Using Aquatic Therapy Programs by Dane and Sue Nelson (1997)


Moderated by Mick Nelson

MN: It’s my pleasure to introduce the speakers to you. This is a unique pleasure because these two speakers are fresh off the Aquatic Therapy Convention as featured speakers in Las Vegas two weeks ago. I almost couldn’t get them to come here and do this. They’ve been doing a lot of work with this field and I asked them specifically if they would come and share some of the stuff that they are doing with you. I’m going to introduce to you ASCA level four coach Sue Nelson and ASCA level three coach Dane Nelson. They are talking today not about aquatic exercise but Aquatic Therapy. So I’m going to turn it over to them. The Nelson name is not a coincidence, because it’s my wife and my oldest son.


SN: Imagine this: Coach, I have something for you. It is a pink slip. Monday is going to be the most devastating day of your life because you are going to go back and not have a job. You don’t have a job because Waterway Therapy Inc. just bought your water time at your facility. Your Administrator is going to say the team is not holding up the financial burden of this facility, we can no longer help you with your team. The pool sits empty for too many hours. The cost of the facility is too much. Hosting a meet is too much because there is too much damage going on. This company Waterway Therapy has just found a way to finance your facility and make money. We’re going to show you who will come in and take over your pool. Imagine that.


All of you have this opportunity that will be knocking at your Administrator’s door. There are Hospitals, Clinics, Fitness Centers, PT’s, OT’s, KT’s, AT’s, COTA, APT, Physiologists, and Water Fitness Instructors. They are all going vertical, they aren’t going horizontal in the water. Aquatic Physical Therapy is the number one growing therapy in the industry right now, in the medical field. Fitness is the second, it’s right in line with that. They are combining. So the Water Wellness Programs are lining up with the Therapies. This is what is happening. They are buying your pool time. We want to show you what you can possibly do to stay in charge and go down another road.


MN: Dane is the Corporate Operations Director of a year and a half old company called Waterway Therapy Inc.. Sue is the Programs Operation Director. I’m the interviewer today. Since some of you may not know what questions to ask or don’t even have a picture of the opportunity which sits in front of us right now we’re doing this in an interview form. You may interrupt and become the interviewer at any time. I know what questions to ask because I’ve watched this happen over a year and a half period. I also know what questions are of interest to me as a coach. I’m a Coach, I don’t want to do this but I want to have the privilege to be able to coach without the team I’m coaching having any financial impact on our budget. That may sound lazy. Question number one. Give us a couple of examples of how the ASCA professional coach fits into the Aquatic Therapy big picture.


DN: Basically, after being an ASCA Coach for the past four or five years and working with an Age Group Program and the Senior Program. I’ve attended many of the Clinics throughout the country. One of the number one things that I’ve heard preached and preached again is the fact that the coach needs to take advantage as much as possible and get into the dry side of the sport, get into the Administrative part. We all love coaching, we all love working with the athletes but the Aquatic Professional, the one that is taking advantage of the opportunities out there which may not just be in swimming, are the ones that are going to solidify their position. They are the ones that will have different organizations looking at you for your answers. One of the number one things I’ve found out, being a swimmer and then becoming a Coach, is that Coaches have a lot to offer when it comes to just plain old movement in the water. I’m not talking only about exercise programs, weight, training, macrocycles, and mini-cycles — just movement in the water. A Coach has that unique feel and insight of what it feels like to move in the water. There is no one else out there, nor any other industry, where you have that opportunity. You may have some people that dabble in swim lessons, they know the basics. They know how to get kids to do things that end up looking like swimming. The number one thing that the coach has to bring the advantage of knowing what movement in the water can do and if not knowing it right off hand and being 100% efficient with it, at least they have the background. They have the knowledge, insight and resources. We have access to one of the largest bodies of knowledge, that being the Training Center, working not just with swimming but all kinds of movement in the water. I really think that after hearing people talk about that here at ASCA.


I thought, “Who better to do this than Coaches?” Coaches have the water time usually. If not they are closely linked with somebody that does.


The second point I’d like to say about that is that I don’t believe I’ve yet heard of a Coach complaining about being overpaid. Being a young coach and a young person, I have pretty big aspirations as to what this industry can do. Seeing and having run a business working with Mick and Sue with the Turtles Swim Team we realize swimming alone is not going to make it. We’ve heard other presenters talk about Swim Shops and other supplemental sources of income like Learn to Swim programs. That’s going to be one you’ll hear me talk about a little bit later. About the dollar figures — just what kind of return, what kind of money is out there? And sources it comes from? Where it can go, what you can do and how the coach fits in? I think these are the keys. The person of the obvious choice, when it comes to the water and the overwhelming opportunity for finances is the coach.


SN: All of our Coaches have been able to do what we’ve fallen in love with. Mick gets to work with the whole team. Dane gets to work with the Administration level and is the Consultant Coach and Fitness Consultant. I get to coach all levels. I get to coach the team when I want to. I get to coach adults. Now that I’ve hit that nice big 50 I know what it’s like looking down the road. I’m one of the Baby Boomers who wants to take charge of my retirement years instead of work. We think you can have the ability to do that as long as you begin on your turf. We feel you have all the right hats to wear to go into this next venture.


MN: I got into Coaching because I love working with kids and athletes, why do I want to work with sick people?


DN: The number one thing you are going to hear me talk about in the next couple of hours is Baby Boomers. You just heard Sue talk about it. To recap some of the statistics, we have 78 million people out there that are getting ready to reach The Over Fifty. A lot of them in 1996 have just turned 50, they are going to stay on a period of 18 years. Seventy eight million people that had the possibility of generating, and this is a staggering figure, 11 trillion dollars in Rehab care. Eleven trillion dollars in the United States that will be spent by the Baby Boomers in Rehab care whether it is Physical Therapy, Recreation or Occupational Therapy. Some source of post surgery, post injury or even maintenance type care is going to be spent from the income in that age group, that population. That population has changed every industry they have ever come in contact with. A lot of the experts in demographics point to that age group as molding American Society in every aspect. Economical, Political, Social, Spiritual, whatever they come in contact with. From the time that they started with the school age classroom, they’ve changed the classroom settings, the education setting all the way up to the Board of Directors in the Corporate world. Everything has changed that they have come in contact with. I think that one of the main things about this new industry of Aquatic Physical Therapy is having Doctors and the medical profession finally come around to admit that there are some medical benefits that can be seen by working with patients in the water. By working with people that have injuries or chronic illnesses or pain syndromes. The water is the place for them to be.


Q: What about the water temperature?


SN: We have found that the ideal temperature to work with people in a multi-setting is 88-89 degrees F. You have people that are being rehabed from injuries, people that are using it for fitness and a third of the people using it for exercise and training. You’ll hear a lot of coaches out there say they can’t train their swimmers in 88 degrees F. There are a lot of studies out there right now about this. Tom Landry Institute has just implemented one. We have tried to get the Training Center to come out for the past two to three years to see our results. Three years ago we started raising our temperature when we were starting to get heavily interested in this. We did a gradual increase in our pool temperature 1/2 degree every three months. We went from holding it at a competition 78 – 80 degrees to 89 degrees over a long period of time. We have an extensive tracking system with all of our benchmark steps and reference sets. We saw absolutely no drop-off, taper times were just as fast, quick rest times were just as fast at the end of the year. We had a few complaints from the swimmers but no medical problems. The normal complaints were that it’s too hot, they couldn’t work. But again the times were there. The practice times were there, the repeat sets were there. We did have one fortunate thing we were able to do. That was install an automatic watering system in the facility. Above each of the lanes there is a watering system that dumps fresh water right into the pool, so that at any time, the swimmer can literally just look up to the ceiling and get as much fresh water as they want. It’s coming down constantly. That was the biggest problem we had to overcome. The water temperature for the Fitness people has been great. They are happy with it. The swimmers are still performing as well as they ever have.


MN: Isn’t there also a branch of thought stating that this new Aquatic Therapy can be done at 80 degrees as well as 88 degrees with the same benefit?


SN: There is all kinds of research going on. Typically you have different diagnoses that will call for a certain degree of water because of the diagnosis.


MN: Don’t arthritic people need 90 degree water?


SN: Yes there is a need for 90 degrees when you have non-movement or passive range of motion. These are often side pools. A pool with a temperature of 88-89 degrees can soothe just about any person with a medical problem including MS, CP, and all the different diagnoses. Cold water, 81 degrees for a person with Arthritis is not acceptable.


MN: It’s not just because of the condition. This is basically because the person is not doing any extensive movement that would get the heart rate up and keep the body warm. The properties of the water don’t change going from 80-89 degrees. The hydrostatic pressure and resistance are constants. It’s the body temperature that a patient gets uncomfortable with. The muscles start to tense up, they start to shiver. When you’re moving you will never notice this because of the constant activity. They are comfortable. You can see them sweat in 80 degree water. But when you have a patient that is doing an hour worth of therapy, where they are only moving a small amount, the heart rate is not rising nor are you increasing the inside body temperature. Having them comfortable allows them to stay in longer to get more benefit. That’s the main purpose behind it. You are going to see a lot more research come out now that the Tom Landry Institute just got a big grant to do full body immersions and they are paying for the setting completely out of grant money.


SN: Also what we have done successfully is establish a Water Wellness Continuum. In our facility, simultaneously, we have Water Therapy for all ages and all diagnoses, a water fitness program, and lap swimming. These are all going on at the same time. That takes a little bit of education and caring of each new member that comes in. But it is workable, it can be done. It has been done with heart patients, that’s why you aren’t going to go any higher than 90 degrees and have movement. That’s a little too much.


MN: What sort of certification or right do you have to do this as an ASCA coach?


SN: I started doing water therapy on my own. I also knew my limits, whether this is ethical. I knew I was an excellent level 2 Swim Coach and I knew what I was doing. However, when getting into the situation where we had people come in and ask more medical questions and for medical advice I knew when to stop. I was getting reimbursed on a few instances. It’s very difficult. It’s long going. We would not have survived if I would have waited to do this on my own and waited for reimbursement. That’s why you go into it with a Physical Therapist. You have your business and hire a P.T.. That’s how we have our private practice. We have a team of a Physical Therapist, Recreational Therapist and a Water Fitness Instructor besides a Water Consultant.


MN: Are you considered employees or independent contractors?


DN: In our specific business they are employees. When we first started doing this we used contract therapists. In other words we actually paid a contracting rate to have them come in and work with people that we had on our own as a referral source. There are companies out there that have nothing but contract therapists. They go from one company to another seeing their patients on a regular basis. This gets a little expensive but if you have the high volume and are in a rehab center, that’s definitely the way they go.


MN: Are there any instances where the therapists will come to you and the pool owner and say they didn’t want to contract pool time.


DN: Yes. We are in a small town and we even had that happen. We are in a town of 30,000 people and one hospital. This is what happened. As soon as we started this business we had a hospital contact us and one wanted to rent water. They didn’t have anything to do with our company but were seeing patients in a controlled setting. We thought we were the professionals in the area and had quite a bit of experience in the aquatic industry. They came and wanted to rent water. It worked out for awhile and then there were conflicting interests as far as where we saw our program going and where they were. And we ran out of space. We had more people that we wanted to see so we ended up saying, “I’m sorry, we can’t rent you water anymore.”


SN: I would at this time like to make a comment so it is on record. If you are wanting reimbursement from third party payers — insurance companies, then yes, you have to have a Physical Therapist on staff. You can do it other ways by charging the individual person. You might work out deals with some grants. I’m sure some of you have been in swim programs that got a grant from another organization. But PT has to be in place at this time for insurance reimbursement.


MN: Is this just a state issue?


SN: No. It’s a federal issue.


MN: How a coach hires a Physical Therapist?


A: Basically what you have to do is use some connections, perhaps from the swim team, the parent group you have, the doctors that you may know. There are a lot companies out there that place therapists rather than just the recruiting company. You tell them you are looking for a Physical Therapist, they’ll do everything in their power to get one to move into your area. 190 One thing that we found out when we started this is that Physical Therapy has the most controls of any industry that I’ve ever seen. You would just hope a coach would have this type of control over their industry. This is because the American Physical Therapy Association actually limits or restricts the number of people that are allowed in through out the country and Universities into Physical Therapy Programs. There by restricting the number that graduate each year. By restricting the amount that are out there in the common market they create the need. It’s legal, they do it, they know exactly how many PTs are graduating every year. They know exactly how many job openings there are for them each year. Hence the high salaries. You have an industry which is growing. There are 73,000 Physical Therapists in the U.S. right now, at the end of the century there will be over 186,000 positions that need filling. It doesn’t take long to figure out that you have a high demand.


MN: Can you tell us what you are doing and how you are doing it so I have a frame of reference?


DN: We have referral sources from around the city, doctors and other people that would like to have their injured patients and deconditioned people in the water. The number one way that we can do that and get the amount of money we need reimbursed is by having a Physical Therapist. So we have hired one. We started seeing about six or seven patients a week. We have grown by word of mouth and a little bit of marketing, television, cable spots, and lots and lots of advertising. Then you have Doctors agreeing to send you a patient. They are happy to know you have a Physical Therapist. We started working with them in the water, three or four times a week. Basically, what we do on the dry side of it is to make sure the insurance companies provide Physical Therapy services in the patient’s policy. Something that you probably take for granted when you go to the doctor’s office is that you have your insurance card and it will be covered. When you go in for Physical Therapy services, you know your insurance is going to cover it. There are a lot of policies out there that were written in the mid 70’s or 80’s that weren’t writing in physical therapy services. They were leaving that out. They were very cheap policies. So you need to have a Coordinator in your office who can check. This is another part where the coach can fit in. If you’re not doing the coaching full-time, this is something else that might supplement that. You check the insurance, you verify that they have coverage, then you can actually see them in the water. The only thing left is the billing. You track and you document. You document everything down to the “t”. From when the patient walks in the door, when they are in the water, when they leave. Keep detailed records of that. Everything is on computer these days. You bill the insurance company, and thirty days later you get a check reimbursing for the services you provided. I’ve simplified this explanation. We do have one other aspect. After the patient is seen for thirty days, they have somewhere to go. We don’t just boot them out like the hospital does. We offer access to the water. We allow them to continue on their own. Those of you know that there is lap swimming available. Get them to move the lane lines and you can have the people doing their work right there in the water. When I say work, I mean vertical exercise, they are doing gait training in the water. They are doing the things that the Physical Therapist has just trained them to do in the water. Now they are doing it on their own. Now you don’t have to ask for insurance anymore. You don’t have to charge the outrageous hourly rate that the insurance company and Physical Therapy industry has created. All we are doing now with this new industry is using the things that are already there. We’re using the concepts that are already there and the practices that are already there.


SN: Let me quickly give you another picture. I can remember us coming to the ASCA World Clinic years and thinking that every situation presented by the speakers is not what I’m used to working with. We need you to be creative. We want to spark some creative thought processes. Picture a USS Swim Team, 25 yard lane pool and another 20 by 40 pool. In that facility only the swim team is working out. The Board of Directors came to us and said this is not working. We have to do something. Being creative, we decided to do the other business by adding it in. We went the opposite direction. We started from our adult fitness program and built up to the Waterway Therapy Inc. You can do it either way. We had a clientele built here which was very small. We decided to go that route to help increase our income, which it did. All of this is going on at the same time. So you have Water Therapy going on. Once they advance out of that, they have Water Fitness Program. You still have your swim team. Now the swim team does not have to have the high burden of the cost because it is in the other program.


MN: Do you call this Water Aerobics?


SN: I don’t care to use that term. It is a Water Fitness Program that teaches people to be as independent as your athletes are.


MN: Without oversimplifying it as far as the treatment and Physical Therapy end, it’s really no different that an independent practice that a Physical Therapist would go out and start. We did find out that there are a lot of people that are not Physical Therapists which start a Physical Therapy practice. People are astounded wondering how they can do that without being a Physical Therapist. Well I do a lot of the things the Therapist is not doing, like the scheduling, the insurance verification. We’ve now progressed to the point that we have hired a Billing Company so I don’t have to do the billing in house anymore, which is a huge load off my shoulders. You progress to the point where the insurance companies, when you are calling for verification on a specific treatment for the patient, just want to know that you have a licensed Physical Therapist. They don’t care where the exercise is done. Case Managers just want to know that you have a licensed Physical Therapist. They want to know how often the therapy will be done. We tell them three times a week and then after a thirty days the Physical Therapist will work up the documentation and send that in to you. The insurance company just tells us to be sure we have the re-eval before we do anything further as far as the treatment plan goes. That’s basically it. There are a lot of other payers that go along with this besides just private insurance.


MN: If you had to start with a new facility, how would you set it up?


DN: I’d build what you see there. Exactly to a duplicate of what we had. Because we just did a $50,000 remodeling this summer to bring the facility up to standards. We spent $150,000 before that to add the reception, waiting and exam rooms, the spa, the hydromassage area etc. So we updated the facility. Any facility will work. Creativity is the key to it. I can do this in a corner of Wichita Swim Club’s deck. For $25,000 I can start this business. There are a lot of different ways to do it.


SN: You don’t have to own your own facility to do this. Be creative because you have all the people on your team with resources. Use these resources and be creative.


MN: Dane, what did you know about Water Therapy 18 months ago?


DN: Very little. I was really involved in coaching and traveled on a couple of the national disabled team trips and was really into designing practices and just working with the swim team. There came a time when we just weren’t making it and had to do something else. Our budget was not surviving. I started doing a little reading.


MN: Are you doing anything in the water?


DN: All of us have the capabilities to do the work in the water. However, I am usually in the office, Sue trains the therapists.


MN: Who writes and who implements the program?


DN: Actually, the therapist joins us in a team effort to write the program. We implement it. The Physical Therapist did not go to school for four years plus a two year graduate program to come out and do what the coach does. The therapist brings the clinical side, everything it takes for a person to walk into their office and after having an hour initial examination, gives a detailed medical diagnosis and comes up with a treatment plan based on exactly what they were educated to do. The only problem is, they get up to the last step, they are ready to get into the water, and they look to Sue for guidance. I know what I would do if I were a Physical Therapist on land but that’s not what necessarily works all the time in the water. That’s not what Physical Therapy in the water is all about. Physical Therapy in the water is about movement and about having a non-structured, non joint moving. Physical Therapists like to do a lot of hands on, let me move it for you. In the water, that’s not taking place. Physical Therapists are turning to people that know water, that know movement and exercise. It’s not going to be long before this great big group of Physical Therapists that are getting into this Aquatics, are going to be knocking on the door of ASCA or USS, the Training Center to seek out the experts in water. I just came back from their convention a couple of weeks ago, that’s all they wanted to ask us, “What do coaches do? What do you do in the water with this? What can we do to learn about water?” They are clue less, they have no idea what to do in the water.


MN: What makes Aqua Therapy exercises better than Aqua Aerobics exercises — besides the fact that you are experts at it?


SN: That’s exactly who they are going to. Fitness people are doing it. In 1989 is when I started traveling because of health reasons and getting into vertical exercise. I was thinking I was so far behind and would have to work so hard to catch up, because I’m thinking horizontal and vertical. When I arrived at a convention, I saw a lot of bouncy little cheerleaders but they know water. So this is who the Therapists are going to. You’ll see standards up here. The ASRI, Aquatics Therapy Rehab Institute has begun the standards. Mick and I are on the committee to develop those standards. We are more qualified because we wear the hats. They are very territorial as you are. This requires a team effort. You can not go in there and tell them you are a Swim Coach and you know how to do this. You don’t do your team that way, so you are not going to work with these people that way. The need is there. When I listened to some of the Therapists relate to a patient, I was appalled. This is not every therapist. If you spoke to your swimmers like that, it would go right over their head. Therapists need communication skills, you guys have that ability.


MN: Aquatics Aerobics Instructors do not spend money and hire Therapists. When you attend an Aquatic Therapy Symposium, the 200 attendees are PTs, another 200 are OTs, and the other 200 people are RTs, or Aquatic Exercise people. And two ASCA coaches in the back, Paul Blair was there. I wondered how these people were going to work with each other, as they couldn’t get along. They didn’t know what a coach was. Nor cared. We saw an opportunity. I’m not going to worry about breaching a gap we are going to get together and hire them. We’re going to put them on a team. So we have both a RT and PT working with an ASCA Coach leading the way as far as the business end of it and 192 the consultation end on water. How much did it cost Waterway Therapy to hire a PT?


DN: Because of the automatic demand that the Physical Therapists create, the fee you pay to a recruiting or placement company will be 20-30% of the first year’s salary. Now when we talked to people about how to begin our business we know this is a fixed cost. You can’t negotiate that. It is a start up cost which you must keep in mind. There are some other start up costs if you aren’t looking at building your own facility. This is like any normal business you begin. There are related expenses that are tagged, start-up. You’ll never have it again, for the most part. It is a necessity. Salary is a cost.


MN: What about equipment?


DN: When we began we didn’t have much equipment, all we were doing was working in the water.


MN: We set up a principle a few years ago called PDQ, pennies, dimes and quarters. Give me a yearly salary without adjectives that we pay a Physical Therapist.


DN: I’d rather give you a range of what Physical Therapists can make. Anywhere from $30,000 to $60,000 a year. That is a drop in the bucket when you are talking about reimbursement rates between $85 and $150 an hour.


MN: Let’s figure it out per hour for Physical Therapists.


DN: The upper end is $33 an hour.


MN: What can we generate with that on an upper end?


DN: Anywhere from $85 to $150 an hour.


MN: So how much is left over? And where does that go?


DN: It goes in your pocket, or your bank account.


MN: How many patients can one Physical Therapist work with at one time, in the water.


SN: This is a moral issue. You go into a hospital and see a Physical Therapist in charge of six or eight patients in a single hour. In a water setting, we’ve been very careful in this area. We haven’t been over aggressive. We’ve been seeing two or three an hour. Now when you do this there are codes you use for billing, diagnosis codes which relate to the patients ailments. All of these are centered around billing in 15 minute increments. If you work with a patient for 16 minutes, it’s a thirty minute charge. This is the wonderful world of medicine. All we are doing is taking advantage of what practices already exist. You have 15 minute increments that you can charge. If you work with a patient for just one minute over that, well there is not a charge for 16 minutes. There is a charge for 30 minutes.


MN: So the $85 to $150 an hour is per patient per hour? So you could possibly be generating $170 or $255 an hour?


SN: Yes.


MN: What happens when the patient is out of insurance, or Workman’s Compensation?


SN: When we started, we felt we knew everything. Being in business for 25 years, our goal was not just to start a new business, but to educate the community on insurance and Water Therapy. As well as educate the Doctors and Insurance Companies. All of this was worked into our business plan. Our number one concern was to not be abusive. We won’t engage in fraud. We will get what we can and get them out of there. We have been able to do this. Our goal for a patient is 30 to 60 days and we are then working on an independent program. Which is called our Praise Program. That’s our post-rehab. They go into that at a cost of $55 a month for a period of four to eight weeks. They come five days a week, with monitoring.


DN: After insurance has run out, if they want to continue, which by the time people are done with us, they usually do, it costs them $55 a month out of their pocket.


MN: How much time do they spend in the water?


DN: As much as they want.


MN: This is a membership facility now. You are into our 501 C-3 or Sub S, on the other side of the membership corporation of Nelson’s School of Swimming and Fitness Facility. It is whatever anyone else that runs the facility wants to charge.


DN: You have to realize every city is different. You need to understand that when they come from the insurance and from Waterway Therapy into the consultation with the Recreational Therapist, or Sue, there is a $35 Consultation charge. Sue then trains that person what to do on their own.


MN: I want to rent a lane in Nelson’s School of Swimming and Fitness for $6 or $10 an hour. It doesn’t sound as though we have the water time to do that, when 18 months ago we could barely keep even.


SN: That is correct. We open at six a.m. and go until noon, have a lunch hour, have another session from 1:00 to 4:00, then Swim Team comes in from 4:00 to 6:30 and at 6:30 we finally close our doors. So every minute is filled with something going on in the water. Our Fitness Program has grown because of our Water Therapy.


MN: What size of city or area would you consider to be 193 adequate to begin a Water Therapy business?


DN: We have done some research about people doing Aquatic Physical Therapy in other states, for example, Physical Therapists that had started up an independent practice and were seeing people in the water. Their towns were well in excess of 100,000, some of them near Atlanta. You are looking at a million people. If I were going to do this in another situation outside of where we are in Danville. I would say you need to have a town over 40 or 50,000 for minimum draw. If not the town, at least the surrounding area. Rural areas are big into getting access to water at reasonable rates. If you don’t have 50 or 60,000 people to draw from, you won’t be able to see 15 to 20 patients a day. That’s where you start seeing the high income. Seeing five or six people can generate income with a profit at the end of a year but the more people you can see the higher it is. There are a couple more start up expenses. Fifty percent of them are salaries. You have the PT salary and any other aids you may hire and an office manager if you don’t want to do it yourself. If it’s in a town any smaller than that, it will be difficult unless you are established and have a Doctor in your back pocket with literally hundreds of patients to refer to you.


MN: How important is it to be near a hospital to get referrals and the start up cost for a Therapeutic pool to be built. What would be the expected revenue/income from it?


SN: It’s very important to be involved with your Physicians and to set your ground work. You have to know your resources and do the leg work. Getting the confidence of your Physicians is fairly easy because the feedback from the patients is that they feel great. Physician referral is not your main source as they can refer but insurance companies can deny. If you have a hospital based program, with both a Water and Fitness Program ongoing, it would be very important to make those contacts. I did for the first five years after leaving the Team. I started making those contacts by being on community projects, being in health fairs, making our presence known. If we just walk in, that could have been a different story but you have to let them know you’re there through the community avenue.


MN: I have another thing to say as a reinforcement before you go. Were you in here on my first talk yesterday when I talked about Boot-strapping? You saw the bottom figure of that. That’s what that money was for. I told you it was a real situation. Look at that figure to know the startup cost to add to an existing facility a waiting room, an exam room, equipment and have enough cash flow to pay salaries until insurance starts coming in. If you want to see the actual cost. That is it. That’s how we financed it. We Bootstrapped it.


DN: To finish it up I want to say a little bit about having some hospital or Physician backing. A scary term going around, which I’m sure you’ve all heard, is Managed Care Contracts, HMOs, Capitation. The main thing you have to worry about is that the Rehab Industry itself, along with every other major corporation, are trying to become more efficient. Just look at the news and you see Medicare and the Health Care Financing Administration fighting literally millions and millions of dollars of fraud. They are trying to get that under control so obviously the industry is going feel it when you have Doctors out there that are performing Physical Therapy and being able to charge six units instead of four on every single patient that they see. It’s very easy to do something like that. There are hardly any checks on it. That’s where this new corporation that the government has hired, Health Care Financing Administration, that’s their job, to get that under control. It’s not going to hurt the industry and the private practices, it’s going to cause them to be more streamlined and efficient. A lot of swim coaches deal with this their whole lives. How do I get the most out of my pool time? How do I get the most out of getting to go to meets? I’ve got a small budget. A lot of coaches are wizards at being able to get the most for their money. This is an industry that’s just now starting to get into this. Being responsible and being called upon to substantiate every single charge. The managed care contracts are definitely a good way to go. It might be a hospital that has a Physical Therapy department of 16 Physical Therapists. But you know what? They don’t have water. And believe me, as much as it’s in their industry of rehab, it’s there every day in their face. Water, water, water. But yet, they are just now starting to find out how to get access to it. They start slow. They go to a Y and rent a couple nights a week, then they move up, go to a Fitness Center, then they can have it all morning long and into the afternoon. Once they start getting access to it they are going to be coming in and have the water from 8:00 a.m. until 4:00 p.m. and they may even bring someone in from 6:00 p.m. to 8:00 p.m. to handle those Workman’s Compensation cases that get off work and need therapy.


MN: When you began, did you consider forming a partnership with a hospital or some other organization that would have the start-up money available? You would end up with a nice pool but not necessarily the long term income. SN: I was out there in left field by myself, guys. These guys are coaches, they did not want to deal with Water Wellness, injured people. I pursued. I made many packets and brought them to Doctors, Hospitals and got on their committees. They are too busy, want to make too much money. Patient care is not a concern, which we were told right to our face. I went to clinics, individual Doctor’s Clinics, Hospitals. We actually have three different groups of them. We have one hospital in town and two other individual clinics that belong to Doctors and the independent group. Nobody wanted to go into this because, in the 70’s they went to the 194 water, it was abused, they couldn’t take care of the water and now they wanted nothing to do with it. This is the little person out there that is doing Water Aerobics. So we said fine. I went on my own to learn about the whole business. When they started saying they had to close the doors, is when we said we were going to close the doors one way or the other. We said “let’s go for it, forget you, we are doing it on our own”.


DN: I think you can approach the hospitals but be very careful. The CEOs of hospitals don’t get there because they are nice guys. They get there because they don’t care what the patient care is, they have a bottom dollar and they make a very large sum of money because of that.


MN: Let’s tell the USMC story. We did this, we struck a contract with the hospital and rented a Therapist for four hours a morning. We did exactly what you said. They didn’t want anything to do with it. We’re the experts, strike a partnership. When they saw the bottom line, they took the people we trained and went into business against us in a hotel pool. They were giving up too many dollars. Since that period of time, we’re going to put them out of business. That’s why we had to Bootstrap $150,000. We can no longer just do it in a little lane in a speed pool. We just remodeled. We have a Therapy pool. A high volume flume pool, we are using our six lane pool to it’s total advantage. We will put them out of business. I promise you. We’ve already struck a contract with a Primary Care Provider with one of the other medical groups in Danville. We’re working on the other one.

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