Quick summary: Physical therapy education is too expensive causing massive student debt and negative ROI for students thus applications to PT schools are way down even though a huge shortage exists. Best solution is for students to take 1st boards midway through doctorate training and get a master’s degree and get licensed. Internships can then pay them and reduce education cost. After successful completion of terminal internship they graduate and get their DPT.
Many healthcare professions have staggering shortages. Physical therapy of course is no exception and a key part of solving this dilemma will be the expansion of physical therapy education programs both in pure number and in class size. This sounds easy enough until you get to a more fundamental problem-the cost of education is staggering and the return on investment of a DPT education is not occurring for the vats number of new entrants. In this post, I provide the background and propose a solution that can be achieved if the right stakeholders check their egos at the door, get together and are sensitive to the plight of students and the market as a whole.
Physical therapy has a fascinating history of education-migrating literally from a certificate program to a bachelors to a master to a doctorate all in the last 50 years, from effectively 2 years of school in the 1930’s to 4 years of schooling in the 1960’s to 6 years in the 1990’s to now 7 and that is if everything goes perfect. To be fair, the body of knowledge continues to evolve and a consensus of physical therapy experts and our national organization worked very hard to drive it to a master’s level curriculum with a mandate that all programs be converted to Master’s by 2002. In an opportunistic way, higher education before many MPT’s even got to conversion found that the acceptance rates and popularity of those wanting to be PT’s was so high that they could claw another year of tuition via migration to a DPT-a doctorate and along the way even had for many years a transition DPT or tDPT to get even more tuition revenue out of their PT’s that had already graduated. While it took literally about 20 years to migrate from bachelors to Master’s, through effective collusion, it only took a handful of years for all programs to convert to the doctorate in the copy cat industry of higher education.ion t Traditionally, University’s have the highest margin on graduate school education when it has many students so DPT education was quite a lucrative strategy and windfall. This windfall in tuition revenue fell on the backs of the graduates over the years. With education creep to DPT level, median student debt went from about 30k to roughly 100k and it keeps climbing.
All of this though has produced a dire consequence. Starting about 5 years ago, there has been a dramatic change in application numbers for PT schools and acceptance rates, both of which are influenced by escalating student debt. When PT was a bachelor’s, many employers would scholarship the last 2 years (the ones dedicated to strictly PT education) and employment was 100% and all was fine. The migration to 6 then 7 years and the dramatic increase in tuition has made it impossible for employers to scholarship expensive education, and unfortunately, salaries for PTs have not kept up lockstep with tuition-not even close. This same education creep has impacted many other professions in healthcare as well. The combination of student debt and relatively low starting salaries has caused many of the best and brightest to consider alternatives to PT-like nurse practitioners, physician’s Assistants or pharmacy which can have shorter education, less student debt, and more to the point, higher salaries even when schooling years is consistent. A noted academic, Dr. Rick Shields, has published that the NPV at currently reported levels ($86,563) was higher than occupational therapy, optometry, veterinary medicine, and chiropractic but lower than dentistry, pharmacy, nurse practitioner, physician assistant, and all medical specialties. At 150k debt where many PT grads have an NPV lower than any other medical career except chiropractic and veterinary medicine. On a practical level, this is exemplified in the dramatic decrease in applications to PT programs. Where has all this left us? We now have about 70% of students getting accepted because applications are way down. We graduate roughly 12k minus the students that don’t pass the exam (record numbers) minus others who go on a backpacking trip and never even start a career in PT-minus others who don’t want to work full time and then there are others who want to work full time as long as it is limited to 30 hours a week and includes a generous sign on bonus, health insurance, tons of paid time off, pet insurance, and no expectation or pressure on productivity. All of this at a time when the estimates are that 15–20k PT’s never came back from COVID. The shortage coupled with inflation in general and labor inflation (PT salaries have gone up but still not to an ROI that is defensible) wreaked havoc on physical therapy particularly in 2022 like it has most healthcare providers. The shortage of PT’s is profound and will continue for awhile despite some in academia who have their head in the sand and who have even suggested we stop opening new programs or expanding.
The final piece of the background is that physical therapy is growing because evidence and cost effectiveness has been widely proven and accepted especially seeing a PT first for all aches, pains, sprains, and strains. Physical therapy is also severely underutilized with patients suffering from musculoskeletal conditions where it is only 10–14% part of the care depending on condition and of course there is long term care where the estimated shortages are so staggering that a futures market on PT’s in 15–20 years ought to be considered so that you can be assured access when you will need PT most.
All of this to say that our education system for PT’s needs a new model as it is currently unsustainable. The biggest problem is MONEY-the cost of education has to come down but let’s not be realistic, decreasing tuition for an institution is more rare than the black rhino so that is not a realistic option. In fact, the system is so rigged that even when a student is on a 6 month to 1 year internship they still pay for tuition at their institution which doesn’t sound logical or legal since the work is being done far outside the classroom and without any school’s resources. The next option is innovation. Moving programs to accelerated hybrid 2 year programs for example can reduce tuition and allow the student to be at work a year earlier which has a terrific ROI. Some colleagues and I actually executed on this strategy about nine years ago with success after getting ridiculed, denied, laughed at, and branded as heretics-and that was by our own profession! Probably a hundred university’s also thought we were a bit jaded as well until a great partner for profit signed up and the rest is history. Our motivation at the time was legit-we were concerned about the high cost of tuition being a deterrent to the best and brightest entering PT. We have several of these programs and have expanded to occupational therapy as well but it hasn’t moved the innovation needle on the traditional incumbents who have with few exceptions kept increasing tuition because demand and filling classes was traditionally very high. Demand has now dropped significantly and many programs are seeing drops in enrollment and let’s just say a less academically prepared student than in the past. This is not to say we don’t have some tremendous PT students in the pipeline, but the concerning data points are undeniable.
Given that innovation in delivery isn’t moving the needle and institutions aren’t going to change tuition, what is left? How about paying students during their internships? I suspect a bit more ridicule but let’s play this out.
First, a bit more background. Prior to COVID, physical therapy schools were contracting with hundreds of clinical sites as many practices limited or simply didn’t take students. Keep in mind that clinical education remains the big black hole of physical therapy education generally. Any clinic can sign up to take students and they take the student and the school takes their tuition during that time as though they were occupying a seat in one of their classrooms. The schools of course hope and pray the student is learning on their choice of internship sites Over the years, policy on students changed relative to payment or third party reimbursement. Medicare is the most limiting relative to supervision effectively prohibiting the service that a student does from being paid unless they are side by side with a licensed PT sharing the same air space. This limitation had tremendous impact on number of clinical sites as students were seen as disruptive and effectively an increase in cost to an already challenged clinic. However, the impact of COVID on shortages was unforeseen and its unintended consequence is that clinics of all types now will take any and all students as part of a larger talent acquisition strategy. Of course, the impact of this is that students generally are even getting less and worse clinical training then ever. This concept, known as lack of “clinical readiness” is growing in that employers are having to remediate, level set, and treat new graduates as though they were students for several months despite them technically being licensed. The time to make a new PT ramp up to expected patient loads has been expanded making the cost even greater to clinics who have withstood inflation and shortages with a complete inability to increase prices like non healthcare businesses can do. During this same time, physical therapy reimbursement by medicare has actually been reduced by 9%.
So, how do we pay students during their internships? While this will take locked arms of our accreditation arm CAPTE as well as the Federation and a consensus of academic in physical therapy, the solution is to take licensure boards half way through their PT training. Their first half they would have at least 8 weeks of clinical time plus didactic at which time they would get a Master’s degree and sit for the state boards and get licensed. They would then finish their DPT education at which time they would graduate with a DPT. The student would know their final clinical long enough in advance that the clinic would file all necessary paperwork to get fully credentialed with payors. The student would either get paid directly in compensation or have their education cost reduced by the employer as the student’s services could now be billed and be accretive to a clinics revenues versus an additional cost. Payment would be relative to a traditional productivity expectation. If a student is roughly 50% as productive as a full time PT, they should expect a 50% starting salary. A student’s final internship, fully licensed, could also accelerate them into a terminal internship, an early residency offering in which they can get to specialty boards faster. Choosing a site that offers this likely assures better education and training since residencies have to be accredited thus making the practice a preferred destination for students and eliminating the “hope and prayer” current strategy of sending students out for clinicals.
This idea, in some forms, has been deliberated in past times by various folks, so I take no pride in originating it but do want to revisit it in a profound way. Lowering student tuition is the only driver to lower student debt, better education ROI, and to get applications back so that we can be assured of the best and brightest going into physical therapy and to address the significant shortage we have in the profession.
Please poke holes in the strategy or start promoting!
larry
@physicaltherapy
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Lastly, 100% of all proceeds from my book Called to Care: A Medical Provider’s Guide for Humanizing Healthcare goes to The Foundation for Physical Therapy Research
