Paying Providers On An ‘Eat What You Kill’ Or Pay-Per-Visit Model With Ryan Wooley, PT

During COVID, problems with having no-shows started taking a toll in many clinics. Ryan Wooley, PT was sick of high cancellation rates and was frustrated with the PTs on his team being less than productive, so he decided to switch things up. In 30 days, he changed to a pay-per-visit provider reimbursement model; in 60 days, his cancellation rates and productivity levels significantly changed—95 percent better! In this episode, Ryan shares with us how he rolled out this program and how it’s affected his practice since doing so. Tune in now and see how Ryan switches to a Per-Per-Visit Model and why the clinic metrics improve.

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In this episode, I’ve got a longtime friend in my peer-to-peer network through the PPS peer-to-peer networking program. We’ve been in the same group for a few years. He’s done some cool stuff this early part of 2022. I want to share it with the readers. I have Ryan Wooley, Owner and Founder of Sentry Safety and Physical Therapy in Roswell, New Mexico. Ryan, thanks for finally taking the time to sit with me.

I appreciate you having me on. I’m glad we could schedule a time.

You’re growing, and you’ve done some good things in your part of New Mexico. Tell us a little bit about where you’re from. What got you started on owning a physical therapy clinic?

I’m from here, but I didn’t live here for a long time. After PT school, I stayed in Florida and had the opportunity to work for one of my professors there and learned a lot from him. My wife and I ultimately decided to move back home. That’s a funny story because I didn’t plan on opening a PT clinic. I moved back to New Mexico with the intention of opening an injury prevention business out in the oil field and going out there and helping them decrease on-job injuries.

Right when we moved back, I built a mobile clinic. I bought a big cargo trailer, built this clinic that I could tow behind my truck, and dumped a bunch of money into it. The bottom fell out of oil, and nobody would return my calls. Emily was pregnant with our second son at the time, and the bills needed to be paid. People in town knew me, so I was getting these random phone calls, “My mom heard this. My sister heard this. Can you come to take a look at them?” That started adding up, so I started taking more clients. I finally got to the point where I couldn’t go to their houses anymore. I was too busy, so I had to rent a building. From there, it turned into a business. Now it’s four other therapists and me. It just happened.

How long has it been since that all started up?

A few years.

We’ve been in a group together for what?

We’re going into a couple of years.

You’ve always been super busy. New patients haven’t been an issue for you.

We’ve never had an issue with getting patients in the door. It’s always been, “Can we find more therapists?” We do things a little differently here, so we stay busy. We have good outcomes, and the patients are happy.

The reason I wanted to bring you on is because earlier in 2022, you switched your pain model for your providers. It was just for providers. Tell me a little bit about that story. What made you think about doing that? What led you to do it? I’m sure my title to the episode is going to be something along the lines of a pay-per-visit model, eat what you kill model, or something like that. Tell me the germination of that.

The whole idea came to me because, for the first time ever, during COVID, we were starting to have problems with no-shows. Justifiably, people get sick. They get exposed. They don’t want to come in, which is all understandable, but then they fall off the schedule. They fall through the cracks, and they get forgotten about. The clinicians were getting a little lackadaisical about any follow-up calls as well. I’m used to this. My census is down. I’m getting paid either way.

After about 4 or 5 months of that and taking a pretty big financial hit, I had decided, “I got to do something about no-shows.” I started with the front desk like, “What are we doing about no-shows?” They tried a couple of things. We’re calling patients. We’re checking lost patient logs. The therapists were even cool with leaving home early and losing a couple of hours here and there. They got in this rut. Finally, I decided, “Let’s give everybody the risk, but if we’re going to give everybody the risk, let’s also give everybody the reward.”

I did the math. I’m not a computer guy. I got a yellow legal pad and started writing things out and doing the math. I ran the numbers. I went to each of my employees individually and compared, “This is what you’re making now. This is what your arrival weight was for the last few years. If you match that arrival rate on this pay model, this is what you’ll make in the next year.” Their eyes got big, and they were, “Tell me a little more.”

It wasn’t like you did a weekend thing about getting these numbers together.

If we give everybody the risk, let's also reward everybody.
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I had this idea on a Wednesday and a Friday when I was only treating patients for half a day. I spent the rest of the day doing the numbers. I talked to them. I eased them into it and wanted to get some feedback. The next week, I came to them with a proposition. I said, “This is what we’re going to do.”

You didn’t come at them with the proposal right off the bat. You said, “This is something that I’m thinking about. Here are the numbers that I want you to chew on if you continue your productivity level. This is what you could make on a different model.” Is it something like that? Is that how it went?

My expectation has always been 85% productivity. I said, “If you meet 85% productivity, this is what you’re going to make. If you meet what you’ve made in the last two years, which has always been a little higher than that, this is what you’re going to make. If you do what you’re doing now, this is what you’re going to make, which is a little bit lower.” I said, “This is what we’re going to do.”

I didn’t give them, “Are you in or out?” question. This is what we’re going to do, but I’m not going to implement it for 30 days. You get one month to figure out how you can increase your own productivity. You can do the math each week and say, “I saw this many visits this week. Do the math. This is what I will make on this new scale.”

There had to be a little bit of fear that they would say no in both because I know your issues with recruiting providers have been difficult for the entire time you’ve been open. Wasn’t there a little bit of fear that you had to get over where they might say, “You’re doing that, but that’s not cool with me. I’m out of here?” How did you get over that?

I showed them the potential because I showed them the last few years of what they had been doing. I’m going, “You haven’t been working all that hard the last few years. This isn’t a patient mill. I don’t make you double and triple book people.” I also showed them the pros and cons of it. By doing it this way, they have complete freedom over their schedule.

What do you mean by that? Do you mean they can manipulate it however they want as long as they get in the numbers?

The numbers reflect their paycheck, so they can manipulate it however they want. If they want to take a three-day weekend and not work on Fridays, they can front-load their schedule. If they have family come into town and want to work 12:00 to 5:00 Monday and Tuesday while their family is in town, they can do that too. I only requested that they communicate that with me. That was a big perk, and a lot of them liked that freedom. I’m not saying, “It’s 8:40. You’re supposed to be here at 8:30,” which I’ve never done anyway, but they want that freedom.

Was there an expectation that there’s going to be at least a minimum? Were you like, “If you’re going to make the salary that you made before, you just got to get the numbers,” and that speaks for itself? Do you let that do all the talking?

That’s what it was. I also knew the personality of all my folks because we’ve all worked together for at least a couple of years. I all knew that none of them were like, “Give me something for free,” type of personality. I knew that they were all going to jump into it. However, none of them seem to take it very seriously in that 30-day buffer period. For the first three weeks there, they weren’t paying much attention to it.

The week before it started, I had to go up to a couple of them and say, “You know this is starting next Monday? Have you thought of any ways to get your patients in the door?” A couple of them gave me a look like, “I hadn’t thought about it.” They started brainstorming. The first week or two weeks of implementing them, two of them had a little bit of trouble and figured it out. The other two took off. They went from 15 to 20 no shows a week to 3. Their productivity skyrocketed, and it’s all because they now had control.

What did you see in their demeanor towards treating patients and how they talked to patients? Did you see night and day changes or subtle differences here and there?

I saw subtle differences. Whereas before, if a patient showed up 15-20 minutes late, they were like, “He’s going to have to reschedule.” Now they’re like, “It’s okay. Come on back. I’ll figure it out.” They’re willing to make some accommodations here and there. There wasn’t anything real drastic. They still treat patients the exact same way. I would say that they’ve got a little bit more creative in how they schedule their patients in terms of your easy patients and your hard patients.

If they’ve got four total knees in an afternoon and are short on time slots, now they’re staggering them where they will offset them twenty minutes and can still do a good job. Whereas before, my initial recruiting was we’re doing one-on-one visits. You do not have to double. I still don’t push them to double, but if there’s a patient where they can easily double, and it doesn’t affect their quality of care, then they’re going for it. It benefits everybody. It doesn’t hurt the patient in those scenarios.

The folks who didn’t initially catch the idea and get caught up in the possibilities there for the first couple of weeks, was there any pushback during that first couple of weeks? Did you say, “This is what it is, so you got to expect it?”

No, because I kept going to him and demonstrating, “I’m concerned about you. I don’t want you to take a hit for this, but I know if you try and put a little thought into this, you can make it work.” I’ve got one PTA that agreed to come on for a one-year contract. He’s going on for a couple of years now because he’s like, “I can’t make this money anywhere else.”

People around the country are going to be like, “You must be getting paid a ton per visit in Roswell, New Mexico,” but I know you’re not super high. Where are you in New Mexico?

Our average is about $90.

Some places are better than that.

A lot of places are better than that. Our averages are $90 because we’re still probably at a 3.6 unit average. We’re still not getting those 4 to 4.5 like a lot of clinics are.

That’s true. I get it. People are going to ask some of the devil’s in-the-details type of stuff. Now you’re paying per visit. Are there any benefits on top of it? Is there no paid time off? Con ed maybe still a benefit. What other benefits do you have?

I still give them $2,000 biannually for con ed. Everybody still gets their con ed money, and they save it up. Usually, they save it up for a big course instead of taking that money and taking a few online classes here and there. If they’re going to get $2,000, they’re going to take something worthwhile to them. That’s what I want. I want them to be the best clinicians that they can be. They get that. Two of my therapists, when they first started, negotiated a monthly health care stipend.

We’re too small to offer health insurance, so they get a couple of hundred dollars to go towards their health insurance on top of their paycheck. That’s the funny thing about this. I thought I was going to get a lot more back budget when I took away PTO because they all had PTO going into this. I said, “You’re going to be making a lot more money. You have complete control over your schedule. If you want to take a week off, then you work a little harder the week before you leave and a little harder the week you get back, and you’re not going to lose any money.” It’s the same thing I have to do as the owner. I don’t get PTO. You make sure you see the patients that they’re taken care of. They’re going to see 10 to 15 more patients the week before they leave and do more when they get back, and it all evens out.

Are they contracted workers? Are they 1099? Are they still regular employees?

One of them is 1099 because he’s always been 1099. That’s the way he chose to do it when he first came on as an employee. He was a traveler who agreed to stay. He became 1099 because I was willing to offer him a higher rate at that as 1099, then we transitioned. He’s still at 1099, but all the rest of them stayed employees.

That makes it easier. You have PTAs and PTs on your team.

Yes, two for each.

What are your PTA and PT per visit ranges? Do you mind sharing?

It all goes off of experience level. Some PTAs can take on a lot harder cases that we hand off to them. Some cannot. I would say that we range between about $26 to $32 for the PTA, which they asked me that whenever we first started, that’s what I’m making per hour. I go, “That’s what you were making per hour. Now you’re making it for 45 minutes and are doubling that if you double book. Instead of $30 an hour, now you’re making $60 an hour for those hours you feel comfortable seeing more patients.” That math adds up pretty quickly. For the PTs, we’re between the $40 and the $45 range.

Is there any concern that maybe they’ll see more of these patients, and their units per visit stat might come down as they’re pushing? They could be making more, but in seeing more, they could be generating less revenue if they shaved off units here and there.

I didn’t put anything in writing, but that was a verbal commitment they would get a minimum of three units. We’re always shooting for four. Prior to us doing this, we were on a 45-minute platform, but our goal for most patients is to keep them for 55. That ten minutes while you’re wrapping up, the other patients are getting warmed up. There’s an easy ten-minute overlap there where it doesn’t affect anything. I had a little bit of concern there. I would say very rarely when I do chart audits, do I ever find a two-unit chart.

What are some of the other benefits that your providers have seen from this model? They can make more and have flexibility and autonomy with their schedule. Is there any other benefit to this model that you have?

It all works out when you do your quality over quantity type deal.
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I also have a home health company. Some of the benefits of being able to modify their schedule as needed have turned into their productivity in the home health field. They can leave a little early and go see a couple of home health patients. They could schedule themselves a long lunch in the clinic, see 2 or 3 home health patients, come back to the clinic, and jump right back where they left off.

That also leads to making a little bit more money and diversifying their day. They’re not in this monotonous routine. They get to go outside and get some sunshine. A lot of them will eat lunch in the car between patients, and they make about double on the home health patients than they do in the clinic. They’re like, “That’s a nice little buffer for a little extra cash.”

I love the opportunity that they have. Not to make more in your clinic, but since the way you have it set up, you also provide opportunities for them to make more. I hadn’t even thought about that. Maybe take a little bit longer lunch if that’s your vibe, and if you want to work during that, even better.

Ironically, there hasn’t been an issue. You think, “What if they’re always late for their next patient?” That doesn’t happen. I can see a couple of things, but we don’t live in a town with very much traffic. If they’re smart with how they plan it and they look at the geography, they’re almost always back before the next patient starts, and they roll in and get going. Occasionally, it happens. You run into something, then they call one of us up and say, “Have our tech get them started on this warmup exercise.” We have 1 tech for 5 clinicians. We don’t use them a whole lot.

How long have you been doing this now?

We’re about a few years now.

Has it been going on that long?

Yes. My wife will tell you that I have no concept of time.

I heard you talk about it at our peer-to-peer networking conference. I thought this was relatively new over the past months, and they’re loving it.

No, I’ve been doing it for a while. It’s funny because it wasn’t a brainchild that I put a lot of effort into. It was like, “This is something we need to do.” I need to share the risk, and if it works out, I need to share the reward.

There is some software out there that will help you set this all up and do it and take you through the proformas of different payment amounts or maybe even set up a minimum salary at $25,000 or $30,000, and then have a per-patient thing. Did you consider those?

I did, even the year before, at PPS. Prateek and I had sat in on a lecture where they were doing a model like that, where they have a low salary. They were per unit paid on top of that. They had three different variations. It was per unit, per patient, and that thing. I looked into that, but I treat myself full-time. I don’t have time to do that. To me, it was the KISS method. Let’s keep it simple.

It makes it easy for them to figure out what they’re going to make in a given week, and they can look forward to the next week and say, “If all these patients come in, I can make this much money.”

It keeps it easy on my scheduler. It keeps it easy on the lady who does my payroll because I have to shoot her, “This is what we’re doing now.” My other company, the home health company, gets a little bit more complicated because I pay per visit type in home health. That’s where it gets a little bit more complicated because they get paid a set amount for starter care, a set amount for a progress note, recertification, a resumption of care, and a daily note or a discharge.

Whenever I send payroll over, I have to delineate what type of visit it was. It’s not a big deal, but they also like that because they like to see, “If I take on these, I’m going to make a little bit more.” My PTs like to go in and do progress notes for their PTAs because they make a little bit more in the same amount of time, and there’s not much more paperwork.

You don’t differentiate that in the clinic. If they do an initial eval, it’s the same as a regular visit.

It’s the same. It’s the same amount of time too. They get 45 minutes for any eval. They get 45 minutes per treatment.

It seems like you implementing this has gone rather amazingly well. Were there any hiccups or hurdles along the road that you had to sort out?

No, there weren’t, which is funny. I had one therapist that I lost prior to doing this who I was paying like that. She wanted more than she could generate, unfortunately. She came back at me after a year and was like, “I want this much per visit.” You’re barely going to generate that per visit. It’s not going to work.

How did you determine those per visit ranges? Did you go back and see what your payroll would have been in previous months if they were meeting these numbers? How did you fall in those ranges? Someone who reads this happens to be like you and getting in the $90 per visit range might be able to use your same ranges. If someone has a $115 per visit reimbursement or a $75 per visit range, what was your formula?

My formula was mostly geographical. Most places are getting reimbursed in Southeast New Mexico, and what they are paying in Southeast New Mexico. I wanted to be able to pay a little bit better than most of them because I wanted to be competitive. Staffing has been my biggest issue as we grow. I have to be able to pay them a little bit better. What are they making compared to what we’re making?

We’re in that same range. We’re probably a little slightly lower because most places are getting four units, if not more than four. We’ve got a waiting list for patients to come in because we don’t treat them the way that they do. We’re not seeing people every fifteen minutes and running it like a patient mill. We’re spending a lot of time with people, and people are getting better. It all works out in the end when you do your quality over quantity type deal.

You tried training them on how to get better compliance during the initial evaluation, talking to patients when they cancel, training the front desk, and what to say on the phone. Some of those meetings don’t have to happen anymore, I assume?

They don’t have to come from me, anyway. I’ve trained all of them. I’ve talked to all of them about it. Whenever I have a therapist getting a lot of no-shows, they’re a little more responsive to jump up and say, “I need to call that person. They were supposed to come in this week. Why didn’t they come in?” They get on the phone. Before, they used to run up to the front desk and ask our coordinator, “Call so-and-so for me and see if they can get scheduled.” Now they’re grabbing the phone themselves and calling them. It makes a lot more difference whether or not that patient is going to come in if they get the phone call from the therapist versus the clinical coordinator.

What have been some of the bottom line benefits to you? I know that number one, the ease with which you have to manage your team has decreased, especially as you’re talking about considering no-shows. Overall, what has been the benefit for you?

It’s the overall energy in the clinic. Everybody’s a lot happier. Nobody feels like they’re being forced to come to work. Nobody feels like they’re being told what to do or how to do it. They have a lot of autonomy now. It shows in their demeanor on how they communicate and treat others.

Is that something that, as you’ve recruited, you’ve highlighted? If so, is it something that has weeded people out and maybe not looked into your clinic? Have you noticed any of that?

I can’t say I’ve noticed a big one. I don’t jump into those types of things right away whenever I’m trying to interview a new candidate. I want to find out if they are of the higher standard that we are, that we expect first before I start saying, “You might make six figures if you’re good.” I don’t want to do that because I don’t want to entice the person that’s only motivated by money.

Everybody wants to make a good living. If you’re in this field, especially working in an outpatient, you’re passionate about it. That’s pretty much how you define outpatient therapists. They know they’re going to make a little less than if they were in a sniff or a hospital or home health, but they love what they do. We want to make sure they love what they do, that they are dedicated to being good at it, and makes sure that they can make a good income.

What do you think it’s also done for the patients? Does it seem like compliance and maybe your completed plan of care percentage has improved, or the episodes per plan of care? Have you noticed if any of those stats are better or if overall results are better?

One negative I have seen is that some patients haven’t gotten discharged probably as soon as they should or could have. Some of them might get a few extra easy visits from time to time. I can’t say their primary motive there is because they need a little bit more safety education in their home exercise program, or they’re not diligent with doing it, and the therapist wants to make sure that they get that last little bit or a combination of both. They’ve got somebody that cruises, and they can bring them in. Who knows?

There is a benefit. It’s one thing to get 100% better, but we all know after discharge, there’s going to be some regression. Why not get them 110% better so you can work in that regression after discharge? There can be some benefits to that.

Everybody wants to make a good living, but they also have to love what they do.
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I can’t call that negative, but it’s different than what it was before. Whereas before, if we were busy, that patient might have gotten discharged a little bit sooner than they should have because the therapist couldn’t find a place for them.

They’re like, “You’re doing well enough.” Even though it’s 8 out of 10 visits, you will say, “It’s good now,” instead of going 10 out of 10 because I’m too busy and don’t want to do more documentation than I’ve already done. I can see that. Also, for the financial health of the clinic, I’m assuming that’s a little bit better because metrics are better.

Metrics are better overall. Surprisingly, I thought we would take that dip in units per visit. We didn’t. Units per visit have stayed about the same. I used to push people whenever we were having those 20 to 30 no-shows a week and be like, “If your next patient cancels, keep them an extra ten minutes. Get that fourth unit,” which I never felt good about doing. I always follow it up with, “Keep them an extra ten minutes if that patient will benefit from it.” Now they got used to what they had to do, and they’re doing what they need to do. They get a combination of 3 and 4 units. Most of the time, it is more ethical, and they’re doing it because that patient needs it.

That’s appropriate. Anything else you want to share about your experience with this? You shared a bunch of detail that would be helpful for those folks that are reading. Anything else that comes to mind about the program that you might want to share?

Not right off the top of my head because it’s not a legitimate program. It’s an idea that I had that I wanted to keep simple and implement. Sometimes, you can over-engineer the wheel.

That’s the beauty of it. It is rather simple. It is so simple that people might want to make it more complicated than it needs to be.

I know initially, I had a couple of backup ideas. If this didn’t work, we could try this and this, and I’m glad I didn’t have to implement those.

One of the smart things about how you laid it out, and I mentioned this at the very beginning, is that you took the time to do the numbers and show them and not tell them, “This is what we’re doing in 30 days, but FYI, we’re going to talk about this next week. Here are some numbers. I’ve run your numbers for the past 3 to 6 months at current and past visit levels dependent on your efficiency levels.”

That’s vital. If you drop this on them cold, they could run for the hills but showing them what they’ve done and showing them, “I’m not making this up. This is a printout from the EMR system. This is what you’ve been doing. This is what you’ve been doing on your own. Nobody is telling you to need to do this and this. That means you can continue doing this without very much effort. You could probably do better if you try to implement a few new strategies,” they took that, and it gave them the motivation and probably the self-awareness that, “I can do this.”

That’s the beauty of it. You did keep it so simple, talked to them through the process, and showed them exact numbers. The fact that it came to fruition and they’ve seen their salaries “increase” because of that has been beneficial and successful for you. From my experience, I don’t know if you talked to other people who have used these models for reimbursement of their providers. For those people who do have that eat what you kill model, I don’t know if I’ve ever heard someone say something negative about it. The providers tend to get into it and appreciate the fact that they have that autonomy, responsibility, and control over what they can make.

They like freedom too. They love being able to take a 3-4 day vacation when they want to.

It’s like, “I need to go to the dentist on Thursday afternoon.”

“Give me a three-hour block. So-and-so can’t afford to miss. When I get back from the dentist, I’m going to see them a little later.” They do that. I was surprised that the schedule didn’t change hardly at all. They were used to the times that they came in. They were used to the times that they closed. I never told them that they couldn’t change any of that. It stayed virtually the same. Every once in a while, there is that three-hour block to go to the dentist or take the dog to the vet. More than anything, the only thing that ever changes is either a Monday or a Friday when they want to take a whole day off. The rest of the week has stayed completely unchanged for the most part.

The last question is more detailed stuff. Do some of your patients switch hands between providers? Will a patient be seeing 2 or 3 providers during the course of care? Are they pretty strict with the one provider?

We tried to stay strict with one provider, but we’ve gotten too busy. There will be a switch between PT and PTA. We have teams. If they’re going to work with me, then they’re going to see my PTA. If they’re going to work with one of the other PTs, then they’re going to see that PTA. They’re not seeing multiple people.

Since you have that, I’m assuming your PTs and PTAs worked together on a schedule.

They work great. They work very good. There are some patients that just don’t care who they see, and that’s fine. It’s a small enough clinic that we communicate. “Ms. Smith didn’t like this last time, so let’s stay away from that and try this.” That communication’s good.

Thanks for sharing. It’s awesome. A lot of people are going to be inspired by the information that you share. If there are any people out there looking to move to New Mexico and have autonomy, how can they get in touch with you?

They can always shoot me an email. It’s WooleyPT@Yahoo.com. Our number is (575) 622-6260. I’m laughing because people always throw out a website, and I don’t have one.

I have tried to look you up online, and I couldn’t find it.

I had a terrible one for like three or four years. I was looking at the numbers of how much traffic we were getting and where they resulted in referrals, and it wasn’t. We had more referrals than we knew what to do with, so I quit messing with it. I do have a page on Facebook that I haven’t updated in probably years. Apologies to the people out there who are techy and think everything has to go through social media. I’m too busy. You can look us up on Facebook, and you could always send me a message that way. Anybody who’s out there and wants to have a fun place to work and have good freedom to be an autonomous therapist, that’s what we’re doing.

That’s awesome. Thanks for sharing, Ryan. I appreciate it.

Thank you. I appreciate your time.

After PT school I was a traveling home health PT for a while. Then went home and worked in the clinic that I origianlly worked as a tech when I was in high school. Found out quickly that seeing 4 patients per hour was too difficult for a new grad, so I went back to FL where I got a job working for one of my old professors. I did that and PRN home health until I paid off my student loans.

Moved back to Roswell after I got married and “accidentally” started a clinic. – That’s a complicated story.

I had 2 clinics for a few years, but decided to consolidate back down to 1 out patient clinic and now I run that one and a home health agency.

I’m married with 3 young boys. And I spend as much time with the family that is possible.

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