As a physical therapist who is a 25-year member of the APTA and someone who cares deeply about the future of our profession, I ponder this question more each year. After the challenges our profession faced in 2020 and a lot of reflection, I decided it was time to try and answer that question. The conclusion I reached is that the APTA is no longer an effective leader for the physical therapy profession. I feel they have spread themselves too thin and lost their focus on their main mission, to support the members and to help the physical therapy profession thrive. I’ll present my case below and let you decide on your own.
Before I dive into specifics, I feel it is important to say that the APTA has done a lot of good for our profession, especially in the early days and through the mid-to-late twentieth century. There are a lot of genuinely good people that serve and work there. Having said that, the Association has failed to keep up with changing times. Most of you know the famous saying that insanity is doing the same thing over and over and expecting different results. That describes how we have approached the last 30 to 40 years in physical therapy. Expenses continue to rise, and reimbursement continues to fall. If we don’t commit to taking a hard, honest look in the mirror, we may not last much longer as a viable profession.
Reimbursement
Off all the issues that should be a priority for our national association, reimbursement should top the list. In this area I feel the APTA has been completely ineffective and continues to be reactive instead of proactive. Our profession is headed towards death by a thousand cuts. If you don’t know by now, The Centers for Medicare and Medicaid Services (a.k.a. CMS, or in other words Medicare) is the trend setter when it comes to payment policies for physical therapy. The private payers tend to follow CMS’s lead. Let’s look at policies affecting Medicare reimbursement that CMS has implemented in the last 25 years and let me know how many of these you would chalk up as wins.
- 1997: The Balanced Budget Act and the therapy cap
Under the BBA, two annual $1,500 caps were established, one for occupational therapy and one for physical therapy and speech therapy combined. While the cap was repealed (kind of, we still have a soft threshold), the administrative reporting implemented with the cap is still a requirement and moving past the $3,000 mark may trigger a targeted review by Medicare. The long and short of it is that for complex patients there is a chance we will not get reimbursed for services.
- 2007: The Physician Quality Reporting System (PQRS)
The PQRS (which started as Physician Quality Reporting Initiative, PQRI) was designed to track outcomes related to a series of outcome measures throughout the healthcare industry. Early participation was voluntary and was rewarded (if you met their threshold) with a modest 0.5% bonus of allowable, covered charges for the reporting period. By 2014 and beyond those not reporting data were penalized initially 1.5% increased to 2.0%. In true CMS fashion, the measures PT ended up reporting on had very little to do with providing data on patient outcomes and created an unreasonable administrative burden on outpatient PT providers.
- 2011: Multiple Procedure Payment Reduction (MPPR)
CMS decided that they were going cut the amount paid when more than one related procedure was done on the same treatment day. The APTA estimated that reimbursement will drop on average 6% to 7% because of this CMS policy. There were so many private insurers that also implemented the MPPR that the APTA use to provide a reference list of all of them, but that is no longer available. Not a legacy that the APTA would want to advertise. The APTA continues still today to assert that MPPS is a flawed policy but it remains in effect.
- 2018: Merit-based Incentive Payment System (MIPS)
The PQRS was discontinued and it’s reporting measures incorporated as part of the Merit-based Incentive Payment System. Basically, all but small practices (billing under $90,000 in part B charges, treating less than 200 Part B patients) must report on quality measures and improvement activities. The carrot on the end of the stick is a possible bonus from CMS. For 2021 the maximum possible incentive is 7.0% and the maximum penalty is -7.0%. Because the MIPS program must be budget neutral, the ACTUAL maximum incentive is 1.79%, but the penalty for a poor score is -7.0% (source: www.MDinteractive.com). Again, we are left with minimal to no incentive, large potential penalties, and are burdened with more administrative responsibilities that take away from actual patient care.
- 2021: “The Cut”
Most of you are well aware of the approximate 9% reduction in reimbursement facing physical therapy in 2021. Due to the Covid-19 pandemic and Congressional Relief legislation that cut is estimated to be about 3.6% (APTA, 12/22/20). We have a temporary stay of execution, but don’t have any illusions that the rest of the cut won’t get implemented. Despite efforts by the APTA over many months, CMS decided to go ahead with the cut. While I applaud the response and advocacy of the membership, the only reason we didn’t get completely crushed is because of the pandemic, not any successful lobbying attempts by the APTA.
- 2022: PTA Reimbursement Reduction
Starting in 2022, if a PTA provides more than 10% of a service then the fee for that service will be reduced by 15%. Again, despite any efforts on the part of the APTA, CMS is pushing ahead with this reduction.
In addition, there have been numerous adverse Correct Coding Initiative (CCI) editing decisions by CMS that have affected our ability to get reimbursed for specific code pairs provided during the same visit. While there may have been a 1% gain mixed in on an occasional year from Medicare, I believe the list above represents a pattern of significant losses, despite the advocacy efforts from the APTA.
According to John LaRosa at Market Research.com, the average net profit margin for an out-patient PT clinic is 14.6%. The CMS cuts above have certainly come close or exceeded the profit margin for treating Medicare patients. The next cut might be the final nail in our proverbial coffin.
My biggest question remains why they continue to use the same losing strategy year after year without trying something else.
Marketing and Brand Recognition
If reimbursement is priority 1, then marketing is priority 1A. All of us physical therapists, physical therapist assistants, physical therapy administrators and support personnel know the value we provide for our patients. BUT DOES ANYONE ELSE?
We have done a very poor job of explaining what we do and how it benefits our patients, to other healthcare providers and more importantly the public at large. I want to try a little experiment, have you ever heard of either of these phrases: “Got Milk?”, or “Beef, it’s what’s for dinner”? I will bet almost all of you will say yes to at least one of those. What do they have in common? They were marketing campaigns created for national boards/associations (California Milk Processor Board and National Cattlemen’s Beef Association respectively).
What is the great marketing campaign for our profession, www.choosePT.com. They describe the site as the official consumer information website of the APTA. I wanted to gauge how easy it is to find this consumer information website, so I conducted a brief experiment.
I went on the three popular search engines and did two simple searches that our potential future patients might ask. I documented the ranking position for any content hit for the APTA main website and for the ChoosePT website. The results can be seen below.
According to internet marketing company imFORZA, 75% of search engine users never scroll past the first page of search results (https://www.imforza.com/blog/8-seo-stats-that-are-hard-to-ignore/). How many searchers do you think ever make it to the ChoosePT website? Well, the APTA must not have time to focus on search engine optimization because of the employees and dollars focused on the print, radio, and television marketing campaigns. As Sheldon on the Big Bang Theory often asked, “that’s sarcasm, right?” In my over 25 years working in physical therapy, I have no recollection of any national marketing done for the PT profession.
We could learn a lesson that the pharmaceutical industry learned a long time ago, if you want to improve your business you need to cut out the middleman (the physicians) and take your message directly to the consumers. Every other commercial these days (for those of us still watching broadcast TV) is for a prescription medication. You see, they figured out that instead of their reps trying to convince MD’s to recommend their products, they would sell the benefit of their medication straight to the consumers. Then, the patients would go into the doctor’s office already informed and ask to try a specific medication. If I had a dollar for every time I heard, “Ask your doctor if … is right for you”, I’d be a rich man!
This is a strategy we could easily adopt with a national marketing campaign. Just imagine if a patient had seen about the benefits of physical therapy in an ad or commercial and went into their general practitioner’s office and told their doctor that they wanted to try PT.
I wanted to find out the importance the APTA currently puts into marketing and was pleased to see one of their four strategic goals is to: “Maximize Stakeholder Awareness of the Value of Physical Therapy”. One of the ways they intend to do this is to “Leverage the #ChoosePT campaign and ChoosePT.com to inform the public about the benefits of physical therapy”. If this is a prime strategy (see ranking chart above) the PT profession is poised to wither away in obscurity.
According to their 2019 annual report, the APTA spent 6.7 million dollars on Public Affairs. It would be helpful to have more transparency on how that money is being spent, especially with a continued lack of public awareness about what we do and how we can help.
If the APTA chooses to continue to follow the current marketing strategy (if there is one), then at least more collaboration with the medical professionals we rely on for referrals might boost business. I checked the APTA website to see who was listed as APTA Partners. There are a few good organizations such as The American College of Sports Medicine, The Arthritis Foundation, and the U.S. Department of Veterans Affairs, but no association with the American Medical Association or American Academy of Family Physicians, you know, the kind of partners needed to grow our business and our brand.
Participation in the Association
For an association to claim it represents the profession it would logically follow that a significant portion of the profession should support it and be involved. Unfortunately, with the APTA this is not the case. Let’s look at some of the numbers. There are over 100,000 members however, about one third of those are students required to join or having their dues paid by grants. The following chart shows the number of PTs and PTAs working in the U.S. and the number for each that are APTA members. As you can see, as of 2019 the APTA represents about 26% of all PTs and a little over 7% of all PTAs.
Despite the growing number of licensed PTs and PTAs, as of 2019 the participation rate is declining. A couple of observations, with only 21% of the profession represented, when it comes time for advocacy we are speaking with a very small voice and in the eyes of our elected representatives we are an insignificant portion of their constituency and not worthy of listening to. There are two things lawmakers respond to, money and votes. We either need to spend more, or speak with a larger voice. It is unlikely that we can spend as much as the insurance industry, but if we can increase our participation, we might improve (?) the chance lawmakers listen.
What have they done to increase participation?
While the APTA has tried to argue that it has increased its value to its members through modified services, a growing number of those in our profession think that membership just isn’t worth the cost. Annual membership dues are among the highest in the country for medical professionals. The chart below lists the APTA and a few other associations and their cost for membership.
For a little frame of reference here is the annual salary for each of the professional groups listed above and the annual cost of association membership as a percentage of their annual income.
It may be hard for the APTA to argue that they provide twice the value over the AOTA or the AMA for their members, and the argument they currently provide enough value for the cost of a membership seems to be a losing one. It’s logical to me that if you want to be the voice of the profession then you would want the highest level of participation, so your organization carries more weight. The APTA has never tried recruiting more members by lowering their annual dues. If the APTA cut their dues in half they might double (or more) the number of people willing to support our association. One way to lower the cost is to reconsider the requirement to subsidize the state chapters, it seems like an unnecessary cost. Especially considering that the other medical associations listed in our chart can function with no state membership requirement. The APTA could generate equal or increased revenue from memberships and have a stronger voice, but I guess we will never know if that strategy would work since they seem unwilling to explore it.
Mission & Governance
There are three major factors about how the APTA chooses to function that for the life of me I can’t understand.
First, The Mission Statement for the APTA is “Building a community that advances the profession of physical therapy to improve the health of society”. I don’t see any mention of the membership or their interests in that mission statement. How can you expect an association to make decisions in the best interest of its members if you don’t make it part of your mission to serve the members? For the sake of argument, let’s assume (you know how that usually ends up) that the needs of the members are hidden within the mission statement. We in physical therapy are taught to rely on data when making decisions about progress and changes to our plan, yet our association makes decisions about the best interest of their members without the benefit of data about member satisfaction. Based on my physical therapy education, I would say that is NOT the right way to measure progress and modify goals.
At least in the past we could provide some feedback through comments on the APTA website. It was interesting to note that when they rebranded and rebuilt their website, they turned off the comments section for any posts. I guess those comments were deemed unnecessary.
I will say after 25 years, in November 2020, I finally received an invitation to provide my opinion to the APTA through a survey. I expressed many of the same concerns to them that I bring up here. I don’t know how they plan to use that data or if they will make the results public, but at least they finally asked.
Second, the organizational structure and the procedures used to conduct association business are based on a model of governance that is over 230 years old! This is one of those instances when the APTA has failed to keep up with the times. We live in a digital age where facilitating comment and votes from all of the membership is an easy task. Why we continue to rely on State Delegates being elected, convening in a House of Delegates meeting where motions are brought to the floor and voted on seems like an arduous and archaic process.
In today’s physical therapy world, things occur and change on a month-to-month or even week-to-week basis. The current structure of the APTA doesn’t allow for the rapid response to constantly evolving circumstances. I believe the Association’s response to guidance during the Covid-19 pandemic is a perfect example. In the early days physical therapy professionals were crying out for some type of guidance regarding changes to procedures, whether to stay open or close, and how best to respond. The best advice the APTA could offer is use your best professional judgment.
Here is an excerpt from a statement from the APTA Board of Directors posted on March 17, 2020:
“As actions are taken across the country to reduce the spread of COVID-19, a virus that spreads easily from close contact, APTA encourages physical therapists to use their professional judgment to determine when, where, and how to provide care, with the understanding this is not the optimal environment for care, for anyone involved.”
And an excerpt from a letter posted by the APTA President on March 20, 2020:
“This is a challenging time to be in health care. I commend all those who are putting their own health at risk to treat their patients and clients who have immediate health needs. I also applaud those who are selflessly closing the doors to their practices because they have determined the risk of spreading COVID-19 outweighs the benefits of providing care that is not urgent. Both actions are heroic.”
Can you tell the best course of action from their advice? Not quite the kind of guidance you might expect from an organization that claims to be leading our profession. They did eventually provide guidance but only after watching how the profession and other health related agencies reacted and then forming an opinion. It was a case of closing the barn door after the horse got out.
Third, I have heard from my early days of PT school how important it is that we use evidence-based practice (EBP) and incorporate the latest research into our clinical decision making. I agree with this philosophy 100%, however every journal publishing PT research guards that information like it is a State secret. I understand there are costs to operating a journal, but the over-monetization of research results only serves to hinder one of the APTA’s strategic plan objectives: “Translate the latest research into tools and resources for practice”. Remember only 21% of our profession belong to the APTA which means only 1/5th of our profession has access to the research in our primary professional resource, PT Journal. You then must be a member of each special section to gain further access to the research available through their specific journals, leading to even further restricted access to research.
I don’t understand why all the research done through the APTA and their Special Sections isn’t available to the entire profession, regardless of membership or not. The APTA’s document on Core Values for PTs and PTAs identifies altruism and collaboration as key values. Although it might cost a small amount of revenue, wouldn’t altruism dictate that making research accessible to everyone in our profession outweighs any monetary gain from selling it? Especially since EBP has been one of the highest priorities for our profession over the last few decades.
Pursuing Policies That Have Little Return On Investment
The APTA has chosen to expend time and resources on policies that don’t appear to provide the expected return on investment, such as the Doctor of Physical Therapy degree and adoption of the movement system.
There was a big rush to transition quickly from the Master’s level degree to a Doctoral level degree to usher in the new era of autonomous practice and primary care physical therapy. However, the APTA didn’t consider the practicality of the transition. With the transition came increased school costs, so now new PTs are coming out of school with crushing amounts of debt. A blog post entitled “Is a DPT degree worth it?” (from fifthwheelpt.com) examines the cost of becoming a physical therapist and a physical therapist assistant. Based on the amount of school and the associated cost, it will take a PT about 20 years to catch up to the PTA in career net earnings. Considering the high rate of burnout (see Burning and churning: Why PTs are leaving patient care, EIM Blog, July 2019), I would be surprised if a PT makes it 20 years to recoup the cost of that Doctoral degree. In addition, having some therapists call themselves doctor while many others don’t (out of choice or because they have a Bachelor’s or Master’s) just confuses people further. Maybe 20 years from now it won’t be an issue, but its hard to argue that more student loan debt and public confusion are helpful.
To pile onto the confusion, we have decided to try to associate ourselves with a body system that doesn’t actually exist. This transition has been a focus of the profession for 40+ years and I ask to what benefit? In 2013 the APTA officially adopted the Movement System as the foundation for physical therapist practice, education, and research. The goals included elevating the public’s perception of our profession by associating with the movement system, as well as to enhance the quality of care and promote the development of more meaningful diagnostic labels for physical therapy. From 1921 to 2013 we encountered significant challenges in educating the public in what we did using terminology they might understand, muscles, nerves, and bones. I can’t see how introducing the movement system will make things clearer for Mr. and Mrs. John Q. Public OR fellow medical professionals. Additionally, we have trouble getting reimbursed when we use currently recognized and accepted ICD-10 diagnosis codes. How do you think the AMA (who administers the code set) and insurance companies will react when we show up with a whole new code set specific to movement system diagnoses?
As a matter of philosophical point of view, pursuing these goals might be worthwhile pursuits but we are struggling to get by in the real world today. Like we always emphasize to PT and PTA students, you have to master the basics before moving on to more advanced concepts and techniques. As a profession, we have not mastered the basics of communicating who we are and what we do, so do we really need to go muddying the water further with more complex questions of identity?
As I stated in my opening, I feel there are several good people involved with the APTA. My beef is not with the people, but with the organization, the mission and the decisions being made. In my opinion the APTA suffers from two major flaws:
- They have branched out into so many areas that they have undermined their own ability to be effective at any one of them. Our leadership should be focused on three priorities, reimbursement, marketing, and growing our knowledge base.
- The APTA suffers from a concept known as paralysis by analysis. In other words, too much time thinking and studying and being reactive. When it comes to the health of our profession, we don’t need another study group or position statement. We need our leaders to be pro-active about today’s most important issues.
I think the KISS (Keep It Simple Stupid) principle can and should be the primary guiding principle for our profession until we have started to show some progress. Let’s get the word out about what we do, let’s develop and use effective research to prove what we do is effective, and let’s fight to get reimbursed appropriately for what we do. When we are winning those battles, we can pursue more lofty professional goals.
I didn’t choose to write this just to complain. My goal is to determine if others feel the way I do and to hopefully be an agent of change to help PT thrive again. If the APTA is unwilling or unable to reassess and make changes, then perhaps the time has come for our profession to consider other alternatives for leadership and representation. I would love to see your thoughts either way, so please participate in our poll and/or leave a comment if you feel motivated to do so.
Thank you for taking the time to read, provide your opinion, and for caring about the future of our great profession.
Well said! This article highlights many of the reasons why I let my APTA membership expire several years back! I didn’t feel that they were representing the profession – or it’s providers in a meaningful way. As the struggles of being a small outpatient practice owner continue to mount, the APTA offers little in the way of tangible guidance or support.
Angela, thank you for adding your voice to the discussion. With the financial challenges of the past year, we all must consider whether continued membership is worth the investment.
Thank you for this needed voice. My membership with APTA has been on and off. I resumed my membership while pursuing my tDPT. So, I can access papers for research. But right now, I do not see the value. I have not received any e-mail from my local state APTA. I agree with everything you mentioned here. I agree that marketing is lacking. They should tell everyone the importance of PT in preventing, recovering, and saving healthcare money by shortening hospitalization and promoting independence with function. We should be one of the first-line providers for musculoskeletal dysfunction, vertigo, and lymphedema. Doctors are more expensive to go to. We are educated and knowledgeable on red flags. We should be able to do more for our patients with less constraint. Why physician assistants and nurse practitioners have more independence in their practice when their education is less than a DPT? We still need to contact a physician for an ambulatory assistive device order. I would not be surprised if there will be a shortage of PT again soon. I cannot recommend any young people to be a PT right now.
Loraine, thanks for your thoughts. How crazy is it that with 40+ years of effort towards direct access that we would still need to get a referral for a cane. Let’s hope the APTA hears our frustration and decides to change course.
Jon, great summary. I want to first thank you for being a member. I too have been a member for almost 30 yrs. Many changes in healthcare during that time, not only to PT. I am posting this to state what is on my mind and how I see things from my seat. I truly believe that “we” are APTA. The 170 employees that are in Alexandria cannot do it alone. I have made it my personal and professional mission to make our profession stronger for those behind me. I feel that patients having the ability to access PT services is the first step, then educating the public on the benefits we offer, and then getting paid appropriately for our services are key to the outward facing world. Inwardly facing, I feel that evidence based practice is key. I have been president of an APTA chapter for 6 years at which time I pushed heavily to educate the public on the benefits of PT and attempting to be the provider of choice for them. We used radio, social media and print marketing elements. In my private practice, we see a large number of direct access patients. I am attempting to start an orthopedic urgent care center where the PT is the practitioner but unfortunately, cannot do that based on poor payment from the insurers. I share your frustrations. I am confident that the APTA has not lost focus. Yes, transparency needs to be increased. I agree with some of your points for sure, but in the past I was on the APTA board of directors. I have seen the hours spent working on all of the issues above. I have always believed that the association is the vehicle to make changes to our profession. Yes, we need to increase membership to have a louder voice. I agree with you 100%. We have discussed many options and attempts to increase that. I think the largest short coming the APTA has is that is does not educate everyone of the programs and work groups that are working on all the issues that are facing our profession. Can the APTA do things better? yes, and there are many changes that are happening that take time to work. I would love to sit down with anyone and discuss issues as it only helps us as a profession when we can all row the boat in the same direction. I am a proud member of the APTA and continue to be active and engaged. I recently put my name in to the governor for the position of our state Dept of Health chair. I feel we also need individuals in our profession to branch out and educate not only potential patients but officials to have some control over healthcare. Thank you for your article as this only helps everyone focus on what our profession needs. Passionate, educated, engage people!
Anthony, Thank you for everything you have done to advocate for the profession. I agree with you that the membership is the APTA, but with the current structure the members have no direct say. The state Delegates have the final vote and in my 25 years I have never had a state Delegate send me an email, let me know about the proposed motions and ask my opinion. The time demands of day-to-day life don’t leave me with much time to do the research and chase down my Delegate. I truly believe that the Association could do a better job of informing us and soliciting input from the members directly about the direction of the profession. They should also provide more transparency on how dollars are being allocated and the specific actions being done to meet the needs of the membership. That might help with the frustration level that seems to exist currently. Best of luck with the Department of Health Chair position, we need more of us in governing positions!
I was a member of APTA years ago. But seems like they have not done enough to protect our profession. We have no voice and representation. I say this because it seems like every year, changes with CMS almost always affect our services. We always get the short straw. We need to have good representation with CMS. I hate to say it, but I feel like APTA is focus more in money making business. What’s the point of getting credits,specialization, and the DPT program if we won’t have any more jobs in the future. Don’t get me wrong, I love my job. Being a physical therapist is dream come true for me, I will keep doing this til my body gives out on me. But I think we need an organization that will protect our profession. Or better, we need APTA to protect our profession.
Sherwin, It is a great profession which is why I am concerned about our future. We do need the APTA to protect us. I think they could re-capture many past members if they refocused their efforts and provided much more transparency.
Lots of great points. Only thing I’d add is the fact that Sections get votes at HOD yet PTAs dont even get a vote and they constantly advocate for the increase in scope of practice for PTs but not PTAs and they still have a stance against PTAs doing any joint mobes, even grade 1 patellar mobes. There is not equal representation allowed by the APTA for PTAs yet they keep wanting to verbally push for increased participation.
Eddie, Just to clarify neither the Sections or the PTA Caucus get to vote on motions, only the State Delegates. However both of those groups can bring motions to the House floor. To your other point, I agree with you 100% that PTA’s are not given an equal voice. I think the Association has not valued their membership as much as they should which is why only 7% of PTA’s decide to join. Thanks for your comments.
Just a clarification, Sections do now have 2 votes in the House of Delegates as of last year.
Thank you for clarifying that.
Great article—thank you! I’ve considered the marketing aspect, too, educating the general public. There are so many conditions physical therapy can help with that I didn’t know about until so decided to become a PTA… things that should be public knowledge. Are there any good sources for memes that could be shared on social media to let people know what PT can do for them?
CB, that is a great idea and is an example of something that should be part of a comprehensive marketing strategy that PT just doesn’t seem to have.
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I love the commercial idea! Seriously what is so hard about lobbying for that? If we simply made a 20 sec commercial stating the “Physical therapy is a service to help any physical ailment or decrease physical pain. If you’re suffering from an injury or chronic pain go see your local PT today. #ChoosePT” we’d immediately more people in the clinic and I wouldn’t have to answer the same question “what is physical therapy?”. Ridiculous that the people in charge aren’t using the simplest ways to promote us to the public
Sage,
Thanks for reading our post and for joining in the conversation. If we can get more people to express their disappointment with the current leadership maybe we can foster some positive changes for our great profession.