From a $400 Church Room to 19 Sites, with Yoni Rosenblatt from True Sports, BOAC E#52

0:00I have a relative who literally wrote the book Rookie's Guide to Owning Your Own Physical Therapy Company. And despite that, I'm doing what I do. Went down the PT world and within a year or two, I'm like, this ain't for me. I turned to the owner and said, hey, remember when I joined here, I told you I would help you blow this thing up. It's time to talk about partnership. He's like, here's an extra five grand. And I'm like, go to hell. I found a church that had been repurposed into a fitness facility. It's the only church I have ever been in. And I rented a room in the back of that church for$400.

0:36I basically slept in that church for a year and a half, just treating patients and trying to provide the best. I actually don't care about your CV. I don't care about your years of experience. I first and foremost, and last but not least, care about your growth mindset and your coachability. This outfit doesn't work if it's owned by one individual. It needs to be a collective group, and there needs to be a small amount of ego when doing this. The difference between responsibility and accountability. They're actually not the same word. So part of growth is pain and risk. Everyone needs to assess their own risk tolerance and levels.

1:19You've got to get really comfortable with changing.

1:30family or how does it how does that work no funny you mention it i i have a relative who literally wrote the book rookie's guide to owning your own physical therapy company and despite that i'm doing what i do so yeah it's like a very um ironically he's a lot like me but it's a very different mindset it was a different time in physical therapy we do things differently um so yeah for for what it's worth but no nothing handed down a million of luck a million lucky turns along the way um tons of mistakes i'm sure we'll get into um and yeah i mean happy to talk about all of it and why are you doing this what's your background

2:18yeah uh that's a good question so i used to run clinic uh in elective care also medical aesthetics term um you're an md no you're what you're the business side on the business side yeah exactly uh so ran ran practice operations in new york and in in london um and uh i don't have background healthcare i don't have a cousin who wrote a book on on running a you know you sort of learn as you go before that i was developing medical lasers for skin care so weird journey into into provider operations um and just found there was just nothing there was just nothing there was everything was learning yourself everything was figured out there was no industry concentration of a lot of stuff on clinical.

3:11No clinical. But the business, and thus the business of a clinic with the business was just white space. People reinventing the wheel every time, you know, make a lot of the same mistakes that I made there and that we see, you know, clinics making now. So I left, I left clinic ops, set up coherent and coherent is always on follow-up basically. So follow up with every patient every time, no matter where they are on the journey, inquiries, consultations, long-standing always follow up in a very high empathy human manner because that was the problem we had. Our treatment journeys were really long.

3:46They were sort of 12 to 18 months. People kept dropping off, disappearing halfway through, constantly trying to do spreadsheet math. It didn't add up. So Coherent is full coverage follow up for the entire patient journey. And the business of a clinic, the podcast, is just trying to get perspectives, stories, experiences around the commercial side of provider operations rather than going down the, let's talk about clinical outcomes, which is important conversation, but there's a lot of that conversation. This is really meant to be on the operational side. You know who I think does it? I think dentists do it well.

4:18I think they have a really good understanding of their operations. There is a robust offering on the business side. PT tries. I think to your point, medicine tries um i don't know why a lot of my buddies are dentists and they own their own practice there is a world where they have it dialed in like dentistry and their ability to produce margin on on such a small operation i i am uh jealous i'm jealous i'm jealous i'm envious it's crazy it's crazy what my buddies do with like three operatories as they call them and just like a staff of assistants and just them as the producer it's bananas i think some are better than others but dude their margins are just awesome it's interesting so we we do we do some work in the u.s but most of our workers in the uk and the dentist that we work with here i think you put it against msk or pt or metastatic dermatology it is more mature yeah it is a more Why?

5:22I think it was consolidated earlier. When PE gets involved, everyone starts thinking about business. And I think that dentists went first. I mean, in the US, there's a huge amount of PE consolidation, et cetera. So I think a lot of dentists go into it thinking, OK, I'm going to build my footprint and then either sell or buy or grow, whatever it is. But I think they come in with maybe a slightly more commercial twist. I don't get from the practice owners that we speak, but I don't get the same feeling from people who go in on the MSK, PT, even metastatic side, GP side, general practicing. I think that there's slightly more, I'm going to be a clinician and then, oh, I'm running a business.

5:57Whoa, this is growing. I've got 21 sites. How did I get here? As opposed to, I think, dental, which probably goes in a bit more methodically, thinking about the business. And they have got the network as well. Dentists like to talk to each other a lot. It's a whole in-club in dentistry. It's a party. In the UK, at least, there are all these conferences in like Marbella for like dentists to go party and talk about running there. I just don't think that infrastructure exists in other parts of healthcare market. So for those joining Business of a Clinic here with Yoni, who's going to tell us a bit about his story going from one to 21 or soon to be 21 and the wins, the challenge along the way.

6:34Yoni, I think a lot of people that are listening, they're joining are probably either a clinician turned entrepreneur. That's one sort of audience. And the second one is business of healthcare, exec operators, private equity, consolidators, people looking to buy and build slightly more sort of commercial first. So I think just to give you a sense of who might be listening in. But maybe just to kick off, do you mind a little bit of an introduction? Take us to, I guess, the two-minute version of where you started and how you ended up here. and then we'll sort of go into bits and pieces of it. Yeah, I'm happy to.

7:13Thanks for having me, Jared. I love what you're putting together. Really fascinating. Also, your background is outstanding. So I'm used to asking you what your background is. What do you have on next? Yeah, exactly. So this is my least favorite topic, but quickly about me. Born and bred in Baltimore. I'm a fifth generation Baltimorean. That's in Maryland. It's close to talk to people internationally. And I've always been a sports geek. I was just obsessed with sports growing up. Was always a jock. Thought I was an athlete until I met actual athletes. But knew I wanted to work in that field and I knew I wanted to help people.

7:53So I went to undergraduate at University of Maryland, go Terps. And I'm like, okay, I know I'm a workaholic. I want to help people with my life. Medicine makes a lot of sense. I took chem. I took bio. And I sucked. I rapidly realized I'm a terrible student, but I took physics, I took biomechanics, and I was like a savant. I loved it, just came naturally. So that kind of started gearing me towards physical therapy. I also have a passion for teaching. So that's what PTs do. We spend, I would say, on average, more time with our patients than a standard medical practitioner. So PT seemed like a good fit for me.

8:34I went down the PT world, got into graduate school by the skin of my freaking teeth because my GPA sucked. I got into grad school and within a year or two, I'm like, this ain't for me. That's all they're like pushing down my throat in graduate school. And I'm like, where the hell's the sports? I thought I'm going to be working with high level athletes, et cetera. So like every good Jewish boy, I'm like, screw this. I should be a lawyer. And through the counsel of others, namely my parents are like, just get your degree. So, um, gritted my teeth, got my degree, got out, made a massive mistake, took my, took the first offer that was the highest offer coming out of graduate school in outpatient orthopedics.

9:12They said, yeah, we treat sports. It even said on the, um, sign walking in sports rehab. I saw like two athletes. It was always at 7 PM. I was doing crap like in hallways and in parking lots. And also I was treating like three, four patients an hour. So I was really juggling like crazy. It took me about a year and a half and I'm like, screw this. I'm out. Interestingly enough, I went up to New York City and interviewed all over New York City because I'm like, this is where athletes are. I did my last rotation in Manhattan and just loved the buzz, which doesn't exist in Baltimore. And I realized rapidly that I could get a job up there, I would have had to take a pay cut to go up to New York City.

9:55I'm like, this is backwards. What the hell am I going to do with that? So I found a guy who was starting to do sports. He had his own clinic for like two years. I was his first hire. We knocked it out of the freaking park. We killed it. I was there for four years, probably three years too long, but I was there for four years, but we doubled our space. We moved up to, I think it was like seven clinicians by the time I was just about done there. I turned to the owner and I said, Hey, remember when I joined here, I told you I would help you blow this thing up. It's time to talk about partnership.

10:24He's like, here's an extra five grand. And I'm like, go to hell. And so that's when I took my jump of, I was like 32 at the time or something. And I'm like, if I'm going to do it, I got to do it now. I'm sick of learning what not to do. I want to do it the right way. So what I did was I put up a giant map on the wall and circled my non-compete and then went to look at my competition, put a little button where my competition was. Then I looked at where are athletes and I started, I had zero money, zero. Um, and I found a church that had been repurposed into a fitness facility. It's the only church I have ever been in.

11:04And I rented a room in the back of that church for$400. I made the entire clinic, uh, movable because I didn't have a long-term lease. I had no idea how long it would last it could be i have to go back up to a hospital maybe it would fail um and i basically like slept in that church for a year and a half just treating patients and trying to provide the best i left baltimore county which is like the mecca of uh elite level lacrosse and i was treating all these prep schoolers i went down to baltimore city this is right before we had massive riots in baltimore city in 2014 and all of those referral sources said, you're great.

11:43I'm not sending my kids downtown until I got one or two. And then all of a sudden I started getting these lacrosse families jumping in their car, driving into Maryland or sorry, driving into Baltimore city, um, at a tough time in Baltimore city. And I'm like, Hey, maybe I got something here. And so that was the origin story of true sports. The only mission at that point was to provide the highest levels of care to the highest levels of athletes. over the next call it 10 years that mission changed yes it's to provide the highest levels of care highest levels of athlete now it is to do that and make this the absolute best place to be a physical therapist not just receive physical therapy and by keeping that front and center and really really trying to live the ethos of we are changing the face of the way outpatient physical therapy is done those are our guiding principles and the lens through which we make all of our decisions there's a lot to uh so much i'm sorry to bore you with that jared like we we then now now we've got we've got the foundations established we can start taking the tweezers and going in and grabbing a little piece of it i i think the um i think the place i'm i'm sort of keen to start is uh you said at the end we want to make this the best place to be a physical therapist, why does that matter?

13:11I mean, I get why it matters, but why does it, why does it matter so much that it's going to be number two to your number one, uh, mantra vision, highest performance athletes, high performance rehabilitation? Why does that matter so much? Two reasons. One, I still treat, I know what it's like to be a physical therapist, to be a sports PT. I know the constraints there. Number one is time. You have to have time with your patient, especially a higher level athlete where you need to load them. You need the muscle to respond. You need to tinker. You need to teach, right? So that's why that's so important to me.

13:46We are so protective of our one-on-one for 45 minutes every goddamn time. And I think that's because of we, because of number one, we need our patients to get better. Secondarily, it's, that's how you scale. You scale by virtue of retaining and facilitating talent. And so if this is not the best place to be a PT, those are going to be a massive struggle. But that's why it's so important. So if we're saying, okay, this is the best place to be a PT, I'm assuming that you have a very specific view of the world when it comes to the kind of person that can fit the cultural mold, reach that level of performance that you're expecting.

14:34And I imagine that it's not CV driven. I mean, CV is a component of it, of course, experience, clinical expertise, et cetera. Those are all the givens. What are the not givens? What are the things that you're looking for in a, I don't know what your interview process looks like, but let's say you spend 45 minutes with someone at the end of an interview process, what are your 10 years of experience? This person crosses the line to no brainer. Yes. And I think, I mean, at least our perspective on this and having previously run clinic as well, we often joke if it's not a hell yes, it's a no. So I guess the question to you is what, what does that selection look like at the last line for the qualified candidates?

15:13What are you looking for in someone that gives you the confidence they're to be able to deliver your tier one, your headline one vision for true sports, and then secondarily to reinforce that scalability in the headcount? I think it's the last line is actually the first line. So I actually don't care about your CV. I don't care about your years of experience. I don't care where you went to graduate school. I don't care the level of sport you played. I first and foremost and last but not least care about your growth mindset and your coachability that's it that is number one and that's on the heels of swinging and missing so many times like I used to make it a mandatory fact that you have had to play elite level sport which is ironic because I never did um and time and again I would hire those people or the people from University of Delaware, which claims they're the number one orthopedic school in the country, or University of Southern California, USC, which has a preponderance of evidence and literature coming out of their establishments.

16:20And I just realized I was hiring for the wrong things. You just have to be an outstanding communicator. You have to be excited to walk into the clinic. My COO, who I'm sure we'll talk about later on, is a linchpin to the success of this clinic. He taught me that no one cares how much you know until they know how much you care. And if you don't care about what you're doing every single day, you're not the right fit for true sports. So you went there, so let's go there. So let's talk about your COO. Curious to understand, where in the journey did they join you? So I think one of the things that's always, we see it two ways.

17:01I'm curious to see which one of these actually lands with you. So one way we see the sort of COO remit come into the practice is it's someone that was there from day one and they grew, understand, learn the business and just kept growing, kept eating, kept taking more responsibility. That's one trajectory that we see quite often for groups that go one to 21 or one to 121, whatever it is. The second one is the founder or the founding team was effectively the shared COO until it got too big. And then they said, you know what, I can't do it anymore. Now someone has to hold this for me, you know, hold my mic so I can go over there and do something else.

17:36So which or a third option, I guess, but which of those is more familiar to your journey with the COO and your practice? Yeah. Dr. Tim Stone came in about two and a half, three years into True Sports. We were one clinic. I was ready to roll in terms of opening other clinics. We did in those first two and a half, three years, start to put our systems in place of how we hire, what do we want the culture to be like, what's marketing look like, how do we treat a given patient, a given pathology, kind of writing rule books around all those things, which I think is so important. Bringing him in allowed me to clone myself and allow me to focus on one de novo location, him to focus on another de novo location, us to jointly manage what we had going on in Fells Point, which was the original location, started to introduce the concept of scale, how you do that.

18:30Some of the pitfalls, like I mentioned previously, we definitely learned a ton by trial and error, but that's where he came in. And I think it's invaluable. And I think it's an amazing lesson because so many clinicians, entrepreneurs, the buck stops with them and it's all about them. And that is, I went through a massive exercise of when you open your own clinic, should I call it Rosenblatt PT, Yoni PT? I mean, neither of those are very attractive in terms of marketing, but I just didn't want the buck to stop with me. And you'll see that. You'll see it's difficult to understand when you look through all of our marketing materials, who owns this then?

19:10And the truth is this outfit doesn't work if it's owned by one individual. It needs to be a collective group and there needs to be a small amount of ego when doing this. And I think that's just an important piece of scale. So if you're out there and you're thinking about, hey, I want to start a clinic or I'm about to go through a growth phase, those are important concepts to think about because if it's based on you, they're only so many hours. So it's interesting using that framework, Mark, obviously, when we speak to private equity buyers, consolidators, they would say one of the big things I was worried about is like single practitioner or few practitioner exposure.

19:53Do they own 80 percent of the book, 70 percent of the book? So it seems like that was something you either found out or knew going in, but you made a decision early on. Actually, this is going to be an us operation, not a me operation. So that's good. Probably helps. But it helps now as you guys are hitting 21. on. I am sort of curious that I think that perspective, that belief that it's going to be us, not me, I think that works very, very well when you get a few things right. And one of the things that has to go right is the non-clinical parts of the journey, because the clinical parts of the journey kind of scale with more clinicians, more patients, more clinicians, more patients, more clinicians, you can sort of, they move together.

20:37Like you fit out a facility, you put maximum number of clinicians inside, you try and get full books. As long as the clinicians are delivering the care to patients, it scales and it does well. But the same is probably not true. Like you don't want that same linear scaling of cost-based operationally on a business side to the patient body. So I'm sort of wondering what were the, I guess, the infrastructure elements, What were the things that really enabled the growth on the non-clinical side? You mentioned systems, processes, et cetera. What were the sort of linchpin moments where you said, ah, we've now cracked that thing.

21:12And now as long as we don't totally mess this up, it's going to basically run. It's going to sweat like an asset. It's in place. It's established. What were those things? You remember what those sort of key moments were? Yeah, I do. One is surrounding myself with a team prior to launching. so what does that mean that doesn't have to be a uh an insanely expensive team but i know enough about accounting to know i don't know crap about accounting so to to find an accountant that understands small business can scale with you can speak your language and then like quick note to the entrepreneur who's hiring this accountant let's say um is really being forthright with what you do and don't know so when the accountant brings something up you're like well wait a minute what the hell does that mean?

21:59I didn't learn that. So I think that was one big piece. Another big member of the team is financial oversight, more so than your day-to-day accountant. But what do I do with revenues as they come in? Where can I put them best to work? What does this mean for my personal financial outlook? So the financial team, I went through an interview process along those lines. And what was eye-opening to me was, again, I had$1.54 in my checking account. But as I walked through and interviewed some of these financial advisors and planners, more importantly, who treats you like you already have a million bucks?

22:38What are the conversations they're having with you? And how good of a teacher are they? Because we need to learn so much from that. So I think that was another member of the team that was very helpful, especially when things aren't going right. Think about COVID. You think about a key employee leaves, et cetera. You need that team to turn to. So that's on the outside. Then on the inside, admin-wise, we started to mirror what we did well clinically. You have a staff PT. You have an outstanding clinic director. Then eventually you have a regional director. How do we mimic that on the admin side and get people that care enough to sweat the details of an authorization, a verification, whatever it is that they really care about those things.

23:23You explain to them and understand how that affects the business and vice versa. And so those are very important investments. And then as you invest in that team, one, make sure you're retaining, educating, and giving them a path to grow because they'll exit stage left immediately if they get a better offer, right? and two that everyone is you start to break down those silos and educate the pts on why the admin is important and vice versa we've seen success with that but i think those were the three big turning points accounting finance admin to bring those people under your tent it's interesting that the idea of education across clinical and admin we see this a lot and i think it happens that's healthcare too.

24:09You see it in education, right? Universities, the teachers and the support staff, this idea of like front office and back office. And actually the whole thing breaks down if either of those parts of business aren't really working. So I think that's really interesting to hear. I'm curious to double click on the admin side. So I think the finance side is obviously detailed. It's a viper's nest by itself, but I think people probably have a general understanding of the sorts of things that end up in the finance conversation. When you think about the admin side of the business, what lives there? What do you put in?

24:46I mean, we call it admin, but ultimately it's like business functions. What lives in there day to day? What is the nine to five or nine to nine or whatever hours you guys work? What lives inside admin function every day? What is that person doing? I think anything that falls outside of the clinical aspect, how many repetitions, how much resistance, I want some type of insight or touch points with the admin side to be owning those. I will not say to a PT, hey, you don't touch scheduling, insurance, stuff like that. That's not your world. So don't worry about it because it is their world because it's the patient's world, right?

25:27So if you keep the patient at the center, you have to understand that all the things that affect the patient affect everyone in this wheel, right? They are the center point of that entire wheel. So my administrative team are experts on, yes, the insurance side, verification, scheduling, and there's a lot you can automate and understand, but someone has to own the systems around that. But I also, you know, I'll keep coming back to it. Like there has to be cross-pollination between these silos. So I won't say that all of this only sits on their desk. It's predominantly on their desk, but the clinicians need to be clued in and vice versa.

26:05Like the admin has to understand that an ACL needs to come in three times a week and here's why, and this is why it's important. Here's how long they're going to be coming in because it affects their life, because it affects the patient's life. So the sort of a patient journey for a minute. So we're talking a little bit about, we use ACL as an example. One of the things I think is really interesting is, we always say this, the patient journey is not a straight line. Probably, it's definitely true in PT. I'm not clinical by background, but you come in for a one and done job. I wouldn't say it's a straight line, but it's like vaguely straight.

26:45It's slanty, but straight. In MSK and PT and many elective care settings, outpatient care settings, you've got forward steps, you've got backward steps, you have a twisty roller coaster of a patient journey, you've got spaghetti in a bowl, you don't have this clean need thing of intake, step one, step two, step three, discharge. Sometimes you get lucky, but more often than not, it's a bit of a mess. So I am sort of curious when you think about patient journey, and you think about someone moving through this system of 21 clinics or soon to be 21 clinics that helps you get that consistency in service quality, get that consistency in throughput, not from a clinical perspective, but from a customer perspective.

27:26What are you looking for? Maybe I'll ask it this way. How do you know something's not working? Let's say you've got one site and there's a performance issue and you think it's about the customer, the patient journey, customer journey. What's your detective hat? How do you go triage that problem? How do you go look inside of it, peel back the layers of the onion? You say, ah, that's the issue. The issue was that these three practitioners weren't setting the treatment plan right. And how do you go do that investigation? Again, it's one of the reasons I keep treating because I'm able to get firsthand information from my patients.

28:04And what I'm looking for is ease, is a lack of friction. So when a patient says to me, you know, I came to you last, uh, last year for my shoulder. You already have my credit card. You already have my insurance. Why are they sending me? Why are they asking this crap again? Right? So if, if I wasn't, if I didn't have my hands in some patient care, I would be blind to that stuff. So that's the way I attack it. I want to, as if I'm a patient walking in, what is easy and what has a bunch of friction. And the more friction there is, The more you're going to have cancellations, the more you're going to have roll off of patients or like self discharges, stuff like that.

28:46So that's the way I approach it. Then once I'm alerted to a problem or I feel a problem or whatever it is, or it shows up in the data, then at least I know who owns what steps. The problem is they keep asking me for my credit card information. I already gave it to you. Okay, I know who owns that intake process. let me look under the hood there and understand what that looks like we've had a real learning curve on patient intake so patients come in from myriad of different ways maybe they filled out an online form maybe they texted me maybe they sent a random email right so like we've had to like really try to set up a standard operating procedure of where does that information funnel to who manages that team where does that buck stop how are they incentivized to get it right I think that's the, if it's, if someone doesn't own the task, the task is going to go awry.

29:43Yeah, we, we share your view of the world. In this, in this sense, we, we often will speak with clinic owners who, you know, we, what we do, we do follow up all day. We follow up with everyone all the time, following up, following up, keep following up. And what we often say is, you know, clinics will say, oh yeah, we, we, we follow up now with our business. Great. Who does that? They say, oh, that person does it. What happens when they're out sick? Who does it next? Oh, I don't know. Okay, so like, actually, there is not ownership. There's someone there picking up the task, but if there was ownership, then the person who went away on holiday would make sure that someone else was doing it because they're responsible for it.

30:20There's that sense of ownership. They are going to live and die. They are accountable entirely for doing that work rather than just like, you know, passing the, getting it along. How do you, I'm sort of wondering. You just hit on an interesting topic. Sorry to cut you off. But the difference between responsibility and accountability, they're actually not the same word. When you are responsible for something, it is your job to check different boxes. When you are accountable for something, it is your job to get the task completed. And so whether you're on holiday or whether you're not, and that's something we enforce mightily.

31:00It's a piece of our leadership programming. which is understanding the nuances and the differences there. And when there is not someone truly accountable, rather only responsible, there is a massive gap in a productivity level. And so making sure that it's not about doing the job, it's about getting the job done is essential to leadership. I wouldn't say a true sports, although yes, in true sports, but that's, that is, yeah, full stop. That's business 101. Yeah. Yeah. It's, it's, it's interesting. The, um, I think I'm reflecting on a few conversations that we've had with other guests who have sort of grown at pace and at scale, including some of the events that we do.

31:42And I think one of the things that usually stands out is people who have really tried to embed that in the DNA see the dividends. The dividends really about because it's no longer on their plate. Yep. No longer the thing. They also need to check. It's the thing that they know where to go to make sure it's getting done, but it's not the thing that they also go to sleep thinking about. And I think that's a huge part. I remember when we were opening second site for myself, the first site, I was accountable for everything. It didn't matter, top to bottom, plumbing, HVAC, like the whole, you've been in that world.

32:19So the whole thing came to one point. But when we had two sites, especially because I wasn't in physically in both locations, that was no longer possible. So then the question became, well, who is going to own what parts of that so that I could continue focusing on these other things? So I think that makes sense. I am wondering on the admin side, what we sometimes hear is that staff retention, staff turnover, staff churn, training, enablement, growth, these are challenges. I'm curious to understand your view on that. From your view on practitioners on the clinical side, it sounds like you're really focused.

32:56I'm assuming this is true on the admin side as well, but it sounds like you're really focused on, it doesn't really matter where you're starting. Tell me about where we can go together. What's the journey? What does the growth look like? So I guess the question is, does that carry across? I'm guessing yes, but does that carry across? And what does that look like on the admin side? It carries across, and I think it has to. And in places when it can't carry across, so an admin is stuck to that receptionist, you're going to get churned because they're going to look for a dollar extra an hour. they don't care about the output because there is no accountability it's just a responsibility of did you check them in or not right so one it's tying like incentives so i think that's an important piece that often gets glossed over two it's painting the picture is there a ladder here and in order to climb the rungs of the ladder what exactly does it take and the reason i would push a uh an entrepreneur to understand that is because it it has to be measurable and if you're going to turn to the receptionist, if you're going to turn to a director or management on the admin side, they need to be accountable for a given output, whether that's check-ins, whether that's appointments kept, whatever it is, you have to be able to turn to that.

34:08And that's where the concept of SOPs come from to create a rubric through which you can score so you know how well they're doing, more importantly, so they know how well they're doing and where they're going. Yeah. We would say right now that everyone's two favorite letters right now in healthcare AI, but actually our three favorite letters are SOP. And actually, that's the magic. If you get the SOP right, everything, especially in World of Air, comes for free. If you know what needs to happen, how it needs to happen, who needs to do what and when, then this whole complexity, the soup of mess that comes from running healthcare provider operations usually sorts itself out if you have that clarity.

34:51I'm wondering if we go one step deeper. So you've got an admin team. You're establishing as best you can the accountabilities, who's doing what. Nobody's perfect. Things fall through the cracks. You're at 21 sites, soon to be at 21 sites, 19 sites, 21 sites soon. Where are things still falling through the cracks? Where if you said, you know what, I'm going to take my wrench, I'm going to go tighten things up, we'll go fix that, fix that. We all have a wish list of like the top three things we would do if we just had the time to do those things. At some point, we will have the time, but right now we don't have the time.

35:28Where do you go if you could pick one thing on the admin side, patient ops side? I'm going to tighten that thing up. That's the thing I'm going to do next. Accounts receivable. Okay. Say more. Go on. Yeah. Like, like understanding what should be collected at time of service, understanding what percent of that you are collecting, easing or smoothing out the points of friction to getting the patient to pay. I think that's the lifeblood of any clinic. So I would put that as number one. Two would be a patient cancellation. like understanding um enact a you know we're paying a given amount to attract a patient when that patient books that's great that's a win when they don't show you just blew that money right so so understanding what leads to cancellation um how do we fill that spot to try to recoup some of that lost revenue good ways to do that i think those are two places that we're always trying to iterate on um and we want to get better at yeah it's interesting In the cancellation one, we're doing some analysis on some of the, we see a lot of data on inquiries and retention and recall and all these different touch points.

36:44And we were looking recently at this marketing campaign. We don't do the marketing, but we sort of receive the marketing, if you will, that inflow. And it was really interesting. the clinic was spending a meaningful, meaningfully on their marketing spend, principally on Meta, bid on Google as well, trying to drive top of funnel and thousands of pounds a month. And what we came to discover when we started seeing that lead volume was that there was a huge amount of volume of patients coming through validating campaign performance that actually had no idea what the clinic was. And that's bad targeting, bad setup.

37:21But if you miss that, You are tens of thousands of dollars in the hole on campaign performance. I think it's interesting you say cancellations, especially at that first visit. Why do people book and then cancel? That data is not easy to stick together. And so, you know, you're optimizing a meta campaign or Google campaign. You're saying, oh, great, we're dragging to the booking. They book. But then there's this issue that happens sometimes after the data is disjointed. You say, hold on a minute. And actually, I'm optimizing spend on a campaign or on a cohort of new inquiries that actually only stuck the landing 70 % of the time, not 90 % of the time.

37:57And that 20 % is a huge problem. How do you interrogate that now? It's like oftentimes gymnastics, but what sort of stuff do you need to do to get in at that level of detail? Yeah. So, I mean, now we're able, yes, we're able to see the flow all the way to booking. But now we're able to reconcile that booking with did the patient actually show. That, in actuality, it's a different metric. The marketers don't want to see that because they're tasked with getting, right? They're tasked with the win is they booked. It's your job as CEO or maybe it's CMO or whatever to say, wait a minute, they're not actually putting dollars in my pocket if they're not seen.

38:36And so it's important to go to your EMR, go to your point of check-in, whatever it is, to really validate and understand, is there leakage there? And if so, how do we put in a stopgap there to make sure that they're coming through? But that's how we check it. I think it's really important. Another thing we'll do is the marketing agency who's controlling your spend and giving you all of that data like that you're seeing, Jared, as it trickles up to you, they're going to claim anything that has a heartbeat. And so I look at it and I'm like, wait a minute. If the doctor says you got to go to True Sports and then they go to Google and they click on our ad, well, marketing says we got you that lead.

39:20I know I got us that lead or whatever. or we did it via grassroots. So it's about having the pulse. This is why, and maybe we'll get into it, but this is why it's so important that you create a leadership structure that knows the pulse of your clinic. And so if I look at a given facility and marketing is saying one thing and I can turn to that clinic director or regional director or whatever and say, hey, what were your numbers the other day? Or what were your numbers last month? Okay, wait a minute. You had this many evals, but marketing saying you have this many evals, what is that gray area there's always going to be gray but it comes back to the teams you're managing and i think this is an important piece this this comes out of extreme ownership by jaco willink and that's something we try to do here at true sports jaco willink doesn't know crap about running a physical therapy company he knows how to run a business and so we're always trying to look at how do we pull from the outside world and apply it to our business he has a great understanding of leadership structures.

40:22And he looks at it and says, how many people can one person manage effectively? And really that number is right around six. Okay. That's way. If it's me being CEO and I got 21 locations, that's a minimum of 21 people directly reporting. It's not going to work. You need levels that are managing six. We say six to eight people at max so that they know the lifeblood or they know the pulse, I should say, of their direct reports, they can get you that data. That's the job of your management structure. And that's how I would handle that. Interesting. I'm sort of smiling because the attribution problem, we see a lot of that in terms of our work with clinics and interacting with marketing agencies, but also for ourselves because we're doing, you know, we do recall programs and follow-up programs or cancellations.

41:18And the clinic rightly is saying, you know, who booked? And we're saying, here are 300 people who booked. They said, oh, that was my cousin. They were going to come back anyway. And we always say like, okay, cool. We don't know. Like, we don't know that's your cousin. We won't contact them. You know, it's fine. System will say no. System will say don't contact the cousin. So I think it's interesting to you say that there is the, and, you know, Google has had this problem for the entirety of its existence. There's like direct and assisted. But it's interesting, the idea of finger on the pulse. Do things feel like they're moving in the right direction?

41:54And we've heard this from other clinic owners as well. It's like, hey, wow, we had a phenomenal month. That's the result of a thousand small things. It's not a silver bullet solution. Wow, we changed the color of the front door and suddenly everyone walked through. It's like, life's not that good. So you have this constant pressure. I'm curious when you think about the gray area. So I think a lot of people experience this in healthcare. You can't really connect. It's not e-commerce. People don't look to the page. You can't track them all the way through, understand all the, oh, they clicked on the red shoes.

42:28Then they bought the green golf club. Then you just, again, life's not that good. How do you think about the gray? How do you think about managing the gray? What is your acceptance of the gray? How gray are you willing to go. That's a very interesting term. I was going to say you have to have comfort. Acceptance is interesting. You got to accept the gray. I think early on, I was not one to do that. And I think it's a fine line. Like you have to understand that there will be gray. You have to manage and mitigate against the gray. And when you put your head on the pillow at night, you have to be able to do that saying to yourself, there will be gray.

43:07Yeah. I share your view. I think it's a hard one to swallow. Oh, yeah. And I guess also, depending on what the shape of the gray is, there's always a question of what else is coming out of this thing? Because your marketing agency may deliver X and you know it's actually 80 % of X. That may still be acceptable, number one. Number two, you might learn a whole bunch of stuff. Maybe you tried a new campaign and you realize, wow, that was crazy and it didn't work. But now I know we shouldn't open site number 22 over there because that really didn't move the needle. So I think it's like, how else can you learn?

43:43Maybe you reach out to a bunch of patients, they book, but they also tell you, hey, they had a bad experience with your practitioner. That's like, great. That's 10x the value of their appointment is that we actually have this infrastructure issue with the staff that needs to be addressed. I mean, you're describing a growth mindset. I think a limiter in growth in scale is not having that and not being comfortable and seeing what you can mine from the gray. I think if you get so wrapped up in the details that things need to be 100%, let's say, on your marketing spend, you're not going to take a gamble to open up two clinics down in Georgia because you're paralyzed by the fact that you haven't figured out every single goddamn thing up here in Maryland.

44:28So part of growth is pain and risk. Everyone needs to assess their own risk tolerance and levels. That gets easier as you scale. But I think you have to be comfortable with it. It's something I preach to my leaders all the time and they preach back to me, which is you got to get really comfortable with change. Change is not a bad thing. Change is pushing the needle forward. And that's something that I mentioned, like, what do I look for in an employee? It's a growth mindset. It's like, are you willing to change and coachable? So it's got to be the same thing with management. It's the same idea.

45:06Yeah, I'm conscious of time and you've been very generous and you've got 21, sorry, 19. I keep living in your future. I appreciate it. 21 times to look after. One final question. That's a lie. Two questions. One question is, I'm always very interested in the idea of patient support. And when I say patient support, I mean the equivalent of customer support. So you buy an airline ticket and you have an issue, you write to their support line, effectively admin equivalent, but customer support outside of healthcare is a multi-billion dollar software and services industry. Support, just support, customer support, you have a problem with your purchase, you have a problem with your...

45:54Where is that in healthcare? Where is healthcare's version of customer support? So one question. And are there tools that you've seen or things that you do? Or how do you think about customer support? Because it seems like healthcare is, I don't know, in the US, it's double digits part of the economy. And yet, massive service and software category, customer support, massive sector, healthcare, these two things seem to be sort of ships in the night. It's not very often that you see a healthcare practice using Zendesk to run their customer support. So patient support is one question. Let's start there.

46:29Patient support. How do you think about patient support? How do you deliver that at scale in a way that you feel is high quality, authentic, high empathy, matches the brand, matches the ambition, but doesn't make people sit in an email inbox all day? To answer the first question, where is it in healthcare? It's in the Stone Ages. the way I think about it comes back to our previous conversation around accountability who am I holding accountable for that patient being responded to and if you can solve that puzzle that patient will be responded to and if they aren't then that person knows or that person's management knows manager knows that they are not being accountable for their desired workout product so you it comes back to those basics but that's the way i think about it so at true sports if you have a problem we have a very simple way for you to reach out to us whether it be billing whether it be admin whether it be clinical we have different people who are accountable for those things that rolls up into a data point to tell us how many people are responded to and by the way like a real outflow of that is our ar it's like how how much is sitting out there that the patient doesn't understand or doesn't know or whatever um and so like understanding and owning those processes comes back to as many things do accountability and the management that that lays within it that's the way i think about it makes sense then now i'll now I'll tell the truth.

48:03My last question for you is you've been doing this for 10 years, plus or minus. A little longer. The journey continues. It sounds like you've got a lot of energy and there's a chapter two, a chapter three, a chapter 25. I think it's probably easy, especially right now, given how much is happening in technology, how much that technology is hitting healthcare. It's very easy to talk about the things that are going to change. I think the thing I'm really interested in is what's not going to change. So if we imagine we reconnect in five years time 10 years time now you're in 215 sites whatever number of sites you're going to be in what will be the same i can imagine a lot of things would be different what will not be different

48:44one-on-one sports physical therapy i honestly i was terrified around covid um covid happens everything shuts down right all these patients are trying to do virtual and i'm like this is going to be the future not only that we have all this markerless motion capture it's really impressive like what we're able to pick up without putting stickies all over your body the way we can coach around it and what i learned during that we weren't using the markerless motion capture because it wasn't available at scale but when we're doing telehealth it pales in comparison to sitting with a patient and watching the full system move and then how do you motivate and that's what we are we're teachers we're coaches who are experts in biomechanics and you can't put those things together you can do the expert biomechanical analysis virtually or from a distance maybe even asynchronously um you can come up with the treatment plants and like understand the clinical to understand what makes someone tick they're coming into your office.

49:50I don't think that's going to change. At least not in your journey. Maybe in 300 years time, we're having a conversation, but yeah, fair enough. I've heard that answer a lot, by the way, very similar version of that. We can automate away 99 % of the background noise, but at the end of the day, there is something about that, I'm going to call it human to human, but there's something about that sixth sense quality, that relationship string that connects provider and patient, if it's vibrant and authentic and trusted, that serves as, you know, there's a great study that says patients who like, trust, and respect, or whatever it is their provider or their practitioner, are X percent more likely to complete a clinical journey, or Y percent more likely to complete a medical journey, take their medication on time, et cetera.

50:43Same as classroom teachers, right? You can automate all the way, all the tutoring away, but kid shows up at 4 p.m. on a Thursday for extra support because they are in it with the teacher. Like that's the emotional connection there is the thing that they're, it's almost the point of leverage is the instructor's ability to move through that. Okay. So two things there. One, I want you, Jared, to poke a hole in that because I worry that I'm so biased. It's my livelihood, right? So I want you to poke a hole in the fact that I can be totally replaced by another offering. So that one. Two, everything that can be automated that would therefore rob me of the ability to spend that one-on-one time and provide the level of care that we pride ourselves on, I am dying to automate, dying to, because I am protective over that holy of holies of the one-on-one patient model.

51:41And we've done that. Like you walk into a true sports, you will not see technicians, meaning like exercise techs. You won't see hot packs and cold packs because that robs me of the ability to provide one-on-one care. We have a kiosk when you walk in. Here's how you pay. you can schedule via kiosk. Why? Because I want to allocate my overhead to the Holy of Holies, not to the other crap and the noise. So that's where my headspace is, but poke a hole in it. Tell me where I'm going to go wrong. Look, I have no idea because I am not a - You're the expert. I'm not a one-to-one PT. I don't have a background in MSK.

52:25I've been a benefactor of great physical therapy, but I certainly wouldn't claim to know enough about that relationship to understand why it is, to your point, holy of holy, the thing that people show up for. I think that the thing that we see, the thing that we're seeing in the UK, there's a business, name is escaping me, but they're doing AI-only physical therapy where you basically interact with a video model and that if you reach a certain point of clinical escalation, it shoots up to a person. That's being done in the public sector. I think I think the thing that's really interesting is there are demographic, societal, socio-demographic implications of this, which are probably for a different conversation.

53:06But I think the reality is that in hands-on health care, and I'll put PT, MSK in hands-on health care, I'd put dental in hands-on health care, I'd put a lot of people touching you. We have a very long road ahead of ours. I mean, I spent seven years regulating, developing and regulating a completely novel medical device that blasted enough energy to light up the city of Paris into your skin. Like, that journey was not straightforward. Yeah. And it was seven years. And we were doing something with skin. I mean, like, how bad can it get? It can get bad. It can't get that bad. You know, it's not going inside of someone to take out their whatever.

53:56The realm of bad is, you know, I think when you touch people, you have two different kinds of almost headwind that are going to accelerate adoption technology in the non-clinical journey, but slow down adoption in the clinical journey. The first headwind is actually what will the customer accept? I think it's very easy to think about innovation and, oh, it's going to make practices more efficient and it's going to put people on jobs. But at the end of the day, people need to pay for a thing. And we don't yet know, we're very far away from knowing what will the mass market accept from a hands-on healthcare perspective.

54:35There's a business in the UK, I think they're opening in New York now, called Neco Health. They do full body scanning, founded by the founder of Spotify. It's a very outer world experience. You go in, they take 10 ,000 pictures of you in like one minute. They profile your whole body. They give you like an Iron Man workup of what you look like. And they say, I went to do it. They told me I had to, they said, oh, we should investigate this thing in your heart that no one looked at. Turned out it was fine, but they catch all kinds of stuff. And probably 10 million pounds,$10 million to set up that facility per site, given the tech that's in there.

55:07You still have a person who's taking you through that journey. I just I think we're probably I think you can probably deliver a lot of the care in automated fashion doesn't mean you should yeah so I think patient acceptance is an unknown practitioner acceptance will need to come first but I think patient acceptance is a thing that's outside of everyone's control what will people actually allow you to do as opposed to what does the business of the clinic actually want to do sure we'll do everything automated cool but if my patient doesn't stick around like I still have a business to run I still have a that's like one unknown I I think the other unknown, and I spent a while very unproductively trying to get involved with electric aviation.

55:46And electric aviation, for many reasons, that was a bad idea. Wasted a long time, but a lot of fun. One of the things I learned in that journey was when you put a bunch of people in a small tube, 30 ,000 feet in the air, with a battery or a hydrogen electric battery, that's not an easy thing to do. and one thing going wrong sets back the clock 20 years. And it's sort of stupid because people hit each other with cars all the time. Actually, it's probably safer to have a fully autonomous car than it is to have a person drive. It just probably is statistically. And yet 10 autonomous car accidents probably set back the clock much more significantly than 10 human accidents.

56:30Every time someone does an accident, they're like, oh, we should redo the driver's license test. We don't respond that way. I don't know why, but we don't respond that way. So I think there's going to, the thing I don't know, and you can look at like social media as an example, social media happened and it went boom. And then suddenly we had a mental health crisis for young people. And the backlash comes 10 years after the swing. and we have no idea what this back like this whole like ai and how we have no clue what the backlash will be will there even be backlash so i think the the question of like will you be replaced with i have no idea but i think the answer will be much more known when we start to see the backlash as opposed to the promise and i think that's like that's a we've got to cook the soup a bit longer you got to soften the soften it up even more i don't know what that's going to look like yeah that makes a lot of sense it kind of it kind of reminds me the way we do home exercise program at True Sports is we have our own in-house app.

57:24And what the app allows you to do is record the patient while they do the exercise that you just taught them six seconds ago. Allow me to put my voice over, create that video, throw it into their file. This is the exact exercise I need you to do. This is how I need you to do it. Here's how you're going to screw it up. I cover that in a 20-second snippet, put it into their app. Okay, it's not genius. It came out of me texting my patients on their iPhones and just sending them the videos that I was making. But the reason I highlight that is because every single patient pathology joint is so unique.

58:04I cannot automate that because I'm going to have to teach the AI certain rules and that rule might not apply to Jared the way it applies to me. And so there are just millions of iterations that get solved with one one-on-one interaction. That's why I am so protective over that. That's why at the core of true sports, it is, is this the best place for a patient to receive one-on-one care? Because all of us are individuals. Yeah, it's interesting. A closing thought for me, at least, is I was speaking to a clinic owner in the UK, she has four sites, she's an osteopath by training. and I was telling her about, I was telling her that I was growing up, my uncle, big guy, very athletic, my uncle, he had back problems.

58:54And he went to, I was a specialist, specialist. Eventually ended up with, I think it was a physio or osteopath car. It was physically there, one-on-one, you know, right there in the seat. And the person looked at him and said, why are you sitting funny? He's like, I'm not sitting funny. He was just standing up for a second. and he had a really thick wallet and he was sitting on the wall and the wallet was throwing off his alignment because he was sitting at all day at a desk and it was you know three inches higher than the other side of his body take the wallet out of your pocket took the wallet out of his pocket and you know four months later things start to feel yeah do you catch that you know purely maybe i don't like who knows yeah but you know that pat that i think that's a hard thing to get rid of i think it's a very very hard thing to get rid of i i don't i don't mean we work with AI all day, we work with tech all day.

59:44We do not yet see a path. We do it in the least clinical part of the healthcare journey. We do not yet see a path where the human disappears. Maybe the human becomes more efficient. Maybe you have less humans. We do not believe that we are yet at a place where you can go bye-bye human. And we're doing booking. I mean, there's only so many way to book someone in. Forget biomechanics. There's a whole long more way. So I just don't think we're there yet. It's my personal opinion. I could be wrong, but that's my personal opinion. I hope you're right. Yes, please. Yoni, listen, thank you so much for the time.