what Dr. Dimi sees in the future, what he recommends, and what his clinic is doing to prepare for the inevitable changes that we’ll have to deal with as physical therapy owners. Are you ready for the new normal of the post-COVID-19 world?

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Ramping Up And The Future Of PT Post-COVID-19 With Dr. Dimitrios Kostopoulos

I’m bringing back a frequent flyer and multi-time guest back on to the show, Dr. Dimitrios Kostopoulos. I am excited to bring him back because I always respect his opinion, foresight and vision especially during this time when there’s so much going on and so much change occurring. I’d love to get his opinion and his recommendations on how to handle things and ramp back up as PT owners. Dimi, thanks for coming back. I appreciate it.

Nathan, thank you so much for having me back. I have no idea what’s going to happen when we start flying again and how much our frequent flyer miles are going to be able to take us. A lot of changes will be happening. I heard that there is a possibility that Virgin Atlantic, the airline, maybe going down.

Isn’t that crazy? It’s amazing how widespread this is affecting everybody and it’s unfortunate. Hopefully, you don’t have any frequent flyer miles on Virgin Atlantic that you’re trying to cash in. We’re going to talk about what you’re recommending and how people can prepare to ramp it back up as we’re on the road to recovery. At least it seems like the numbers are trending in that direction. Prior to that, how do you think this is going to affect the physical therapy industry specifically from your point of view? A lot of clinics have closed down and starting to do telehealth. What are your thoughts on how it might affect our industry going forward?

I believe that we are going to have some fundamental changes moving forward in many different industries. I know that people may not be thinking so much about that but a lot of things will be different. What do I mean by that? I cannot fathom that all of us will go to a restaurant in Manhattan and we are going to be sitting about 8 to 10 inches away from the next table. This is not going to happen. There has to be some degree of social distancing that will continue at least for a couple of years. I do expect some fundamental changes. Let’s talk about the airline industry. I cannot fathom that you are going to have somebody sitting in the middle seat with a person to their right and to their left. All of a sudden, somebody clears their throat and the whole plane jumps up in the air trying to escape the potential Coronavirus contamination. We have to have some changes that will happen in the industry.

In terms of physical therapy, will physical therapy in clinic services go away? Absolutely not. However, they will be modified. For example, a patient would want to know that you have implemented some degree of cleaning, sterilizing and disinfecting procedures within your facility. They would not feel very comfortable if they are extremely close to another patient in another bed next to them. They will start valuing perhaps private rooms for manual therapy instead of doing in an open gym space. I believe we’re going to have changes in terms of space. This specific period of time creates opportunities of access of patients and reach of physical therapists. Those who are smart and are implementing and investing on advanced technologies or physical therapy delivery for the future will be able to have a 180% increase of where their business and production was before COVID-19, based on my projections.

Are you basing that mostly on telehealth services? What kind of delivery methods are you talking about?

I’m basing it on the delivery of telehealth services in both proximity and distant location delivery, as well as in implementation of diagnostics. I will talk about both of these things as part of my five mitigation factors.

Considering we recognize some of those changes are taking place, we also have to recognize that if we haven’t already, we need to make sure that we have policy and procedures in place to disinfect, sanitize, have more precautions and whatnot. Even if you don’t think the Coronavirus is that serious, infectious or whatever it is, a lot of it is about perception. It’s all a lot about what people perceive and if you’re not there, you’re going to lose business.

We filmed a new commercial for our physical therapy location in Astoria where we are going to put it on our website, YouTube, and other social media. The whole verbiage in the message, the pictures and video shots that were taken for this commercial all show large spaces. They show distancing, protective equipment, therapists and patients with masks so that they can give the audience and the consumer the feeling and certainty that they will be protected. This is going to be a deal-breaker or maker for some practices. If you have a competitor next to you that it’s business as usual for them, I don’t believe they’ll be able to survive in this day and age.

Those who take advantage of this opportunity to change their PT clinics will improve 180% and thrive in the new normal. Click To Tweet

It’s going to be tougher for them for sure. For those people who are on the edge, they’re going to say, “I have kids at home,” or “I want to visit my elderly mother every so often. I better go to a place that’s a little bit more cautious in their approach.” Now is the time to get those policies and procedures together, to start planning on how you’re going to approach, and show that you’re following some of the precautions. I love the idea of putting a video together and posting that on your website instead of just saying, “We’re following precautions.” Pictures are better than words. Are you using telehealth yourself in your clinic?

Yes, we do. About 37% of our visits are on telehealth. My intention is to have 70% of the visits on telehealth if possible. I know that if I manage to maintain a high telehealth ratio, the in-house visits will only increase when the economy is back up and open. We’re in New York, we’re ground zero, but we’re expecting that they’ll open and lift the social distancing regulations. People will start going out and going to various offices. We expect that at that time we’re going to have a significant influx of in-office patients. If you maintain the telehealth up there, then you start waging in having an increase in your overall visits.

That’s a great goal because a lot of people might be looking at telehealth as a Band-Aid that when this is all over, they’ll just take it off and get back to brick and mortar manual services. For people who want to take advantage of how physical therapy is going to be done in the future and how it can positively affect your clinic in the future, consider what can it do for you if their cars break down or their kids get sick or they get stuck at work. Instead of a cancel, that can be switched over to telehealth service if you set it up appropriately. I love your intention of keeping your numbers high on the telehealth side because inevitably, people are going to still walk in and get services. Not to go down that road too far, if there are 1 or 2 things you could share with me and the audience that you have found successful in maintaining people or providing telehealth services. Are there a couple of things that have been successful for you?

Here are a couple of things I’m going to bring up in regard to that. I’m going to bring this up not because we made that mistake, but because with many therapists that I see in the webinars and the town hall meetings that we do, I hear what they say. One big mistake that somebody can do is to give their staff a platform and say, “This is Zoom, this is TelePT for me, this is whatever platform. Go ahead and start doing telehealth visits,” without training the staff on how to do a telehealth visit. Therapists then are at loss and they don’t feel certain about something. The less certain you are, the less you want to do that something. If they are not certain, they don’t want to do it, and they are not effective in converting patients from non-telehealth to telehealth.

Train your staff. A training solution for that is a course, the Hands-On Seminars skills, which is a certification course in telehealth. It’s only five hours long and you can certify your staff on how to do it. It covers all the special tests and everything. That is one thing. The second thing would be when you implement telehealth, you have to decide based on the reimbursement that you are getting how you are going to pay the therapist. Are you going to pay the therapist per hour of delivery? Are you going to pay the therapist based on the number of telehealth visits they do? That’s something that each private practitioner has to decide. For example, in our practice, what we do is for two 30-minute telehealth visits, we pay an hour of work equivalent.

Your therapists aren’t salaried.

We start talking about my mitigation factors.

As people are starting to get busier, as things are starting to loosen across the country in terms of restrictions and regulations, and patients start having those elective surgeries again, what are some of your recommendations to ramp your clinics back up?

First of all, I have five specific mitigation factors that every single physical therapy private practice must be implementing. The first one has to do with money. The first one is liquidity. I don’t care if you have $1 million in the bank or $5 million in your business account, apply for the PPP loan. If you didn’t get it, hopefully with this new package, you are going to get it. Having the money there or some portion of that money can be forgiven. It’s a no-brainer, you must get that money. Tap into that and tap also into the EIDL. Some people are thinking that EIDL is only $10,000. It is not. EIDL can be up to $2 million based on the size of your practice at 3.75% interest rate. You can take an EIDL loan and you can use that money to expand your practice. Practice expansion is important. There are tremendous opportunities out there, even for other practice acquisitions.

PTO 101 | Future Of Physical Therapy — Future Of Physical Therapy: There has to be some degree of social distancing that will continue after the lockdown and quarantine are lifted.

I was going to say at 3.75% on a commercial loan, that is crazy. It is historically low. Could you buy real estate if you wanted to buy an office space. Do you know if there are restrictions in regard to that?

I am not certain if EIDL specifically can be used for real estate, but SBA has specific real estate loans that you can get. However, acquiring a practice, you can do that. Think about this, there is a projection from IFA, the International Franchise Association, that about 17% of the restaurants around the country will be permanently shutting down their doors. That is significant. That can give you an approximate idea about other practices. There will be physical therapy practices that will not be able to recover. That will provide opportunities for those who have cash or those who have liquidity to be able to acquire these practices at a great discount.

If expansion is your goal, now is the time. People are going to be suffering. Maybe they want stability or maybe they want cash that if you are in such a position, you can acquire other physical therapy practices and expand. There’s an opportunity there.

That takes us to the second mitigation strategy, which is controlling your expenses. I want to give this message. I have heard from several people, “We are going to take the PPP money and we’re going to bring all these therapists back full-time. We’ll have them in our practice even if they are not producing and we’ll still pay them.” I believe this can create a major problem. It will create a morale problem among your staff. If you start paying someone where they have no production, they deliver nothing back to you, that’s a criminal exchange. They are getting something for giving back nothing. That can create a tremendous problem. Instead, give them specific tasks to do. Give them tasks to study. Give them tasks to help with organizing your business. Redo your office policies and procedures and have them do the project. Create your new strategic plan. Have them do some of the work. Create or update your marketing plans, strategies, protocols and marketing final products. Have them do the work. If you bring them back and you pay them so that this money can be forgiven from the PPP, have them produce. Once they produce, they’ll feel better about it and they’ll be more vested into your business.

Especially if you as an owner are doing a ton of work watching webinars and trying to stay on top of things, if you’ve ever needed an assistant, now is the time to use one of those people to become your assistant. If you’re not doing any digital marketing, now is the time when all of your consumers in your community are on the internet. They’re on social media and now is the time to look into digital marketing vendors. I had Tracy Repchuk on and I’ve had Edric Zheng. It’s important to look into those other things because productivity is the basis of morale. If they aren’t productive, your culture is going to shift and change. I’ve seen that in some of my coaching clients that talk about techs that they have still on staff because they’ve got the funding, but they’re in the back office on their cell phones. He said, “These are techs that were super productive when we were busy. They kept us humming. They were great. They were ahead of everybody else. They were looking ahead to see what the providers needed next. With this downtime, they can’t simply keep the office clean and I have to get on them all the time.” You have to keep them steady, busy, and productive like you talked about.

I believe that’s very important. The two mitigation strategies that I talked about, liquidity cash and reduction of expenses, those have nothing to do with production. They are strategies where you are using either free money because they will be forgiven or a low-interest loan. How long a country, a nation, the planet Earth can live on borrowed money without creating new resources? Only for a very limited amount of time. We have to start creating again. We have to start producing. Through the webinars and the town hall meetings, I’ve talked to hundreds of people and here is what I’m saying at this point in time. We felt bad about the whole thing. Maybe we even lost a relative or a friend or we know of somebody who did. That was horrible, but we cannot go into a state of apathy and do nothing about it. We have to shake ourselves away from that state, move forward, start doing things and taking action.

Shake off the dust, get up and start moving along. Let the emotions flow through you. Let them happen. Let them pass but come through it with greater resolve.

That is our third mitigation strategy, which is implementing telehealth right here, right now. Telehealth is here to stay. It’s not going to be going away. Very soon, Medicare will be announcing that they’ll pay for full telehealth for physical therapy. It makes sense. The Coronavirus is not going to disappear in 1, 2 or 3 months. There is a large possibility that we’re going to have a significant rise of incidents again. If we are prepared as a nation and as a profession to handle all this in a more efficient way and more practical way by having Medicare pay for telehealth, the whole process will be seamless and the economy will be affected much less. HHS and CMS are looking at these things. In the town hall we’re doing, we’re going to have APTA’s Director of Government Affairs who will speak exactly about Medicare. It is a matter of a few weeks until Medicare will be paying full payment for telehealth for PTs. I’m confident about that.

If people wanted to join in on your town halls, where do they go?

Implement telehealth because it is here to stay. Click To Tweet

They can go to SavePhysicalTherapy.com. They can register there and also watch past town hall meetings.

We were talking about these mitigation strategies. You also have a website for that. I want to make sure we cover that.

What we are doing is we offer to people a free eBook. If they go to FastTrackToRecovery.com, they’ll be able to get an eBook that describes all of these five mitigation strategies and more. I talked about telehealth, the importance of it, and something that I mentioned in terms of the future and the greater access, not only at a restricted locality but a wider access. I want to talk to you about what I mean by that. The new commercial we’re putting out talks about our practice in New York. That’s our main practice. We will be offering telehealth evaluation and treatments in five different states, New York, Florida, Maryland, Pennsylvania and New Jersey. In all of these five states, we have licensed therapists. The requirement is to have a licensed service on the state where the patient is receiving the telehealth visit. Provided you have contracts with insurances or you create contracts, you’ll be able to bill for those. That starts creating a unique opportunity to offer these telehealth services across states either in a third-party reimbursement capacity or in a cash paid capacity.

Are there some states that will recognize your license as long as you simply apply to do so? Most states might have you go through the whole licensure process. Are there some states that work together and allow you to simply turn in an application?

That is correct. There is a website. If people go to the APTA’s website, they can find the states that they have this immediate reciprocity across the board.

You have licenses in those states and so you can provide them across borders. That’s a great business opportunity there for sure.

That takes me to mitigation strategy number four. Mitigation strategy number four is right here, right now, implement diagnostic testing in your practice. This is the future of physical therapy. I’m talking about the implementation of musculoskeletal ultrasound and electromyography testing. These are tests that our organization, Hands-On Diagnostics, teach you how to perform them. Nathan, you’ve been a veteran on diagnostics. You’re board-certified in clinical electrophysiology. These tests have great patient value. They reimbursed significantly more than a PT visit. With the new program that we have, not only do we make it very real for you to join Hands-On Diagnostics even during this difficult time, but also for you to start performing the testing and getting reimbursed within 30 days from the moment you get your training. Essentially people can join HODS with an initial payment of $5,000. They can start learning all of this technology and implement it, then we work out a payment plan.

It’s heading that direction anyway. I’m seeing more and more practices providing ultrasound in their clinics. It’s an opportunity to provide some objective data to your providers and to your patients and show exactly how well you are performing. To begin with, if you’re working on the right thing, if your idea behind the diagnosis was appropriate or not, it gives you that real objective data that you can use going forward to treat patients and change your treatment plans if necessary.

The way you implement the diagnostics is as part of that continuum of care, after you do your initial evaluation for these patients who are appropriate, you perform also the EMG and/or the ultrasound. You create a treatment plan based not only on the findings of your clinical evaluation but based on the findings of also the objective diagnostic testing data. You implement that not only as an in-house business but as an outside business. You can perform the services for various physician’s offices on-site and you can get paid from those.

If you don’t mind, I would like to talk about a couple of people who have been with HODS. I don’t know how many of you know of Jeanine and Tim McLellan from Northern Physical Therapy. Before they joined HODS, they were making $85 average per PT visit. With HODS, they’re making $116 a visit. That is a 36.7% increase on what they make per visit. In a period of twelve months, they made $800,000 from diagnostics. Bart McDonald from Superior Physical Therapy, before HODS, was making $104 a visit. With HODS, with the diagnostics, his average per visit is $137. That’s a 31.7% increase. In a period of twelve months, he made $360,000. That’s what I’m talking about. There is potential.

To talk about the effect on patient care, studies have shown that with the diagnostics, 60% of the plans of care change significantly.

You can have a 61% better patient management because of the proper implementation of diagnostics on the appropriate patients. There is a tremendous value. This is the future for physical therapy.

It’s not something that’s an adjunct or niche that’s totally separate from what we’re doing, but rather something that dovetails into what we’re already doing. It enhances our care and in turn, it enhances the value that we provide to patients and then also increases reimbursement and the profit margins.

Sometimes therapists tell me, “What do you think? Should I invest to put diagnostics in my practice or should I go and open right now another new practice?” Here is what I’m going to say. Those two things are very different. I would say you can do both. Why? When you open a new location, you still need to do marketing from the beginning. You need to pay overhead expense for the space, the lease, rent or mortgage. You need to have lots of fixed expenses like electricity, utilities, all that stuff. The diagnostics, you implement them within your existing practice. You don’t need the additional or new space. You don’t need more marketing. If you do, that’s great. You’re going to get more patients. You use your existing patient population who perform the diagnostic testing. You have a captive audience ready for you to give them more information about their condition and to give them more value of service.

What’s the last mitigation strategy?

Number five mitigation strategy is for those practices that are in the verge to decide to either stay open or they have closed their doors already or they’re thinking of closing their doors because they have low patients. Here is what I’m going to tell you. Stay open for as long as you can and modify things. Put people hourly instead of salary. Put them part-time. If you furlough them, you go and you work in it. Keeping your doors open creates the perception from the community that you are maintaining care. You are still there. It is different when you are here open and your competitor who is let’s say five blocks away, they have shut down their doors. The public perceives that. They perceive the fact that your doors are open and you are still delivering service.

I believe that is important. There might be ethical dilemmas. I’m not going to deal with those right now. These five mitigation strategies, what they are going to do is this. If a practice before COVID-19 was making let’s say $100,000 a week, per month or whatever, I don’t care. They bring in maybe $30,000 or maybe zero in some practices because of the reduction of production. If you go from zero or from 20%, 30%, start climbing up back to normal. It’s going to take you forever. It’s going to be a slow path to recovery. It’s possible that you may not even recover completely. If you implement these mitigation strategies and instead of you going down from $100,000 to $10,000 or zero, you go down maybe to $50,000 or $60,000 or $45,000 or something. Your recovery will be much faster and you’re going to be able to go above and beyond where you were before. That’s what I’m talking about.

I truly believe that those people who take advantage of this time and are intentional with the opportunity that they have before them to make serious significant changes for the better in their clinic, they will see exactly that. They will thrive after this. They will see and look back on this as a difficult experience that ended up being a blessing in their lives going forward if they handle it appropriately and intentionally.

You can have 61% better patient management if you implement better diagnostics. Click To Tweet

That’s the way it is. I want to make sure that I also give my sincere appreciation to all of these physical therapists across the nation who have joined the PTForHeroes.com effort. They are providing free physical therapy services to our first responders.

Tell us a little bit more about that.

This is not an organization. This is a community grassroots effort. We decided to put it together. We paid a little bit of money and we created a website, PTForHeroes.com. It’s a commercial that gives awareness to the doctors, nurses and other healthcare providers in the frontlines of COVID-19. They can receive free PT services, OT services and speech services for them and their kids. They can receive these services from providers who are willing to do that across the nation. We have a couple of hundred practices across all states that are participating in the program. They are writing their stories. They are writing stories about the people that they treat. It’s a beautiful thing. It has taken a life of its own.

If people want to join in on the effort, they just go to PTForHeroes.com.

Please share your stories, share videos and put your practice up there. It’s for the greater good.

It might go on for a while as you said. People are going to be dealing with this for a few months. We’re talking about business, but there are opportunities still to serve, especially the immediate communities that we’re in. With telehealth, maybe even the communities that are distant to us. It’s an opportunity for us to serve even if our immediate community is not affected.

Also, this grassroots effort does something else. It brings the physical therapy, occupational therapy and speech pathology professions in the frontlines of COVID-19 by offering those services to the people, to our heroes who are serving the patients. They need help.

Thank you for spearheading that and getting it going. I appreciate it. Anything else you want to share with us, Dimi?

I want to share that if anyone is interested to find out more information about how you can learn the diagnostic testing, how you can implement it in your practice, and how you can join with the COVID-19 special financial deal for $5,000. Go to www.HODSMeeting.com and schedule a discovery call or go to FastTrackToRecovery.com and grab a free eBook.

Thank you so much for your time and efforts. I know you’re putting out free webinars and town halls to guide people through how to process these loans, what to do with their money, what’s happening on the regulatory side of things. You’re providing a lot of content. I highly recommend people at least follow you and see what’s happening because I know you’re on the frontlines of what’s happening in PT industry and are willing to share that. Thank you for the efforts and the work that you’ve put into it. This PT for Heroes is a great value add to our communities. I appreciate you setting that up as well.

Nathan, thank you not only for having me again in the program but also for everything that you do. You’re reaching out to the physical therapy community and informing people about many valuable things that they can be doing to get back on their feet and develop other practices to the next level. Our best days are ahead of us.

Thank you so much for your time, Dimi.

Thank you too, Nathan. Take care.

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About Dimitrios Kostopoulos

Dr. Kostopoulos is a Board Certified Clinical Electrophysiology Specialist with over 29 years of clinical experience and over 20 years experience in electrophysiology testing. He is one of very few Electrophysiology Specialists who have achieved a Doctorate of Science (DSc) in Clinical Electrophysiology Testing.

He is a Clinical Affiliate Assistant Professor. at Charles E. Schmidt College of Medicine at Florida Atlantic University, past member of SACE (Specialization Academy of Content Experts) for the electrophysiology board exam of ABPTS and serves as an elected member of the Nominating Committee of the Academy of Clinical Electrophysiology (ACEWM) of the APTA. He is also an Adjunct Faculty of Springfield College teaching the Clinical Electrophysiology module.

A world renowned, leading expert and best-selling author in Myofascial Pain and co-founder of the Hands-On Companies (Est. 1992 in New York). Dr. Kostopoulos has extensive training and teaching experience in different areas of manual therapy with an emphasis in Trigger Point, MyoFascial, NeuroFascial Therapy and Manipulation.

He earned his Doctorate (PhD) and Master’s degrees at New York University and his second Doctorate of Science (DSc) degree at Rocky Mountain University (Clinical Electrophysiology). Dr. Kostopoulos has obtained his MD degree as a medical graduate from UHSA School of Medicine.

He has numerous publications; he is an Associate Editor for the Journal of Bodywork and Movement Therapies published by Elsevier and has taught thousands of students worldwide through Hands-On Seminars.

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