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Transcript

How Do We Get Paid? · Pelvic PT Rising

• 0:02
  Speaker 1: In the last 10 years, our field has gone from an unknown specialty to a household name.
• 0:09
  Speaker 1: This brings unprecedented opportunities, but we need to rise up to meet them and give our patients the care that they deserve.
• 0:17
  Speaker 1: In order to help others get better, we need to be better.
• 0:23
  Speaker 1: This podcast will help you to become more confident with your patients, more successful in your practice or business and a leader in pelvic health, and we're going to have some fun along the way.
• 0:36
  Speaker 1: Join us as we rise together.
• 0:39
  Speaker 1: We're Jesse and Nicole Cozine, founders of Pelvic Sanity Physical Therapy and the creators of the Pelvic PT Huddle, and this is Pelvic PT Rising.
• 0:53
  Speaker 2: Hey guys, welcome back to another episode of the Pelvic PT Rising podcast with Jesse and Nicole Cozine.
• 0:58
  Speaker 2: Hi, Nicole, Hello, All right.
• 1:01
  Speaker 2: Talking today this is a fan request on how PTs get paid and the different ways that that happens.
• 1:08
  Speaker 2: We actually did an episode on this, Nicole, almost three years ago.
• 1:11
  Speaker 2: We actually focused on a little bit of a different side of this question, on the business structure and how everything works.
• 1:17
  Speaker 2: We're going to be talking a little bit more individually, which I think is going to be more interesting for you guys listening on how you the listener right now actually gets paid.
• 1:26
  Speaker 1: It's a super important thing to talk about because I feel like a lot of times, if we are talking at each other but not on the same page, when we're negotiating salaries and we're trying to get a job and we're trying to figure out, is something worth it to jump ship at your current position and go to a new one, we have to be comparing apples to apples or as close to that as we can get.
• 1:49
  Speaker 1: And if we don't understand the broader aspect of how we get paid, as the clinic gets paid and as the individual gets paid, then we're not able to ask good questions of each other in this sort of context.
• 2:05
  Speaker 2: So we're going to dive into all of that before we do.
• 2:07
  Speaker 2: We're really excited to announce a little bit of a reorganization of everything we're doing on the rising business front.
• 2:14
  Speaker 2: For those of you guys who might be new ear listeners, we do a lot of business mentorship.
• 2:19
  Speaker 2: We've worked with now over 400 pelvic health practices, which is kind of crazy to say, Nicole Insane.
• 2:26
  Speaker 1: It just speaks a lot to the growth of overall the cash pelvic rehab world, the cash PT world, and we're really proud to be able to say that we've helped that many businesses and, by extension, we've helped that many people offer great services and love their job and their life as they serve their patients in the way that they feel like they should.
• 2:48
  Speaker 2: Yeah.
• 2:48
  Speaker 2: So as we were thinking about this reorganization, our goal was to have something to offer everybody, no matter what stage of business you are, from a wannabe to thinking about this and getting ready to open your doors for the first time, all the way up to somebody who's running a multi-clinician or a multi-site practice, who really wants to settle in and be a true CEO so four different levels of what we do.
• 3:08
  Speaker 2: If you are a wannabe, we have the business kickstart program.
• 3:12
  Speaker 2: That is everything you need to cut out all of the fluff and noise and nonsense and actually get your business started so you can be able to just really confidently go through that, get people in the door, get your first patient in.
• 3:24
  Speaker 2: That's all the business structure.
• 3:26
  Speaker 2: That's all the forms we give you, literally everything that you need in order to get started.
• 3:32
  Speaker 2: Next thing we've got which you figure this thing should be paying attention to is our accelerator program.
• 3:37
  Speaker 2: That is our six month coaching intensive, no matter where you're at, if you want to enter, kind of our world, our ecosystem of business coaching.
• 3:45
  Speaker 2: That is the foundation, that's where you start.
• 3:47
  Speaker 2: So, whether you've been in business for 10 years or 10 days, that is where you would go.
• 3:52
  Speaker 2: We have a new cohort of that going through starting in January.
• 3:56
  Speaker 2: We're just finishing up with our first cohort of 132 of you guys who went through in the very first accelerator.
• 4:02
  Speaker 2: It's been really exciting to see all of the changes in the business that happen in that kind of condensed format.
• 4:08
  Speaker 2: You can go to a publicptrisingcom slash accelerator to get more information, get on the waitlist for that.
• 4:13
  Speaker 2: There's a little form you fill out.
• 4:15
  Speaker 2: We reach back out to you, make sure that you're a good fit before we get started.
• 4:19
  Speaker 2: Then, above that, once you graduate from the accelerator program, you graduate into our one-on-one mentorship with our rising coaches.
• 4:26
  Speaker 2: Those are we do every six week calls.
• 4:30
  Speaker 2: We really dive into your individualized business.
• 4:33
  Speaker 2: We really get into the nitty gritty details and have that one-on-one coaching experience that really makes such a huge difference.
• 4:39
  Speaker 2: Then, finally, we also have a CEO boardroom program, which is for businesses that are bringing in more than $250,000 a year.
• 4:48
  Speaker 2: Those are the folks who we work with probably most closely.
• 4:52
  Speaker 2: Really, it's a whole another level of problem when you get to that level.
• 4:56
  Speaker 2: We wanted to create something for those of you who are really working toward that CEO level of the business.
• 5:03
  Speaker 2: So, nicole, that was it in a nutshell.
• 5:05
  Speaker 2: How?
• 5:06
  Speaker 1: did it go Great.
• 5:07
  Speaker 1: I feel like this has been in the works for quite some time.
• 5:11
  Speaker 1: I feel like whenever we roll out and restructure something like this, it's just know that we're doing it very intentionally and making sure that we have surpassed the level that we're coaching as well.
• 5:26
  Speaker 1: We feel now very competent that we have had a multi-clinician practice now since 2016 and do well.
• 5:35
  Speaker 1: We would be well into that CEO program if we were taking it ourselves.
• 5:39
  Speaker 1: It's something that we wish we would have had early on in our career when we were making all of the mistakes.
• 5:44
  Speaker 1: One of our things is to help you shortcut all of that and not make the same mistakes that we did.
• 5:49
  Speaker 1: Grow faster, stronger, better, with a better foundation and, honestly, a better work-life balance and love your job again.
• 5:57
  Speaker 1: That's the Rising Business News.
• 6:02
  Speaker 1: Here we go.
• 6:03
  Speaker 1: We're going to go into a little bit, jesse, of why don't you give the overview of how PT clinics get paid?
• 6:13
  Speaker 1: Go ahead.
• 6:14
  Speaker 2: Perfect.
• 6:14
  Speaker 2: Let's start there, because this actually becomes really important to really understand the nuts and bolts of how our industry works.
• 6:22
  Speaker 2: I think a lot of it is hidden behind a little bit of smoke and mirrors when dealing with insurance companies and just how all of that stuff works.
• 6:30
  Speaker 2: There's really three different types of practices.
• 6:32
  Speaker 2: Fundamentally, there are in-network insurance-based practices.
• 6:36
  Speaker 2: You've got a contract with an insurance company.
• 6:40
  Speaker 2: The patient comes to you.
• 6:42
  Speaker 2: They pay their deductible, they pay their copay.
• 6:45
  Speaker 2: For the most part, you're getting your money at that clinic directly from an insurance company.
• 6:52
  Speaker 2: What this is is it's a volume game.
• 6:55
  Speaker 2: The insurance company basically guarantees you a regular supply of patients.
• 7:01
  Speaker 2: That's how folks find you.
• 7:03
  Speaker 2: You're the closest person who's in-network Great, you don't have a problem finding your patients.
• 7:09
  Speaker 2: The downside is that you are, as a clinic, then capped at what that insurance company wants to pay you and, as we've seen again and again, insurance reimbursement just keeps going down because insurance companies are trying to make money, which means they make money by not paying out to people, right?
• 7:29
  Speaker 2: So insurance reimbursement goes down and that really caps the way that in network insurance-based practices are able to pay their staff.
• 7:39
  Speaker 1: And whether or not you have a business that is an insurance-based practice or you're working for somebody that's an insurance-based practice, whether that's hospital or private insurance-based practice, like.
• 7:50
  Speaker 1: It's important to understand here that what this means is that the business, the clinic, has gone into literally a contract that has negotiated a certain rate for what the services are that you're going to bill for.
• 8:06
  Speaker 1: So a lot of times it's a lower rate because they're guaranteeing volume and, like Jesse said, that's the game, and so from a business perspective, you don't have control over how much you charge, except for you have control over which insurance contracts you sign and go under.
• 8:24
  Speaker 1: But it's literally a contract.
• 8:25
  Speaker 1: You can't break that contract.
• 8:26
  Speaker 1: You can't do things outside of that contract.
• 8:29
  Speaker 1: That's what it is, and so I really want you to understand that at some level.
• 8:34
  Speaker 1: If you're working for an insurance-based practice, the business part of it has had to do this.
• 8:39
  Speaker 1: Essentially, deal with the devil a little bit about how you're going to get paid.
• 8:44
  Speaker 2: And that deal with the devil puts a lot of pressure on that business because it means that the business has low margins.
• 8:51
  Speaker 2: It means the business needs to be very full in order usually to be profitable.
• 8:55
  Speaker 2: It means that the best thing for the business owner is to reduce costs, because they can't make any more money.
• 9:03
  Speaker 2: So this is why you see a lot of times there's no advantage to an insurance-based practice of having somebody who's got 20 years of experience in a WCS, because they get reimbursed the exact same, whether it's you with 20 years of experience or a brand new grad who's never been to a single course, or whether it's a PTA or whether it's an aid.
• 9:24
  Speaker 2: And the pressure then, or the financial incentive, is to have shorter appointments.
• 9:29
  Speaker 2: It's to have aides doing as much of the work as humanly possible, because you have to pay them a lot less and you get reimbursed the exact same.
• 9:37
  Speaker 2: So that's where all of the financial pressure is.
• 9:39
  Speaker 2: So if you are seeing patients for shorter periods of time, seeing two patients at once, overseeing a lot of aides, that is because of that financial pressure in the system.
• 9:50
  Speaker 2: What you are billing is capped.
• 9:52
  Speaker 2: This is why a lot of times, owners of those type of clinics are so aggro about your billing metrics and how much you bill and all of that.
• 10:01
  Speaker 2: That's really the pressure that those kind of practices are under.
• 10:05
  Speaker 1: And I want to also point out that that can halfway work.
• 10:10
  Speaker 1: I mean, you could argue that it doesn't really work at all in any sort of thing to make it good for the patient really.
• 10:16
  Speaker 1: But in an orthopedic world that can make sense.
• 10:20
  Speaker 1: In a pelvic floor world where people are coming in with very intimate details, you can't really outsource internal works to anybody else.
• 10:28
  Speaker 1: The amount of time that you're spending on a patient care needs to be one on one because we're private treatment rooms, we're doing all that kind of stuff.
• 10:37
  Speaker 1: That model really starts to break down when you start to talk about pelvic floor clinics trying to work in this in network insurance model where you're capped at the amount of time essentially that you can spend with a patient.
• 10:53
  Speaker 1: That makes financial sense.
• 10:56
  Speaker 2: So the next example of a type of practice is an out-of-network but still insurance-based practice.
• 11:01
  Speaker 2: And this is one of the cool things.
• 11:02
  Speaker 2: That cool is, you've actually worked at one of each of our three types here.
• 11:06
  Speaker 2: But to be honest, we kind of feel like this is a little bit of the worst of both worlds If you are basically out of network but then billing insurance and then what's called balance billing your patient, and so the insurance company says, hey, we're going to pay 60% of what the patient's thing is.
• 11:24
  Speaker 2: Now you're collecting some of what you have from the insurance company, you're collecting the rest from the patient.
• 11:30
  Speaker 2: It ends up being twice as much work because you're dealing with both entities all of the time.
• 11:35
  Speaker 2: You're not getting the same volume benefits that an in-network insurance practice has, but you're also not getting the control and not having to deal with insurance the way that a true cash-based practice has.
• 11:46
  Speaker 2: So it's a little bit of this hybrid between the two other options.
• 11:51
  Speaker 2: And then the final category is a true cash-based practice.
• 11:56
  Speaker 2: And now when we say cash-based, I just want to kind of define this for folks.
• 12:00
  Speaker 2: It is still an out-of-network operation, so patients are still able to submit for reimbursement.
• 12:06
  Speaker 2: You get a super bill.
• 12:08
  Speaker 2: They're eligible for the same reimbursement they would get in an out-of-network place.
• 12:11
  Speaker 2: It's just that the cash-based practice says fuck dealing with insurance companies.
• 12:17
  Speaker 2: I'm not doing that.
• 12:18
  Speaker 2: I'm going to deal complete with the patient.
• 12:20
  Speaker 2: I get fee for service is another name you'll hear for it.
• 12:23
  Speaker 2: I get paid at the time and then the patient's responsibility is to negotiate and get money back from their insurance company.
• 12:29
  Speaker 2: And it just simplifies that whole process.
• 12:32
  Speaker 2: It allows you to set your own pricing.
• 12:34
  Speaker 2: But the big challenge is actually getting people in the door and people who would rather use their insurance or for whom there are paying potentially more in order to come see you.
• 12:44
  Speaker 2: That's the trade-off.
• 12:46
  Speaker 1: Totally.
• 12:46
  Speaker 1: And so we're going to hit this home a little bit here.
• 12:49
  Speaker 1: Cash-based slash, out-of-network slash, fee for service is really the most simple form of a service-based industry.
• 12:57
  Speaker 1: It's I give you a service.
• 12:59
  Speaker 1: If you find that that's valuable, you're going to pay me money and we're square.
• 13:04
  Speaker 1: And I think where the problem comes in, or the challenge I'll say, is that sometimes patients who are paying high deductibles excuse me, high premiums for a high deductible plan they want to be able to use, they feel like the need to use insurance, as they feel like going in an out-of-network place is somehow not utilizing the maximum allowed benefits that they have which you know you could argue that either way which, like, you're still allowed to use it.
• 13:34
  Speaker 1: And as a business owner, you're also saying, like well, I didn't make that insurance contract, so I like don't really care what they're reimbursing you, I just want to get paid a wage for what I am providing.
• 13:48
  Speaker 1: And if you think that that value is there, we're going to be square.
• 13:51
  Speaker 1: And then, like you can go to the insurance company and get what's yours, because you're the one patient who signed that contract with the insurance company and said I want this plan and it does this for me.
• 14:01
  Speaker 1: I didn't do that as the business owner, so I want nothing to do with that shit and, quite literally, fuck you insurance company.
• 14:08
  Speaker 2: Yes.
• 14:08
  Speaker 2: So the other things on that just to be thinking about is usually cash based practices will make their bones with longer sessions with no aids, like that's.
• 14:18
  Speaker 2: A differentiating factor is if you are going to ask people to be paying more out of pocket, then usually you're trying to present that as a premium service and give something better for your people.
• 14:31
  Speaker 2: So that's the different types of practices and this, I think, is really important because it directly impacts how much you can get paid, how well you're paid and just how the entire model works.
• 14:42
  Speaker 2: So we want you to understand basically the money flow, the economy of physical therapy.
• 14:48
  Speaker 1: And I will say this you might be sitting there in your car or on your walk or whatever, being like wow, I work for an insurance based practice and I do see patients for 45 minutes for an hour and I would say like fucking wonderful, like something about that.
• 15:04
  Speaker 1: There's something there, like, there's something in a contract negotiation that they've done to make that advantageous for them.
• 15:11
  Speaker 1: There's some states that still reimburse at a relatively high rate, like Washington State is still one of those ones on one of the holdouts where it's like oh, the average reimbursement rate for PT is still pretty high at like $148 a session or so, so like, but it should make you pause, if, like, how long can that really last if insurance on average reimbursement is going down every freaking year and that is not going to change?
• 15:37
  Speaker 2: And sometimes that's just a matter of your employer being willing to eat the cost, whether it's because they are passionate about pelvic health and they want to provide the kind of service that they really want to, whether it's because you know they're part of a department that doesn't really need to make money.
• 15:51
  Speaker 2: That's kind of where you were at, nicole at a big hospital place where they're making more than enough money with all the surgeries they were doing and they only wanted PT to maybe break even.
• 16:00
  Speaker 1: Yeah, they actually only needed PT to break even at that point with the way that it was structured when I was there I don't know if it's still the same, of no idea but when I was there it was very interesting because I was like you know, me being like the knocking on my boss's door being the pain in the ass employee being like I don't understand why I can't do this.
• 16:16
  Speaker 1: It would make the clinic so much more money.
• 16:18
  Speaker 1: And my rehab director finally probably to just shut me up was like Nicole, we don't care.
• 16:23
  Speaker 1: Rehab actually, and it was a nonprofit hospital rehab actually needs to break even or even lose a little bit of money.
• 16:31
  Speaker 2: They wanted to write off basically from you people.
• 16:33
  Speaker 1: Yes, and so it was very interesting to learn that.
• 16:35
  Speaker 1: So there's usually a catch if you're in an insurance based practice and you still get to treat patients for 45 minutes or an hour and friggin hold on to that.
• 16:44
  Speaker 1: If you're there, awesome, and you know, just look for signs that that might go away at some point who knows when, right because there is a financial pressure to not do it that way.
• 16:55
  Speaker 2: So now, as we dive into a little bit more of the personal side of how people actually get paid.
• 17:02
  Speaker 2: So there's a couple of different options and dichotomies.
• 17:05
  Speaker 2: We're going to walk through each of them for you here.
• 17:07
  Speaker 2: One is as a contractor or as an employee.
• 17:11
  Speaker 2: You'll also sometimes hear this is a 1099.
• 17:14
  Speaker 2: That is a contractor.
• 17:15
  Speaker 2: That is the tax document that a contractor receives.
• 17:18
  Speaker 2: Or a W2 employee, that is somebody who has paid through a payroll system and they file a W2 with the IRS to report your earnings.
• 17:28
  Speaker 2: Now, just to define these terms, an independent contractor is basically the biggest thing about this is all about who pays the payroll tax.
• 17:38
  Speaker 2: The government wants 15.3% of everybody's wages, whether you are a contractor or a W2 employee.
• 17:48
  Speaker 2: So if you're a contractor and the reason that this is attractive to employers is if they hire you as a contractor you are responsible for all 15.3% of that payroll tax.
• 18:01
  Speaker 2: It's called self-employment tax at that point or SE tax, and you pay 15% off the top of everything that you make and then play employment income tax on top of that.
• 18:14
  Speaker 2: So you're basically being double taxed when you are a contractor.
• 18:18
  Speaker 2: I've worked as a contractor my whole life.
• 18:20
  Speaker 2: That's just kind of how that goes.
• 18:23
  Speaker 2: But that is the reason that an employer would be wanting to try to pay you as a independent contractor instead of an employee.
• 18:31
  Speaker 2: They save money on their taxes.
• 18:34
  Speaker 2: Now, if you're an employee, the employer pays 7.5% and you pay 7.5%, so you guys basically split that tax.
• 18:46
  Speaker 2: So this is one of the things that's really interesting about this.
• 18:49
  Speaker 2: If you're a contractor, a lot of times you're going along, you're actually making more money because none of it is subject to withholding, so you're getting the full amount.
• 18:57
  Speaker 2: If they say you're going to be paying this, you get basically your wage times, the number of hours and you get all of that in a check.
• 19:04
  Speaker 2: But what you don't often realize is that come April 15th, you're going to be owing a boatload of money and we've actually run into people who have been really surprised and hurt by this.
• 19:13
  Speaker 2: If you're not planning on that and you don't have $20, $30, $40,000 set aside for your taxes at that point it's going to be pretty rough on you Totally.
• 19:22
  Speaker 2: So things to be thinking about with some of that stuff.
• 19:25
  Speaker 2: We'll also just say and kind of, leave it with this.
• 19:27
  Speaker 2: But basically, if you're providing the service of the business.
• 19:33
  Speaker 2: You're not an independent contractor.
• 19:35
  Speaker 2: If you're being paid as an independent contractor, sometimes that can be beneficial to both you, both parties, but it is probably illegal Now.
• 19:44
  Speaker 2: Some states take a more of an interest in this than others.
• 19:47
  Speaker 2: So California, as a blue state, is very pro labor, is going to actually audit people and then investigate and make sure that everybody's being paid as an employee.
• 19:57
  Speaker 2: Other states aren't as diligent about that.
• 19:59
  Speaker 2: But you're also leaving a lot of risk on the table.
• 20:03
  Speaker 2: If you're supposed to be paid as a W2 employee, then you can always go back and actually petition and say, hey, I should have been getting all of these benefits as an employee.
• 20:11
  Speaker 2: I should have been getting you paying my stuff.
• 20:13
  Speaker 2: And a lot of times your employer who was trying to save a couple of dollars on taxes is now going to owe three years of back taxes and penalties and a whole bunch of other stuff if they've been paying you improperly with all this.
• 20:27
  Speaker 2: So if you really think about it, a contractor is somebody.
• 20:30
  Speaker 2: It's a painter.
• 20:31
  Speaker 2: You bring somebody in to paint your building.
• 20:33
  Speaker 2: Do you need to hire them as employee?
• 20:35
  Speaker 2: Absolutely not.
• 20:35
  Speaker 2: They work for a bunch of other people.
• 20:37
  Speaker 2: They do something that you don't know about.
• 20:39
  Speaker 2: They bring their own supplies.
• 20:41
  Speaker 2: All of these are things hallmarks of independent contractors.
• 20:43
  Speaker 2: But at the point where the independent contractor quote unquote is providing the literal service that you do, they're not an independent contractor, they're an integral part of your business, they're providing the service Like this is just crazy.
• 20:57
  Speaker 2: So it just is mind boggling to me that anybody is still paid as a contractor in these days and age.
• 21:04
  Speaker 2: I mean, it's not correct and it's something I certainly wouldn't fuck with.
• 21:08
  Speaker 1: What's so funny to me, too, is that us PTs and rehab providers and OTs like we're such rule followers in certain aspects at most aspects and then, for some reason, this is one of the areas where everyone's like I don't give a fuck about the rules, I'm gonna do whatever I want and not look into anything about this at all.
• 21:30
  Speaker 1: So we have personally known people that have been audited have gotten absolutely fucked by this, and so it is something especially if you're in a state that is an employee friendly state.
• 21:44
  Speaker 1: This is something that you definitely don't wanna screw with and just take it from us.
• 21:48
  Speaker 1: Most people do not fall into the 1099 category Period.
• 21:52
  Speaker 1: End of story.
• 21:53
  Speaker 1: Don't at me either, because I'm just gonna be like shut up, go listen, go look at the fricking Google.
• 21:58
  Speaker 2: Actually look at the IRS tax codes.
• 22:00
  Speaker 2: It's not pretty.
• 22:01
  Speaker 2: And I will say this if you are that worried about the payroll tax and owing that extra 7.5%, you are not ready to have employees 100%.
• 22:12
  Speaker 2: Then don't have employees.
• 22:13
  Speaker 2: If you don't wanna pay taxes on your employees, then don't have employees.
• 22:16
  Speaker 2: But if you're looking at that stuff and being like man, I could save so much in taxes hey, you're not saving that much and be the risk or reward ratio on this is totally skewed.
• 22:25
  Speaker 2: So if you are being paid as a contractor right now, then you could take this information, do it with it what you will, it's not your problem.
• 22:35
  Speaker 1: Yeah, that's another thing to point out.
• 22:37
  Speaker 1: If you're getting paid this way, it is not your problem, unless you can't pay your tax at the end because you don't understand your life.
• 22:43
  Speaker 1: But it's not the employee's problem or the contractor's problem.
• 22:49
  Speaker 1: It's not their problem, it's the employer's risk.
• 22:53
  Speaker 2: Yes, and so if anybody comes down on this, it's gonna be so.
• 22:57
  Speaker 2: Don't feel like you have to go back to the person who's paying you and say, oh, I have to be paid as a W2 employee, you don't need to do that.
• 23:03
  Speaker 2: But I mean just, all in all, I don't know why this is a thing.
• 23:07
  Speaker 2: It's literally as incomprehensible to me why anybody is still being paid as a contractor.
• 23:11
  Speaker 2: The other caveat to that is if you're working for a company like Luna that's the only time I could ever see that making a little bit of sense.
• 23:20
  Speaker 2: I think Luna could make the argument hey, we're not a physical therapy company, we're a marketing company.
• 23:25
  Speaker 2: We just get leads and then we farm them out to these physical therapists who then fulfill this service.
• 23:32
  Speaker 2: I think it's still pretty tenuous.
• 23:34
  Speaker 2: Actually, I could see that going either way, but that's one where it's like okay, that kind of falls within the spirit of the rule.
• 23:41
  Speaker 2: Luna itself is not made up of physical therapists providing physical therapy.
• 23:46
  Speaker 2: They're basically like a website that farms out work.
• 23:48
  Speaker 2: So that would be the one caveat with that.
• 23:52
  Speaker 2: Here's the next one we've got.
• 23:53
  Speaker 2: Nicole is whether you are paid hourly with a salary or per patient.
• 23:59
  Speaker 2: So are you paid hourly versus salary versus per patient.
• 24:03
  Speaker 2: Each one of these has different pros and cons, but this is an interesting debate and this is one of the reasons it's really hard to compare apples to apples with different job offers.
• 24:14
  Speaker 1: Yeah so, and I've been in all of these different categories.
• 24:19
  Speaker 1: If you just look at it, on the surface level it can seem pretty simple, Like oh, I'm just gonna get paid for the work I do, but the reality is is that it's really important for you all?
• 24:30
  Speaker 1: I really want you guys to be educated in what you're actually saying yes to when you say yes to a job.
• 24:37
  Speaker 1: So if you are an hourly employee, then you like clock in and out, you're paid for the hours worked, kind of regardless of the number of patients that are on your schedule, and then you're subject to things like overtime and all that kind of stuff.
• 24:56
  Speaker 1: If you get paid per patient hour, that means that you get paid for the number of patients that you see on your schedule and you don't get paid for anything else outside of that, unless you've negotiated any sort of other rate to get paid for other time.
• 25:13
  Speaker 1: That's not patient focused.
• 25:17
  Speaker 2: So what you kill if you're hanging around the clinic for 40 hours but you see 12 patients, you're paid for 12 patients.
• 25:23
  Speaker 2: You can decide whether or not with your negotiations, whether you're paid for late cancellations or no shows.
• 25:28
  Speaker 2: It's our feeling that you very much should be just as an ethical thing for us.
• 25:33
  Speaker 2: But that's up to you.
• 25:35
  Speaker 2: It doesn't have to be that way and a lot of people don't do that.
• 25:38
  Speaker 2: If you're a per patient kind of pay structure, so then the third area is to be paid.
• 25:45
  Speaker 1: As a salaried employee and this is something where they take you have certain qualifications that you need to meet in order to meet this salary thing.
• 25:54
  Speaker 1: So in a in a world where you're opening 40 patient slots on your schedule, your ability to see 40 patients is there.
• 26:03
  Speaker 1: You're there for 40 hours, maybe more, and you get paid a set amount every two weeks, regardless of the number of hours that you work, regardless of the number of patients that you see, and that's how it works.
• 26:20
  Speaker 1: There's advantages and disadvantages to that in the where we want to sort of talk to you guys today about the differences between industries where salary sometimes is deemed something that an employer is going to take advantage of an employee by being put on salary.
• 26:43
  Speaker 2: Well, let's just give an example.
• 26:44
  Speaker 2: Your sister was actually a great example of this right.
• 26:46
  Speaker 2: She graduated law school top of her class.
• 26:48
  Speaker 2: She was a really high priced attorney.
• 26:51
  Speaker 2: But the downside of that, they paid her a salary but they expected her to work 18 hours a day and be on call on Sunday and Saturday and basically whenever the senior partner, you know, said jump, she had to ask how high.
• 27:03
  Speaker 1: Right, right.
• 27:04
  Speaker 1: So that's like where you're more project based right and you do the work to finish a project, meet a deadline, to do all the stuff and you get paid for that time.
• 27:13
  Speaker 1: But the number of hours that you're actually putting in if you actually worked that out to what her per hour rate was, it was probably significantly less than it would seem that it would be if you were just doing regular 40 hours a week.
• 27:24
  Speaker 2: Exactly so.
• 27:25
  Speaker 2: The employer in that case is basically taking advantage of salary.
• 27:28
  Speaker 2: I think there's some studies out there that the average salaried worker is paid for on a 40 hour basis but actually generally works like 54 hours.
• 27:37
  Speaker 2: That's a benefit to the employer.
• 27:39
  Speaker 2: Now it's very, very different in physical therapy.
• 27:42
  Speaker 1: Totally, and this is where I want you guys to fucking use your brains.
• 27:45
  Speaker 1: Okay, you see patients like you have patient at eight and at nine and at 10 and 11 and you take a break for lunch.
• 27:55
  Speaker 1: In an 40 hour day you literally can't work that much more than the number of patients that you see.
• 28:02
  Speaker 1: And you might want to say, oh, I argue documentation time and we'll get into that here in a second.
• 28:07
  Speaker 1: But in this industry, in your industry, if you're listening to this podcast and your public rehab provider, salary actually usually is either neutral or skews in the employee's favor, because if you don't see a patient and if the job of the clinic or the hospital or whatever doesn't give you a patient, you still get paid on a salary.
• 28:30
  Speaker 1: If you're sitting there and your schedule's 80% full and you've had five cancellations today and you're just sitting there with your thumb up your ass, not your patient's ass, but you're sitting there with your thumb up your ass and, like you still get paid, that's an advantage to you.
• 28:44
  Speaker 1: And so if your uncle fucking Fred at the dinner table at on Thanksgiving was like, wow, how are you getting paid salary?
• 28:51
  Speaker 1: Oh, that employer is chicken and re-interview it's like no, uncle Fred, that is not the case, because in this industry it's a pretty big exception.
• 29:00
  Speaker 2: And so that is I mean for us.
• 29:02
  Speaker 2: We I mean to be fair.
• 29:04
  Speaker 2: We're always going to be transparent with kind of how we do things.
• 29:06
  Speaker 2: We believe that salary is kind of the gold standard If you're looking for a position.
• 29:11
  Speaker 2: That's what we provide at public sanity.
• 29:13
  Speaker 2: Because you're right, nicole, we run a pretty tight ship at public sanity.
• 29:16
  Speaker 2: We're 85 to 90% full, but that means we're 10 to 15% not full and we're still paying everybody for that 10 to 15%.
• 29:24
  Speaker 2: It's like a 10 to 15% bonus over what we would be paying them if they were being paid per patient.
• 29:31
  Speaker 2: And this is why comparing this stuff is so important.
• 29:34
  Speaker 2: So we actually had a one of our employees had been at a place where she was actually getting paid significantly more per patient than her effective rate at public sanity.
• 29:44
  Speaker 2: We were talking about that as we were negotiating salary and all of that stuff, and so we just started asking questions.
• 29:50
  Speaker 2: And this is, if you guys are in this kind of negotiating position, just ask questions.
• 29:54
  Speaker 2: You just want to understand each other.
• 29:56
  Speaker 2: I feel like a lot of times we get uncomfortable talking about money and we start talking past each other.
• 30:01
  Speaker 2: But you know she was saying, hey, I was getting a higher hourly rage.
• 30:04
  Speaker 2: It was hard for me to go down in what I'm making and I said, oh, that's so interesting.
• 30:09
  Speaker 2: I'm actually shocked that anybody's paying more than we were.
• 30:12
  Speaker 2: How many hours a week were you getting paid for?
• 30:16
  Speaker 2: She says, well, I was seeing about 12 patients a week but I was responsible for doing all of my own marketing and they expected me to be there and be available for patients.
• 30:25
  Speaker 2: So we ended up seeing that she was at the clinic and working about 30 hours a week.
• 30:29
  Speaker 2: She was getting paid for 12.
• 30:31
  Speaker 2: Well, now she's working 40, and she's getting paid for 40.
• 30:35
  Speaker 2: Literally, we walked through the numbers and found out that she was going to be making three times more by being paid salary.
• 30:42
  Speaker 2: Then she was at this quote unquote higher per patient rate where she wasn't getting paid for, like cancellations, no shows and all of these massive holes in her schedule because the place she was working couldn't fill her.
• 30:54
  Speaker 2: So at the end of the day I was like, hey, I mean here's the numbers, like what you're going to be making three times more at the end of the year coming to work for us.
• 31:02
  Speaker 2: This is kind of a no brainer.
• 31:04
  Speaker 2: Yeah but that's the difficulty of not talking apples to apples.
• 31:07
  Speaker 2: We had to have that conversation because that's not apparent when it's like oh, this is my rate here and this is my rate here, but you would never expect that you're making three times more at a salary position because of the differences in the way you're paid.
• 31:21
  Speaker 1: Totally so.
• 31:22
  Speaker 1: Yeah, again, just to reiterate to it it's just so important to be talking the same language and talking about the same stuff when we are either negotiating salaries or deciding whether or not something's worth it to leave a job and all that stuff.
• 31:36
  Speaker 1: You've got to make sure that at some level, we are taking away any fluff and getting down to what's actually happening with the paycheck and how many hours you actually working or expected to work, and what does that look like for this purpose, Well, two of the things that we want to touch on here really quickly.
• 31:58
  Speaker 2: One is how are you paid for documentation?
• 32:01
  Speaker 2: So some places you're not paid at all for documentation.
• 32:05
  Speaker 2: Some places you're paid at a lower admin rate for documentation.
• 32:09
  Speaker 2: Some places expect you to do it during cancellations and no shows.
• 32:13
  Speaker 2: Some places will fully pay you for that.
• 32:15
  Speaker 2: I think one of the biggest things here is just how much documentation are we talking about?
• 32:19
  Speaker 1: Yeah, this is where, again, full transparency At public sanity.
• 32:23
  Speaker 1: People are paid with salary and so if you're going to see 36 patients hours, you're there for 36 patient hours and you are expected to complete your documentation in order to service those 36 patients in that amount of time.
• 32:40
  Speaker 1: Now, if we were in insurance-based practice and you were spending three hours a day, even an hour and a half a day, for documentation, then that would be a problem.
• 32:50
  Speaker 1: When it's less than two to three minutes for a daily note and less than 10 minutes for an eval and on average you're 90% full, which means you're 10% not full you do get paid for documentation time.
• 33:04
  Speaker 1: You're expected to do it in the hours that you are there and not seeing patients.
• 33:10
  Speaker 2: It's part of your salary.
• 33:11
  Speaker 1: It's part of the salary.
• 33:12
  Speaker 2: And if you have to go over by 10 or 15 minutes every once in a while, that's what you have to do.
• 33:17
  Speaker 2: That's part of the deal, basically.
• 33:20
  Speaker 1: Yeah.
• 33:20
  Speaker 1: And so when someone says, oh, do you get paid for documentation?
• 33:23
  Speaker 1: Every single one of our people should say and if they're fucking listening, they should say yes, right, because they get paid a salary, and that salary includes paid documentation time for the patient hours that they're also seeing.
• 33:39
  Speaker 2: Now you know, nicole, we're at a position where they would take advantage of your documentation time when you work to the hospital program with how many people you were seeing.
• 33:48
  Speaker 2: This is actually a real bone of contention between you and I early in our relationship, pulling back the curtain a little bit here, but you were going over.
• 33:56
  Speaker 2: You were coming home and working for hours.
• 33:59
  Speaker 2: I'm sure some of you guys out there can relate to this.
• 34:01
  Speaker 2: You would come home and work for hours on your documentation, yep, and I was like, wait a second, who's paying for this?
• 34:07
  Speaker 2: And you're like, well, it's my license, I need to do it.
• 34:10
  Speaker 2: I was like what the fuck are you talking about?
• 34:12
  Speaker 2: Why are you sitting here and spending three hours tonight on documentation that you're not being paid for?
• 34:17
  Speaker 1: And at that point I got paid hourly right, so I was actually clocking out and then completing my documentation, which was a problem.
• 34:27
  Speaker 1: Yes, that should not be happening.
• 34:29
  Speaker 2: I still get fired up thinking about that.
• 34:31
  Speaker 1: I know, but I was young, I didn't understand what was going on and and.
• 34:35
  Speaker 1: But to my credit, when I actually started to think about it, I actually went to my boss and I was like, listen, I was seeing patients once a week.
• 34:41
  Speaker 1: Every other person at my place was seeing patients three times a week.
• 34:45
  Speaker 1: Their patient load was way less three times less than mine was.
• 34:50
  Speaker 1: So I had more patients, more of those fucking progress notes and all kinds of other pre-authorizations and appeals and all kinds of other BS and I had three times more of that.
• 35:01
  Speaker 1: And I presented that to my clinic manager and I was like, listen, I'm spending a chit ton of time, I'm not dilly-dallying, I'm a fast worker.
• 35:10
  Speaker 1: I at that point we didn't even have EMR, it was all like handwritten checkbox notes and stuff that I created my own documentation system and I still was having a hard time.
• 35:21
  Speaker 1: Anyways, long story short is that I ended up basically getting approved to like do get paid for my documentation time.
• 35:29
  Speaker 1: And yeah, I got paid time and a half because I was going over those eight hours and all the things.
• 35:33
  Speaker 1: So all that is to say is that nobody should be totally, totally not paid for documentation time, but I do want you to pay attention to are you actually paid for it?
• 35:46
  Speaker 1: You're just not being efficient at it.
• 35:48
  Speaker 2: Right, because if you're taking a lot of time or you're having late cancellations and no shows and deciding to go to Trader Joe's and pick up stuff, that's totally fine, that's not a bad thing, but you also can't be surprised when, at the end of the day, you've got some notes left that you could have been working on earlier.
• 36:03
  Speaker 2: Last thing we want to hit is benefits, nicole.
• 36:06
  Speaker 2: This one always gets me a little bit buyery, because I feel like no one really understands the benefit of benefits, and I think one of the things we want folks to understand if you're listening that basically your compensation package is one big pot of money and what your employer is doing with benefits is that they are pulling out from the money they give you, money that they are deciding to spend in certain ways, and in some cases that can be really beneficial for you, and in some cases those benefits aren't really benefits at all and they're actually just decreasing your overall take home pay for things that you don't need.
• 36:48
  Speaker 2: So we think about things like health insurance.
• 36:51
  Speaker 2: That's something that is important to a lot of people, but that's also something that you can usually get on your independent exchange, and so sometimes I think we just ask the question.
• 37:00
  Speaker 2: We almost just want to hear a yes, do you guys do health insurance?
• 37:03
  Speaker 2: And the answer is yes and then nobody asks any further questions.
• 37:06
  Speaker 2: But health insurance?
• 37:09
  Speaker 2: They're usually pulling out a bunch of money out of your paycheck in order to pay for that.
• 37:12
  Speaker 1: Or they're not, and then you get a shitty HMO right, or it's like quote, unquote free, you don't have to do any employee contribution towards it, and it's all of the mostly cons that have to do with HMO.
• 37:25
  Speaker 2: So just know, if you're again apples to apples, if you're saying, hey, they have health benefits, that's great.
• 37:29
  Speaker 2: Well, what is that actually worth to you?
• 37:30
  Speaker 2: What would you pay for a health insurance plan on the open exchange?
• 37:35
  Speaker 2: You know, for example, a lot of our people.
• 37:37
  Speaker 2: It's like 300 bucks a month.
• 37:39
  Speaker 2: Well, that's $3,600 a year.
• 37:42
  Speaker 2: Cool, that's like a number.
• 37:43
  Speaker 2: Now, is that included in your payroll or is it not Right?
• 37:47
  Speaker 2: But you can be thinking about how that stuff matters.
• 37:51
  Speaker 2: 401k and retirement this is something that we offer at Public Sanity.
• 37:54
  Speaker 2: I think it's something that we're actually really me personally, actually I'm really passionate about, because I want people to be setting themselves up financially to do well for the rest of their lives.
• 38:03
  Speaker 2: But, by the way, you can do a retirement plan yourself.
• 38:06
  Speaker 2: You're not beholden that.
• 38:09
  Speaker 2: This is not.
• 38:09
  Speaker 2: The only way you can do this is through your employer, right?
• 38:11
  Speaker 2: So if your employer doesn't offer this but they offer a higher rate than fantastic, then you can take that money, put it into an IRA, either a Roth or a traditional one, and you can sock away up to $6,500 a year tax-free for that.
• 38:25
  Speaker 2: I just want you guys to understand what the actual benefit is to you for some of these things.
• 38:32
  Speaker 1: And something else that you're really passionate about, jesse, is that there's different types of ways that you can get compensated in your 401k Right.
• 38:37
  Speaker 1: Some people can do a 3% off the top of your just, whatever your salary is.
• 38:43
  Speaker 1: Or sometimes employers will take advantage and say, well, we're going to match 50 cents on the dollar to every dollar that you put in, and they're only going to pay if you put in.
• 38:51
  Speaker 2: Okay, If you're listening to this, please, please, please, listen to me.
• 38:55
  Speaker 2: If anybody does this, I will be so happy.
• 38:57
  Speaker 2: This podcast will have been worth doing on this Friday night.
• 39:01
  Speaker 2: We're fired up here.
• 39:02
  Speaker 2: Put into your 401k every dime that your employer will match, for two reasons.
• 39:08
  Speaker 2: One, it's free money.
• 39:09
  Speaker 2: You put in a dollar.
• 39:13
  Speaker 2: Your employer has to put in a dollar.
• 39:14
  Speaker 2: Right, Do it.
• 39:14
  Speaker 2: It's tax exempt savings and you're doubling up for every little bit that your employer matches.
• 39:21
  Speaker 2: So if it's a 3% match, put in 3% at least.
• 39:24
  Speaker 2: If it's 4%, put in that.
• 39:25
  Speaker 2: If it's 6%, put in 6%.
• 39:28
  Speaker 2: Find a way to do it.
• 39:29
  Speaker 2: It is free money.
• 39:29
  Speaker 2: You have to do it.
• 39:30
  Speaker 2: Also, I feel like I'm fired up about this because your employer, if they're doing a match, is basically trying to fuck you over.
• 39:41
  Speaker 1: And they're trying to bet on the fact that you're not going to put money in, so they won't have to put money in.
• 39:45
  Speaker 2: Exactly so they could just give you money.
• 39:48
  Speaker 2: Instead of doing that, they are betting that you're not going to be smart enough to max out their match and they're not going to have to put the money in, because if you put nothing in because you want the maximum in your paycheck which I understand at certain points of life I get it, all the things but they're basically betting that you're going to do that so that they don't have to pay it and if they wanted to, they could just put the money right in.
• 40:11
  Speaker 2: That's what we do at Public Sandy.
• 40:12
  Speaker 2: We do a 3% for all of our people.
• 40:14
  Speaker 2: I don't care whether that you match or don't.
• 40:15
  Speaker 2: Right, save up money for go for your honeymoon, I don't care.
• 40:18
  Speaker 2: I'm not going to force you to save there, but if you guys have a matching program that is free money, make sure that you are maxing that out.
• 40:27
  Speaker 2: So a couple other things that are on their con head budget.
• 40:30
  Speaker 2: I think this is something we need to do.
• 40:32
  Speaker 2: A whole con head episode, nicole, but you know.
• 40:35
  Speaker 1: I'm fucking fired up about this too.
• 40:36
  Speaker 1: We can't get too derailed on this.
• 40:38
  Speaker 1: But con head can be a benefit that your employer puts money in and then the way that they you use that is also something to look at.
• 40:48
  Speaker 1: So for instance, at pelvic sanity we don't say, oh, it has to be used for course fees only If someone wants money to travel somewhere we will.
• 40:59
  Speaker 1: It's a pot of money that we can a lot towards doing whatever they want to do for that con head money.
• 41:05
  Speaker 2: So ultimately here, benefits.
• 41:08
  Speaker 2: We just want you to think about that as, again, one big pot.
• 41:12
  Speaker 2: What is your compensation like?
• 41:14
  Speaker 2: And Nicole, you've done this.
• 41:15
  Speaker 2: As you've gone from place to place, you were saying, wait, cool, I'm at a large hospital program.
• 41:20
  Speaker 2: They've got great benefits, they do a lot with health insurance, they do a retirement plan, they did pet insurance, they did all the things.
• 41:28
  Speaker 2: And I remember when we were calculating, cool, does it make sense to move to take a position in private practice?
• 41:33
  Speaker 2: You're trying to do apples to apples and saying, wait, what does my salary need to be at this private practice in order to basically make up for those benefits?
• 41:42
  Speaker 2: And we just treat them as dollar amounts because you can go and get all of those benefits for yourself.
• 41:47
  Speaker 1: Short-term disability, long-term disability if that's important to you, you can do it.
• 41:51
  Speaker 1: And then that's the other point is that make sure that the benefits that you think you have are ones that you actually are going to use.
• 41:58
  Speaker 1: So, for instance, if there's a long-term disability benefit at your hospital-based system, like I had there, it's like is that worth it enough to you to go get an additional supplemental long-term disability policy at Northwestern Meshaw or whatever?
• 42:16
  Speaker 1: Is that something that you would actually be willing to spend money on?
• 42:19
  Speaker 1: If the answer is no, then you can't count that as a benefit at your current benefit package.
• 42:23
  Speaker 1: You're not using it.
• 42:25
  Speaker 2: Like it's like your pet insurance.
• 42:26
  Speaker 2: If you don't have a pet, it doesn't matter.
• 42:29
  Speaker 1: So that those places will make it seem like it's really amazing.
• 42:32
  Speaker 1: And it is amazing if you have a pet and if you get hurt in long-term disability and your state doesn't cover stuff and all that stuff.
• 42:39
  Speaker 1: So all we want you to do is think critically about the ways that both clinics get paid and the ways that they can compensate you and at the end of the day, when we are speaking the same language and deciding for ourselves should we hire this person, should I move jobs we can start to ask better questions of each other and come to just really like adult-level conversations on things like compensation and compensation packages and benefits and all kinds of things, to see what is best for everybody.
• 43:22
  Speaker 1: And the best types of employer and employee relationships are where it's win-win.
• 43:27
  Speaker 2: It has to be.
• 43:28
  Speaker 2: It's either win-win or it's no deal With any negotiation.
• 43:31
  Speaker 2: It should be a win-win for both.
• 43:33
  Speaker 2: Or you know what?
• 43:34
  Speaker 2: This isn't the right place for you, and that's great, that's totally understandable, we get it.
• 43:38
  Speaker 2: But we're not going to.
• 43:39
  Speaker 2: It's just not going to work out.
• 43:41
  Speaker 2: And so I think this does hopefully give you guys some of the language to be able to compare apples to apples, to be able to have these conversations and to just make more informed decisions about how you're being paid and understand the way that the type of practice that you're working within is going to inevitably affect your options and how you get paid.
• 44:02
  Speaker 2: It's going to affect how much, in terms of just absolute amount, you're able to get paid.
• 44:07
  Speaker 2: If you're an insurance-based practice, there will likely be some sort of cap on what you can get paid because there's a cap on insurance reimbursement.
• 44:14
  Speaker 2: So if you're at that, that's not unusual Because, again, insurance company doesn't care whether you're a 30-year veteran or a brand new grad or an aide.
• 44:24
  Speaker 2: They're going to reimburse the same amount.
• 44:26
  Speaker 2: So just want you to understand that whole kind of economy of the way that the clinic is getting paid and how that trickles down basically to you and your compensation and what you should be looking about and talking about with your employer.
• 44:39
  Speaker 2: Hope this has been really helpful for you guys.
• 44:42
  Speaker 2: If you do have questions about this, we'd love obviously talking about it.
• 44:45
  Speaker 2: We've gone way over on our time for this episode because we're fired up about it, so please feel free to reach out.
• 44:51
  Speaker 2: We'd love to keep this conversation going.
• 44:53
  Speaker 1: And let's continue to rise.