How Many Patients Are Way Too Many?

Money is the topic most therapists find the hardest to examine.

Most therapists can trace their hang-ups about money to the fact that they’ve not reconciled two seemingly opposite concepts: profit and service.

For some, service is honorable and profit is evil.

For others in a service-oriented industry like healthcare, making a profit is a natural order of business.

It’s a paradox that can put very sincere, well-meaning people into a state of antagonism that may take many years to reconcile, if ever.

Previous generations planted economic seeds in healthcare that have come to fruition towards the end of the twentieth century. We are now finding ourselves having to deal with the excesses and obsessions that erode the very essence of our professions.


Therapy Is Not Brain Surgery (Thank God)

In 2017, The Seattle Times published an exposé on one of the largest hospital systems in the United States. The Times investigation revealed the high-volume practices of several neurosurgeons at Swedish-Cherry Hill Hospital.

The paper alleged Cherry Hill’s neuroscience program’s approach to the business of medicine enriched the hospital and its star surgeons, sometimes at the expense of the patients’ well-being.

The Seattle Times wrote:

“A steady churn of high-risk patients undergoing invasive brain and spine procedures allowed Cherry Hill to generate half a billion dollars in net operating revenue in 2015 — a 39 percent increase from just three years prior. It also had the highest Medicare reimbursements per inpatient visit of any U.S. hospital with at least 150 beds.”

“But the aggressive pursuit of more patients, more surgeries and more dollars has undermined Providence’s values — rooted in the nonprofit’s founding as a humble home where nuns served the poor — and placed patient care in jeopardy, a Seattle Times investigation has found.”

The paper’s investigators blew the whistle on a business approach that maximized reimbursement while trying to improve and save the lives of patients.

Among their findings were:

  1. The neurosurgeons were incentivized to pursue a high-volume approach with contracts that compensated them for large patient numbers and complicated surgical techniques.
  2. Hospital staff reported that the highly touted surgeons would sometimes do little in the operating room once the patient was under anesthesia, leaving less experienced doctors in training to handle parts of the surgery. 
  3. There were indications that the high-volume business practice was taking a toll on quality care. Regulators flagged Cherry Hill for lower performance on quality control benchmarks such as blood clots and surgical complications. 
  4. The increased patient volumes left the support staff overwhelmed by providing one-on-one patient care. 


Cast No Stones

Let’s not be too quick to stone the Cherry Hill neurosurgeons and hospital administrators. There are frightening similarities between their business model and the current practices of high-volume therapy practices.

Let us put down our stones and step back for some self-reflection on what might have led the neurosurgeons down this treacherous path of profit and lack of accountability.

Whether you are a staff therapist, manager, owner, or an educator, let’s take a look at a few factors that undergird the current productivity-quality care debate.

The struggle between making money and serving others has its roots in Western medicine, pragmatism, and unbridled individualism.



Pragmatism is synonymous with Western medicine, particularly with healthcare in the United States.

Pragmatism comes from the Greek word pragma, which means “business.” The root word has a connotation of practicality, efficiency, and productivity.

Pragmatism is a philosophy and a worldview that assumes that the worth of an idea or action lies in its practical productivity. The value of a thing lies in what it produces.

Things are good if they produce, and what produces the most is best.

The ideals of pragmatism are at the heart of Western culture. It surfaces in America’s healthcare system with the rejection of anything that is not useful, scientific, or efficient.

We can see the dumbing down of rehab to a commodity delivery status via the McDonaldization of healthcare.

This is not to say a pragmatic approach to healthcare has not helped to move our profession forward and make the world a healthier place.

The scientific method and evidence-based practices are essential to providing effective and quality care. But it’s important to recognize the detrimental effects of an overzealous practical approach to medicine.


What We Do vs. Who We Are

Unfortunately, in a pragmatic society, we can only feel good about our work and ourselves when we are producing and contributing to the bottom line. Measurable results are admired and rewarded.

Human acts of kindness and emotional support, which are difficult to quantify, seem unimportant or undervalued.

In an algorithm-driven society, artificial intelligence is valued more than emotional intelligence.

Kai-Fu Lee, the ‘Oracle of Artificial Intelligence’,  was shaken to his core by a cancer diagnosis before he realized there are certain jobs that can’t be replaced by robots.

“These jobs require compassion, trust, and empathy — which AI does not have. And even if AI tried to fake it, nobody would want a chatbot telling them they have cancer, or a robot to baby­sit their children,” Lee writes.

When we receive more recognition for the numbers we produce rather than who we are and the lives we transform, our work and job satisfaction takes a nose-dive.

An out of control pragmatic business approach to healthcare is at the core of the productivity–quality debate.

Each of us will need to come to terms with the achievement of our career goals, professional identity, and organizational loyalty in order to negotiate limits to our daily schedules.


Unbridled Individualism

As therapists feel more pressure to produce, we begin to fatigue; we eventually lose our motivation as we move towards cynicism and burnout.

To escape, we imagine ideal work settings where we have all the time we need to help patients. We long for a utopian work-life balance.

Some dream about being their own boss–free from the constraints of company policies and benchmarks.

There is nothing inherently wrong with pursuing meaningful work and making a living. What is at issue here is an excessive preoccupation with our private worlds while being blind to the reality of others.

For most of us, it is our inner world that seems massively real. Other people’s lives and the needs of our society are not as authentic. We can easily fall into the trap of seeing our patients and employers as a means to an end.

There has been a constant movement towards individualization and self-fulfillment in virtually every area of American life. Expectations of therapists have not been immune to excessive individualism.


The Ideal Therapy Job

In today’s culture, the ideal therapy job is to have the ultimate paycheck, a schedule filled with ideal patients (but not too full), opportunities to develop your clinical skills, a perfect boss who will mentor you, and support staff that takes care of all the hassles.

When our narcissistic desires are left unchecked, we lose contact with the bigger picture and double down on our private worlds. We lose touch with reality beyond ourselves, which contributes to impersonal patient care and job dissatisfaction.

We can become so preoccupied with achieving our personal goals that we find it challenging to recognize and appreciate the reality of our patients and the organizations where we work.

Our employers are under tremendous pressure to deliver quality care through the people they lead while keeping their eye on revenues and expenses. That’s their reality.

To escape the snare of self-obsession, we all need to see our interdependence upon the community around us to do our work and to find fulfillment.


No Easy Answers

So, how many patients are too many?

Beneath the question of how much is too much is the ever-present anxiety that something else is going on.

The great paradox of our time is that for many of us:

Our schedules are full yet we are unfulfilled.

We are busy and bored at the same time.

Most of us have incomes that make us rich by any world standard, but we have poor self-worth.


What’s a therapist to do?

Socrates spoke of the futility of living an unexamined life. We are living in a time where sober reflection, self-examination, and resolute perseverance are necessary.

Whether you are a worker or boss, I encourage you to step away from our pragmatic, data-driven, work to the point of exhaustion, healthcare system to regain your perspective.

I recommend taking a personal retreat to examine your beliefs about money and service. I know for some of you a time of solitude and silence is unsettling. (A University Of Virginia study found that people would prefer an electrical shock to being alone with their thoughts.)

Recover your center. Rediscover your purpose. Reconnect with your community.

Michael Hyatt’s approach to Living Forward can be a good place to start. For those of you who want to include a spiritual dimension, Creighton University’s Online Retreat may work into your busy schedule.

Learn to operate and communicate with others from your true center as you pursue meaningful work while setting boundaries on how much is enough. 

I’d like to hear about how you reconcile money and service. Please comment below or email me or click here if you want to chat about it.

6 responses to “How Many Patients Are Way Too Many?

  1. Paul, this is one of the most difficult topics to deal with in the current world of PT. With all of the consolidation going on and “big business” getting into the private practice world it has brought to light a number of personal/philosophical crossroads. My personal experience absolutely matches up with what you are describing, and I am struggling with how to reconcile these issues. As we are getting ready to celebrate our 20th anniversary as a company in June, I’m having a harder and harder time being excited about the future.
    Full disclosure, we participated in the big buying spree and joined up with a larger entity backed by private equity. We did a lot of due diligence, lots of conversations, lots of soul searching and all of the things you should do before selling a portion of the company. There were so many conversations about “nothing changes” “keep doing what has made you successful” and I think all of those conversations were sincere at the time. However, the reality is a couple of years later, we are now owned by a large, corporate organization that has values that are different than what my personal values are. It’s not right or wrong, but we fundamentally look at the world of PT through very different lenses.
    Historically in my company over a 17 year period, we NEVER set out with a profit goal at the beginning of a year for a clinic. We met as a group, looked back on the prior year, talked about what went right, what went wrong etc. We would set out with visit number goals based on the prior year, current staff and other factors. We had a formula we utilized that we called the “Staffing Ratio” which looked at total clinic production and divided by total staff and we found a healthy range that had a top and bottom to it. If you were too low (not enough production and too many staff) that wasn’t healthy financially for the clinic long term and we would make adjustments. But, just as important, if you were too high and too focused on productivity and money, we learned the patient experience suffered and therapists were overworked and prone to burnout. We ran at those levels for years with fantastic success. Over the past 19 years we have broken patient visit and revenue records for 19 straight years with that approach. But, as we’ve now become more “integrated” with the larger company it looks like this year could very well be the first year in a 20 year history that we won’t break records.
    The more emphasis that has been put on production, visits per day, EBITDA, charge per visit etc. the more I see PT’s feeling pressured and reporting burn out. I’m not naïve that these are important metrics/KPI’s but at the end of the day, we got into this profession to help people, not generate statistics and EBITDA. We run a for profit business, no doubt about it, but how much profit (or how many visits) is too much? And if the goal is only about predictable profits then there can rarely be a sense of balance.
    I firmly believe we are seeing the beginnings of a foundational shift in the way PT is practiced and it’s not being driven factors that most PT’s value such as the patient’s outcome, best practices or simply helping people. These changes are being driven by squeezing the most productivity and profits out of each and every therapist, patient visit and unit billed.
    I’ve been a PT since 1997 and I have told so many people this is more than a job for me, I’ve always believed it was my calling. Seeing the direction we’re moving in, is making me do some serious soul searching and questioning.

    Galen Danielson PT, DPT, OCS, Cert. MDT, CSMT, CSCS

  2. Paul Potter says:

    Galen, I appreciate your thoughtful, personal comments. Your owner “insider” perspective was enlightening; You know how highly I respect your integrity and leadership.

    Your perspective and insights are golden. Your commentary on an exclusive bottom line focus led to a lower bottom line was fascinating.

    Hopefully, my article provided insight into why such results are predictable and why therapy veterans like you and I must keep up the good fight.

    1. Marc Foster says:

      Thank you for touching on the elephant in the room that seems to get very little attention. Emphasis on maximizing billable units per visit pushes billing for work done by aides, which is not allowed per Medicare and others too. Insurance companies look at average paid per visit and the number is upwardly skewed due to fraudulent billing. My clinic makes less per visit now than what we made when I first started my private practice 16 years ago. I am busier than ever and still struggling because can’t find PTs to hire as I am a rural health care provider in competition with companies that offer astronomical salaries because they over-bill.

      1. Paul Potter says:

        Marc, thanks for taking the time to add to the conversation. I managed a rural solo practice for nearly 20 years. Hang in there, You’ll know when and how to make your next move when the time comes.

  3. Nick Rainey says:

    Thanks Paul for the great article. I am a private practice owner. This article brought to mind a few thoughts I’ve had.

    First, burnout, at least to me, is not a function of the number of patients as much as it is with how comfortable we are with those patients. If we have patients that are coming in doing better and love us, then we can see a ton of those without burning out. If we don’t understand what we’re seeing with a patient and people aren’t improving then this is extremely tiring.
    Second, one feature of our profession is that we like to spend time with people. We often say that we have the opportunity spend more time with patients. This is partly due to our willingness to be paid less than some of our medical colleagues.
    Third, volume of practice is somewhat dependent on need. It is much easier to see a higher volume if you realize the need to see those patients instead of feeling the pressure to do it primarily for revenue. Many of us have had an experience of describing to a patient how we can help them, then they go to schedule and there are no openings. We then agree to stay late, squish them in, or put them over a lunch. We don’t do this because we want more money, but because we just created a relationship with someone, made promises, and now we want to fulfill them. If we had to overbook because someone is telling us to so the company can make more money then we feel more burnout.

    Thanks again Paul. Thanks for letting me share some of my thoughts!

  4. Paul Potter says:

    Hey Nick, thanks for adding your thoughtful comments to the post. I appreciate how you pointed out that the underlying motivations to patient care are an essential component to a full schedule.

    Many of us can relate to the sense of satisfaction a long work day full with patients we’ve had the privilege of serving. Paul

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