Have We Achieved Vision 2020?

A Review of APTA Vision 2020 and its Effects on PPS.

By Stephanie Weyrauch, PT, DPT

The Private Practice Section (PPS) has a history of being at the forefront of innovation and rapid change.

Given that the organization has traditionally hosted members who challenge the status quo, it has had fewer bureaucratic barriers relative to other components within American Physical Therapy Association (APTA). Our membership is filled with visionary leaders who have started companies, invented revolutionary health care delivery methods, and adapted quickly to the ever-changing environment of health care.

In 2000, the APTA House of Delegates approved a vision of what our profession would be like in 2020. Vision 2020¹ was summarized in one sentence:

“By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, activity limitations, participation restrictions, and environmental barriers related to movement, function, and health.”

There were six key elements that encompassed Vision 2020:

1. Autonomous practice
2. Direct access
3. Doctor of physical therapy
4. Evidenced-based practice
5. Practitioner of choice
6. Professionalism

When debate commenced on the floor of House of Delegates, there were few (if any) discussions of pandemics, stock market crashes, stark health care unemployment, and unity under the Black Lives Matter movement. A lot has changed since Vision 2020 was adopted. This article provides a commentary on Vision 2020 and its effects on PPS.

In his acceptance speech of the 2000 Dicus Award, Michael Weinpar, PT, DPT, MPH, stated, “Change, like gravity, cannot be avoided; it is going to happen in all aspects of our lives. So why do we often resist change? Perhaps because our level of comfort is in jeopardy. We like things to be predictable, but life just isn’t that way…the best way to predict the future is to create it.”² The health care industry continues to be erratic, requiring rapid change in private practice and physical therapy. So how successful has our profession and our Section been in accomplishing the goals of Vision 2020?

EDUCATION OF THE PHYSICAL THERAPIST

Vision 2020 predicted that physical therapists would be doctors of physical therapy and, possibly, board-certified specialists. As of 2020, all physical therapy training programs have transitioned to a doctoral degree. Additionally, APTA now offers nine specialty board certifications with another (wound management) slated to begin in 2022. However, this success has come at a cost. Student debt for people pursuing a career as a physical therapist has increased significantly with a mean debt-to-income ratio of 197%, with most total debt amounts ranging from $100,000 to $124,999. This high amount of debt has been a barrier for new graduates when considering their career trajectory.^3,4 Fewer graduates are opening private practices, or even choosing to work in a private practice. This phenomenon has resulted in a more homogenous workforce with high risk for burnout, decreased productivity, and reduced job satisfaction. In private practice, a healthy, productive workforce is essential in order to optimally serve our communities and give clients an excellent patient experience.

APTA is actively investigating ways to decrease student debt, and PPS is in a position to help guide new graduates through these uncertainties. First, PPS members and private practice owners need to continue advocating for student loan forgiveness and increased payment for services. Policymakers and insurance companies listen to collective groups bound together by a common purpose. We need to continue advocating to and educating the public, payers, and lawmakers about our profession and value to society. Second, when negotiating payer contracts, private practice owners and executives must know when to say no. We cannot accept low fees with private insurance contracts. It may be worth seeing fewer patients for more money, especially since high-volume patient loads are a source of decreased job satisfaction for private practice physical therapists. Private practice owners should consider volunteering to teach basic economic principles, supply/demand economics and the costs of doing business to their high school and college interns.

DIRECT ACCESS

Direct access was another foundational aspect of Vision 2020: Consumers will have direct access to physical therapists in all environments for patient/client management, prevention and wellness services. As of 2020, we have achieved some form of direct access in all 50 states, though this direct access for patients is not created equal. Only 40% of states have unlimited direct access as of June 2020. Three states have limited direct access, meaning a physician referral is required for patient evaluation and treatment. Twenty-seven states have direct access with provisions, meaning time or visit limits exist or a referral is needed for specific treatment interventions (e.g., needle EMG or spinal manipulation). Twenty states have unlimited direct access without restrictions or limitations, even if a referral is not provided.⁵

The fight for direct access to physical therapy has been a long, arduous process. Much of the advocacy in this area has been led by state-level components, though PPS has been a significant supporter of these efforts. PPS offers legislative grants to chapters to help fund lobbying efforts for full, unrestricted direct access and protection of state practice acts. The PPS Marketing and Public Relations Committee also provides monthly Marketing Toolkits to help inform consumers about direct access, as well as prevention and wellness services offered by their community private practice. As private practice owners and employees, we need to lead the expansion of stronger advocates in our home state. In states that have unrestricted direct access, insurance companies see physical therapy as a cost savings mechanism for a patient’s entry into the healthcare system. We need to continue to teach legislators about our profession, the benefits of our services and the cost savings we can provide to the state.

AUTONOMOUS PRACTICE AND PRACTITIONER OF CHOICE

Our goal of becoming practitioners of choice in patient/client health networks with all privileges of autonomous practice has not yet been achieved. Less than 10% of the population sees a physical therapist for their movement system problem. Payment by third party payers for physical therapy services continues to decline. Many states still restrict physical therapists from making a diagnosis. We still have work to do to become providers of choice.

APTA and PPS lobbying efforts have focused heavily on improving payment for services both at the governmental and private insurance levels. One recent victory was coverage of telehealth services provided by physical therapists during the COVID-19 pandemic. APTA’s #ChoosePT campaign and PPS’s social media materials have pushed hard to provide private practitioners with materials to market directly to the consumer. Most states currently do not limit patient access to wellness and preventative services provided by a physical therapist (third-party payments for these services is more problematic), representing an opportunity for the private practice owner. Partnering with local news media can help increase our reach and educate the community on the services we provide.

EVIDENCE-BASED PRACTICE AND PROFESSIONALISM

Over the past 20 years, the body of knowledge guiding physical therapist practice has grown exponentially (Figure 1). APTA and its components have invested heavily in expanding evidenced-based practice through development of CoSTAR, the Foundation for Physical Therapy Research, the Outcomes Registry, Clinical Practice Guidelines, and production of high-impact journals like Physical Therapy and Journal of Orthopaedic & Sports Physical Therapy. This has fostered lifelong learning in many of our colleagues, encouraging rejection of archaic methods of treatment in exchange for more effective treatments like exercise and manual therapy. However, there are improvements to be made. Confirmation bias, “guru practice,” and followership of “treatment fads” continue. Predatory journals have cropped up and threatened the integrity of science. Variation in practice quality persists.

We physical therapists must do better to critique our practice tendencies and be appropriately skeptical of the literature. We must support and encourage colleagues to attend professional conferences both inside and outside physical therapy. We should invest in high-quality continuing education courses. We must create a culture where employees are engaging in discussions with other health care professionals and are ambitious in community and professional involvement. Professionalism demands that we are altruistic, caring, respectful, and accountable. As of 2020, APTA is a cohort of 100,000 physical therapists, physical therapist assistants, and students, encompassing approximately 30% of this collective in the United States. I believe success in this professional domain will be met when a majority of physical therapists, physical therapist assistants, and students are members, and when we happily leave our silos and collaborate with our health care colleagues.

CONCLUSION

We have reached many of the goals set by Vision 2020. We are a doctoring profession with increasing clinical specialization, with some form of direct access in all U.S. states, and a growing evidence base. However, we fell short on other select aspects of Vision 2020 including being practitioners of choice with full autonomous practice. We must realize that some of our ideals have resulted in an underpaid workforce with unacceptably high student debt burden, and a homogenous workforce facing risk of job unsatisfaction. PPS will continue to be at the forefront of change, and over the coming 20 years we must continue to groom the next generation of leaders in private practice. The best way to predict the future is to create it. 

References:

¹American Physical Therapy Association. Vision 2020. https://www.apta.org/vision2020/

²Weinpar M. 2000 Robert G. Dicus Award Acceptance Speech. 2000. https://ppsapta.org/userfiles/File/Weinper%20Dicus%20Speech.pdf

³Ambler S. The Debt Burden of Entry-Level Physical Therapists. Phys Ther. 2020;100(4):591-599. https://academic.oup.com/ptj/article-abstract/100/4/591/5651322?redirectedFrom=fulltext

⁴Shields R, Dudley-Javoroski S. Physiotherapy education is a good financial investment, up to a certain levelof student debt: an inter-professional economic analysis. J Physiother. 2018;64:183-191. https://reader.elsevier.com/reader/sd/pii/S1836955318300596?token=6C9B5DF2FD948F94E70A86DA2E410E231AB4A3CF79A6175324EDA4AF62133D55DC9E54EE8372C93DC66D667DBE2FAC59

⁵American Physical Therapy Association. Levels of Patient Access to Physical Therapist Services in the US. https://www.apta.org/advocacy/issues/direct-access-advocacy/direct-access-by-state. Updated October 3, 2019.

Stephanie Weyrauch, DPT, is a physical therapist at Physical Therapy & Sports Medicine Centers in Orange, Connecticut. She is a member of the PPS Nominating Committee and can be reached at sweyrauchpt@gmail.com and on Twitter @TheSteph21.

Acknowledgement: The author would like to thank Michael Weinpar, PT, DPT, MPH, for his input on this article. Supplemental online material: An interview conducted by the author of 2000 Dicus Award winner Michael Weinpar. In this interview, Dr. Weinpar reflects on his predictions about Vision 2020 when he received the 2000 PPS Dicus Award.

Listen to the Vision 2020 podcast with Stephanie Weyrauch, DPT, and Michael Weinpar, PT, DPT, MPH, at podcast.healthywealthysmart.com/dr-michael-weinper/.