Athletic Trainers: Nobody Cares About Your ROI

Brutal title...I know. Hear me out.

I was inspired by the response of my last article from ATs from around the country who said over and over that my words resonated with them on a fundamental level. If you would like to read my honest thoughts on my career in AT, please see it here: Why I Left Athletic Training (And Why I Stayed).

The discussions I've seen for many years on the state and future of Athletic Training have been frustrating to say the least. However, necessity is the mother of invention. Among the array of skills that Athletic Trainers possess, problem-solving and resourcefulness are among the top. If you're an AT, you know what I mean. So, if we can figure out just about any sports medicine problem that comes our way, how have we not yet figured out how to get paid what we deserve?

There really is an element of truth in the title of this article. If it angered you, good! Maybe it will spur you on to action. Some of our best ideas are the ones we develop out of a fire in our bellies. The truth is that we have to face the fact that when we are assessing and reporting on our value as Athletic Trainers, our ROI argument is garbage. It's the professional equivalent of: "Hey, I helped too!!" The sooner Athletic Trainers wake up and realize this idea holds very little water in the eyes of decision-makers, the better off the profession will be. Bear in mind that I understand there are a variety of opinions on this subject. This article represents my own - I can only speak for myself.

First, What Is ROI?

I don't want to make the mistake of assuming that everyone knows what ROI is. After all, you don't know what you know until you know it, right? For the newbies and non-business folk...ROI is an acronym which stands for Return On Investment. ROI is the amount of money, assets, or value returned following an investment in a business, program, person, stock, mutual fund, or other. I'll admit that this is a very simplistic definition. But in short, I invest money in order to receive more money.

There are many ways to measure ROI. But which do you think is the most concrete, measurable, and meaningful to decision-makers? You guessed it. Cash. There are a few exceptions to this rule, but overall the best assets produce money as a return on their investment. Not just money to make up the original amount, but MORE money than was originally invested. The best assets are those which are profitable well-above and beyond cost.

Some programs and employees produce a softer, harder-to-measure ROI. Things such as marketing (a sign at a football stadium), community goodwill, and monetary savings for a program. And I would suggest that although there is some value in these softer items, they are not nearly as strong as a program that produces cold, hard, cash.

Asset vs. Liability: Athletic Trainers are NOT Assets.

It's important to understand the difference between an asset and a liability. In his book Rich Dad, Poor Dad, Robert Kiyosaki defines an asset as something that makes you money. A Liability is something that costs you money. Regardless of what your bank will tell you, your home does not qualify as an asset under this definition. Nor does your car. Now if you owned a rental home that generated monthly income, or owned a car rental business, then you might have some true assets (so long as they are generating more money than they are costing).

The reason I've brought in this logic is because Athletic Trainers in the traditional setting are liabilities. They are not assets. Now before everybody gets all offended and smears me in the comments. Think in terms of money. Does an Athletic Trainer that's employed by a university generate money, or cost money? If you answered with the latter, you'd be correct.

But Ryan! Athletic Trainers take care of the athletes! Athletes generate money! Ticket Sales! Royalties! Merchandise! Student Attendance! That counts!

You're right, you helped too. But if the people in charge who are approving budgets recognized this, wouldn't ATs be flocking to work in the collegiate setting? Surely the pay would be significantly better.

Laying The Foundation: ROI In Practice

Let's use a very simple example using a house. Let's say I buy a house for $100,000.00. The house is a fixer-upper. I invest $50,000.00 for repairs and upgrades so I can then sell it for a profit. In order to sell house this for a meaningful profit, I would need to sell it well above my initial investment of $150,000.00.

• Total Investment: $150,000.00
• Sale Price: $250,000.00
• Total Profit/ROI: +$100,000.00

This is just a silly hypothetical example. But you get the idea. In order for your ROI to be meaningful, you have to be able to demonstrate that you made more money than you spent...hopefully in a significant amount.

Why Athletic Trainers Should Care

The same principle rings true for healthcare, and Athletic Trainers are no exception. Let's all remember our paychecks don't just come out of thin air. Using conservative round numbers, let's suppose we hire an AT with a base annual salary of $50,000.00 with approximately $20,000.00 per year in benefits (PTO, health/vision/dental insurance, retirement match, and CEU fund). Add payroll taxes on top of that (15%-ish), and you've got yourself quite a budget to make up. By the way, if you don't think benefits cost that much, do some homework. You might be surprised.

In this scenario, the Athletic Trainer would have to produce $77,500.00 of direct revenue just to break even on the cost of their existence. That doesn't even include supplies and equipment. Let's take this principle and apply it to a few very real-world examples.

The Traditional AT: Employed By The Institution

Let's apply this set of Athletic Trainer data to the traditional employment setting where the AT is employed by the institution (high school, college, athletic team, etc.). So we have round numbers, let's assume that the program is allotted $22,500.00 for supplies and costs, bringing our overall budget to $100,000.00 for the year for the Athletic Training Program. That's a very real number that your employing institution has to come up with every year in order to sustain your employment. Oftentimes ATs in this setting do not produce direct revenue. This makes them a liability, not an asset. So, they are left with trying to demonstrate value other ways.

I see many times ATs in this setting tend to take the angle of "money saved." In other words, they try to demonstrate how much money they saved the institution when compared to what things might look like in the absence of the AT.

They will compare median prices of things like MD and PT visits, other healthcare associated costs, and what it would've cost the organization had the AT not been on-site. I get that, and I can agree that in these settings, that may be one of the only ways to quantify program success. Maybe they also find a way to demonstrate minimizing time lost for athletes, try to tie it to athletic wins, etc. However, this type of reporting still only results in data which suggests to the organization: "Hey, we didn't make you money, but we sure spent less!" How do you think that sounds to investors, team owners, decision-makers, corporate leaders, and your school board? Maybe I'll never know. But I'd be willing to bet that they'd like a report on how much profit you generated a whole lot more.

The Traditional AT: Employed By A Third Party

Now a look at ATs employed by an outside entity to provide on-site event and training room coverage. I worked in this setting for many years. I was employed by a large company to provide on-site AT services. Our role was to use our clinical skills to drive Physical Therapy Referrals and provide great care to the community. It's a common model and can provide some measure of success. But even still, let's look at the numbers, just on salary alone. Let's bring that $100,000.00 AT cost back in. For argument's sake, a $100,000.00 in a full-time job equates to roughly $48.07 per hour ($100,000/52wks/40hrs).

Now, we also have to consider the cost of a PT in order to provide that service. Conservatively let's consider $100,000.00 per year annual salary, plus $20,000.00 in benefits, and another $15,000.00 in payroll taxes. That is $135,000.00 per year, or $64.90 per hour.

Summary of total hourly costs:

• AT Costs: $48.07
• PT Costs: $64.90
• Total Hourly Cost: $112.97 per hour (Or $235,000.00 per year).

I live in Michigan. When you look at the average reimbursement rate in Physical Therapy for the best insurance payers, you're going to land somewhere around $145 per hour/visit. That's IF the appointments are billed optimally and reimbursed successfully.

• Total Program Cost: $112.97 per hour
• Total Program Revenue: $145 per hour
• Total Program Profit: $32.03 per hour

So with a little math, let's put that into some practical numbers.

1. Just to break even on the cost of the program, 1,621 Physical Therapy Visits would be required. That's 31 visits per week. Let me tell you - that's a LOT of referrals.
2. For a 35 patient-per-week case load, that doesn't leave a lot of room for profit. At a full case load of 52 weeks in the year, this would result in (up to) $30,160 in profit for the year. When you look at this as a percentage of overall cost, at best it represents roughly a 13% profit. Not bad right?

Now, take away the AT salary and benefits, and focus on the PT ROI. I'll leave you to calculate the numbers of what this would mean over an annual basis in comparison to the previous program. In short, you're look at somewhere between 3 and 4 times the amount of profit in contrast to the AT referral model. From a monetary standpoint, it's unfortunate but true. This model leaves the AT at best as mildly profitable, and at worst an unnecessary extra. Most likely reality will be somewhere in the middle.

The Clinical AT: Employed By the Clinic

When an AT is employed directly by the clinic, it becomes much easier to measure direct benefit to the company you work for, so long as you are employed as a revenue-producing employee. If you run a work-comp program, or see patients directly in any capacity, you can pretty easily run a report for how much revenue you are responsible for billing. This is especially easy in the physician practice setting, where you're often doing billable tasks such as brace fitting, casting, taking vitals, crutch fitting, or assisting in surgery. I won't get into the numbers here because you should be able to do that yourself. Look into what you billed out for your organization last year, and see what you come up with. Demonstrating cash value should be pretty easy.

The Problem with the ROI Argument

Simply put, many (not all) ATs have a skewed view of what an ROI actually is. Hear me clearly. I don't think there's necessarily anything wrong with attempting to demonstrate value in terms of money saved. I just don't think it's effective at getting the result you want. Because nobody cares about a program that at best just "costs less." Is that what you want to be known for? A program (and a profession) that just "costs less"? Institutions want to know what is going to MAKE them money, not just cost them less.

It was never my intention to sound harsh with this topic. Maybe the title should have been "Redefining ROI in Athletic Training" or "What even is ROI, Anyway?". But if I did that, you probably wouldn't have read this article, would you? What I'm getting at here is that nobody really cares about your ROI, because in the traditional setting, your traditional definition of ROI sucks unless it includes direct revenue to your organization. That revenue needs to be well-above and beyond the cost it takes to employ you in order to get anyone's attention. Hard pill to swallow, yes. But that doesn't make it less true.

I love and respect the AT profession. It's what I chose. I'm a friend to ATs everywhere. But faithful are the wounds of a friend. Sometimes a coach or loved one is tough on us because they see greater potential in us. They expose our weaknesses to give us an opportunity to correct our mistakes. They don't pull punches because they're afraid of hurting our feelings. They care deeply enough about us to risk hurting our pride for our own betterment, and the refining of our character. There are very few things that I consider more caring in this world than that.