Then and Now in #PhysicalTherapy—Many Differences Except the Grievances

Reflections Post Private Practice Section Meeting 2024 National Harbor, MD

Just wrapped up the 2024 Private Practice Section (PPS) Meeting at National Harbor—and believe it or not, that was my 32nd! Time flies when you’re having fun (and attending endless seminars). Reflecting on how things have changed since circa 1989, here are some of the more salient differences. Spoiler alert: the grievances, surprisingly, are still holding steady.

**Conference Participation: From All-Inclusive to Option Overload**

Back in the day, conference attendees were all in this together—no picky options, just one-track minds soaking up every bit of information. Fast forward to today, and we’re drowning in lecture and content choices. It’s like being at an all-you-can-eat buffet but deciding to starve because there are too many options. Sparse attendance at some talks? Blame it on the paradox of choice—too many options can sometimes mean you you do nothing.

**Equipment Evolution: From Modality Mania to Tech Takeover**

Remember when the exhibits were dominated by modalities and isokinetic machines? Those were the days! Fast forward to this year, and good luck finding either. Instead, the exhibits are a tech playground, dominated by AI and practice management systems. It’s like we traded our trusty treadmills for the latest smartphone—useful, but not exactly the same workout.

**Content: From How to get more patients to ……..**

Back in the day, everybody was trying to get an edge on getting more patients for their therapists who seldom left their employers. Lectures included writing a press release, creating collaterals, hiring a marketer, and aggressive techniques seen in multilevel marketing. In 2024, there are no complaints about the current volume by practices but about how to keep staff to service them.

**The Big Party: From Legendary Chattanooga to Experiential Extravaganzas**

The big party back then was the legendary Chattanooga bash—memorable and singular. Today, parties are more experiential and scattered across numerous events, mostly hosted by practice management companies. They’re tremendous, sure, but they now speak more to the investment thesis around recurrent revenue versus cash flow. Who knew networking could become so… subsidized?

**Miscellaneous Changes: From Buttoned-Up to Casual and Connected**

PPS used to be a buttoned-up affair, with casual attire dominating today. Gone are the days of holding onto a voluminous tote bag (remember those?)—now it’s all about the smartphones and QR codes. Wifi wasn’t even a thing back then, and the only lines you had were for payphones. Try finding one today, and good luck!

**Private Practice Ownership: From Clinicians to Corporate Behemoths**

Most PPS owners in the late '80s maintained some sense of clinical practice. Fast forward to today, and that’s a rarity. Back then, PPS budgets were paltry and constantly challenged. Today? They’re well-stabilized with high reserves. It’s like the difference between riding a rusty bike and cruising in a brand-new car, PPS is a stalwart in private practice physical therapy management.

**Fragmentation and Consolidation: From Dozens of Independents to Mild Consolidation**

In the '90s, there was a clear divide between "corporates" and "independents" in private practice. The profession was incredibly fragmented, with more than a dozen public companies owning physical therapy practices. Private equity-backed companies? Nonexistent. POPTS (physician-owned private practices) were shunned and rarely attended PPS. Today, while fragmentation remains, more PTs are working for larger companies, and there’s mild consolidation. Plus, there are many more locations and PTs overall. It’s like the Wild West of the '90s versus the slightly organized chaos of today.

**Collaboration: From Solo Acts to Peer Power**

Collaboration in the profession was minimal back then. I was lucky enough to be part of a peer group of like-minded practices called PTEC (Physical Therapy Exec Committee). We’d meet before PPS and several times a year. Thankfully, things are much better now, with tons of PPS-organized peer-to-peer groups enhancing the entire profession. It’s like going from solitary camping to joining a well-organized hiking club.

**Clinical Practice: From Wild West Techniques to Evidence-Based Excellence**

Clinical practice was all over the map—reimbursement favored modalities and was pretty much unrestricted in units and visits. Continuing education revolved around gurus who claimed to move craniums, manipulate fascia unrelated to the area of pain, and use reflect hammers to hit people in the jaw as some sort of reflex treatment miracle. Enter the Centers for Medicare and Medicaid Services (CMS), who, years later, would refer to physical therapy as a "black hole." Thankfully, today we have research, evidence-based practice, residencies, and fellowships leading the way. However, we’re now battling tremendous restrictions in units, visits, and superimposed rules that contribute to burnout and exits from the profession. It’s a double-edged sword—better practices but tighter reins and a huge productivity loss.

While these differences are vast, some things remain the same—like the fun of the conferences and the common gripes. The Dicus Award presentation, then and now, is still a highlight. Big shoutout to Karen Litzy this year—well-deserved! One of the most impressive things about the 2024 PPS was the board presentation at the annual meeting. We’re fortunate to have a volunteer board and executive team dedicated to advancing our practice—kudos to all of them.

**Common Grievances: Then and Now**

Despite all the changes, some things never change—like the gripes. In the late '80s and early '90s, the complaints were shortages, reimbursement issues, and Medicare headaches. Fast forward to today, and it's the same old song and dance. As the French writer Jean-Baptiste Alphonse Karr once said, "the more things change, the more they stay the same." Medicare grievances have evolved from lacking reimbursement for evaluations to now dealing with reimbursement restrictions, arbitrary financial limitations, visit caps, and the infamous "8-minute rule" (not to be confused with the rule of 8s).

**Why Overmanage a Small Slice?**

Then and now, physical therapy is a very small component of Medicare—currently absorbing about **1.44%** of total expenditures. The real question is, why are they absolutely overburdening our profession? According to CMS, outpatient PT expenditures have skyrocketed from approximately $1.2 billion in the early '90s to a whopping $14.4 billion in 2023. With Medicare enrollees doubling from 35 million in 1990 to an estimated 70 million in 2024, and the population aged 65 (who have the most physical therapy needs) and over doubling as well, a 0.44% increase in spending isn’t much. Yet, CMS continues to view physical therapy in a silo, focusing on overmanagement rather than considering how increased PT utilization could actually reduce overall costs. We remain a service to be cut rather than a profession to be managed wisely.

### **Final Thoughts: Optimism Amidst Grievances**

One last commonality—after every PPS meeting, I leave feeling more optimistic about our future and the tremendous opportunities we have. Despite the gripes, the sense of renewal and gratitude for the profession keeps us moving forward. Here’s to continuing to navigate the changes, manage the gripes, and celebrate the wins together!

Thoughts?

@physicaltherapy

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*Disclaimer: The numbers and percentages mentioned here are based on data available up to October 2023. For the most current and detailed information, please refer to official Medicare reports and resources from the Centers for Medicare & Medicaid Services (CMS).*