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One Year On

a pen positioned on top of an open calendar book

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.

References:

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 rhall@ppsapta.org.