What Is Your Game Plan?

Creating a successful team in your private practice.

By Jean Darling, PT, LAT

Imagine The 1992 United States men’s Olympic basketball team, nicknamed the “Dream Team;” it was the first American Olympic team to feature active National Basketball Association (NBA) players. Described by American journalists as the greatest sports team ever assembled and called by the Naismith Memorial Basketball Hall of Fame “The greatest collection of basketball talent on the planet.” This team defeated its opponents by an average of almost 44 points en route to the gold medal. What if you could assemble your Dream Team, what would it look like? If you have your top picks when it comes to basketball players would LeBron James and Stephen Curry be in your starting line up? That sounds like a great start up plan but what if your team can only practice once a week, due to being spread out geographically?

This is a problem that mid- to large-sized physical therapy companies may be presented with, but having a stellar executive team is the key to success. What makes a winning team within a company? Certainly an all for one and one for all mentality comes into play, but we must consider the overall mission statement that a business has. If a business has the following three core qualities, it can assemble a winning team of its own.

1) Hard Workers
A business needs to employ people who realize that good things come to people who put out good effort. This is a trait that will become the backbone for your business and keep you afloat in the event of a crisis or even just a down period. Hard work must be given out willingly, too, without asking constantly, “What’s in it for me?” Consistent, strong effort rarely goes unnoticed, but someone who always wants a little something extra for themselves and is looking out for only “number one” might not be the best fit as a team player.

2) Bring in Your Unique You!
Now that you have a backbone established, you can begin rounding out the team and honing in on the particular strengths each member has to offer. Diversity is what makes a business strong—not everyone can or should be the same. Embrace that. Otherwise we would have 50 CEOs in the same corporation and that would be a real disaster. Celebrate what skill sets your team members have that made them stand out from the crowd when you decided to hire them, from great writing skills to stellar negotiation tactics and focus on assignment deadlines.

3) Problems? Communication Assemble!
You have the backbone and sharp characteristics of your team players established now but even with all of these strengths going into play, there is always a challenge to address or a crisis to be prepared for and face head-on. Do not do it alone or it will overwhelm you. Know how to communicate with your team members—all of them. Whether you communicate best via email, in person, or within an organized meeting, keep communication lines open and be available to new ideas and options suggested in the process.

Last, How do you reward these individuals within your management team?
An obvious answer is to get to know your new employee well! Are they motivated by cash, bonus, or stock options in accordance with how well the company does this year? It would be an excellent fit to find someone who enjoys a modest salary and is happy with a challenging job, and those individuals do exist. Some are happy with family time and a fun culture, while others may be attracted to being part of innovation or a world changing effort.

Do not forget, once the new members of your team are on board, it is time for the truly hard part: putting your trust in them. Your gut will fight you every step of the way. You will assume your instructions are clear and misunderstandings are their fault. You will assume when you disagree that you are right and they are wrong. But you will sometimes be wrong. The key to successful executive relationships is changing what your gut tells you. Remember how you interviewed for trust? That is important because once you hire an executive team, you must let them take their responsibilities and run with them. That means agreeing with them about what their roles are, what deliverables they are responsible for and on what timeframe.

Entrepreneurship and business creation is about going for the things that are much bigger than what you could do alone. Your job is not to reach the goal; it is to build a team that will reach the goal. If you really want to reach your goals, you will need to bring on others to help. Creating a good executive team means knowing what you need them to do, finding good candidates, promoting from within, and giving them what they need to do their jobs. If you choose well, they will be successful and make you successful as well. Now you can build your Dream Team of 2016!

Jean Darling, PT, LAT, is an Impact editorial board member and vice president of Advanced Physical Therapy & Sports Medicine. She can be reached at jean@advancedptsm.com.

Dip into the Pool

Guidelines to providing excellent aquatic care

By Kelly McFarland, PT, DPT

Risk. Thrill. Heartache. Sleepless nights. Profit.

Perhaps like many of you, I come from a family of entrepreneurs. My father started his own business. As did my mother, and my brother, and my sister, and myself. We are passionate about what we do. This makes for some interesting kitchen table discussions about customer service, leadership, return on investment (ROI), return on equity (ROE), and net operating income (NOI).

Business may run in my veins, but so does another substance.


I opened my physical therapy practice with the goal of helping people heal the best way—my way—with personalized plans and individual care. I knew going into private practice would be my best shot at accomplishing this. Because of personal experience and the positive outcomes that I have witnessed, I believe in aquatic therapy as an adjunct to a patient’s care. Water soothes, relaxes, promotes movement, compresses, and—when used correctly—heals. From the beginning, I wanted to make water my “niche.” I researched many options and eventually chose to invest in a therapy pool with an underwater treadmill, resistance jets, and underwater video monitoring system. With a pool and a place to put it, I was ready to roll.

Twelve years, three clinics, and 18 employees later, aquatic therapy remains a focal point of our practice. Its mere existence in our practice draws clients to us and its effectiveness brings them—and their friends—back. Water has helped brand us as a premier clinic; expanding into new markets, and serving people with diverse conditions. Along the way we have learned a few things about how to create and maintain a high-quality aquatics program.

One Patient at a Time

Treating multiple patients in the therapy pool at the same time is possible, but at Premier, we like to specialize in individualized care as a best practice. We found patients tend to feel apprehensive when they are being treated in the pool in a small group setting. Some are not comfortable exposing their bodies “publically” in a swimsuit. They want privacy. Others may be rehabbing from a joint replacement surgery and are unsure of their body’s functionality, while others are ready for speed training. They want personalized attention. When a therapist is juggling multiple patients it cuts down the quality of care, at least in the patient’s mind. With a single-patient policy and 45-minute sessions, the maximum capacity each day for our pools is 12 patients. We average 8-12 patients per day.

Invest in the Best Product on the Market

I heard a respected attorney once answer this question from a young, soon-to-be law student. “I’m choosing between two schools. One will pay my way but the other is in the top 10. Where should I go?” His answer: “Always choose the better school. It will pay off in spades.”

I opened my first clinic in 2003 with the crowning feature being a therapy pool with underwater treadmill, resistance jets, and video monitoring system. Since the day we opened, we have strived to provide premium service, special attention, and a more personalized approach, much like a “private school” version of physical therapy. People notice that we are different. Having water helps us “niche” our practice and stand out, but having the best water and using its tools creatively conveys to our patients our dedication to innovation and quality care. Many patients seek us out simply for our aquatic tools.

Create Personalized Programs

Our patients receive individual care created specifically for their situation. Some programming inevitably overlaps, but we progress patients based on their needs for each visit.


Judy suffered from scoliosis since she was a child, undergoing various amounts of pain medication and physical therapy through the years. As she progressed through middle age, the pain and neuropathy increased dramatically. She lost function. At age 55, Judy chose lumbar spinal fusion surgery, from T9 to sacrum, totaling nearly half of her back.

Judy was presented to our clinic two and a half months postsurgery. She was unable to sit during the initial evaluation due to her pain level and limited mobility. After an initial evaluation, we moved her immediately into the pool.

We instituted a Core/Lumbar Stabilization program where we were able to focus on muscle reeducation and establishing the proper firing patterns from the core stabilizers. We also incorporated functional movements such as squats, step ups, and walking.

Judy began the walking program without the use of the resistance jets, holding the handrails 100 percent of the time. She progressed quickly. Soon she was able to walk pain-free in the pool. We increased the treadmill speed, duration of the walk, and added resistance jets.

Judy now walks pain-free on land and has increased her stride length and range of motion. She also drives, sits for longer periods of time and walks—pain free—up stairs. She feels her “spirit has been lifted” as she has regained her functional mobility that she thought might be forever lost.

Educate Others about the Value of Water

Because of some therapists’ perceptions that patients are simply “floating around in the water,” aquatic therapy sometimes gets dismissed as a nonaggressive modality. With the underwater treadmill, resistance jets, and monitoring equipment, this is not true. Many research studies show its effectiveness for advanced recovery time, return to running, exercise advancements, weight loss, and rehabilitation.

Doctors W. Matthews Silvers and Dennis Dolny conducted several conclusive hydrotherapy research experiments at the University of Idaho. In the first study, it was found that training on an underwater treadmill can create a metabolic and cardiovascular environment as stressful as traditional land-based treadmills but with reduced joint stress. In follow-up studies, positive results were also verified with factors such as maximal oxygen consumption, heart rate, ventilation, blood lactate, leg stride rate and length, and perception of effort. Each study confirmed the effectiveness and equivalent responses with aquatic fitness vs. land-based treadmills.1

Offering a low-pain and less-feared method of exercise, physical therapy can greatly enhance patients’ quality of life. In the water, there is no fear of falling. Research from the University of Utah shows that older adults who consistently exercise on an underwater treadmill improve flexibility and even sleep patterns. 2 As we educate patients, caregivers, and practitioners about the benefits of aquatic exercise, we become the “facility of choice” in the region and a valuable asset to their overall health.

Business ownership may be many things, but it is always interesting. My goal in opening a physical therapy practice was to provide the highest standard of therapy with compassion to each patient, focusing on return to function, education, and wellness. Creating and maintaining an innovative aquatics program helped me accomplish this and in so doing, brand our practice as “creative,” “premier,” and “innovative.”

Run a quick check to see what is running through your veins. I bet you’ll find some platelets, plasma, and—if you’re lucky—a little water.

Kelly McFarland, PT, DPT, is a member of the American Physical therapy Association and serves as a guest lecturer for the Texas Physical Therapy Association, HydroWorx. She founded Premier Rehab Physical Therapy in 2003. She can be reached at premierrehab@sbcglobal.net.

Hope and Opportunity

By Stacy M. Menz, PT, DPT, PCS

As I read through Sturdy’s article this month, appropriately titled, “Hope and Opportunity,” I was struck by exactly that, the hope and opportunity that our profession has. The article discusses how when we contract with employers directly to provide services to their employees, we are not only getting their employees back to work, but also we are preventing lost time from work—creating a savings on the company’s bottom line. Through these actions, we are demonstrating our value as a profession.

What I found even more compelling was that therapists are contracting with companies in ways that are innovative. One therapist is working with the ballet, while another works with a tech company. If you are in pediatrics like me, you can contract with school systems (this is the kiddo version of work). The opportunities are there if we as a profession look for them and continue to promote our own value.

Even more exciting is how we have moved beyond just getting employees back to work, we are also preventing injuries and thereby preventing days missed. And as employers ourselves, who cannot get behind the idea of keeping our employees working! What are some of the innovative ideas you and your company have supported employers by keeping their staff healthy? I can only speak from a pediatric perspective, but I know that we have begun using motor groups in the pre-schools where we work, which has cut down on the number of referrals for physical therapy overall; it has also empowered the teachers and staff on how to support their kiddos. It would be great to hear your ideas on our discussion board www.ppsapta.org.

On a different topic, we are going to start running a new column occasionally called “What’s on my Desk?” I know as a business owner, and as a person, I am always looking for new and interesting ideas for things to listen to, read, and explore. So, I am sharing four of the things that I am into at the moment. I would love to hear from other members of the private practice section with regards to what’s on your desk (or iphone, or computer, or ipad). If you want to share, please write it up and send it into me, and we will include it in one of our issues.


More Health Legislation to Come


Is our grassroots program ready?

By Jerome Connolly, PT, CAE
July 7, 2015

Compliments of the Physical Therapy Political Action Committee (PT-PAC), your lobbyist was afforded the opportunity on June 2 to have dinner with Rep. Paul Ryan (R-WI), chairman of the House Ways and Means Committee. For over an hour the chairman engaged in a discussion of a wide range of topics from trade to tax reform. Rep. Ryan shared his philosophy, goals, and strategies as a leader of the conservative movement, the Republican vice presidential nominee in 2012, and chairman of the powerful panel that oversees almost every issue—including Medicare—in the House of Representatives.

The chairman was demonstrably proud that Congress accomplished the reform of the flawed sustainable growth rate (SGR) Medicare payment formula in April, but he openly continues to harbor aspirations for reforming the entire Medicare benefit. He sincerely believes the program as it is currently structured is not sustainable. He is convinced that it can only be saved by converting the entitlement to a premium support plan.

This is not new. Private Practice Section (PPS) members will recall that as chairman of the House Budget Committee, Ryan twice proposed spending plans that would replace the traditional Medicare benefit with a voucher system. To offset the cost, Ryan’s 2015 budget would have taken $140 billion from the SGR (provider payments), and another $110 billion in general Medicare cuts.1 Today, as a consequence of the successful repeal of the SGR in April, such savings would be hard to find.

But now Chairman Ryan says converting Medicare to a premium support plan will pay for itself by increasing competition, improving quality, and giving the beneficiary the choice of the type of insurance coverage purchased on the private market.

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This emphasis on private insurance would further empower health insurers that were situated strategically and considerably emboldened by the Affordable Care Act (ACA), which has resulted in record earnings reports of the nation’s largest insurers since the enactment of Obamacare. To wit: The five biggest insurers in the country are heading into a more stable future after their first quarter earnings reports show that they all are in good financial health in the post-reform market.2

  • Aetna reported that it made $777 million in net profit and $15.09 billion in revenue, an 8 percent increase from last year.
  • Anthem saw a 4.3 percent increase in enrollment (reaching about 38.5 total million members), particularly from its Medicaid plans’ 25 percent jump in enrollment to 5.6 million people in the first quarter. The company achieved a better-than-expected first quarter profit of about $865 million.
  • Cigna’s revenues reached $9.5 billion, an increase of 11 percent from the same time last year, which reflected a growth in premiums and fees.
  • Humana said its revenue rose 18 percent to $13.8 billion.
  • UnitedHealth posted revenue of $36 billion and net income of $1.41 billion in the first quarter, amounting to a 13 percent year-over-year growth. The nation’s largest insurer also added 1.6 million members in the past year.

These are the same insurers who are proposing double-digit rate hikes for 2016.3

Chairman Ryan’s Medicare reform proposal would replace Medicare’s guarantee of health coverage with a flat premium-support payment, or voucher, that beneficiaries would use to purchase either private health insurance or a form of traditional fee-for-service Medicare. (It would also raise the age of eligibility for Medicare from 65 to 67.)

Despite promoting this idea for several years, Ryan has provided few specifications for his premium-support proposal. However, his staff says that he is considering the “average-bid” model described in a recent Congressional Budget Office (CBO) report.4 Under this illustrative option, the value of the premium-support payment in a given region would be based on a weighted average of bids made by participating private plans and traditional Medicare in that region. (The bids would represent the amount that a plan would require to provide Medicare to a beneficiary of average health.) Beneficiaries who chose a plan with an average bid would pay only the standard Medicare premium. Those who chose a plan with an above-average bid would have to pay a premium that was higher by the full amount of the difference.

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The proposal’s impact on individual beneficiaries would differ depending on whether traditional Medicare or private plans cost less in their region, but it would disadvantage beneficiaries in at least two ways. First, in many regions, traditional Medicare would cost more than the premium-support voucher, so beneficiaries who chose to enroll in traditional Medicare would have to pay higher premiums than under current law. Second, beneficiaries who enrolled in a private plan would not receive the federally subsidized supplemental benefits that enrollees in private Medicare Advantage plans receive under current law.5

Chairman Ryan says that his premium-support proposal would not affect people aged 56 and older in 2014. But this claim is unlikely to be completely true since traditional Medicare would tend to attract a less healthy pool of enrollees (adverse selection), while private plans would attract healthier patients. The Medicare Advantage program provides a current example of this phenomenon. Although the proposal calls for “risk-adjusting” payments to health plans—that is, adjusting them to reflect their enrollees’ health status—the risk-adjustment process is highly imperfect and captures only part of the cost differences across plans that stem from differences in enrollees’ health.1

The process of legislating, according to Chairman Ryan, will essentially cease in Congress when the presidential political campaigns get going in earnest (some would argue they already are) so there is a limited legislative window. However, the GOP vice presidential nominee said he expects the Republican presidential candidate to be selected no later than May 2016 due to changes the Republican National Committee (RNC) has made to front-load the primary elections process. This means that little if any substantive legislation will get passed once Congress recesses for the holidays at the end of this year. Whatever does pass prior to that still must gain the approval of the current occupant of the Oval Office.

While Ryan is realistic, he is also determined to use the legislative process in every way possible to help the GOP win the White House in 2016, thus enabling one-party control of the legislative and executive branches. Once this occurs, he will be positioned to attain his goal of “voucherizing” Medicare.

In addition to Medicare reform, Chairman Ryan will attack other health care issues throughout the remainder of the year including bolstering the health savings account program, which he says was eviscerated by the ACA. Two other ACA provisions on Ryan’s radar for repeal include the medical device tax and the Independent Payment Advisory Board (IPAB); provisions that were included as a way to help pay for the health reform legislation. Moreover, he is also interested in reforming the post–acute care market by introducing bundled payment.

Given Ryan’s health policy priorities and our as yet unaddressed PPS priorities that include locum tenens, opting out of Medicare, and the therapy cap, it is clear that there is considerable cause for vigilance and engagement for the remainder of 2015.

Your PPS lobby team is leading the staunch effort on locum tenens and opt-out and participating with the American Physical Therapy Association (APTA)-led Therapy Cap Coalition in positioning the therapy cap repeal for the optimal political outcome.

However, a full PPS membership effort will be needed to accomplish our legislative goals and that brings me to the strength and effectiveness of our PPS grassroots mechanism.

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Your advocacy team was pleased with the responsive engagement many PPS members demonstrated in response to our numerous grassroots alerts on the SGR and therapy cap legislation in April. A similar membership-wide effort will be necessary again this year if we are to succeed.

While we can be justifiably proud that we have grown a large Key Contact program, it must be pointed out that we still lack Key Contacts for important target legislators (see sidebar). Therefore, it is critical that we quickly take determined strides to broaden and strengthen the PPS Key Contact program through which a PPS member acts as a trusted resource and PPS ambassador to a specific member of Congress.

In the Senate alone, a dozen critical legislators do not yet have a PPS member constituent committed to serve as a resource, an educator, and a relationship builder. These vacancies include four senators (Coats, Nelson, Stabenow, Warner) on the important Finance Committee and four members of the Health Education Labor and Pensions (HELP) Committee (Collins, Kirk, Murkowski, Sanders). Separately, three members of Senate leadership (Barrasso, Klobuchar, Wicker) are also without a PPS Key Contact.

In April, we fell two votes short of passing an amendment on the Senate floor that would have fully repealed the therapy cap. Sure, we can be proud of coming so close, but at the same time we should be disappointed. Two changed votes could have permanently eliminated an adverse and discriminatory policy that has been dogging our profession and our patients for nearly two decades. Yet we lack strong constituent relationships with twelve critical senators.

If we had had those strong relationships, which can be established and nurtured through an effective Key Contact program, would the outcome in the Senate have been different? We will never know for sure. However, what I do know from my vantage point of working in congressional relations for over 20 years is that without such connections, the chance of optimal outcome on such a vote is diminished if not obliterated.

On June 4, APTA coordinated a physical therapist Hill Day preparing and ushering nearly a thousand APTA members to Capitol Hill for a rally and for visits with their members of Congress. The previous evening, in her remarks opening the APTA Annual Conference (“NEXT”), legendary tennis professional Billy Jean King stated: “Every single one of you is an influencer.”

PPS has established a Key Contact Task Force charged with the mission of recruiting and training PPS members to become effective Key Contacts. For your patients, your profession, and your practices, please step forward and let’s fill our Key Contact vacancies with eager and enthusiastic private practice physical therapy advocates. Please contact task force chair Kathleen Picard (kathleenpicard28@gmail.com) and tell her you are willing to do your part.

“Every single one of you is an influencer!”


1. Van de Water P, Medicare in Ryan’s 2015 Budget, Center on Budget and Policy Priorities, April 8, 2014.

2. Insurers Navigate Health Overhaul to Rising Profits, Associated Press, April 29, 2015.

3. Nesper M, Insurers propose double-digit rate hikes, Employee Benefit News, June 3, 2015.

4. Congressional Budget Office, A Premium Support System for Medicare: Analysis of Illustrative Options, September 2013.

5. Congressional Budget Office, A Premium Support System for Medicare, pp. 4-5.


Jerome Connolly, PT, CAE, is a registered federal lobbyist whose firm, Connolly Strategies & Initiatives, has been retained by PPS. A physical therapist by training, he is a former private practitioner who throughout his career has served in leadership roles of PPS and APTA. Connolly also served as APTA’s Senior Vice President for Health Policy from 1995–2001.

Insurance Verification


An open door to communication about financial issues with patients.

By Connie Ziccarelli

In these changing times, insurance benefits are also changing with every renewal date. Because of these constant changes and your clinic’s need for cash flow, it is important to verify insurance coverage and benefits for every patient. Whether the patient is new to your office or a return patient, knowledge is the key to smooth payment issues.

With today’s technology, it has become easier to verify coverage and check for benefits on your computer. Most companies make this process easy and user friendly but that is not always the case. Some companies do not delineate outpatient physical therapy benefits from their standard medical benefits. Sometimes the benefits are the same, but I have also found that the limitations differ from policy to policy and even patient to patient within the same employer group. Employers offer different benefit levels based on the policy the patient wants to subscribe to. Do not assume they are the same. Know what those limitations are—whether it is the number of visits allowed, maximum payout, or specific exclusions.

Most patients are uneasy about what their insurance company will or will not pay and what their out-of-pocket expense will be. Notifying the patient of their financial responsibility is an important part of the treatment cycle and to the clinic’s cash flow. Having a conversation or presenting a written explanation of benefits often opens the door to understanding on both parts.

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The important components of an insurance verification letter should be:

  • The date of verification
  • The person that quoted you the benefits (if you spoke to someone)
  • The effective date of the policy and as well as the termination date, if quoted
  • The deductible amount and the amount applied to it, especially if outpatient physical therapy gets applied to it
  • Coinsurance amount after deductible is met
  • Out-of-pocket amount that must be paid before insurance will consider payment at 100 percent and the amount that has been applied to it
  • The copay amount per visit
  • Physical therapy limitations on the policy
  • Whether physical therapy needs to be preauthorized and who to contact if so
  • Who you spoke to in order to authorize care and the number of visits that they authorized
  • Always include a disclaimer stating that the authorization are not a guarantee of benefits and that payment will be considered based on the policy provisions in effect at the time the service is rendered.
  • Include an estimated amount that is due from the patient at the time of service unless prior arrangements have been made with the patient and the method of payment has been agreed on (credit card, cash, or check).
  • Always include a thank you for your business and a contact number if they should have questions regarding these benefits.

By opening the door of communication with your patients regarding their financial obligation you will create a smooth experience and a healthy cash flow. 


Connie Ziccarelli is the chairperson of the PPS Administrator’s Council and an APTA member. She is also the cofounder, principal and chief operations officer of Rehab Management Solutions in Sturtevant, Wisconsin, where she manages, grows, owns, and operates a nationwide network of private practice physical therapy clinics..

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