Building a Cash-Based Physical Therapy Practice

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Preparation, research, and assembling the proper team can help clinicians expand their practices and move toward offering cash-based services

By Ada Wells, MPT, PMA-CPT

Fifteen years ago, my future husband asked me a question that I remember well. “Ada,” he asked. “Do you think you would ever want to own your own practice?” I quickly and firmly responded, “Oh, I could never and would never want to own my own practice. I don’t think that I could ever figure out how to navigate the insurance world.” Just 5 years later, I found myself giving notice to my employer and branching out on my own for an adventure that I have never regretted.

In 2000, I started using Pilates in the rehab environment, and while I was able to utilize the basic exercises, I couldn’t go into the depth of the work due to time and equipment restraints. In 2004, I decided to take a chance and open ProBalance, a cash-based physical therapy and Pilates wellness center in Alameda, Calif.

Opening a cash-based practice has its challenges, but the rewards are obvious early on. Below are six basic questions you’ll want to ask yourself as you move forward.

1) Why do I want to open a practice? It is important to determine your goals early on, as this will guide the type and culture of your practice. This is the phase when you start thinking about your mission statement to help drive the direction you intend to go. In my case, I wanted to open a facility where I could share what the best physical therapists have to offer with an emphasis on Pilates, golf fitness/rehab, and personalized care. I had quality versus quantity in mind. I also wanted to be a resource for patients and other rehabilitation and fitness professionals. Most importantly, I wanted to build a practice that would have the flexibility to adapt as my own life, my goals, and market conditions changed. Today, my practice has all of these components and has evolved in a positive direction along the way.

2) Where will I open a practice? Time is money, so consider how much time will be spent commuting to your business versus developing it. Also, consider whether the location has the demographic that can support the cash-based services that you’ll be providing, and if there are already similar service providers nearby. This is where online search engines and ratings sites, Yellow Pages, and social media sites can help. Take a drive or walk around the area you are considering. Be mindful of parking, nearby public transportation, noise, stairs/elevators, safety, and the surrounding neighborhood. There may also be nearby businesses that are complimentary to yours that would make it a win-win situation.

I initially leased a space near the center of town where I resided across the street from a high-traffic shopping center. Once my name and the ProBalance brand had caught on, I was able to expand and move my business to a location at the edge of town but closer to my home. Because I took the right steps to properly develop the business at the more central location, there was little disruption when we moved. In fact, my numbers increased because ProBalance was now in a space that was suitable for delivering the full spectrum of services that had evolved over the years, and which I couldn’t easily provide in the previous location.

3) Do you have a specialty? The most important piece of advice I can give is to know that you can’t be everything to everyone. Trying to do so will make you a miserable and lonely practitioner. It is more fruitful to offer services that might be underrepresented within your community. Also, having a specialty helps broaden your patient/client base to outside your geographical location. As a Pilates-trained physical therapist with a specialty in golf rehab, I saw the other local practitioners in my geographical and professional area (physical therapists, Pilates instructors, fitness trainers, chiropractors, massage therapists, acupuncturists, golf professionals, etc) as part of my team to refer to and to receive referrals or recommendations from rather than compete against. This team approach built a sense of community and trust among my colleagues and clientele. Word of mouth spread, which then led to clients who live several hours away wanting to come in for consultations for our specialized services.

4) What equipment will I need? Considerations that you will need to make are: 1) Does your focus or specialty require special equipment? 2) How do you choose a manufacturer or vendor? 3) Should you lease or buy? 4) How big do you want to be? 5) Will your choices allow for the flexibility to expand or contract?

Since Pilates was my specialty, I researched several companies in professional publications, talked to various colleagues in the industry, tried out the equipment at various conferences, and decided on Balanced Body Inc, a Sacramento-based manufacturer of Pilates equipment.

The Pilates Trapeze Table is a great piece of equipment as it doubles as a treatment plinth with springs that can be used as levers to provide resistance or assistance to the movement, or even act as another set of “hands.” For example, I can use the Trapeze Table in one configuration to assist in performing reciprocal movements with my patient with multiple sclerosis, then I can easily change the spring and lever setup to work with my next client, who is an elite athlete, and provide challenging movement-integration exercises that mimic his sport.

I have several Allegro Reformers with the Tower feature that I use for both group classes and for individual sessions. These space-saving units allow me to use Pilates Reformers either independently or in conjunction with most of the functionality of the Trapeze Table. This adds to the flexibility of my clinic/studio because they allow for a nearly limitless number of exercises that may be performed on one piece of equipment, they leave a smaller footprint, and they can even be folded and stacked vertically to the side when I want to use the entire floor space for a mat class.

The Wunda chair and Combo chairs are similar pieces of apparatus that, once again, take up a small footprint, but are great for progressing strength, balance, and alignment in an upright position. The Combo chairs have a split pedal that allow for further variations and flexibility with a wide patient/client population. I purchased several Pilates Arcs, which are lightweight foam variations of the more traditional Step Barrels, which are wonderful props for group classes to integrate spine articulation with core control. Finally, I utilize the Orbit, which is a very small piece that has multidirectional capabilities that are wonderful when working with rotational athletes. Each of these products are manufactured by Balanced Body Inc, Sacramento, Calif. A number of other companies also offer Pilates equipment and accessories, including OPTP, Minneapolis; Exertools, based in Petaluma, Calif; and PHI Pilates, Pittsburgh.

I used other vendors to purchase items that would be found in a more traditional setting, including hi-lo tables, which are offered by companies such as Dynatronics, Salt Lake City; a Schwinn Airdyne stationary bicycle from Schwinn, headquartered in Vancouver, Wash; exercise bikes made by the Washington State-based manufacturer Precor; free weights, such as those offered by Body Solid, Forest Park, Ill; and a functional cable trainer and treadmill from Physical Enterprise, Petaluma, Calif. I purchase other supplies such as foam rollers, resistance bands, and tape from OPTP, a provider of healthcare and fitness products for rehabilitation professionals.

I opted to purchase my equipment outright versus leasing because Pilates equipment tends to have a longer shelf life and doesn’t become outdated quickly. The manufacturer I used also had a fabulous reputation for building easy and relatively inexpensive retrofit kits as it made design improvements and upgrades to its basic models. Because of various tax write-offs, I was able to see a positive net gain on investment in just 6 months. As my business evolved, it transformed from primarily a physical therapy model to a larger percentage shifting toward a wellness center model. This led to purchasing more equipment to conduct group classes as the patients “graduated” from physical therapy. It also widened my net of potential clientele.

When I expanded to a larger facility 2 years ago, I found that these vendor relationships were invaluable in assisting me in my expansion efforts. We now offer a wide range of services beyond traditional physical therapy, including Pilates apparatus and mat classes, sports-specific classes, barre classes, golf-focused fitness/rehab, injury-prevention workshops, and even Pilates teacher training programs.

5) What resources are there to help me get started? Today, the Internet has brought together communities of like-minded people and professionals to discuss their practice issues and gain recommendations through various forums. The 21st century resume is a LinkedIn profile, and with it comes the fabulous opportunity to network and brainstorm with thousands of professionals. Whether you start your own group (which I did) or you join other discussion groups, the Internet is a great source for ideas. I would also highly recommend finding a continuing education course about how to start a physical therapy business. The Private Practice Section of the American Physical Therapy Association and Small business Association are helpful here.

6) Do you have a team in place? Remember what you are good at and where your dollars are best spent. Get the professionals to do their jobs and answer the questions that aren’t part of your primary expertise. This team may include an accountant, bookkeeper, attorney, graphics design and/or IT professional, and even friends/family or a business coach who can provide additional support with business development. Your team can give you guidance on which type of business entity you wish to be (sole proprietor, corporation, etc) and what paperwork needs to be filed (business license, EIN—Employee Identification Number, DBA—Doing Business As, NPI registry, liability insurance, etc). Your team can also give you guidance on how best to track your day-to-day flow, know when it makes sense to bring on competent staff, and how to market and brand your business.

A Rewarding Result
Today, my business is about to start its 10th year, and there are about a dozen physical therapy, fitness, and wellness practitioners who operate out of my facility. As long as you remember why you decided to make the jump to a cash-based practice, stay true to your mission, ask plenty of questions, and don’t try to be an expert at everything, your persistence and patience will pay off. PTP

Ada Wells, MPT, PMA-CPT, owner of ProBalance Inc in Alameda, California, is a physical therapist, PMA-certified Pilates instructor, a Polestar Pilates Educator, and a Level 3 Certified Titleist Performance Institute Golf Medical Professional. She has nearly 20 years of experience in designing fitness, Pilates, and rehab programs for athletes, with a specialty in golf and sailing. For more information, contact