One Year On
By Robert Hall, JD, MPAff
As Americans prepare for 4th of July celebrations, many without masks now that they are vaccinated, it seems appropriate to look back on the impact of the pandemic on physical therapy patients and physical therapy practices.
There have been huge shifts in patient health and physical therapy practice over the last year, and nothing but more change is on the horizon.
First, patients. When one steps back and looks at the enormity of mortality and morbidity that the pandemic created, it’s hard to avoid emotion and analyze its impact objectively. More than half a million Americans are dead. A recent National Academies of Sciences research paper also shows that the total reported death toll from COVID-19 actually undercounts mortality.1 That’s because it does not take into account factors indirectly associated with the pandemic, including people who died because they delayed care. Even when they survive the disease, those with post-acute sequelae of SARS-CoV-2 infections (PASC) have life-altering health impacts, oftentimes in surprising ways. For instance, one study showed that a third of patients diagnosed with the coronavirus had also experienced a psychiatric or neurological illness as of six months later.2 Mood disorders like anxiety and depression were especially common, but researchers also found increased rates of serious complications like strokes and dementia. And the common morbidities related to COVID-19 infection should also not be ignored. According to the Harvard Health Letter, “the most common symptoms are fatigue, body aches, shortness of breath, difficulty concentrating, inability to exercise, headache, and difficulty sleeping. And since COVID-19 is a new disease that first appeared in December 2019, we have no information on long-term recovery rates.”3 An Italian study showed that a host of other symptoms persist for 50% to 80% of those post-COVID infection.4
Americans also saw their weight fluctuate during the lock down. One American Psychological Association poll reported that the for 43% of those who reported gaining weight, the average gain was 29 pounds, with 10% reporting a gain of 50 pounds or more.5 And while some lost weight during the period (18% lost more weight than they wanted), those losses were less extreme. Americans drank more too, with 1 in 4 Americans reporting they drank more during the pandemic to cope with its stress.
There are surprising and/or conflicting reports about other impacts of the pandemic on patient health. As roads were less filled with traffic due to the lockdowns, car crash deaths actually increased during certain quarters of 2020,6 while at least one preliminary study in Massachusetts suggested that adult suicides decreased during the pandemic. This is very different for the pediatric population.7
Even before the pandemic, the health issues that harm or kill children and young adults are fundamentally different than for older Americans. For older adults up to and including age 65, the top two causes of mortality in 2018 shift between cancer and heart disease. From ages 10 to 24, the top two causes of death in 2018 were unintentional injury and suicide. This makes the mental health challenge for younger Americans caused by the pandemic and lockdown most concerning. A national poll shows that 46% of parents say their teen had shown signs of a new or worsening mental health condition since the beginning of the pandemic in March 2020.8 And data from the Children’s Hospital Association showed that emergency room visits for adolescents who had attempted suicide, had suicidal ideation, or unmanaged neurodevelopmental disorders increased by 20%.9 Pediatric behavioral health inpatient discharges increased by 40% from the prior year.9 You know the impact the pandemic has had on you and your practice. For the whole country, though, an American Medical Association poll of physical therapy and other provider practices reported an average 34% decrease in physical therapy practice spending by Medicare. Physical therapy practices were hit harder than any other surveyed group, as the average drop in revenue for physician practices was 32%, with significant variation depending on specialty. Telehealth use also exploded for physical therapy and other provider practices, with the survey showing that while prior to COVID-19, the typical week pre-pandemic saw 20% of providers using telehealth, 77% of providers were using telehealth at the height of the pandemic. Expenses on PPE were also significant, with fully one quarter of all health care practices increasing their expenditures by 75% on PPE.
Physical therapy is big business in the United States, with nearly $34 billion spent on physical therapy services in 2021 according to IBISWorld.10 Even with the significant impacts of the pandemic in 2020, the same group projects that there will be a growth in the physical therapy market of 2.3%, pushing against the trend over the last five years combined that saw a 0.8% decrease in the US annualized market growth for physical therapy. This will also be driven by modest growth in the number of physical therapist businesses, which currently stands at almost 120,000. On a national scale, because our population of elderly, overweight and obese is increasing, demand for physical therapy services will continue to expand, and it may be difficult for the current number of physical therapists to care for these populations.
Medicare cuts have highlighted the need for diverse revenue streams for the average physical therapy practice. Other trends also slashed revenue streams during the pandemic, including widespread delays in elective surgeries hitting physical therapy practices that support a high volume of post-operative patients very hard. The good news is that many of those delays will be addressed in 2021. According to Medrisk’s COO Mary O’ Donoghue, “Researchers predicted it would take about 45 weeks to catch up with a backlog of surgeries and other medical procedures postponed because of COVID.”11
So, what does all this mean? For one thing, it should be an encouragement to advocate with payers and government at all levels to help address the aftermath of the pandemic on your patients and your practice. PPS has resources to help you thrive post-COVID-19, including new materials and a recording of a well-attended webinar on succeeding with utilization management and insurance coverage denials. These materials are available at ppsapta.org/practice-management/payment-resources/. Additionally, please get involved in advocacy with your federal government. My colleagues working with the Governmental Affairs Committee have produced an excellent list of priorities for the 117th Congress available at ppsapta.org/advocacy/legislative-priorities.cfm.
I urge you to recommit to your advocacy journey and educate leaders in your community that physical therapy can help with a host of conditions–mental health, overweight and obesity, and even addressing the needs of COVID-19 survivors with PASC. We as a country are just starting to get past the pandemic. Physical therapists will play a critical part in helping us get healthy again.
1Stoto MA, Wynia MK. Assessing Morbidity and Mortality Associated with the COVID-19 Pandemic. In: A Framework for Assessing Mortality and Morbidity After Large-Scale Disasters. Washington, DC: National Academies Press; 2020.
2Taquet M, Geddes JR, Hausain M, Luciano S, Harrison PJ. 6-month neurological and psychiatric outcomes in 236 379 survivors of COVID-19: a retrospective cohort study using electronic health records. Lancet. 2021;8(5):P416-427.
3Komaroff A. The tragedy of long COVID. Harvard Health Blog. https://www.health.harvard.edu/blog/the-tragedy-of-the-post-covid-long-haulers-2020101521173. Published October 15, 2020.
4Carfì A, Bernabei R, Landi F; Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020 Aug 11;324(6):603-605. doi: 10.1001/jama.2020.12603. PMID: 32644129; PMCID: PMC7349096.
5American Psychological Association. One year on: Unhealthy weight gains, increased drinking reported by Americans coping with pandemic stress. https://www.apa.org/news/press/releases/2021/03/one-year-pandemic-stress. Published March 11, 2021.
6Associated Press. Risky driving: US traffic deaths up despite virus lockdowns. https://apnews.com/article/pandemics-health-traffic-coronavirus-pandemic-799e455b73902b1638cc2ac46a172972. Published January 13, 2021.
7Faust JS, Shah SB, Du C, Li S, Lin Z, Krumholz HM. Suicide Deaths During the COVID-19 Stay-at-Home Advisory in Massachusetts, March to May 2020. JAMA Netw Open. 2021;4(1):e2034273. doi:10.1001/jamanetworkopen.2020.34273
8Mostafavi B. National Poll: Pandemic Negatively Impacted Teens’ Mental Health. Michigan Health. https://healthblog.uofmhealth.org/childrens-health/national-poll-pandemic-negatively-impacted-teens-mental-health. Published March 15, 2021.
9Ray G. Mental and Behavioral Health in Children: A Crisis Made Worse by the Pandemic. Children’s Hospital Association. https://www.childrenshospitals.org/Newsroom/Press-Releases/2021/Mental-and-Behavioral-Health-Crisis-in-Children. Published February 24, 2021.
10IBIS World. Physical Therapists in the US – Number of Businesses 2001–2026. https://www.ibisworld.com/industry-statistics/number-of-businesses/physical-therapists-united-states/. Published November 2, 2020.
11Smith R. COVID-19 delays PT for many injured workers – report. Insurance Business America. https://www.insurancebusinessmag.com/us/news/workers-comp/covid19-delays-pt-for-many-injured-workers–report-241521.aspx. Published December 9, 2020.
Robert Hall, JD, MPAff, is a senior consultant for PPS working to advocate with private payers. He may be reached at firstname.lastname@example.org.