How One PT Practice Owner Kept His Business Stable Through COVID-19

In this Q&A, Simon Hargus, PT, DPT, OCS, MBA, the owner of First Settlement Physical Therapy (FSPT), explains how he is leading his organization through the COVID-19 pandemic. He covers FSPT’s approach to continuity planning, the steps the company is taking to stay financially stable through the current situation, and the changes he plans to implement in the future based on what he has learned over the last few weeks (including an increased focus on telehealth and cash-based services). Want to learn more about Simon and the team at FSPT? Check out the practice's website.

What is the size of your practice (e.g., how many locations and therapists do you have)?

I run and own a very rural outpatient physical therapy business with 23 locations in Ohio and West Virginia. We employ around 145 people. 

Can you describe your feelings as this pandemic (and the subsequent response) unfolded?

We saw visits starting to drop on March 16, and we were at 50% of our normal caseload by March 30. Watching something you've put years into (or in our company’s example, generations) dissolve in days is traumatic. It was around day eight or nine before I could sleep for more than three or four hours in a row.

What steps did you take to approach the situation with a level head?

I tend to focus heavily on data and analytics, but responding to a situation of this severity and scale required more than metrics. I took a few key steps:

1. I formed a worst-case cash flow plan with guidelines through June.
2. I talked to our staff until I had a genuine understanding of how they were feeling—and what our patients were saying. Some people were eager to be laid off, and some were eager to stay at work. They were all eager to keep themselves and their patients as safe as possible, and they wanted protocols and rules for doing so.
3. I talked with other leaders who were in a similar boat—competitors included. Finding catharsis by talking to others is not typically my style, but it has been a surprising relief to share anxieties and hopes with others during this time. At the end of the day, we’re all in this together.   

Describe your cash flow plan in more detail. How are you using this to stay on track?

The overarching idea is to plan and act—not hope and wait. I'm actively winding down our expenses as revenue decreases—while also ensuring there’s enough in the tank (cash and debt) to ramp back up when it’s appropriate to do so. My hour-to-hour priority is to keep the trust and confidence of the staff—who will transfer that trust and confidence to patients—but I’m also trying hard to keep in mind that AR is like running with the wind at my back right now. It’ll be the opposite once we’re ready to pick back up.

Most of my planning and actions right now are rooted in one Excel spreadsheet. Each row represents a week. The column headers are:

• Date,
• Evaluations,
• Visits,
• Total deposits,
• Total expenses,
• Non-personnel expenses,
• Personnel expenses, and
• The difference between deposits and expenses.

I started mid-January and planned through the end of June—mostly looking at my estimated floor visits for the duration. I have no real idea of what visits will look like in the future, but I can take a guess at what the worst-case scenario will be and work backward from there. 

I know my average reimbursement per visit, and I know that three weeks after the date of service, my weekly deposit roughly reflects my weekly visits. That's crucially important information to get a feel for—with respect to both the “wind down” (i.e., right now) and the “ramp up” (i.e., post-pandemic). 

I have a guideline that I built into the bottom of this spreadsheet, and it keeps me honest. If I see a certain number of visits this week, I can project my rough deposit in about three weeks. I then set an expense goal for three weeks from the current date. I give myself two weeks to be at that real expense number during the third week. I also give myself flexibility. I know the goal may change—because deposits, visits, telehealth, or SBA loans could pleasantly surprise me—but it’s a cold, hard number that I can focus on reaching. Without surprises, I know I will get there. Using this approach, I can get an idea of projected debt, and I know how much debt I can incur before I dip into the reserves we have set aside to ramp the business back up. 

What is your post-pandemic outlook? What would you consider to be your “light at the end of the tunnel?”

Right now, I'm assuming we’ll have four weeks of increasing payroll and marketing expenses—without much of an increase in revenue when things start up again. That might be a lot different for someone with cash-based programs, but that’s not our model. Our picture is slightly rosier, because a lot of our lost visits are from Medicare patients, and Medicare typically pays well and quickly. That being said, I'm trying to err on the pessimistic side. The green light in my mind is two weeks before elective surgeries begin happening again.

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What else are you keeping in mind to aid with the ramp-up?

I’m focusing on referral sources, engaging our staff, and minding some important financial milestones: 

Re-engage past patients.

You’re going to need patients in order to ramp your practice back up. I’ve been keeping a running list of folks who want to come back (but aren’t doing telehealth or home PT). We plan on touching base with them—as well as those who were interested in workshops—regularly. We also will reach out to past patients. 

Know the wheres and whats of your referral sources.

Some of our referral sources are still actively referring; others have put their patients on hold. We are pretty rural, so we have a mix. It’ll be important once the dust settles to focus on warming up those referral relationships again. A lot of the hospital referral staff—even some physicians—have gotten moved or have new preferred ways of being contacted.

Bring the right staff back and establish protocols.

Make sure you understand who is eager to return, and who would prefer to stay distant for as long as possible. Now is also the time to formalize safety steps in the clinic that ensure the comfort of staff and patients. 

Understand the factors that will impact your finances in the short term.

You should know the exact rules and timing for the forgiveness part of the PPP loans (if you are getting them). It’s also an important time to check out the Medicare Accelerated and Advance Payment Program.

Spend this time working on your business.

Now is a great time to work on ideas that you seemingly never had time for before. You can focus on process improvements for billing efficiency, create a social media strategy, formulate a contract negotiation gameplan, optimize your outcomes tracking efforts, or cross-train staff who will have time to help with other tasks in your business for the next month. Participating in these projects will keep your staff engaged and build pride in what they’ve worked on.

What has this pandemic taught you about continuity planning, and how are you planning to adjust your long-term strategy?

For years, I resisted a lot of advice to take on more debt and have lower rainy-day cash reserves outside of just credit lines. At the time, I thought those reserves would be more for large payers having computer/credentialing issues or Medicare being closed due to a government shutdown. The way this situation played out has given me even more reason to get back to low/no debt and respectable cash reserves. 

Another buffer we’ll seriously look at is revenue diversification. That will look different for everyone. In our case, we hadn’t dabbled in anything cash-based or virtual before the pandemic. In this brave new world, we’re seriously looking at changing that. Many of the changes following this pandemic will require large culture shifts, so they will take time. It’s important to remain patient but persistent to make sure your changes take place and stick around for good.

Ultimately, I think an emergency like this highlights your vulnerabilities. How you respond is what determines your trajectory on the other side.

We’re all in a constant state of change right now, and while that can be dizzying, Simon’s reminder to focus on the fundamentals is an important one. And if you feel stuck, we’ve put together a comprehensive guide for navigating COVID-19 that will help you with everything from communicating with staff and patients about difficult decisions to delivering and charging for alternative services, like home visits and telehealth.