The Eye-Popping Truth About #PhysicalTherapy
Alright, it's time for some honesty. This and Part I weren’t really about comparing productivity across three professions. Nope, the real goal here is to highlight some eye-popping data about physical therapy. Second confession: I’m a PT who doesn’t see patients anymore — and that’s after achieving board certification in two specialties! So yes, my criticisms partly point back at me. Let’s dive in.
The Numbers Don’t Lie (But They Do Squint a Bit)
Let’s start with the fact that the numbers for ortho, family practice, and PT include everyone licensed in that specialty. This means part-timers, full-timers, those licensed but not working clinically, and probably even a few retirees who just can’t let go of that shiny certificate on the wall. So, by definition, the number of visits per practitioner is grossly understated.
Keep in mind, these figures don’t account for the use of NPs, PAs, or PTAs, which effectively lowers the per-practitioner visit count even more. It’s like counting the number of chefs without acknowledging the sous-chefs chopping veggies in the back.
A Tale of Three Professions
The data is also quite instructive. Compared to ortho and family practice, PTs have a higher proportion working part-time, not in a clinical role, or who are retired but keeping their license active. Said differently, less of our licensees do clinical work than ortho or family practice. Part of this is cultural, but there’s also a practical side.
Orthopedic surgeons and family physicians earn significantly higher salaries than PTs. Their best and highest use is — surprise! — seeing patients. Their salaries are higher and far more often than PT’s, they are on a “eat what you kill model”, rewarding productivity and revenue produced-and their reimbursement is much higher with far less regulations than physical therapy. Their practice acts allow them to extend their reach through the use of practice extenders who can perform evaluations — a vast difference from PTAs, who are restricted from initial evaluations. It’s like having a sous chef who isn’t allowed to touch the ingredients until after you’ve prepped them. As for PT’s, a system has been created that rewards transition out of clinical care. While an argument can be made that this is not the best and highest use for a physical therapist, this transition is typically accompanied by higher compensation-quite the opposite of our orthopedic and family physician counterparts.
Crunching the Numbers: Brace Yourself
The PT data suggests that less than 20% of PTs see patients, which might be overstated when factoring in PTAs. Here’s some conservative math:
- Total Annual PT Visits: 100 million (multiple data sources and using 3% of the population at 10 visits per also approximates this number)
- Licensed PTs: 250,000 (multiple data sources; this might be slightly high due to multiple licensees in various states)
- Average Visits per PT per Year: 9 patients/day × 46 weeks/year = 2,070 visits
So, the number of PTs needed to cover these visits is:
- Needed PTs: 100,000,000 visits ÷ 2,070 visits/PT ≈ 48,309 PTs
Net effect: Approximately 19% of PTs are clinicians. Of course, more than 19% might be seeing patients, but the conversation is to full-time equivalents.
Too Many PTs or Not Enough? The Paradox
On one hand, it seems we have too many PTs. On the other, we all know there’s a shortage of PTs. How do we reconcile this?
Like all professions, some PTs are attracted to research and academia — thank goodness we do. But in aggregate, and as a percentage, the number of PTs in these roles is minimal. Let’s estimate:
- PT Programs: 300
- High Estimate of PT Faculty per Program: 15
- Total PTs in Academia: 300 programs × 15 PTs = 4,500 PTs
Most are drawn to the profession to do clinical work — not to drown in compliance, documentation, or counting in eights (seriously, who came up with that?). Yet, due largely to “the system,” we seem to do everything in our power to drive clinicians away from seeing patients. Compensation increases often come in the form of management promotions — in ortho and family practice, it’s often the opposite. In other words, we reward our best clinical PTs by giving them roles that take them away from being clinicians and then pay them more. Makes perfect sense, right?
The Other Half of the Equation
This, of course, is only half the story. PTs are restricted from being even more productive due to a combination of our profession’s reluctance to embrace our own practice acts and payors who have reduced our “neck-up” skills to those of regulated widget makers, limiting the number of widgets we can produce.
On the former, we see practices bragging about exclusive one-on-one care and criticizing PT practices that abide by state practice acts allowing PTs to practice differently. Can you imagine an ortho or family practice advertising this “exclusive one-on-one” bit? Even concierge practices, designed for more personalized care, use extenders liberally. This is an old issue that I have enjoyed writing about since 2008- some samplings.
Payors are also part of the problem. Arbitrary limitations on the use of extenders (looking at you, Medicare) or superimposed time element rules (hello again, Medicare and the Blues with the 8-Minute Rule — not to be confused with the “Rule of 8s”) hamper our productivity. Of course, much of this is related to payor mix and geography, with those in California and upstate NY needing to be far more productive to keep the lights on than PTs in other states. I’ve seen some third-party data recently that shows a PT’s productivity over the last several years has dropped from roughly 12 patients per day to 10. Let’s absorb that data point for a minute. How many professions or industries in the last 20 years have seen productivity decrease? Despite technology and automation, physical therapy productivity on a patient per day basis has reduced! Is this not a core problem that has to be addressed?
Perhaps a third and understated factor is that many are drawn to physical therapy due to flexibility in the field vs. physicians. It is not typical for a physical therapist to provide clinical care for their entire career, just the opposite for orthopedists and family physicians. Their is an age cliff for physical therapists in roughly their mid to late 50’s. Walk into any physical therapy setting in America and you see very few older PT’s. Again, nothing is inherently wrong with this, but it is an issue seldom discussed. Perhaps it is simply that compensation for clinical physical therapists reaches a peak, and the ongoing reimbursement declines, particularly when set against inflation, have caused PTs to seek other types of employment away from seeing patients knowing they have “capped” their compensation.
The Irony of Non-Clinicians Complaining About Clinicians
In the past year, in conversations with colleagues, I have heard more practice owners and administrators complaining about PTs’ lack of productivity than at any time in our profession’s history. I think this is partly driven by shortages, inflation, expensive regulations, and the continued drop in reimbursement relative to the cost of living — all creating unprecedented headwinds for PT practices, leading to stagnation and low margins. The irony, of course, is that the clinical PTs have to produce enough revenue to cover the cost of middle-management PTs who see a limited number of patients. Does any other provider business have this type of ponzi scheme?
A big reason for lack of productivity is the externalities placed upon PT’s. Medicare rules overrule state practice acts by not allowing the use of PT technicians. Medicare also pays less for treatments performed by PTAs. Our good friends over at Medicare Advantage do the same and sometimes worse, with pre-cert requirements designed to take away care from patients who need it most.
The Great Escape from Clinical Care
There is a growing trend towards PT’s leaving the profession entirely. PTs have incredible transferable skills that allow them to work in non-clinical roles, including specialized orthopedic sales, managerial positions outside of physical therapy, as well as using their educational background as a stepping stone for professions far outside of rehab. Many PT’s pursue these roles in part due to higher compensation and because they become disenfranchised with healthcare. While this trend is increasing, like academia, in aggregate it is a very low percentage of overall licensed physical therapists. Undoubtedly, there are also orthopedists, family practice physicians, and PTs who pursue paths outside their licenses — nothing wrong with that at all. The data suggests that PT’s mostly stay in physical therapy-just not as a clinician. This is a small fraction amongst the 81% of PTs who are non-clinicians.
Time for a Change (No, Really)
Times are changing, and we need to reward clinicians differently. We have to stop incentivizing PTs to stop seeing patients through an overemphasis on management roles that detract from patient care. How many orthopedic surgeons or family practice docs manage their practice by not practicing their craft? It’s like training a chef for years only to have them spend their days doing inventory in the back office.
Final Thoughts
So, there you have it — a candid look at some uncomfortable truths in our profession. Maybe it’s time we rethink our priorities and start valuing and more financially rewarding clinical excellence over administrative ascent. After all, isn’t patient care why we got into this field in the first place? Perhaps we unleash a series of reforms that enable a PT to be more productive to meet the needs of the patients who need our service. Until we do, it is going to be a tough road to address more than 85–90% of those who need PT and aren’t currently getting it.
Until next time….
Thoughts?
larry
@physicaltherapy
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