Rehabbit
I have a long history with pain.
I started climbing at the end of COVID-19.
Lockdown restrictions were loosening and I, just like many others, was anxious almost rabid to get out and about. Climbing hadn’t appealed much to me before - I’d been taken a few times in Seattle by tech yuppies, a predominant faction of gyms’ clientele, and found it boring. A modern-day social sport, the equivalent of bowling alleys in the 90s. But be it for one reason or another (likely some pent-up ennui), this time I was hooked.
I’m quite obsessive. I’m the sort of person to look for purpose in pursuit and commit myself wholly to it, often times to my own detriment. I was addicted to work, I was addicted to video games, and this time, I got addicted to climbing.
There’s a certain combination of traits I look for in a discipline. Climbing had them all: it was individualist (you don’t need a team to climb), it was a skill sport (that lent itself well to progression), and it suited me well (one of the few sports a skinny 5”7 guy could excel at). So I did as I always have, I obsessed over it: climbing as much as my body would allow me, tossing myself relentlessly at the wall, and spending copious amounts of time analyzing my own climbing and that of others.
That led to two outcomes: I got a lot stronger and I got a lot of injuries.
Not a particular surprise, when you consider moments like these:
And that started my history with pain.
The first injury I ever got was a lumbrical injury, a minor muscle in the palm of the hand. I sprained mine while matching the finish hold on my first V8. I felt something funny immediately which cascaded into a sharp pain radiating through my palm. The morning after, I was unable to open or close my hand without intense pain shooting through my arm.
That terrified me. To have something you’ve taken for granted, something you’ve done millions of times before, be rendered decrepit in a day. It was traumatic.
In hindsight, after receiving and rehabilitating a long list of injuries, this episode seems almost minor. I’ve had TFCC tears, MCL sprains, pulley injuries, joint synovitis, shoulder impingement, and even a cervical herniated disc. Many of those hurt far worse and disabled me for far longer. Yet the first is still hard to forget.
Now again, I’m obsessive.
So when I, a try-hard who would literally do anything to climb harder, was set back by injury; what did I do? I contacted sports doctors, physical therapists, certified hand therapists and spent copious amounts of time and money to fix my body. I learned a lot about injury.
Take shoulder impingement for example. Patients typically present pain in the shoulder, limited range of motion, and weakness. The underlying pathophysiology is vague. The hypothesis is that something in your shoulder’s subacromial space is impinging against each other: tendon rubbing across bone or inflamed bursas. But we don’t know what. In other words, something in your shoulder is inflamed and it’s causing you pain.
When I went to my sports doctor for a diagnosis, he didn’t administer any scans or MRIs, he simply moved my shoulder around a few times and gave me a referral to physical therapy. The physical therapist did the same. He moved my shoulder around a few times and told me to do a bunch of shoulder exercises.
That bewildered me. I advocated for myself and pushed for scans, but they were deemed medically unnecessary. How was it that my doctor could accurately diagnose me based off nothing but a few questions and physical tests? How was it that the only treatment I was prescribed were a bunch of exercises with rubber bands?
I was skeptical.
I began to research the literature myself: buying orthopedic textbooks, reading dozens of papers on treatment efficacy, and experimenting with myself (running A/B tests on different treatments and recording progress/pain over time).
And the evidence was clear: physical therapy does work. It’s a proven scientifically backed treatment to many forms of physical pain. It’s a long-term fix that addresses fundamental root causes. It was the only thing that truly helped me.
But while physical therapy as a treatment was effective, the industry wasn’t.
It’s expensive. It costs a minimum of $125 per session in New York, running up to $250 for boutique clinics. That’s a recurring cost - one session of PT isn’t enough, you need 2-3 visits a week for months.
The quality of care is going down. As margins grow thinner for clinics, “mills” are becoming the prevalent model of care. Clinics where the primary form of treatment is group sessions, where a single physical therapist aide runs around supervising groups of 8-12 patients doing exercises.
The real value of physical therapy is information. The diagnosis and the exercise plan. Once I know what to do, it’s a matter of doing my exercises regularly. I don’t need to go into a clinic to do that; I can do that on my own time in my own home.
And that’s the PT idea. We founded Rehabbit on three beliefs.
Physical therapy is effective
Physical therapy is just exercise
Anyone can exercise
Our MVP.
A medical chatbot.
A historically bad startup idea.
But we believed our approach to be different for two reasons:
We mitigate risk
Diagnosing physical injuries is easier than medical conditions.
A sore throat can indicate a large range of diseases, ranging from minor colds to serious conditions. Muscular pain is a lot easier and a lot less risky.
We treat directly
A chatbot might be right in diagnosing you with the flu. But what’s the next step? It can’t prescribe treatment.
But we can. If we diagnose a patient with shoulder impingement, we can recommend a personalized rehab plan immediately.
We showed it to climbers.
The response was largely positive. People liked the immediacy, the diagnosis, and the simplicity. But we had to take that with a grain of salt: they were churning. They would use it initially, do some exercises for a few days, and then quit subsequently after. We had an adherence problem. Our app could diagnose injuries and tell people what exercises to do. But how do we ensure patients adhere?
We decided to onboard physical therapists.
Our pitch to providers was simple: $30 for a 30 minute call. After the call, patients would be able to text their providers and vice-versa. What we wanted was accountability. We believed that patients would be more likely to adhere if they were told to do so by a real person, not an app. Someone they could call, someone they could text, someone they would see - whenever they opened the app.
The pitch worked. We cold-called therapists and were able to onboard a dozen or so with nearly all calls converting.
We launched a few weeks later. Our go-to-market targeted climbers: a chronically injured and obsessive customer base. We launched on Reddit, first on a smaller niche /r/climbharder subreddit and again on the larger /r/climbing subreddit.
The response was overwhelming. 150K impressions, 1K upvotes, 100 comments, 500 shares, and 500 installs within a few days. But it felt odd.
Mikkel and I would often talk about firsts. Our first customer, our first dollar, our first employee. How good it would feel, how motivated we’d be, to know that what we’re working on is no longer just an idea, but a business. A small business no doubt, but a business nonetheless. Something real.
It didn’t feel that good.
I was at the climbing gym when Mikkel texted me the numbers. For a few minutes, I was euphoric bouncing around the walls grinning like an idiot. But then I started thinking what next. Now that we have customers, how do we scale, how do we grow, how do we raise?
The ending of this story is as abrupt as reality. I quit working on Rehabbit a few days after we launched.
Life happened. I won’t explain the details, but my time was cut short. If I wanted to keep working on Rehabbit, I needed it to succeed and do so in a short time-frame.
So I quit.
Fear was a factor. If I had full confidence, the conviction that our idea would succeed no matter what, I would’ve stuck with it. I would’ve made things work. I didn’t - I’ll admit it.
We were struggling to raise capital to scale. We didn’t have a concrete plan on how we’d support insurance. We didn’t have a why now. Why our idea wasn’t done already given the underlying technology was all present years prior.
If I had the pluck I typically carry myself with, I probably would’ve kept trying. Kept bullishly pursuing my beliefs, regardless the obstacle. I didn’t.
Startups are hard. Really hard.
There will always be questions unanswered and challenges to confront. There will never be a point with certainty where we can say we’ve succeeded. It is, and always will be, an uphill battle.
I didn’t know what it means to start a business a year ago. I won’t claim that I do now.
But what is clear is that your business is your life. And nothing else in your life, takes precedent. To succeed, you need to commit - for as long as it takes.
To end, here are some thoughts.
Physical therapy is broken.
It’s growing rapidly as a whole, projected market cap from $60B to 2024 to $128B in 2032. But margins are thin. Net profits are single digit percentages. There’s a huge discrepancy between what’s billed for a session and what the therapist takes home. Reimbursements for a session can total over $200. A therapist takes home $50.
The existing business model isn’t scaling.
Clinics can’t set their own prices. They’re subject to billing the CPT codes mandated, which means their only means of leverage over revenue is optimizing costs. That leads to acquisition and conglomerations: larger groups buying up individual clinics and standardizing operations. More “mills”, more group sessions, all of which directly reduce the quality of care.
The model needs to change. And it has already.
What we’ve built is Hinge Health for the public. Hinge Health is a MSK startup valued at $6.2B. It has the same model of care we do. Patients get assigned physical therapists who provide initial 15 minute consultations and support through text messages. Patients then do their exercises without in-person supervision.
This model has been proven to work.
It’s cheaper and more effective than traditional models of care. But, it’s hard to take it and deploy it en masse. Insurance is the blocker. Telehealth consultations with physical therapists aren’t supported. You can’t bill for text message support and monitoring. So what MSK startups, such as Hinge Health, have done is sell their product directly as a cost savings to employers, given that insurers don’t support their model as-is.
However - things are changing.
This model can be supported by insurers now.
Telehealth consultations can be billed for under COVID provisions. RTM devices are a new class of billables that let providers charge for remote patient monitoring and text support. Admittedly, these codes are on shaky ground. Some of the bills are temporary and it’s unclear whether they’ll be permanent. Others are nascent and their reimbursement rates remain to be negotiated. But it is possible.
And if it were, we could take a proven superior model of care and directly replace traditional clinics.
That’s the vision for Rehabbit: to redefine physical therapy.
Personalize physical therapy for the patient
Build a sustainable model for the provider