I have been making #physicaltherapy predictions for a long time!  Here are the last three years: 2021, 2020 and 2019. Despite the pandemic, I think many of them were accurate, particularly COVID ones. On the other hand, I missed the mark on some (MIPS!!) and obviously we haven’t and might not hit “post pandemic.”

For 2021, here were my top #physicaltherapy predictions:

1. Physical therapy will become much more integrated with behavioral health.
2. Virtualization of #physicaltherapy visits as a replacement for hands-on numbers will continue to decline from Covid highs.
3. MIPS growth will be significant and become the outcome standard for a growing number of players including payors.
4. Direct to employer and self-insured care will continue to rise while value-based care will be at a stalemate.
5. After a sideways year in growth in 2020 for the obvious, the profession will grow by double digits in 2021.
6. PT schools will continue to expand in new programs, expanding programs, and multiple cohorts.

Also, I spoke with WebPT to outline similar predictions,

“The obstacles are not our patients; they have shown their consumption can change,” Benz says. “It’s us advocating, messaging, and highlighting the data and evidence that already exists. But we have to get our own companies all-in before we can convince others.”

You can view the full article here.

Here are my predictions for 2022:

1. PT Schools will have a declining application pool and test failure and dropout rates will be at all-time highs.

Call it the #physicaltherapy version of the Great Resignation, we cannot ignore the data on “burnout rate”, departures from the profession, labor shortage, and education during this pandemic, particularly the first several months when schools were remote only. Our PT shortage is at all-time levels relative to PT openings, and it did not help that the American Physical Therapy Association (APTA) has yet to retract its misguided workforce development plan from 2020, which estimated that by 2030 we would be over 25k surplus! (Please note, APTA’s work on this using BLS, and other data is normally good.) It also did not help that in May 2021, The American Council of Academic Physical Therapy (ACAPT) urged changing the landscape of physical therapy education before adding new programs or expanding others. But don’t worry, several of us challenged all of this with data and real-time market conditions – traditionally not explored by academics within ACAPT. Before we start blasting PT programs, let’s look in the mirror a bit and note that clinical education, the long term “black hole” of PT education, got far worse with more clinic staffing shortages caused by pandemic furloughs and layoffs while being tasked to educate students who had not spent any time in a clinical lab or classroom in weeks. The students had to pick up the burden and were understandably underprepared.  Their education suffered along with their ability to pass the exam which frankly is a pretty low level barrier when one takes the perspective that it simply means they are “safe”. On the academic side, many instructors were still bragging they would never, ever, ever “over their dead body” teach an online class when they finally realized they would be unemployed and then were enlightened by those early adopters of blended education. Yes, old dogs had to learn new tricks as they went through the instructional design learning curve familiarizing themselves with modern-day education technology. Let’s not let the “declining application pool” confuse you into thinking we have too many PT programs because we don’t. The adequate application pool is a very hard judgment to make – we are coming from very high numbers and the central application process has continued to be modified, thus allowing applicants to apply to as many or as few programs as possible, creating an illusion. There are still tons of talented students who want to impact lives and become physical therapists which is a good thing. Given that the musculoskeletal (MSK) spend is over $300B and PT is roughly 8-10% of it, we can’t expand unless we have more therapists. The obstacles, student debt, wages not in lockstep with tuition, and other ills of higher education combined with the pandemic effect of high burnout rates amongst healthcare workers, are genuine challenges for our profession and we need to address them thoughtfully and soon.

2. PT shortages hit record levels in all settings causing hospitals to move to institutional credentialing and legislators to bring the wrong legislative changes.

Alluded to in #1, the shortages in health care are well documented with lots of correlations being attributed as causality. Professionals in nursing, physician, mental health, home care providers, and physical therapy are all being pointed at as lacking. This impacts everything from where care is performed (ex: home market shortages will decrease home care). But who can provide care through extended licensure or institutionalized credentialing? Virtual health is seen as a panacea because it can scale, but it can’t without providers. All those behavioral health apps out there? See if any of them have a licensed or real qualified therapist vs. an online “health coaching”credentialing course. In the #physicaltherapy world, a good percent of PTs who were furloughed or let go, haven’t come back and many will not. Burnout (the continued word of 2022 for health care) is dominant as we get the combined effects of more regulations (including masks and testing), declining reimbursement, “death by a thousand clicks” (which for PTs in Medicare means 25% of your time you are trying to comply with the nonsensical documentation requirements) wreak their toll on therapists. Expect to see settings like Acute Care, go back to paraprofessionals or institutionally trained technicians for interventions like gait training and range of motion amongst others that are traditionally off limits to anybody but licensed PTs. At the same time, this truly is an opportunity for PTs to become the first choice in all things MSK through physician and mid-level practitioner shortages and the best timing to convince Medicare to pay and promote for PT direct access. Expect to see legislators debating increasing numbers of nursing programs, increasing the numbers of allowed students, and other expansions in health care despite those not really being the root of the problem! It’s not the lack of providers – it’s the system that drives providers away.

3. Direct to consumer (DTC) marketing in physical therapy increases drastically.

Why? It works. Some estimates show patients accessing physical therapy directly has doubled during COVID, as our population has become more sensitive to technology uses (Uber, DoorDash, Open Table) and is now expecting the same in healthcare. Google didn’t become Alphabet, Facebook-Meta, Bezos-Bezos without the science of digital advertising and direct-to-consumer messaging. This trend occurs despite any ability to handle direct access caused by shortages even though health care is not generally thought of by consumers as a supply/demand issue (it is!). I will once again use this platform to encourage APTA and/or Private Practice Section (PPS) to create a Foundation around #physicaltherapy messaging utilizing experts. Left to our own devices, we can only cloud and hurt the right approach to branding and messaging.

4. There will be continued emphasis on replacement and displacement of physical therapy by digital solutions.

Digital healthcare was the rage in funding and valuations in 2021 with many valuations having greater than or greater than the combined valuations of several large public and private physical therapy companies, yet they have no revenue! These technology companies (not healthcare companies) are of the narrow mindset that patients comply with digital exercise programs and that PTs don’t do anything other than prescribe them. Many have convinced self-insureds to pilot and offer as an incentive by not charging copays vs the “in clinic” model. Anecdotal evidence suggests they are already failing but that doesn’t mean they won’t be popular. (It was Howard Cosell that coined “what is true isn’t always popular, and what is popular isn’t always true.”)  The good news in all of this though is that any news for physical therapy with self-insureds to decrease cost, access physical therapy and get a better outcome is good news for our profession. Like our academic counterparts, who swore “over my dead body” (see above), PT’s are doing the same yet migration to more hybrid or blended physical therapy is the reality-long term and most of these purely digital solutions will go the way of myspace and the PPM’s of the 1990s.

5. VR gains traction in health care but so does evolving technology.

There is already tremendous movement afloat ranging from fall/balance, chronic pain, and mental health but that only touches the surface of the issues. VR can be effectively used for education (conferences), simulation (surgery is just one example), and patient experiences-like teaching us about the challenges of the elderly. We have seen in our own company, tremendous traction of it for patient neuroscience education (PNE) with BehaVR (full disclosure, we are a strategic partner) and the bigger area of movement is just starting. VR is starting to scale with more functional and affordable units, and we are in an early stage. I can see its use expanding dramatically for home use and monitoring activities. It’s also great to see a device that the elderly can do with their great grandchildren and for once, kids are moving in play again rather than idly sitting with computer games (these movement games will flourish). I also expect to see the AirPods play a role in healthcare as Apple admits it is putting cameras in them and future generations just might help us with fall/balance and uses in early detection.

6. Direct to employer via self-insured gains traction for physical therapy.

The facts are the facts – 70% or more of U.S. employers are self-insured. Their number one health spend is MSK when you factor group health, disability, and worker’s compensation together. It is its own pandemic that the best and brightest employers are tackling using physical therapists. We already have plenty enough data and evidence of the role of PT First pathway of care and the examination skills of a physical therapist, yet new data continues to emerge (PPS national conference) showing dramatic savings in using #physicaltherapy. This trend has strong network effects, the more self-insured using PT and sharing results, the more that want to participate. This trend will grow in 2022.

Other predictions:

• Chronic pain/opioid dependency continues to grow in numbers-PT is finally recognized as a “player” due to our ability to integrate cognitive, calming, and movement to a population that needs all 3
• Larger PT groups get larger, smaller get smaller for a bunch of reasons to including low barriers to entry, financing, and scale. We are still a fragmented profession but in outpatient, become less so.
• Hospitals will grow in their outsourcing of physical therapy for a bunch of reasons. They can’t hide losses of provider-based reimbursement any longer, have difficulty managing staff shortages, and tired of trying to convince PTs that more than 6 visits per is unethical. One major Catholic system even invested in physical therapy management company via their own private equity mechanism
• Reimbursement will continue to drive practice more than evidence-as the adage goes “the more things change, the more they stay the same”, reimbursement for physical therapy is horrible. This means simply that the number 1 variability in patient visits per PT is where you live (sorry NY and CA).
• Value-based conversations will begin with some increased activity in physical therapy as the pause taken on during COVID begins to end (providers were not willing to take on additional risks when they are getting battered).

Thoughts? What are your predictions?

Happy New Year to friends and colleagues.  To a successful, healthy, #physicaltherapy year

@physicaltherapy