Episode 13

Could Faulty Data Have Made the PT Labor Shortage Worse?

Executive Chair of Confluent Health, Larry Benz, joins Scott in talking about one of the most pressing issues in healthcare today: labor. Some of what we talk about: How the shortage wasn’t a surprise The CAPTE bottleneck How a ACAPT paper may have exacerbated the shortage
Published on 08/24/2023
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Episode Transcript

Scott Rongo: Hey, good morning, good afternoon, and good evening, and welcome to the Therapy Matters podcast, your one stop resource for expert insights, advice, and everything therapy rehab. I’m your host, Scott Rongo, and today I’m joined by Larry Benz, the executive chair and founder of Confluent Health. Thanks for joining us today, Larry.

Larry Benz: You’re welcome. I’m honored and pleased to be part of this discussion. 

Scott Rongo: Awesome. Larry, you’re not new to the space, you’ve been in it for quite some time, but maybe for our audience, just give a little bit of background on yourself and share a little bit about what you’ve done.

Larry Benz: Sure. I’m a physical therapist by background. I am the founder and currently the executive chair, having just migrated from a CEO to executive chair of Confluent Health. Confluent Health is a physical therapy platform. We’re a holding company that has interest in education and outpatient clinics. We have over 600 of them. We have a division that manages lots of hospitals around the country’s physical therapy and rehab. Then we have an occupational health group called Fit for Work amongst other things that we do. 

I’ve been a physical therapist since the mid-80s and have been very involved in private practice and all things education through our EIM, Evidence In Motion company.

Scott Rongo: Awesome. Like I said, we are just delighted to have you on the program. You and I were together a few months ago at a dinner with about 15 folks and a conversation of topic that got brought up was the PT labor shortage that we’re faced with. You had a lot of perspective and insights and clearly through your background and the work that you guys have been doing.

We thought it’d be a good idea to maybe bring you to this program and have that conversation for a broader audience. Again, certainly appreciate you and thank you for doing so. At a high level talk through, you had a lot of data and there was a lot of commentary around PT labor shortage. What’s your overall consensus? 

Larry Benz: Yes, I’m really passionate about this topic for a number of reasons. All of us that are PTs have had this journey of how we became a PT. Did we get accepted the first time that we get accepted in the school that we wanted to?

I’ve had this burning desire to make sure from a legacy standpoint that our best and brightest students become physical therapists that they’re enabled to and that they have the opportunity to, and what I can tell you is that the shortage is nothing new. It’s been predicted as early as 2012, arguably earlier than that. What we’re seeing is the result of the shortage and the shortage itself. We’ve had this dilemma in physical therapy about trying to control the number of individuals that become PTs and I think that what we could look backwards, unfortunately, is that was not well-grounded.

Scott Rongo: Yes. You could start to see it, like you said, roughly back in 2012. But what are some of the causes. How do we get to this point where we are today?

Larry Benz: About this topic, I think about a great quote by Oscar Wilde, which is that there are two tragedies of life. One is not getting what one wants and the other is getting it. In physical therapy, we have data, we have evidence, we have efficacy on the use and interventions of physical therapy for force multipliers that can direct care initially, particularly in musculoskeletal. 

Musculoskeletal is about $300-billion industry. We need physical therapists to curve this problem. About a dollar out of every 6 is spent in aches, pains, sprains, and strains. In order to do this, we got what we want through evidence and efficacy and demonstration of our value. However, the tragedy is we don’t have enough PTs. My concern is that we have this market opportunity and we don’t want to fall flat on our face. This is not a new thing. Early as 2012, the APTA’s workforce report at that time as has the Bureau of Labor Statistics demonstrated the shortage every time they’ve published data, but all of this has gotten amplified during covid. 

If you’d like, I’m happy to walk through the players, the history, current status of where they’re at, you just turn the spigot on and let me go. 

Scott Rongo: Yes, let’s do it. Let’s dig deeper into it. Absolutely. That’d be great.

Larry Benz: Dr. John Childs, one of the other co-founders of Evidence In Motion along with some other really good fine folks have written about this and lectured about it extensively, but it probably helps to talk a little bit about who are the players because those of us that are in private practice, which I imagine is a good portion of your audience may not know some of these organizations or know them that well, or they might know their acronyms.

The first one is the American Council of academic physical therapy what we sometimes call ACAPT. They’re a nonprofit and they’re really dedicated to making sure that all physical therapist entry level education is excellent. They are the leaders. 95% of all US-accredited PT programs are represented by these folks and, roughly 250 to 260 institutions. I actually point the finger a little bit at them for causing this temporary hiccup into publishing the fact that we don’t have a shortage. 

In March of 2020, right around the time COVID began, they actually published some data and articles saying that increased student debt has outpaced the rate of salary growth. They’re very accurate on that. It absolutely has. If there’s a nationwide shortage of faculty of PT, which is true as there’s about one to two open faculty positions at every program, there’s this increased competition for clinical education sites. At the same time, they believed that looking at the Bureau of Labor Statistic’s data, in particular, the fact that there were fewer reimbursable visits per episode. All that to be said, they came up with this very faulty conclusion that physical therapy employment does not match BLS projections, and they estimated that there would be a surplus of 25,000 physical therapists by 2030. 

Now, I’m not bad-mouthing ACAPT. They’re a wonderful organization. We need them engaged in a collaborative process here but their data was flawed. Here’s what they did that was actually worse: They sent letters to every higher education institute basically saying that if you’re looking at opening up a PT program, forget about it, don’t expand your current size, please don’t increase tuition. As you well know, PT programs in a higher education institute have no control over tuition. That’s determined much more. They published this. 

In response, Dr. John Childs, myself, a couple of data folks that we enlisted for their help, as well as Dr. Mike Walker, who is very noted physical therapy academic who’s led programs, who actually works with Evidence In Motion, published an article that came out around 2021 in October that basically said we’re going to challenge these assumptions about the future and the supply and demand of PTs in the United States.

What we did was we demonstrated that ACAPT and APTA significantly underestimated the current demand for PTs. APTA has had a number of workforce analysis in many years. 2012, for example, they predicted a shortage of 19,000 PTs. In 2017, they predicted a shortage of 45,000. However, when they updated their assumptions in 2020, in what we consider very shoddy work, they helped predict this surplus of PTs. Now, APTA has since effectively put that Workforce Development Survey on the shelf and said, “Yes, we agree that this analysis was flawed.”

Unfortunately, though, because all those letters went out to the programs, it really has hurt the situation where we’re at now because we can only produce a number of PTs that we have in the physical therapy schools. 

There’s one other factor that people oftentimes forget. Prior to 2001, if we all remember 9/11, we would actually have about 10,000 PTs enter the United States, foreign-trained therapists, and about half would pass their exam. That was about 5,000 PTs and we would produce about 5,000 from the schools. That was roughly 10,000 per year. To date, that was largely eliminated after 9/11, and so from 2001 to 2023, we now are only producing about 11,000 PTs per year. So, it’s about the same as we were back in 2001, with the expansion of the field.

Now that seems to be common sense, but as we all know, common sense isn’t necessarily common practice. We have high attrition in our practice. At the same time, we also have a geographical variability. In the Midwest, Rhode Island, and Vermont, they have enough PT programs to satisfy their demand.

Virtually the rest of the United States does not, so it’s also very regional. If you’re in Rhode Island or Vermont, you may not feel a shortage. If you’re in New York, Connecticut, California, or Washington, many, in fact, most other states, have some graphs that demonstrate this. You’re going to see these shortages and feel them in real time.

Scott Rongo: So, programs start to slow down. There’s also the then applicants. Are the programs filled to capacity today? Are folks going in saying they want to be PTs but there’s just not enough capacity for the education for it, or is it that programs are not being filled either?

Larry Benz: That is absolutely the right question. the other major constraint is another regulatory body called CAPTE, the Commission on Accreditation of Physical Therapy Education Programs. They have a monopoly. They are the only ones that have the authority to expand DPT education.

If you’re in nursing, for example, there are at least two to three organizations that allow you to expand, but we have one in PT. Now, again, not bad-mouthing them, they’re a volunteer organization. They’re a wonderful group who seeks to expand PT education, but because of the fact that they’re a volunteer, they only have one cycle per year. The bottleneck is that there are lots and lots of schools that want to have PT programs, but they’re about five years behind relative to the ability to get programs approved. 

The other thing that they’ve not typically done very well, and it’s starting to change, is they’ve not embraced the innovative programs. A rough statistic is that in Medicine, if you want to become a physician or an MD, they have about a third as many programs producing three times as many physicians as we do. Our class sizes in PT tend to be ridiculously small, inefficient, and very expensive. 

Because they’re the only credentialing organization, they have a peer review process and it becomes a waiting line, so lots of programs want to become approved, but there are only two times per year. They only review six programs in a cycle or about 12 per year. Historically, they actually get together about four times per year to review them. It represents a 75% reduction in the ability to review the capacity over the next 10 years. Now, part of that is because of lack of resources, part of that is that some of the incumbent programs are slowing down. 

We had what we call the CAPTE queue. These are the number of programs that would like to be approved. It’s five years out from the initial submission to launching a program. Now, it only takes 18 months to 24 months to develop a DPT program. The average program is three to three and a half years. 

The take home point on all this, by the way, is that this shortage is not going away quickly. Because there’s this bottleneck. We have worked tirelessly with other organizations to encourage more volunteers. Again, CAPTE has a lack of resources. We need to help them with that and allow them to expand the number of review cycles per year. If a program has the financial means, and you have already hired your faculty, you’re willing to go, you financially have the wherewithal to do it, they should jump to the top of the queue rather than having to wait. Many other programs during the waiting period might not have the financial wherewithal, the staffing, or have hired the appropriate number of PTs. 

Scott Rongo: If you can only review four to five per year, which I’m assuming is that there are more applicants than that, in a given year, who gets put to the top of that list for review. Is there a qualification?

Larry Benz: Right now, it’s simply a function of time. You have a lot of programs in PT. If you think about innovation, many of the newer programs, and EIM has been at the forefront of this, and have worked with universities to go from a three-year program to a two-year program, drastically reducing the cost for students. Instead of taking 30 students, take 100. Then on top of that, put them in their internship of six months in their last two years so that they can graduate.

Lastly, it doesn’t have to all be brick and mortar. They can do it in a hybrid or blended environment, which blended and hybrid actually wins. As it turns out, when you look at educational outcomes, not just for PT, but in all of education, it’s the blended that works. A lot of folks are surprised that many students who are on campus are undergraduates. Up to 50% of them are taking a couple of courses online while they’re sitting in their dorms. Blended is the right approach and there’s been a failure by the traditional incumbents to expand their programs.

It’s getting a little bit better, but unless we get this bottleneck solved, the shortage is not going away quickly, which is really problematic because musculoskeletal spend has gone way up where we have the largest factor to play, or largest sandbox to play in terms of lowering cost and providing a better outcome.

Scott Rongo: Certainly not to make light of it, but just this week, they came out with a study on the increased health care cost of what pickleball is doing. Here in Indiana, pickleball is all the craze and it’s it. I think there’s going to be a lot more need for PT just even based on pickleball play across the country. 

We know at its core, one of the challenges is fixing that bottleneck, which is not an easy task. What recommendations on what you can do to assist with that, or if you’re a listener sitting there saying, “Yes, we know the problem but what can I do? What can a lonely Scott Rongo do 10 years from now to help address the issue?” Thoughts and comments around that?

Larry Benz: You have to take a holistic approach. On an individual level, please volunteer with CAPTE. Demonstrate your willingness to be in an academic review light.

They’re always looking for more volunteers, but the holistic solution is really to collaborate. We have to get ACAPT, the academic group, CAPTI, the federation, organizations like APTQI, the American Physical Therapy Quality and Innovation, which is a nonprofit comprised of many of the public and private equity-backed large scale PT groups.

There are other groups involved as well, like state associations. We have to encourage APTA and help fund it. We can’t just encourage it. We have to have a clear workforce development department. In 2012, 2017, 2020, we produced workforce development, but particularly the last one was very flawed.

Let’s have a real department with real professionals. With real statisticians and demographers and folks who really are experts in demographics and predictions and who could take in the Bureau of Labor statistics, who listen to market phenomenon.

In 2012, who would have thought we’d have the direct access pickup in MSK, and who would have predicted that MSK would be the number one spend now that we’ve got cardiology under control a little bit, oncology under control a little bit, and diabetes under control a little bit.

All these combination of market dynamics and individual organizational perspectives need to be in a true workforce development that is nonprofit. APTA would be the place to house it. They have a willingness to do so and we have to get all these groups at the table collaborating on it.

We also have to encourage CAPTE to lighten up on this queue and to start approving programs. Until that happens, then we’re caught. Five or ten years out, we have a chance to really lighten the load of this shortage. We also have to have a deeper understanding of the impact of burnout and of the regulatory impact on physical therapists and what that does to our profession. People don’t go into physical therapy to do notes, to do compliance, to count eight-minute rules on Medicare, to worry about how many units and how many patients a day to produce. Those are all externalities.

We have to have a deeper understanding of that impact and it’s cause on attrition. There’s an estimation that 20,000 PTs have been on the sidelines since covid, but maybe some of them have come back. We also know that about 15% of PTs are part time by desire. They come into the profession wanting to work part time.

Absolutely nothing wrong with that, but we have to take in all those into account in order to really solve the problem. The symptoms are the shortage, but the reality is we have to take a holistic view, diagnose it, and game plan it correctly. 

Scott Rongo: It makes a ton of sense. I think we’re about out of time, but is there anything that you would want to leave our audience with before we put a close?

Larry Benz: Just the subtle message that, we have a tremendous profession. We want our best and brightest to go into it. We also have to have a holistic response to student debt, burnout, and shortages. Those are the top three priorities and it’s incumbent upon us as professionals, as PTs to help resolve those. 

Scott Rongo: We appreciate you joining us and you’re welcome anytime. 

Larry Benz: Thanks, Scott, for the opportunity to get this conversation moving and get a top of mind for our profession.

Scott Rongo: Absolutely. Thank you to the audience for tuning into the therapy matters podcast, your one stop resource for expert insights and advice on everything therapy and rehab. Look forward to seeing you guys on the next episode. Thanks so much and have a great rest of the day. 


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