Episode 9

Addressing the Biggest Therapy & Rehab Workforce Challenges

Senior Vice President at the American Physical Therapy Association Tara Manal joins the show this week to give us some insight into some of the biggest workforce challenges facing the Therapy and Rehab space. Some of what we talk about: What’s driving the shortage of physical therapists How to address burnout How student debt relates to the shortages
Published on 07/13/2023
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Episode Transcript

Allison Jones: Good morning, good afternoon, and good evening, and welcome to the Therapy Matters podcast, your one-stop resource for expert insights and advice on everything therapy and rehab. I’m your host, Allison Jones, and today I am joined by Tara Manal, the Senior Vice President, Scientific Affairs at the American Physical Therapy Association. Tara, thank you for joining me today.

Tara Manal: Thank you for having me. 

Allison Jones: Excellent. We’re going to be talking about workforce challenges in physical therapy, but before we jump into that, let’s start by giving our listeners a little bit of your background. 

Tara Manal: I’ve been at the American Physical Therapy Association for almost two years. Prior to that, I had been at the University of Delaware. I was an associate professor in the physical therapy department, but I was also director of clinical services and residency training. Throughout my career, I’ve spent time in academics, but in academics with an embedded physical therapy clinic inserted within the department itself so that we saw patients, gave treatments, billed, and did all the things that a physical therapist does in an outpatient-type setting. 

That’s what I did for my first career for the first 28 years. Then I came over to the American Physical Therapy Association just shy of two years ago in order to lead the division that we have, which is called Scientific Affairs. That’s inclusive of our physical therapy journal, which is our premier journal for scholarly activity in the profession, and our career advancement division, which includes all of our educational opportunities for our members and non-members to learn more about physical therapy, as well as our entire practice and innovation department. All of those things are within the Scientific Affairs unit. We have a research component as well. 

Allison Jones: Okay, great. That’s quite a bit to cover. You have a big job there. As I said, we’re going to be talking about workforce challenges today, specifically the impact that’s having on the physical therapy industry. This stems from a conversation that happened a few weeks back in a previous episode of Therapy Matters. My co-host, Scott Rongo, spoke with one of your colleagues, Justin Moore, about the challenges and opportunities that are facing therapy over the next five years. They talked about a couple different areas, but one of them was workforce challenges. They covered challenges generally, so today we wanted to take it a step further and do a deeper dive into the dynamics that are shaping the physical therapy workforce, how it impacts the industry, and what the community at large can do about it. 

There are multiple factors affecting physical therapists and the workforce, including the supply of physical therapists that are available, the demand for services, job satisfaction, and educational debt, just to name a few. There’s quite a bit to unpack there, so let’s dig in. My first question for you is, it’s no secret that there is a shortage of therapists right now. It’s a pretty regular headline in the news. It’s something that we hear quite often when we’re talking with practices. It’s a challenge they run into quite regularly. My question to you is, how serious is this shortage, and what’s driving it? 

Tara Manal: It’s an excellent question. It’s something we’re trying to start to really unpack, and as you described, it’s such a dynamic entity that it’s really about what are all of the components? We’re pretty confident there’s not a singular component. Our graduation rates have gone up. It’s a small increase on a regular basis because of the size of the programs, but it’s not going down. It’s not that that level of supply is a challenge. I think there are some factors that are driving increased demand, and that’s a good thing. It’s certainly a good thing for the health of society because we know that so many people with musculoskeletal as well as other conditions that physical therapy helps with aren’t getting the care they need. The idea that they could start getting the care they need is a good thing. That’s actually a demand we want to see go up because we know that there’s an underserved, not unserved, but underserved. That’s something we really want to get at. We certainly know that there’s a dynamic on the demand side that’s probably very real. 

We also do know that there was, at least according to one study, a definitive health study indicated or suggested that almost 22,000 physical therapists may have left the field in 2021. That would be a significant blow to the supply of physical therapists. The idea that people left the field and whether or not they returned is something that we’re going to have to watch to find out if that was a temporary or permanent change. We don’t know the answer to that right now. It hadn’t been looked at in the way that they actually did the study. That particular way of looking for that loss hadn’t been done that way. We also need to understand how reliable that process is and whether it’s actually telling us something critical or not. It’s going to remain to be seen, but it’s something that we now really need to watch.

But if it’s true, and it’s very possible that it is, that’s almost two graduation cohorts from two different years just for that one exodus. But we also think that’s a large exodus. We don’t have anything to tell us that many physical therapists have been leaving on a regular and ongoing basis for many, many years. Understanding why that happened, whether that’s related to the pandemic and its consequences or there are other reasons, is clearly something we want to understand. But maybe more importantly, we want to say that one critical factor is to make sure that those who are in the workforce stay in the workforce. For those who’ve left and are willing or interested in coming back in some capacity, like part-time, what would it take to facilitate their return to the workforce? 

Some of our colleagues in the field have been talking about some programs they’re even putting in place, which is transition back and come work for us, and we’re going to help you transition even if it’s only going to be one or two days a week that you choose to work for us. They’re trying to really reignite the workforce that may have either left or reduced their workload. 

Another thing that we’re hearing from our constituents and members about is a decision that some physical therapists are making related to the number of hours that they want to work and that they are more interested in working not full-time 40 hours a week but a lower amount of full-time, maybe 34, maybe 38, maybe 32. If four or five people do that, you’re losing an individual because the hours add up to another whole human. 

That’s another thing that we’re starting to look at. Is it the number of bodies, or is it the number of hours that they’re working? Is that another way of trying to capture some of the challenges? It’s really just examples of things that we’re trying to keep our eye on. 

Allison Jones: That’s quite a few different factors that are contributing to the overall issue. There are a couple things that I want to follow up on with you on that topic. One of the things we hear a lot about is burnout. We hear the term, burnout and that being a contributing factor to people leaving the profession. In your opinion, what can businesses, practices, and owners do to help with the burnout issue?

Tara Manal: It’s something to take very seriously. I think it’s not a stretch to say that most of us haven’t really recovered from COVID and its aftermath. We’re not quite the same people we were before, and we’re surviving. Now, we need to switch from surviving to thriving, and that’s probably going to take some actual effort. It doesn’t just bounce back. The way you think about it, this has now improved so much that I’m just going to go back to where I was. We know that doesn’t happen to patients after they recover from an injury. They don’t go back to exactly what they did before. They have to transition back to it. I think that we are in that transition period now. I think the health crisis has ended by most measures, but now we need to actually transition back and not just assume we will bounce back.

Things that employers have been looking at, and it’s being discussed throughout all healthcare, it’s not just a physical therapy challenge, but we certainly are having our challenge, is what does it mean to allow or help an individual be fit for practice? Those are the things that we are doing for ourselves as physical therapists in order to be sure that we are fit for practice, that we are fit to bring our best selves, and that we have the energy, dedication, and ability to focus on our patients and their needs. That starts with all the things that you can think of to be a healthy person: appropriate sleep, appropriate nutrition, and appropriate activity levels. 

But things that particularly employers are looking at is what kind of services might physical therapists need that they haven’t accessed previously? That can be mental health services. It can even be apps. Some employers are providing calming apps to their therapists as a perk, things like that that you say, these are the things that we could do to reset ourselves so that we have that energy, compassion, and that depth that we need to draw on. There are many times where we are put in very difficult, challenging circumstances. It’s important that we have that energy to draw upon when we need it in practice. 

They’re also looking at different types of flex schedules. I’ve heard of everything from four-day work weeks to trying to balance your work schedule so that you mix some administrative with some clinicals so that you take a break from being, what we call on the floor, particularly hands-on with an individual patient. Something else that I know we’ll want to talk about is administrative burden. It’s the other things that overload the therapist beyond the care that if we could reduce those, you are giving them more time. That’s something that we really think is an important factor. 

Allison Jones: Before we jump over to administrative burden and dig into that, let’s stay on this and talk a little bit about the shortages. Now are these shortages everywhere, or are there particular areas that are suffering more than others? Do we know that?

Tara Manal: We don’t, and that is something else we’re trying to understand. We certainly know that there have been shortages in rural areas, as an example, and that’s been going on for some time. We don’t have strong evidence across the entire country where that is. There are certain states, for example, that have better information about where physical therapists live and work, and other states that have very little to no data on that. It’s actually quite idiosyncratic to the individual state that has information.

But there is some movement and effort across the states to try to encourage states to collect more of this data so that we could literally say, oh, there’s only one physical therapist in this area that’s certified or specialized in a specific area. For example, you could have quite a few physical therapists in an area, but you might have none that have pediatrics training. Yes, there are a lot of physical therapists, but you still have a pediatric physical therapy shortage because they are there, but they’re not trained in the area where the care is needed, for example. 

We have that potential. Even when we have enough physical therapists in some areas, we might not have the right mix of physical therapists and their specialties and practice areas in that exact area. The other challenge, as you noted, is that we don’t know the exact number or ratio for a set number of individuals, even by a specific age group, how many exact physical therapists is the right match to provide care for that group. We don’t have that ratio available to us right now, but I do believe that it’s something that we will seek and hope to determine. It might take years to figure that out, but I actually hope that’s something that we start to look for and look to determine so that we can have much better information as well as direction to people on where the best places are with the greatest needs.

Allison Jones: Are these some of the initiatives that the APTA is championing in the industry? 

Tara Manal: Yes. We’re really looking ourselves at what do we already know? We’re trying to identify what we know so that we can identify where to invest the energy to find out what we don’t know. We’re just preparing and putting out a demographics report that’s going to give us a sense of some of the things that we do know. But the individual states at the level of licensure have a lot of ability to tap into their licensees. APTA doesn’t directly have that linked to the licensees, but the state regulatory boards do. That’s a group working with our partners at the Federation of State Physical Therapy Boards, working with them to say, yes, that is information that’s really valuable. They are working on a proposed minimum data set that could be collected at the level of the licensee that could then give us much greater and richer information than what we have right now about who’s where, what they’re doing, and maybe more importantly, how many hours are they working, not just that they are employed. Some physical therapists want this 34-hour week, and others are working full-time and doing gig work on the weekends, either in hospitals or in their CrossFit gyms. That’s a handle of understanding who’s working and how many hours we would need to know, again, to identify a need. If people stopped doing the second job, then we would need a physical therapist available to pick up that work, or we would be underserving again, so really understanding literally how much people are working in hours. 

Allison Jones: That would be great. It would be wonderful if we could accomplish that. Another item that we really haven’t touched on just yet is student debt and its impact on workforce shortages, workforce challenges, folks potentially seeking out other opportunities because of the burden of debt. Can you talk a little bit about that?

Tara Manal: Student debt is another complicated issue. But when you think about really boiling it down, it’s the costs that have been incurred and then the payment that’s received throughout the career, and it’s the relationship between these two. There are many ways to impact that. For example, if salaries were higher, then that debt burden would be lowered. If the debt burden started lower, then the salary could be sufficient at a lower level. It’s this relationship. 

The other thing is how long a program is. If someone gets out six months earlier and starts working full-time six months earlier, that other individual who’s six months more in a program has the foregone earnings of not working for six more months, plus the payments of tuition, living expenses, et cetera, for that time period. There’s a lot of interplay in relationships that can happen that can get this student debt ratio to a better place, a healthier place, a place that’s more tolerable, if you will, for the purposes. We have to figure out that relationship and where best to modify it so that students aren’t overburdened in their beginning. If they can’t get that caught up over their career with their income over their career, then they could be stuck behind that eight ball the whole time because they can never quite make enough. 

That’s where some of the gig economy that we see is coming. Some of the youngest therapists are working extra nights and weekends so that they can gather extra money to pay off that debt so that they resolve that sooner. But there’s quite a few programs looking at ways to help with scholarships and reducing costs so that our physical therapists and physical assistants aren’t coming out with a big burden or a burden that they can’t overcome. 

Allison Jones: Now, and correct me if I’m wrong, but when we were prepping for this session, I think you mentioned that there’s some potential legislation that is being considered right now to help reduce some of the potential student debt burden.

Tara Manal: Yes, there’s a physical therapist workforce and patient access act that APTA has been spearheading with colleagues, but the idea is to allow physical therapists to participate in the National Health Services Corps. That has a loan repayment for those who are involved in rural and underserved care. Being recognized as an individual in that corps would then allow physical therapists to be able to apply for that. That’s $50,000 over two years. It’s $50,000 of loan repayment for two years’ work in rural and underserved areas, which, as you can imagine, is a double win. We assist with the student debt, but we also bring excellence and care to those who are not receiving the care that they need and deserve right now. It really is a win-win, and we’re really hopeful that it will be successful. 

Allison Jones: Let’s go back to administrative burden. I understand that there’s some work that’s being done to help lower administrative burden for PTs. Tell me a little bit more about what the challenge is for PTs around administrative tasks and how, I believe it’s some legislation, to help reduce that burden. 

Tara Manal: This past month, the Centers for Medicare & Medicaid Services (CMS) came out with their 2024 Medicare Advantage final ruling. In that, they specifically spent a decent amount of time addressing some serious issues related to prior authorizations. Prior authorizations are the opportunity to say that someone is allowed to receive the services that they’re going to receive and for how long. 

One of the things that Medicare identified was that Medicare Advantage individuals were not necessarily always receiving the same services as Medicare fee-for-service individuals, and they sought to make corrections to that. They wanted to be sure that prior authorizations were valid for as long as the individual and care was deemed medically necessary. They put some limits on the use of prior authorizations. They’re slowing things down to say that this person needs this care because they have a specific diagnosis or they meet the medical criteria to receive that care. That’s the purpose of it—to check. That’s a prior authorization. Before you do it, let me check.

But they were being clearer that it can’t be used for other reasons. It can’t be used to delay or not allow care. They’re being clearer about that so that Medicare Advantage programs are clearer on what their expectations for them are. Then there’s always this challenge where Medicare Advantage enrollees are switching plans, so they fall through the cracks. It said, nope, you can’t do that. If it’s medically necessary and they need to receive it, you can’t allow that to happen as well. Those are really important. One, because CMS does set the tone. But two, they’re identifying where an important, something that was put in place with a purpose in mind may actually have unintended consequences, and now they need to be clearer to stop those from happening so that patients can get the care without undue burden on the care providers in order to let them get the care that they need.

We’ve seen that spill over slightly and hopefully more and more into private payers. Aetna and UnitedHealthcare have both put in some provisions to improve prior authorizations and reduce some of the burden associated with them. Again, following the lead, CMS, does set that tone. It is really important that we take these as huge wins because it is a domino effect, and it will affect some of these burdens like prior authorization, even in other payers besides Medicare and Medicaid services. 

We had done a study on administrative burden in the field, and what we found was between 77% and 83% of front desk people take more than 10 minutes per individual patient just on prior authorizations, per individual. Just think about that time. They felt that if prior auths could be cleaned up and streamlined, it would probably save 25% of admin or staff and clinician time. 

Allison Jones: That’s massive. 

Tara Manal: That affects our supply and demand issue. If we find this time, then we could provide more care. These are so intertwined. That’s why it’s hard to give a short answer to some of the great questions, because if you change this, then maybe we don’t have as much of a supply problem. Every time you change one, you actually influence the other. 

But another interesting thing that creeps in is that 40% of clinicians identified that prior authorization was used as a denial when prior authorization wasn’t required. You’re denying my service on something that isn’t even a required litmus test to meet to get the services. But it’s an easy button to push. It’s an easy thing to create. This burden that’s out there is waste. It’s just waste. It can be described in monetary terms. It can be described any way you want to, but it’s waste. If we reduce the waste, we will be able to provide more and better care. Period. 

Allison Jones: Absolutely. I was reading an article the other day just about administrative waste across healthcare in general, and the numbers are just so enormous on what we, the healthcare industry in general, are wasting on administrative tasks and administrative burden. It would be wonderful if we could fix that problem and allow our clinicians to spend more time with patients and focus on patient care, which is our ultimate goal.

Tara Manal: Amen. 

Allison Jones: Yes, exactly. We’re going to solve the problems of the world right here today. 

Tara Manal: That’s right. 

Allison Jones: We’ve been talking a lot about different pieces of legislation. What can PTs do to get involved and advocate to make sure that these legislative pieces are being heard and getting the attention that they need? 

Tara Manal: The American Physical Therapy Association has an advocacy center on its website, and it is really easy, intuitive, and useful. Not only do they have locations where physical therapists can log in and instantly send information to their senators and congressmen, but it literally populates things for you. It’s so well done. They have things at the state level as well as the federal level. They even have patient resource centers where, for example, there was a time in our clinic where we ended up having a Medicare issue pop up, and we set up a laptop at the check-in station. We said, if you have Medicare, sign in here and let people know how you feel about what’s going on. 

That was through the APTA because they had an advocacy center, and we just made it easy for our patients to do it. But the American Physical Therapy Association has made lobbying efforts. I’ll just be honest. I’m not the best lobbyist you’ve ever met. It’s not my comfort zone, so my philosophy is that if you’re not going to go do it, then you donate to make sure the people who do it have the money they need to do those things. I feel strongly about the fact that in your professional association, you seek out the ability to donate to your political action committees and recognize that those entities are representing you and need the resources to be successful. That would be an example of the PT PAC, which is our political action group. It’s a donation as well as truly letting your voice be heard. 

I’ve been on the Hill. Like I said, I’m not the first person to go, but I’ve been there, and what really resonates with people are the stories—the actual patient stories—and physical therapists are the ones who have them, and they have them in spades. When they write in and use a story and describe an actual patient that got caught up in whatever issue is trying to be resolved, it makes a difference. It genuinely does. There’s also the Advocacy Academy. There’s a training program at the American Physical Therapy Association to help people who want to be more involved in advocacy, but they might not have the confidence and/or the skills because it’s a skillset. There are opportunities to learn here at the American Physical Therapy Association about how to do that.

We have this really rich model where the American Physical Therapy Association is the entity, but we have what are called components within our federated model. There’s an American Physical Therapy Association group in every state. You can literally go to your own home state group and say, how can I help? What are you working on? Who should I talk to? Do you need a story? Do you need a patient that I could connect you with and that you could bring with you when you go to talk to your state legislators, as an example? If you think of it as a wheel with spokes, there are so many places where physical therapists can connect and get involved in order to fight for what they need and deserve. We need all of those voices in order to be successful. 

Allison Jones: Excellent. I like that. Get involved. Let your voice be heard, donate, and just participate in your community. 

Tara Manal: Absolutely. Make change happen. 

Allison Jones: Yes, make change happen. I love it. As we’re wrapping up here, what are the main takeaways that you want our listeners to walk away with today?

Tara Manal: I want people to realize that the dice are not cast here on any of these issues. It’s about understanding and recognizing what we need to work on and diligently working on it until we solve it. It is what physical therapists excel at. We do it with every single patient, every time. We see what we need to do, and we diligently break it down, and we attack it until we win. We work with the patient. We collaborate. We agree on what’s important, and we facilitate their success. That is the same thing that we can do in the challenges we have in workforce. It does start with understanding it, that’s the part we’re working on, and then it goes to breaking it down into what could I do about that? And then being relentless about pushing that forward until we succeed. It’s a long game and not a short game, but I do think that overall, the health and the longevity of our profession will benefit from all of those activities. It is something that every single physical therapist at one level or another, everything from the dollar to the mouthpiece, to the efforts, to the march, can do something about. There’s a place for everyone in making these things happen. 

Allison Jones: That’s awesome. Thank you so much. That is some amazing insights today. Great conversation. We are out of time, but I do want to thank you so much for joining us today. We probably could have gone on for another hour or two on this topic, so certainly more to come on this. I want to thank our audience for tuning in to Therapy Matters podcast. As a reminder, this is your one-stop resource for expert insights and advice on everything therapy and rehab, and we look forward to seeing you on the next episode. Thank you so much.

 

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