Taking the Risk to Start Your Cash Based Practice with Jeff Bitter
We are continuing with our interview series of cash practice owners and entrepreneurs. I want to introduce to you Jeff Bitter! We've been friends for almost two years and he has some great advice about how starting a practice. Jeff owns CustomFit Concierge, a mobile PT practice in Chicago.
Looking back, his journey may seem like it could be an easy decision to make because of how well he is doing, but starting a business can come with a lot of risks! Today, Jeff shares with us how he came to the decision to start his practice and how he managed each step of the way.
What we will be covering:
Tell us a little bit about like your background and what led you to what you do now?
Jeff: My name is Jeff. I'm a physical therapist from Chicago. I have started my practice about five years ago. I've been a PT for a little over 10 years now. I went to University of Iowa, worked in multiple settings for about eight years or so prior to starting my business. Then I started my business as a side hustle, cash, in-home practice in downtown Chicago and have been obsessed with all the content in the cash PT space, all the books, and learning from people like Morgan and other cash PT owners pretty much every day for the last five years. Fast forward to now, I'm starting to build a team and continue to grow my business every year. My goal is to see progress every year and I've been able to do that for five years, and I'm trying to keep keep the ball rolling.
Morgan: I I feel like there's been, based on what you've told me, a lot of ups and downs in the past five years.
For anybody who isn't familiar with CustomFit Concierge, can you describe your practice model and the way that you deliver care?
Jeff: Yeah, back to my previous background, I started off in outpatient orthopedics and got my feet wet that way as a staff PT for about two years. Then ended up early in my career managing a clinic for a large outpatient company and got burnt out with the churn and burn model and decided to lead that practice with the goal being "become a really good manual therapist" and go the manual therapy certification route. I ended up going on with a small, more hands-on private practice owned by another therapist that was a really good manual therapist and I felt like I really developed my skill set. I got confident with treating a myriad of diagnoses in the outpatient space. While I was doing that, I did home health rehab that was more geriatric and total joints and got used to going into people's homes and treating in that environment. It was while I was doing both that I realized that my own personal preference was going into people's homes. I love the "getting out of the clinic" aspect of it and being in the environment where the patient lives. I felt like that was the most effective way of getting someone better, so I really enjoyed that process. However, like most of us, I didn't love the paperwork and the other things that you had to do as a PT that didn't involve patient care. I just wanted to be able to do that, so around that time, three or four years into that combination of doing those two things, I got turned on to the cash PT model. I can't even remember exactly how. I learned of it I think scrolling through Facebook and came on to a podcasts with some people in the space that have been doing it for a while. I started listening to a podcast while I was in between patients and learned of this other world that was new at the time, involved no insurance, involved focusing on treating one-on-one, and gave really good care to really good people. I learned about that and figured out this was my thing. Once I learned of it, I got obsessed with learning more and learning more. Then I got to the point where I thought I could actually do this, so I started CustomFit Concierge five years ago in addition to those two jobs. I did it on a very small scale at the beginning and the idea was to have low risk and dabble in it to make sure that I could handle it. I did like it like I thought I would, so I started taking essentially private clients inside of their homes in downtown Chicago and treating a myriad out of diagnosis with the skills that I've had accumulated with my other jobs prior and I loved it. I was finally in this environment where I felt like I could really do the best thing for the person in front of me and there was no other barriers to that.
From a business perspective, I really loved the clean low overhead low risk model. From there, I started to think about if I could really do this full time for myself. Could I replace the income of my other jobs? Is this actually feasible to be my full-time job? I just started the baby steps of that, month over month trying to get more patients and get closer to saving up enough money to get rid of my other jobs and jump full into it. At about six months into it, I was seeing 10 to 15 patients a week on the side of some other jobs. I basically backed down my home health job but I kept my outpatient job for a little while and did the side hustle until it got to be too much to manage. I saved all the money that I was making in the business to be able to make the jump. Then, six months in I quit my other stuff and focused on that 100% of my time. For some reason the same week I moved and bought two puppies and did a lot of other crazy things in my life. It was an interesting month, but four and a half years later it was the best decision that I've made and I really enjoy it. I never thought of myself prior to that risk-taking experience as a business owner, or I never really was going through PT school thinking that I wanted to start my own practice. I never really thought that was going to be my thing until I learned this type of way of doing it that I felt way more confident with doing that.
Now four years and a half years since I started full-time, I have taken on an admin employee that's been with me for about four years, and then I've started to accumulate other physical therapists like myself. We're currently six full-time PT's, including myself, and Susan our admin. We have no clinic, no office, Susan works out of her home, and the six of us run around Chicago in our cars with treatment tables and equipment and treat people in their homes. I love it! I think the other five love it as well. We're happy doing it that way and we've met a lot of amazing people like Morgan and doctor referral sources. I've learned a lot of stuff along the way.
Morgan: I feel like I always come back to this thing of "starting your own practice" is so much more than just starting a business, you know? You end up getting so much more out of it, like you said. Meeting a lot of people and doing things that you never really would see yourself doing, which is really cool.
Did you have any fears related to starting a business and how did you overcome those barriers?
Jeff: For me, I think the first thing that comes to mind is student loan debt. I got out of PT school and had a lot of student loan debt that I didn't quite understand being in school, being young, and how that would affect your life and your finances. In going through the process, I decided once I was out of school to pay off my debt as quickly as possible, so I basically worked really hard to make as much money as I could working for other people to pay my debt off. I decided at the time that I wasn't comfortable taking another risk in my life with a business until my debt was gone. I don't know if that's the right way to think about it or not, but for me at least, I needed to be comfortable doing something else that involved risk, getting rid of my debt. For me, once I paid off the debt it gave me a mental springboard to be able to be at square one. Very slowly this little micro risk of starting my own practice seemed like a good option to me. Because my fear was I guess being in debt again or having it not work out from a financial perspective, and being able to provide for my family. I would imagine that's a lot of people's fear, but that's the reason that I decided to do it without a clinic and do it with a low overhead, low risk model at the beginning. I wanted to be able to be confident to know that it wasn't that risky to do essentially because I was fed up with the fact that I had paid so much money from my loan debt at the time. I didn't want to be back in a bad financial position ever again.
Morgan: Absolutely! That's definitely a big motivator. For you it was a "hurry up and pay off all this debt" so that you can do other things with your life and not have to worry about it. I think that that could also be a motivating factor to start a business, or at least a side hustle because then you can do this on the side and put all the extra money towards student loan debt. That's always an idea too. I think a lot of us have very similar fears and I guess that would be something that I would want to pass to everybody: you're not alone with whatever it is that you're worrying about. Whether it's finances or imposter syndrome.
Did you ever struggle with imposter syndrome?
(Who am I to do this? Who am I to run my own practice? Who's gonna pay me for this type of thing?)
Jeff: I think for me, it was never really in my brain to be someone who was like, "Oh yeah I'm going to start my own business. I'm going through PT school so that I can start my own practice." When I was working for other people also I was like, "I don't think I could see myself doing that." I didn't think there was a pathway for me to be a traditional "Physical Therapy through insurance clinic owner" type person. However, I think the the two things they gave me the confidence to get past the imposter syndrome and being fearful about starting my own practice.
The first thing was paying off the debt. It made me feel like I was under control. My life, my destiny. Some people have the mentality of things that are just happening to them like they can't control them. However, being able to pay off this mountain of debt, put in the work over a long period of time and see a result gave me a bit to overcome the imposter syndrome. I could show myself that I could control a really hard variable and have success with it.
Then the second one was seeing an interest in my skill set. I was in the home treating through another business,(in a traditional in-home setting). I started to get requests. I was taking good care of people so people would ask if they could pay me privately to continue to treat them. I saw that there was some interest. That gave me confidence to know that these people are willing to go outside of insurance and pay for my skill set. It kind of gave me validation because there was actually some interest in that from the patients that I was seeing through another business. Those two things I think helped.
Morgan: That's why I always tell people to get their LLC because people are going to ask if you can see them privately. You have to be ready. I think not everybody has the experience of going into a home for patients, but there are going to be people when you tell them that you're starting your own practice or that you're seeing patients privately, people are going to ask for you to come and see them, whether you've seen them before or not.
Jeff: If you're good at what you do.
Morgan: Yes, and if you're not then they're not going to come back.
Jeff: Yeah, early in my career no one was asking for me. I did not know what I was doing.
Morgan: Then that would probably be a good signal like you said for you to start looking into it when the day comes when somebody asks for you. Then go for it!
Being a mobile practice, in this process of growing a mobile practice, did you learn anything about being a mobile provider that surprised you?
Jeff: That's a good one. I think that someone who's never treated in the home before would always ask the question of "How do you have the space?" and "How do you have the equipment?" One thing that surprised me is literally you can do a PT visit anywhere. I've done it out outside in backyards, in closets, in kitchens, in bedrooms, in bathrooms, in literally anywhere that has a floor. You can do a really effective physical therapy visit. I think most physical therapists that have been around for a little while probably would understand that they could be effective anywhere, but I think that sometimes is a barrier for someone's thinking, "Oh, in the home. What am I going do? I don't have the clinic with all my equipment." I guess that was a surprising thing for me was how how much you could do with very minimal equipment.
Morgan: Yeah. A lot of it too is talking. I feel like I talk a lot more now with my patients than I did in the outpatient clinic. Really just exploring your lifestyle, your habits, and are there things that we can change to help support your physical recovery. Being in somebody's home, what's a more perfect functional gym to be honest?
Jeff: The personal connection you make with your patients in a clinic. We've all had those patients that you've been treating for a while that you feel very connected to that come to see you in the clinic. It's an even deeper and sometimes more personal, and sometimes overly personal, experience. You're going into their home on a regular basis for sometimes long periods of time. You get to the point where you feel like you're family with some of your patients. I like that because it's another extra layer of trust. They send their family to you and they they come back to you for multiple injuries even more so than they would if you were in a clinic.
Morgan: Yeah, it makes a much bigger difference than we expect. If I were the patient and I had a provider that I was on first name basis with and I could text them and tell them, "I hurt my knee. When can you see me?" Yeah, it's really cool to have that relationship with patients.
What would be the minimal equipment that you would need as a mobile provider?
(Your desert island equipment that you would take as a mobile practitioner. You get the one thing)
Jeff: To answer that question directly I would say I would need no equipment at all. I mean seriously, if I have someone on the edge of a bed, with stairs in the house, my hands, I would be confident to deliver value to most patients I would say.
The desert island part though, I'm very tall and awkward and have an awkward body shape, so treating at the edge of a small bed would be really debilitating for myself. That's why having a treatment table that I've adjusted to my proper height that most of my patients can't get on without a step stool or me lifting them, that would probably be number one. I do a lot of manual therapy with most patients that I see and to have a table that's adjusted to my height would be probably number one.
After that, when it comes to exercise equipment, I love the BOSU and the Airex pad. I think a lot can be accomplished with those two things, exercise wise. I bring an Airex pad in with almost every patient. I, if you can imagine, not being in a clinic without a rolling stool and without a table that goes up and down, so I use the Airex pad to kneel on a lot because I'm doing visits on hardwood floors, tile floors, or whatever surface that I'm on. The Airex pad is really a saver more so for me probably rather than exercises with patients, but the table adjusted to my height and the Airex pad would probably be two necessities.
Morgan: That's good to know. I think like those are definitely really good things to consider. It's not just what the patient might need, but how are you going to make it through a 14 hour a day driving around Chicago and still make it home okay. My first thought is I would need a notebook and a pen because if I don't have something to write everything down on I'm going to forget everything by the end of the day.
Jeff: I remember when I was in PT school on one of my clinical rotations I shadowed this older female PT that was in her 60s and she was doing inpatient rehab in a hospital. She had been at the same hospital as a PT, doing this rehab for about 40 years. I just remember trying to keep up with her, following her around. She was fit, very good at her job and very into it. We were going room to room to room, seeing people with all of these different surgeries, different names, we're doing all this exercise for 12 patients in a row, all day long without like sitting down. Then, I remember her and I sitting down in the office to do the treatment notes at the end of the day and she would literally regurgitate every set, every rep, every right/left side, literally every distance that someone walked, every stair training. She just had it down pat and would do the notes in like 15 minutes. I remember sitting there as a new grad that has never worked before just being like, "What is going on here? How is this woman doing this?" I couldn't remember anything from what we did, but I guess my point is, once you do fit something every day for five years, you get really good at remembering all that stuff because five years later now I look back on that and it makes sense.
Mobile practice does bring another layer to it because you have to remember where people live and where to park. In the city, as you might imagine, that's a challenging aspect of this type of practice as well, but for some reason some people hate it. It's definitely not for everyone, but for some reason I like being outside and having the variability of it. I like the challenge of trying to navigate around and be on time all day for some reason.
Morgan: I totally get it, and that's something I really liked about home health too. You know your schedule and you can change your environment a lot like like you said, the variability. Something else that I learned too is to pay attention to where in the city people are when you go to schedule them so you're not crisscross zigzagging all over the place that you live in. It's a bad idea.
Jeff: Yeah, I've been there. I still have days that are like that for sure because us as PTs are always willing to go the extra mile for our patients usually. You know someone that wants to pay you to see them. It's hard to say, "Oh, no I'm not going to drive the extra 15 minutes."
There is again another layer of skills that you have to develop to be able to optimally navigate through a schedule and schedule your patients in a way that's manageable for you from a transportation perspective. Some days work out really well and other days don't. Now that I have other PTs that I'm trying to teach and train how to do this as well I'm noticing that it just takes time and reps to do that. Again, there's only one way to learn and kind of to jump in and do it, and you get better with it every day. As long as you hire people that are willing to accept that challenge, they surprisingly get better at it very quickly.
I just wanted to go back to that question about equipment so that people understands what exactly I actually bring in every day. I have a backpack that's basically full of table cleaning supplies, bands, mobilization belts, mobilization wedges, stretch out strap, foldable hurdles for balance exercises, and a myriad of different things. I have like a theragun and some random stuff that I use sometimes in a backpack that I carry in to almost every patient. Then I have the Airex pad, a rocker board, and a BOSU ball usually in my car that I can select depending on who I'm seeing. I also have a fold up treatment table. I've probably bought 20 to 25 different treatment tables over the years, but I've found one that is relatively light that's a little smaller and narrower. It's easier to get out of cars and transport, it has a handle on the top that only costs about $90.
Morgan: Do you know what brand it is?
Jeff: It's some weird off-brand that I bought. Some of the ones that are more expensive are usually too big and bulky. They're heavy and not as user friendly. It does make a difference.
Morgan: I think a lot of people ask what kind of table to bring. I mean mine that I have, it was about $80 on Amazon I think and it's almost three years old, hasn't cracked yet.
Jeff: I think another another interesting part too is the type of people that we tend to treat, a lot of them have home gyms, extensive equipment in their home, or live in a building in the city that has a really good gym space that we can utilize. There's a lot of patients that have access to facilities that we don't pay to use that have access to that we do our sessions in, which is always nice.
Morgan: Yeah that was something that surprised me too at the apartment complex I used to live in. They had a gym and I asked about treating patients there and they had no problem and let me use it whenever. "Be resourceful" was probably a good piece of advice doing this.
Jeff: I would say one other interesting point to the startups. One thing I learned is if you're sitting out there and are waiting because you're afraid of maybe the financial commitment of starting. I started my practice with probably $2,000 total. It was literally that group of equipment that I just described and starting an LLC, (which was a couple hundred dollars), and maybe a few other things. That was about all I did to get the ball rolling. Once I started seeing patients, I basically saved all the money that I made from the first handful of 100 or 200 visits. That's all I needed to springboard from there.
Morgan: That's another question that I do get asked a lot: "How much is it going to cost?" Honestly, if you're able to save $1,000 - $2,000, and that $2,000 is probably even the top of a budget for a pretty lean mobile, gym based, or whatever practice. I think that's a really good point. You should make that back 100% within six months I would say.
Jeff: People think it has to be this complete package, like you have to have a website and you have to have this and that ready. Really what's most important is that you have a couple clients to start.
Morgan: Yes, clients are good! We were saying before definitely if people express interest in your services it's a good indication that things are going to go well.
If I were just starting my practice, where do I find clients? What's worked best for you?
Jeff: For me, because I chose to start my practice in the same location that I was already in the network of patients, previous PT's, friends, and family, honestly my first couple patients were patients that saw me through the home health company. The people that were requesting me to come see them. I literally organized the business and then called them up and said I could come see them. That was kind of where I got my start. I had a couple clients that I was seeing in the clinic that chose to follow me into the private pay realm and I think I can remember who my first four or five patients were, and they're still my patients today.
What you're getting at is marketing. I would say at the beginning there wasn't much marketing that I was doing. It was more tapping into whatever relationships I could think of to tell people that I had a business. That got me started enough to start accumulating a little bit of word of mouth. At the beginning when I was part-time, that was really all that I did. I didn't really start marketing more aggressively until I went full time.
Morgan: Even though you're saying you didn't do a ton of marketing, what I really like about this approach is that when you started you went right to your potential customers and talk to them about it instead of, "let me build a website" and "let me do some ads", "let me go talk to other referral sources", and just hoping that people are going to come in. It almost sounds too simple, but one of the easiest way to find clients is to go and talk to potential clients. Say "Hello. Would you like to work with me?" or "Do you know anybody who might?"
Jeff: Fast forward to now, as I'm starting to hire other physical therapists and help them build their practice. The first thing we do is I have them look through their entire cell phone, their entire email list, any sort of person that they have any relationship with in the area and draft up an email that tells them that they're starting a practice, this is how it works, and that they're asking for word of mouth referrals. To this day the word of mouth referral from a previous client is the #1 best referral in the business.
Morgan: That's awesome. That's kind of like the 100 challenge that I ran in the group last year. Basically make a list of 100 people and then reach out to them. Whether or not you actually sign up a patient or client from either of those things, it really helps to get your momentum going. You rip the Band-Aid off of the fear of how people might react. You just go right into it.
What do you do to market now?
Jeff: The thing that I've had the most success in marketing is to private concierge medicine, private practice physicians. Essentially their private paid doctors that patients pay for a membership practice. I have the luxury of being in downtown Chicago where there's several of those types of practices. When I brought my admin Susan on, she and I sat down and went through finding as many of those types of practices that we could and started to make phone calls. We would try to set up meetings and get to know who these physicians were. Five years later, that has also been, after word of mouth referrals, my best form of marketing. Relationships with physicians. Which I guess in my observation of the cash PT space and all the education and podcasting out there, a lot of people's advice is not necessarily to market to doctors, which I understand that perspective. However, at least in my experience, I've gotten lucky enough to be able to focus on that and get in on a text message basis/ first name basis with some of these doctors that have sent us people that we've done well with. That's been really good for us.
Thanks to Morgan, we built a new website that we also are proud of and we're getting more traffic on the website. We're starting to be a little more proactive with trying to generate potential patients from online sources, but we haven't been as successful in that as we have with the traditional kind of networking type marketing which has been what I was more confident and comfortable with earlier on.
Morgan: People always want to know what the best type of marketing is and honestly just like the best type of fitness, it is the one that you'll do! Sometimes the best type of marketing is the kind that you feel you're really good at, that matches your personality, it matches your values, it's worked before, so keep doing it. There's always room to try new things and have a primary and secondary version marketing, but if you're newer to this, trying different things is a great idea. Then when you find something that like feels good and also has a return on the time investment, definitely follow with that.
I also like too when you're creating relationships with concierge medicine providers. You're a concierge medicine provider so I assume you guys speak the same language and I think that is important when you are reaching out to other providers for potential, mutual referral relationships versus I wouldn't necessarily suggest reaching out to all of the possible medical providers in the area especially if your practice philosophies are not similar. It might not be a great match.
Jeff: I think that's a good point. A lot of the doctors that we work with are also broken off from bigger hospitals like I broke off from the bigger PT companies. They tend to be experienced and know that they want to give better care to their patients essentially, so we're both in it for the same reasons which helps us connect. My experience on the front end was kind of like business owner to business owner because a lot of them are starting their little couple doctor practices very similar to what my practice is so I connect with them that way. It's a relationship that naturally happens. They want to refer their patients if they think their patient is going to benefit from physical therapy, they're not wanting to send them to some of these other bigger companies that they used to send to when they were at the hospitals that they had bad experiences. We were positioned in a way where we could cater to their type of clientele very nicely and I think they realized that once they got to know us a little bit more.
Then obviously taking really good care of the first couple of referrals that you get from a doctor is super important. You have to do the right thing and wow them and hope that they get better and hope that they're not crazy patients that speak negatively of you. I think I also got lucky that I had a couple referrals early on from certain doctors that were really good patients. They did really, really well that I made one of those long-term connections with. They then went back and talked to their doctor and told them about us and I think that's the best marketing to the doctors, to have a patient of theirs that goes back to them and says positive things about us. That sticks in the doctor's head and makes them way more likely to refer to you again.
Morgan: Absolutely. You know when you're, as a provider, able to find other providers that you know your patients will be safe with and will be taken care of. It's huge because at the end of the day, all the business stuff, we are in it to take care of it and to take care of other humans.
What are your top three pieces of advice for a new practice owner or soon-to-being new practice owner?
Jeff: Number one, when you're 75% sure of something, just do it. You're never going to be 100% certain.
Number two, this might be more specific to me, but I do recommend starting as a side hustle. I think that was an important start, especially for someone who's hesitant and scared. Don't ditch your primary income right away. Dabble a little bit to make sure you know your system works, you like it, and it is the right decision for you. I would say start with a side hustle if you're 75% sure then do it now.
Last piece of advice, I think with every decision you make within the business, always focus on what's best for the patient. That's why, if I have a dilemma on something, I always go back to, "In this situation, what is the best thing for the patient?" Then that helps me decide how we're going to do things. It always seems to never steer us wrong.
Morgan: I love that. I think that's a really good way of thinking. Whenever you're feeling lost or conflicted, thats your North star to look to. When there is a decision you have to make and are wondering what the financial implications are or how it's going to affect you or your team. Ultimately though, this is for the patient. Sometimes that can be scary especially when the first thing that comes to mind is if a patient is coming close to being discharged and they don't really need you anymore, but you don't necessarily have somebody coming in to replace them. I know that can be something that causes fear in newer practice owners because then you're worried about the money, how you're going to get that back. However, if you put out there what you want to be taking care of patients well and do what's best for them, it's going to come back and you have to trust that it's going to come back too.
Jeff: If you're focused on like the money side of it or you put yourself in a situation where you have too much risk and you have to focus on the money side of it, I think that's dangerous. I think we alluded to this earlier. My story of getting rid of the debt and starting with $2,000 slowly, it allowed me to focus on the patient at the beginning and then not have to live off the income of the business when it's really small and have stability still somewhere else. That allowed me to accumulate savings in the business to again be able to then jump over to another job and have stability still and still focus on the patient. Then the business side took care of itself over time.
How to contact Jeff:
His website: www.customfitc.com
His email: jeffb@customfitc.com
Listen to this episode on our podcast!
