He Treated in High-Security Prisons & NHS, Now He Leads 160 US Clinics | with Richard Leaver, Alliance PT

0:00I have worked a little more than 10 years in the private equity world for outpatient physical therapy. A real cultural shock in many ways, both one practices as a clinician, but also really philosophically how treatment is provided, even how healthcare is positioned as almost a commodity here. If you don't provide quality care, nobody's going to consume your service. Then only then can you then worry about the financial aspect. Nine years ago we didn't exist and then we have grown to a point now where we have approximately 160 clinics in 18 different states. In the past we've had to throw significant non-clinical labour at it through the use of bots and AI.

0:45That is changing. We have the technology to automate 90 % of tasks but we can't do it because of the human side. We are waiting for people to catch up. Every business is now a technology business. Whether you like it or not, the problem within the U.S. healthcare system is how care is reimbursed. And that needs to change.

1:21Hey, everybody. We're back for another episode of Business of a Clinic.

1:26Jared Aron: Today with Richard, with Alliance Healthcare. Full transparency, we tried this earlier in the week. We had some pretty horrific Wi-Fi and technical issues. So we're back for what is effectively round two of part one. So I think with that in mind, Richard would love to just get everyone to know who you are, give them a backstory. How did you end up here on this call, doing what you're doing? Just take us from the start to now. Absolutely. Again, thank you for allowing me to join your show. I'm humbled to be a guest. Without further ado, yes, I am currently the CEO of Alliance Physical Therapy Partners.

2:03But to get to that position, I've had a long and winding journey, starting obviously by the accent originating from England, training in England as a physical therapist, working 10 years in England in various health care settings, including the National Health Service, and then spent many years in industry. before meeting my American wife and then ending up actually in the U.S. So I've been in the U.S. for approximately 25 years now, and I continued as a physiotherapist or physical therapist, treated for many years, worked in pretty much every conceivable healthcare environment imaginable from high-security prisons, industry, physician-owned practices, managed service agreements, magnet status, hospitals, etc., etc.

2:54But I think what's probably most interesting for the listeners is actually I have worked approximately 10 years or a little more than 10 years actually in the private equity world for outpatient physical therapy. So my whole career has been in physical therapists. The majority of it has been actually treating and then I gravitated towards leadership over the latter third of my career. And then I joined Alliance Physical Therapy Partners when it was really a startup nine years ago. now. And from that humble beginnings, we've grown into a well-recognized, respected national provider of ag patient therapy within the U.S.

3:35Jared Aron: It's a transatlantic journey. It's an enormous journey. NHS to U.S. private equity. Yes, a real cultural shock in many ways, both one practices as a clinician, but also really philosophically how treatment is provided and even really how healthcare is positioned as almost a commodity here and the kind of the differences between internal, external, locus control when it comes to patients, et cetera, et cetera. But we're not here to talk about the clinical side so much, but yeah, definitely some blood, sweat and tears went into change with practice patterns when it came to the US. I'm this is not the the we'll get into other territory but I can't not take the bait and the bait here is for someone who doesn't know anything about U.S.

4:31Jared Aron: private equity in a health care and the NHS what metaphor would you use to describe the two of those how would you describe the differences between the national health system in the UK and U.S. private equity based outpatient health care How would you describe those two things for somebody who knows nothing about either of them? There are differences and similarities. Obviously, the NHS I left 25 years or 30 years ago now is very different than the NHS now, so I'll preface that. However, philosophically, I think the NHS is still the ideals of the NHS, to the say. The NHS essentially is free at source.

5:12It is there to, there is no discrimination in any manner. And the concept of also it's there to help individuals or help society improve their quality of life through healthcare provision. So it's very much an ancillary service where the responsibility, I believe, in large part is down to the individual and certainly places responsibility of individuals within society to respect and to control consumption because there is a cost to society associated with it. So one could say it's socialist. I say that half in jest. And then when you look at the private equity world, it is ultimately a for-profit system.

6:03So if you compare and contrast, again, being flippant, you could argue capitalist in nature. But having said that, though, in order to be able to provide great care, the same principles are the same. They're the same principles. It's essentially how to get to deliver great care ultimately is the same, regardless of whether one is focusing on a profit-loss sheet or not. So I don't want to bash one system over another. It's just a different way. And again, it's really just saying one's private, one's public, which is better, which is worse. They both had advantages, but they both have disadvantages.

6:44Jared Aron: So I think it's interesting. You can tell, obviously, I did the opposite journey to you. And we talked about that last time I was US based and now I'm here in the UK. So I think coming from a for profit health care system and now being in the UK is my first experience with the national health care system. I always think that one of the things very interesting is when you run the business of health care, you think about care delivery, not clinical delivery, clinical delivery to your point, they're probably still very consistent themes in providing great care. But from an operational perspective, you think about it differently because you are accountable to a number at the end of the year.

7:23Jared Aron: And that number determines whether or not you exist the next year and the year after that. And I think the DNA and the decision making that comes with that posture, there are some merits. There are some issues as well, but I think there are certainly some merits to letting the business agenda drive and or be a big part of the healthcare agenda or the service agenda, I should say, not the clinical agenda, but the service-based agenda because ultimately it is a consumer-facing service. I'm curious, when you think about your work today, when you look at making decisions that drive the organization forward, how often are you wearing a hat that says, I'm going to look at this problem and understand this problem through the lens of a clinician?

8:11Jared Aron: I'm going to make this a clinical in nature problem, as opposed to I'm going to make this a business in nature problem? Or actually, are those two things inextricably linked? And actually, every problem is both? How do you think about that? Yes. Yeah, that's really good. I think to finish off the NHS versus any American system, I think the one final point which ties into the next question is the irony is the American system is trying to move towards concepts and types of delivery systems that are actually more aligned with the NHS. and then the NHS is trying to embrace ideas, concepts, strategies that are aligned with the US, which is really quite amusing.

8:58But regardless of that, as it pertains to being, how do I think about the business and is it clinically orientated in my decision-making, I think what works well in the US, for physical therapy at least, is delivering great clinical outcomes thankfully aligns with financial success or viability. Because those are aligned, it allows me as the leader and the clinician, it allows me to be able to broach operational conversations and strategic conversations around the clinical side in the knowledge that the majority of the business aspects will also be positively influenced. So I have a saying with the team, and what I say to the team is our goal is to provide compliant, quality care on a fiscally responsible manner.

10:04That's one of my mantras. I have many mantras. And this is really important to unpack because this really gets to the crux of it. Regardless of which system you work in, first of all, you have to be compliant.

10:19Jared Aron: Okay. And compliance, we can argue about the nuances of various compliance programs through commercial payers, et cetera, et cetera, federal government. But ultimately, compliance is there to ultimately try and achieve a certain level of quality. Okay? And safety primarily, and then quality secondly, but safety. And you have to be compliant to be able to have your doors open. If you're non-compliant, you won't even have an organization or a business. So that's the first thing. You've got to have your doors open. Once you've got your doors open, then you've got to provide quality care. Because if you don't provide quality care, nobody's going to consume your service, and certainly nobody's going to come back and consume it.

11:04And then only then can you then worry about the financial aspect. Because if you haven't got the first two in place, you won't even have a business to worry about financially. And I think where businesses sometimes slip up, and certainly within health care, is when they get this order incorrect. Either they miss a component, or the order is wrong, or the emphasis is inappropriate. So as a clinician, I find it easier, I believe, compared to non-clinicians, and this is a gross generalization, to really comprehend the compliance and quality side. Where I struggle a little bit more, perhaps, is the financial side.

11:49But I have great non-clinicians to worry about those things.

11:54Jared Aron: It's interesting. There's a gentleman that we spoke with recently by the name of David. it. He's on the fund side. So they have a large healthcare portfolio. They buy businesses, all up and down life sciences, including in healthcare provider operations. And he was telling us a story about a care home network that they acquired. That was, everything was down to the right or down to the left or however you want to describe it. It was not going well. And they acquired the business and the fund strategy actually matches is exactly what you just described. So he didn't use those words, but the fun strategy was, he didn't use the word compliance, but he ultimately talked about quality first.

12:35Jared Aron: So let's establish the quality, then the financials come for free. Rather than going in and thinking like, how can we hack this thing out and cut here and cut there and change this? The focus was very much on the core business of delivering, as you're suggesting, compliant quality care, and then subsequently focusing on financials because the foundation is really in place. So it's interesting to hear that come through. And I imagine a lot of providers would feel similarly. Just so that folks who are listening, just so that they have a sense of when we're talking about compliant quality care, can you give us a sense of the scale of the footprint right now for your group?

13:12Jared Aron: How many patients per week, sites per whatever, your choice of metrics, just to put us in a world so that we understand how we think about this? Yes. Nine years ago, we didn't exist. And then And it was really a startup mashed together with a turnaround. And then we have grown to a point now where I think we have approximately 160 clinics in 18 different states. We have injury prevention services as well in other states. But our bread and butter is our outpatient physical therapy clinics. And we see this year we're on Powerley Target to see about 1.5 million visits within our outpatient clinic.

13:49So a sizable operation. And we have a level of complexity where we are in so many different states. And that definitely presents some challenges for really compliance beside of it and the idiosyncrasies of various state laws. But yeah, we're a medium-sized provider, I would say, compared to some of the others. That's certainly large enough to have scale.

14:14Jared Aron: Yes, it's 100 plus. I mean, it's an incredible journey to go on in the course of a decade. So congratulations. either things are going very well or people are losing a lot of money it's one one of those two things let's assume it's the former that's really interesting so a million plus patients per year now i think so i come from healthcare provider operations background as well i used to run medical aesthetics dermatology sites one of the things that i always thought was interesting was the inevitable truth in serving patients is that you have infinite patients and finite staff. So your patient body continues to grow.

14:54Jared Aron: Every year you see another million people. So by the end of the second year, you've got 2 million people, but you haven't doubled your staff size. So your staff are a fixed resource. Obviously, you can add more on the business side, on the admin side, the clinician side, but ultimately you have a rapidly accelerating patient body, rapidly growing patient body, and you have a much slower growing team to support those patients. And when I say support, I'm thinking specifically about the non-clinical components of support. Obviously, you can add more practitioners. But if we think about the admin side, the service side, that relationship, the ratio changes very quickly.

15:30Jared Aron: If you think back nine years ago, your first patient, you had one administrator, the relationship between patient administrators and patients was one-to-one. And now it is certainly not one-to-one. It's probably one to many. I don't know exactly how many, but many. I'm curious from a leadership perspective in terms of creating business value, but also in terms of serving your patients well, how do you think about scaling and enabling patient support at that scale, at that volume? A million plus patients a year, a lot of people, far too many people to match one-to-one. So how How do you deliver at scale in a way that maybe others don't or can't really imagine if they're not operating at that scale?

16:13Yes. Before I answer the question, I think just for clarification, we see over approximately one and a half million visits. So not quite a number of patients because all patients have an episode of care, but it's still pretty large. A lot of patients. Yeah, fair enough.

16:26Jared Aron: Still a big number. The question of the non-clinical side is actually not as relevant or as important as the clinical side. So let me explain a little bit. Ten years ago, I would imagine the majority of outpatient physical therapy clinics in the States, their primary concern was actually patient volume, achieving sufficient number of new patients to actually achieve a certain level of more what I call normal comfortability in the clinic. It's flipped. The majority of clinics now are challenged through a structural long-term shortage of licensed physical therapists within the U.S. And there are a number of reasons for that.

17:21the one that's most commonly talked about is really the aging population. But there's also really the financial ROI of actually becoming a physical therapist now has been diminished to the point where other healthcare professionals or other professions generally are more attractive from a financial perspective, et cetera, et cetera, et cetera. So really the ability to serve from a conservative musculoskeletal perspective if the American population is, as you say, being constrained, but not so much from the non-clinical side as primary for the clinical side. The non-clinical side, the way that's being addressed, and I think for the first time in my career, is truly through technology advances.

18:10We've talked about technology for many years and the idea that technology would generate both improvements in quality and also financial savings. And I think only now or recently have I really seen this in practice. And I definitely believe that the implementation of AI across the clinical and what's more importantly at the moment is the non-clinical side, to be honest, is delivering significant changes, improving quality, but reducing cost as well. So I think we're in a watershed moment where society is acknowledging multi-generationally the use of technology, is accepting that. because the technology has been around for a little bit.

19:03It's the acceptance has been the primary issue that has allowed us to scale or will allow us to scale without increasing substantially the non-clinical labor hours. Now, there will be an increase, but incrementally it's going to be less or ratio-wise. And the other difference is when I worked in hospital, the ratio of non-clinical and clinical was very different than when I worked in the private equity well. In hospitals they had a very high number of non-clinical staff like you were talking about compared to the ratio that we have. But an example of revenue cycle for instance, in the past we've had to throw significant labor, non-clinical labor at it to be able to get verification, authorization, dropping bills, reworking claims.

19:57But through the use of bots and AI, that is changing. And for the good, but you're going to almost end up with a battle between the payers and against the providers with regards to the technology, innovation and application of it. But again, that's a different podcast.

20:16Jared Aron: It's interesting. A lot of the work that we do, we don't touch revenue cycle. We are very much focused on engagement, patient support, help desk effectively, but help desk that's very empathetic, very conscious and aware of the patient body, very sensitive, very high empathy. So we don't really touch revenue cycle in the same way. Someone wants to describe it as sort of Zen desk for healthcare in a sort of one-liner. And it's interesting to hear you say that because one of the things that we find is that we agree technology can offload, AI can offload an incredible amount of

20:58Jared Aron: low value repetitive work. This is something that it is exceptionally good at doing. And there is something at that last mile, at least in the patient interaction, that we have struggled to make non-human. What we often see is that 99 % of the job, 95 % of the job, 90 % of the job can be automated away that at least when it comes to the patient interface, that final threshold, that monitoring safety reliability piece, it's not there yet. Maybe it gets there. Maybe it doesn't get there. But there's something in that last mile that we have not yet felt comfortable to say, you know what, we can go totally hands free, human out of the loop entirely.

21:50Jared Aron: It's getting more and more loop and less human. But we've not yet, at least in health care, found that you can reliably deliver that end to end resolution. I think it's probably different than buying shoes online. Quite frankly, if someone gives you the wrong return order slip, it only you can deal with that. The downside is manageable, is compressible. You don't have the same reality in healthcare. So I'm curious, from a CEO perspective, you're now looking at this technology. You're saying, okay, we're at this moment, this critical moment in time where technology can actually do the thing it's been promising to do for the last 10 years, but hasn't actually done.

22:25Jared Aron: So that's an exciting thing.

22:30Jared Aron: But how far away are we from the happy land of it actually going all the way through? Or is there always going to be a human overlay? Again, on the admin non-clinical side, how are you thinking about that? Where do you accept risk? What's your tolerance for risk? How do you think about adoption of this new technology? What are you going to phase out first? Take us on that journey. Yes, a lot to unpack here. The limitation is consumer behavior. And not only that, also is the clinician's behavior as well. For physical therapy, it's a relationship business, ultimately. So you always have both clinical and non-clinical team members.

23:13It's just the proportion and the number and how technology can, ultimately, if technology is there to enhance the service. I don't think, certainly in physical therapy and a lot of healthcare, you're going to eliminate non-clinical team members. So, for instance, we use a virtual front desk. Okay. And Aaron, we got to the point where a lot of people would prefer to check in with a virtual front desk than actually check in with the person that is stood six feet away. But five years ago, the uptake of using that technology solution was much less. But people have become more comfortable. I think we'll see continued progress as the consumer accepts and expects and utilizes this technology.

24:06For instance, getting my tires rotated. Five years ago, I would turn up and just wait around, and now they don't even allow you to come in, and just randomly you have to book online, and there's just this acceptance. And now there has become an expectation I should be able to book online, for instance. So I think the way you have to look at technology is there to enhance the existing infrastructure rather than to replace it. And then over time, people will tend to gravitate more and more towards the technology solution, which will then naturally tend to change the level of non-religionical team members that one requires.

24:46So where companies have gone in, a couple of PT companies did this a few years ago. It backfired temporarily. Where you try and push technology solutions onto team members, that's when you get pushback and lack of implementation issues and then usage issues. Every stakeholder has to benefit from the implementation of any technology solution, whatever it is. But as long as you can position it that way and achieve that, then we will see continued progress. I believe there's two key differentiators in healthcare. There's very few. And one is the ability to attract and retain talent. And the second is actually technology.

25:40Over time, technology will become a level playing field, but there's a long journey before we achieve that. And I think those entities that truly embrace technology and understand how technology can help the business rather than starting with the technology first, I believe that will be a differentiator which will drive value for not only the patient but for the team members, but also the value for the investors as well.

26:11Jared Aron: It's interesting. The US and the UK, as you were saying earlier, there are many reasons that those two markets are different. I think commercial appetite and technology readiness is also a big part of it. The UK, I think, is from a healthcare perspective, a slower adoption market. Decision makers are more discerning. There's less of a commercial backbone, not everywhere, but largely even in private healthcare, I think there's just a slower moving market behavior, which is an interesting thing and maybe has cultural. It may also just be that the private health care market is less mature. And so it takes a bit longer.

26:48Jared Aron: But one of the things that we have found, and I found this running clinic as well, technology adoption in health care lives and dies post-implementation. there is so often the case that even the best tools in the world, and we see this all the time, practices that we work with in the practice management software, their EMR, EHR, they're using 5 % of the functionality. They're not using it the right way. The training isn't done properly. The integration is 80 % good enough, so it's 100 % bad enough. There is this constant headcount turn that means retraining keeps happening. Eventually, the knowledge doesn't get passed on.

27:28Jared Aron: And so everything sort of regresses to the lowest common denominator. And in most cases, that's a spreadsheet. And one thing I found so frustrating when in clinic was we tried to implement the latest and the greatest, but we couldn't quite bridge the gap. And so we ended up implementing technology, not using it correctly, and then being equally frustrated as we were. But now we were paying more because we had this kit in place that wasn't actually doing the job. I'm curious at your scale, 1.5 million visits per year, a large team, clinical, non-clinical to support that, many sites, 100 plus sites.

28:04Jared Aron: If you found tomorrow a technology, a platform, an agent, a managed service provider that used their own technology, if you found something tomorrow and you said, hey, this has the potential to deliver very meaningful business clinical ROI. let's say you've made the buyer decision, you want to move forward with it, it's the right thing, you're confident about that. What does that journey forward look like for you? How do you take believe can really move the needle in your provider operation all the way through the front line, make sure that it delivers on the promise and doesn't die halfway through because of adoption or training or retraining or integration or interoperability, whatever the reasons might be, How do you think about that change management program from a new technology perspective across the group?

28:59It's tough. I'll give you a couple of examples of technology that we've implemented. And I say low-tech technology that we still struggle with getting users to embrace. For instance, we've had the ability for clinicians to generate home exercise programs electronically and provide those through a patient app. And it saves the clinician time. It's a much better experience for the patient. They can not only get videos of their exercises, but they can also track their progress, etc. et cetera. And as I say, it's quicker for the clinician. Only 20 % of our clinicians use that. The other 80 % are still printing out exercise sheets.

29:52Another example more recent is we've implemented like a lot of the EMRs, we have our own preparatory EMR, we implemented AI voice capture for our clinical documentation. It's still in the early phases, but it works certainly for of the initial evaluation. We have less than 10 % of our clinicians that use it on a regular basis. So you're right. Just having the technology is the stuff. The way that we try our best to get a successful implementation is education, trying to explain to them the benefits, repetition more education making sure the barriers to the implementation are removed to the best of our abilities so make sure hardware is there making sure all stakeholders understand it and it's the why ultimately and this really brings us to the kind of the topic of culture as well.

30:57Even with our limitations as it pertains to embracing technology, I think healthcare as a whole, private equity healthcare, certainly within the organization I have, embrace change to the best of our ability. Everybody hates change, okay? Nobody wants to change. But certainly within outpatient therapy and healthcare generally in the States, There is constant change. And culturally, we are always talking about change and understanding that to not only survive, but certainly to thrive, we have to change at a high rate to ultimately keep the business functioning well, continuing to provide clinical outcomes, and maintaining margin.

31:47so we've got this kind of push pull a little bit for the first time ever in it i believe we can significantly in may improve margin or at least maintain margin against reductions in revenue through technology solutions but then we've got to make sure that they are implemented in a way that is positive and embraced. And if we're lucky, they both go together. But oftentimes, as you infer and say, it's certainly a challenge and takes time. People only change at a certain rate. And the ability for people to change is the main limiting factor than technology advancements currently. Like I said earlier, technology is not the limiting factor here.

32:36We have the technology to automate probably 90 % of tasks, but we can't do it because of the human side. We are waiting for people to catch up. And if you push too hard, then that creates unsettled team damage to your culture and then ultimately damage to patient care. It's really interesting.

33:03Jared Aron: The point you're describing is very familiar. I think other folks that we've spoken to on the series, they would share your belief that pushing harder doesn't need pushing further. They say fast but not far. There is a natural movement that I think is just part of doing this. I think the other thing is, and more and more is this the case now, we are seeing providers in healthcare and outside of healthcare, but in healthcare in particular. And we are one of those providers that we're seeing this sort of wave of providers try to deliver a done-for-you solution, almost more managed services shaped than DIY with tech.

33:45Jared Aron: I think that's not new. There have always been BPO partners and offshore partners that have provided front office, back office solutions to groups. So I don't think that's new, but I think what is new now is that a lot of those partners are now very much tech driven as opposed to being pure play outsourced or offshored services. I'm wondering, given that market movement to now you can buy the software yourself and use it and implement it, or you can buy the team that implements their own software and helps you manage it, almost a managed deployment of software rather than just the software itself.

34:29Jared Aron: I'm curious as to whether or not that's an exciting thing, a terrifying thing, just a thing. Does that feel like it fits your growth agenda? Do you feel like the way you're buying innovation might change at a group level? Are you now buying things differently? Are you expecting things differently of suppliers? Or is innovation, adopting innovation today, similar to adopting innovation 10 years ago? it's different innovation, but it's ultimately a similar process of finding tech, implementing tech, integrating tech, so on and so forth. Or has actually that behavior, that market dynamic changed because of what you're seeing in market.

35:08So at a very high level, all I can talk about really is the private equity to healthcare providers or businesses. Highest level, philosophically, the businesses tried their very best to put technology, not to incorporate technology into their core business. What I mean by that was not to be responsible for it. So they definitely saw it as buying a product from a third party. We don't want to worry about that. We don't want to be concerned about that. That is not our core business. and we want to focus on what belief drives value over here. That's what the company provides, and technology is just another vendor solution to be able to do this call business.

36:03And I understand that, and I wholly bought into that because I'm not a technologist, I'm a clinician. that what has changed is the technology has changed to the point where it is embedded in every aspect of the business and with increasing importance to the point that every business is now a technology business. Whether you like it or not, before it was just, okay, I've got a server room, I need IT support to manage the hardware. Now it's really, it's gravitating now, cloud-based and software world. And even the software world is changing very quickly. And those entities that are able to embrace technology will have to understand that they are a technology-enabled business and plan and strategize accordingly for them.

37:08and it's interesting to think i think that has changed i think you're right i think the the way in which providers either dance with or dance around technology has probably changed a

37:21Jared Aron: lot even in the mindset we see clinic leaders group leaders today who come be it organically or through a more private equity-shaped background, I think they will come in and they will say, okay, part of my strategy for the next X years, my forward-looking strategy is, many of the things you said earlier, compliant, quality, financially responsible care provision, but also, one way or another, this is going to be a technology story, whether that's ambient voice scribe technology, whether that's going to be augmentation in the patient journey, whether that's going to be patient support and follow-up, somewhere along the way, what we do is going to be human healthcare and tech.

38:05Jared Aron: And the question is, how do we then make that latter pillar sustainable and not a distraction from core business? You said earlier, I didn't push on it, but you said earlier, custom EHR? So it's like you've built in-house or with a partner, you've built a bespoke... Very unusual. We're very unusual. We respect that we have a proprietary system that actually is commercially available. but we've never really set out to commercialize it. Most providers buy off the shelf from them with the degree of customization depending on the size of the provider. But we actually have our own core software and then we bolt on different functions to really get an end-to-end solution.

38:51Going back slightly to what you've just said, though, with regards to how we perceive technology, I believe as an entity, when we've set our strategic plan, we have a number of pillars and we have four pillars. We have people, we have optimization, and we have finance, but that's kind of, you know, that's fine. But technology, we have a pillar for technology. okay and i think any entity that does not have technology as a core component of their strategic plan is going to get in a lot of trouble in the immediate term they're going to get left behind and that's really fits into what we've been talking about makes sense richard i'm conscious

39:46Jared Aron: of time and now this is the second time you've given us your time given our tech issues the first time around. I think one of the things that I always like to try and close with is this idea that you've just done, in your case, a chapter of nine, ten years. And if we were to come back together in nine or ten years, and you were to tell me the story of the second chapter, if you do another nine, ten years, which you may not, but if you do another nine, ten years, what do you think will be the one thing that has changed the most? And similarly, what do you think will be the one thing that has not changed at all.

40:21Jared Aron: So where are those sort of points of bedrock versus grass and seaweed moving all over the place? What do you think is going to look really different, almost unrecognizable by comparison? And what do you think is actually 50 years ago, 100 years ago, this is just what it is. There's no movement here. I'd be interested to understand your view of that. I think for me, it's fairly easy to answer so they won't change because we're a niche healthcare service provider for physical therapy where the actual care of the patient, whilst there'd be further evidence-based practice and development of clinical protocols, etc., but the care itself, the clinical reasoning, the hands-on care, how we care as clinicians, I would hope, will not change.

41:17Now, obviously what we do within that clinical care will change based off evidence, but the caring will not change. And what will change will be pretty much everything around it. The problem within the U.S. healthcare system is how care is reimbursed for. and that needs to change. It is needed to change over a considerable period of time and I live in hope that will change because it's not the way that it's carers deliver and reimbursed do for so many different methodology and rules. That has to change and I think there is a desire of multiple stakeholders for that to change And I would hope at some point that to be able to get that change, to not only make it easier, but better for everybody, be that the payer, be that the member for the healthcare insurance, or be that for the provider.

42:22Jared Aron: makes sense Richard thank you so much for taking us on the journey for sharing a bit about the last nine years going to one site to 100 plus sites to 1.5 million visits not patients per year but maybe in 10 years it will be 1.5 million patients per year it's been really interesting to hear the story thanks so much for joining for those interested in learning more about Alliance I'm sure you can find Richard online reach out to him