American Physical Therapy Association environmental statement.

Foreword 

As part of its efforts to develop strategic plans to deal effectively with the future, the American Physical Therapy Association (APTA) has undertaken an assessment of the environment in which the physical therapy profession and the Association will operate during the first half of this decade.

An Ad Hoc Strategic Planning Task Force was commissioned by the APTA Board of Directors to undertake a review of the current environment and to project trends and/or changes that may affect the profession and the Association. The 14-member panel comprised representatives of the physical therapy profession, health care, higher education, and public policy.

This environmental assessment reflects the discussions and deliberations of the Task Force. The document will serve as a foundation for development by the Board of Directors of Association goals and objectives for the next 3 years.

Executive Summary

Since its origins, American society has undergone constant change stimulated by economic factors, technological advances, and the needs of the people. The 1990s will be a decade of continued evolution, extending to virtually all aspects of life. During this period, the Nation's health care system will face tremendous challenges. The ability of the health care sector - and the professions that provide care to our people - to change and meet these challenges will be essential to the advancement of the country.

The ability to change and evolve successfully is dependent on an understanding of the environment in which we exist; the factors that will affect change in this environment; and the opportunities, challenges, and threats presented by these factors. Thus, the concept of an environmental assessment has become an integral part of the strategic planning of many organizations and groups.

As part of its efforts to develop strategic plans to deal effectively with the future, the APTA has undertaken an assessment of the environment in which the physical therapy profession and the Association will operate in the coming decade. This effort was undertaken by a panel of 14 members representing the physical therapy profession, health care, higher education, and public policy. The work of the panel was aided by APTA staff members. The panel approached its task by organizing its work into the following six major areas, which were not ranked in priority order:

* The Economics of Health Care

* The Demographics of the American

Population

* Human Resources in Physical

Therapy

* The Physical Therapy Profession in

the Health Care Sector

* The Shaping of Public Policy

* The Role of the Association

The Economics of Health Care

Health care expenditures in the United States have escalated rapidly during the past several decades and are expected to reach $750 billion - or 12% of the gross national product (GNP) - in 1991. On its present course, the cost of health care could reach $1.5 trillion by the end of the decade. Despite these expenditures, an estimated 60 million Americans are uninsured or underinsured.

Slower growth in the Nation's economy, coupled with the need to control escalating health care costs, will reshape the financial structure of health care. Physical therapy, like all health professions, will be affected by the following economic trends:

* Health care expenditures for the

Nation will continue to increase;

however, there will be heightened

attention on reducing health care

costs. Business and industry, payers,

and the government will be active

participants in cost-containment efforts.

Attempts to reduce health care

costs will lead to a continuation of

the shift from inpatient to outpatient 

services.

* Managed-care programs will account

for a steadily increasing proportion

of health care coverage plans offered

by private and governmental

payers.

* Health care payers will put increasing

pressure on physical therapists

and other health care providers to

demonstrate effectiveness of care.

Effectiveness studies must be carefully

and appropriately designed

and implemented and must include

quality and cost perspectives.

* The financial structure of health

care will lead to further aggregation

of physical therapy providers. This

trend will encompass the acquisition

of smaller practices by larger

health care conglomerates and the

expansion of physical therapy involvement

in preferred provider

organizations (PPOs). Small practices

will continue to exist, provided

they are able to define and respond

to specific health care niches and

avoid head-on competition with

larger health care conglomerates.

* The economic advantage of prevention

will be a major incentive within

the health care system. Physical therapy

has a major opportunity in this

area; however, the profession must

be prepared to demonstrate the

overall effectiveness of its prevention

efforts.

* The health care industry, including

physical therapy, will benefit from

thorough evaluations of the components

of care delivery and associated

costs. The movement toward

the concept of "total quality management"

will enable the health

care industry to respond more effectively

to cost-containment mandates 

and competition.

* The focus on health care cost containment 

will enhance public and

legislative opposition to referralfor-profit

scenarios. Joint venture

opportunities within the health

care system may continue in cases

in which the effectiveness of such

approaches can be demonstrated.

This structure, however, is more

likely, to encompass economic

partnership and greater professional

parity among physical therapists

and physicians.

The Demographics of the

American Population

During the 1990s, the rate of growth of the US population will continue to decrease as a result of the decline in the overall birth rate. Concurrently, the American population is aging, with significant increases expected in the population over age 45 years. The number of persons over age 65 years will approach 35 million by the year 2000; the population over age 85 years will increase by more than 30%. During this period, economic expansion is expected to create up to 18 million new jobs. Coming at a time of decline in the number of young job seekers, this growth will put greater pressures on maintaining a healthy, well-functioning older work force. This challenge will be further complicated by shifts in the cultural and socioeconomic profile of the population. Minority populations will represent 30% of the population and will constitute a major portion of new entrants to the work force.

The physical therapy profession can make significant contributions toward enhancing the health and well being of the American population. The changing demographic profile, however, will present new challenges to the profession, as summarized below:

* The aging of the US population will

expand the need for preventive 

care, acute and long-term care, and

rehabilitative physical therapy care.

In addition, the more complicated

health characteristics of this population

will present new challenges to

physical therapy and other health

care professions.

* The increasing racial and cultural

diversity of the US population will

affect the health profile of the population,

as well as their needs for and

attitudes toward health care services.

* The continued growth of poverty

and the accompanying lack of adequate

health insurance coverage will

increase pressure to provide universal

access to health care services,

including physical therapy. The

number of children living in poverty

and/or without health care coverage,

and the need for these children

to enter the work force in the

future, will place greater demands

on pediatric physical therapy.

* The changing demographics of the

US population will result in a

greater complexity of health problems.

Physical therapists, like other

health care providers, will be faced

with patients with multiple health

problems and problems of greater

severity.

* Geographic migration among the

population may require redistribution 

of physical therapy services. In

addition, the distribution of the total

population and of various economic,

cultural, and age groups will

affect the funding of health-related

programs.

Human Resources in

Physical Therapy

Career opportunities in physical therapy will grow rapidly, far exceeding the growth in many other fields. Amid a work force that is growing only slightly, the profession will be faced with significant challenges. Failure to meet the needs of society will invite other segments of the health care system to develop alternative strategies for providing care. The challenges and opportunities that lie ahead include the following:

* To meet human resource needs,

physical therapy must actively recruit

minority students and members

of the work force who are

seeking mid-career changes. The

profession will face tremendous

competition from other health care

and scientific disciplines in recruiting

qualified personnel.

* Meeting society's needs for physical

therapy care will require the profession

to approach consensus on

models of physical therapy practice

that will result in more efficient and

effective use of physical therapists,

physical therapist assistants (PTAs),

and other support personnel. Collaboration 

within physical therapy

and with other segments of the

health care system will become of

even greater importance than it has

been.

* Retention will continue to be a

critical factor. The profession must

be prepared to deal with the

needs of a predominantly female

work force, including provision of

child care services and work

schedule flexibility.

* Personnel shortages will affect immigration 

policy, allowing more

foreign-trained physical therapists to

enter the country. Existing questions

related to recruiting, training, and

licensing of foreign-trained therapists

must be addressed as quickly

as possible.

* Problems in the educational system

will continue to escalate. Failure to

prepare secondary-school-aged children

adequately will affect the future

student pool for physical therapy.

The increasing costs of higher

education, including the resources

to expand educational programs,

could limit the ability to meet human

resource requirements. Finally,

the higher education system must

contend with continuing difficulties

in recruiting and retaining faculty.

The Physical Therapy Profession

in the Health Care Sector

The expected changes in the American health care system will offer tremendous challenge and opportunity, for the physical therapy profession. The evolution of health care will create change within all facets of the profession, including practice, research, and education. The next years will present the opportunity for the profession to attain a greater leadership role in our Nation's health care system.

The potential for growth of physical therapy resides, to a great extent, within the profession. The evolution of physical therapy to a role of leadership within health care first will require that the profession delineate its role in the health care spectrum. It then must face development of effective strategies to enhance the research and educational base of the profession and to reinforce involvement in health care policy and decision making. The major trends that will shape advancement in this area include the following:

* Physical therapy will continue to

gain public recognition. Enhancing

the image and perception of the

profession, however, first will require

that the profession develop a

strong self-image and a commitment

to becoming a leader in health care

delivery.

* Physical therapists must become

actively involved in peer review and

quality assessment. The health care

environment soon will mandate development

of practice guidelines 

and demonstration of effectiveness.

The profession must become proactive

in this area, thus enhancing its

professional status and providing a

base for dealing with reimbursement 

issues.

* Opportunities for research involvement

will increase and will be an

important aspect of advancement of

the profession. Although needs will

exist throughout the research spectrum,

physical therapy will face the

greatest opportunities in areas related

to outcome/effectiveness studies

and health services research.

Success in the research arena will

require thorough understanding of

the research process and establishment

of strong collaborative ties

with scientists in other disciplines.

* Higher education in general will

continue to face crises in funding

and public confidence. Concurrently,

the educational enterprise will undergo

major transitions, including

increased emphasis on problem solving,

decision analysis, and effective

learning behavior. Physical therapy

and its academic communities will

have an opportunity to assume a

major role in facilitating this educational

paradigm shift. This will require

a careful review of needs in

entry-level education, a focus on developing

more effective approaches

to education, and a willingness to

become involved in education policy

formulation.

* Physical therapy professional development

will become of increasing

importance. Professional development

will encompass not only acquisition

of new clinical knowledge

and skills, but also a strong focus on

enhanced nonclinical knowledge

and skills necessary to participate

and compete successfully in the

evolving health care system.

The Shaping of Public Policy

During the 1990s, the Nation will be challenged by sociopolitical issues that will grow from and shape our society. Economics and demographics will have enormous impact on our policy agendas. Changes in the health care system will be among the most difficult issues that we will face.

Public policy will continue to be shaped by individuals, groups, and the government. Effective management of those issues facing the Nation that will have direct and indirect implications for physical therapy will require organized and active efforts by and on behalf of the profession. The key issues that physical therapy will face will include the following:

* Health care reform will be a major

focus for the country and for the

health care system. The process of

reform in general will move slowly.

Cost-containment, coverage, and

reimbursement policies; the ethics 

of health care delivery systems; and

access to both health care and third-party

payment for services will be

major considerations in the development

of national policy.

* The Nation will face other important

sociopolitical issues, many of which

will have direct and/or indirect effects

on physical therapy, including

prevention, education, women's and

family issues, immigration issues,

and cultural diversity.

* The issue of the emotionally/behaviorally

impaired practitioner will

pose a challenge to the public and

the health care industry. Physical

therapy has an opportunity to assume

a leadership role in this issue

by developing responsive efforts to

deal with ethical concerns and rehabilitation 

programs.

* The participation of physical therapists

in the development of public

policy has been sporadic, at best.

The profession must recognize the

importance of this participation an

work to expand upon the foundation

it creates.

* Although the profession has been

involved in the shaping of public

policy related directly to physical

therapy, care, there has been less

involvement in other sociopolitical

issues. The profession and the Association

can play a major, proactive

role in the public policy arena by

carefully selecting focal issues most

closely related to physical therapy,

shaping policy positions consistent

with its professional orientation an

philosophy, and participating within

coalitions and as individuals.

* Expanded involvement in public

policy will enhance the image and

status of the profession and will

contribute to a more prominent

role for physical therapy. Failure to

become an active participant in the

policy arena may jeopardize not

only the growth but also the viability

of the profession.

The Role of the Association

The success and viability of virtually a organizations and groups will depend on careful definition of roles, resources, and strategies. The APTA has strengthened its position as a professional association and has an opportunity to continue this trend. As the profession further defines its role and position in the health care realm, however, the Association must also delineate its mission in serving the profession and functioning as an effective business organization. In shaping its future, the APTA will be faced with several challenges and opportunities:

* The Association will be the major

resource for effecting the growth

and increased status of the profession.

The successful evolution of

the profession, however, will require

the commitment and active

involvement of all members of the

physical therapy community. The

APTA must be prepared to effectively

communicate with and involve

its constituents.

* A lack of understanding of the role

and importance of the Association,

and of the value of membership,

among many practitioners will continue

to impede membership

growth. The importance of Association

membership and its relevance

to the future growth and status of

physical therapy must be conveyed

initially during educational preparation

and reinforced subsequently by

professional colleagues.

* The Association must respond to the

increasing cultural diversity in the

United States. The changing demographic

profile of the population

will affect the delivery of care as

well as the composition of the profession.

The Association must be

prepared to recruit minorities to the

profession and to encourage active

participation of minority therapists,

including involvement in leadership

roles.

* The Association will be presented

with opportunities to expand its

interaction and collaboration with

external groups. Many opportunity

will focus on sociopolitical issues

related indirectly to physical therapy

care. Efforts in this area, however,

will enhance the status and leadership

role of the profession and the

APTA. Further, such efforts can serve

as the foundation for enhancing

communication and collaboration

between physical therapy and other

health-related professions.

* Information and technology will

become increasingly important to

associations and to professions. The

Association has begun to integrate

technological advances into its operation

and to access and organize

information relevant to the profession.

The APTA can play a vital role

by continuing to access and organize

information into useful entities.

The emergence of technological

advances and concepts also will provide

the Association with an opportunity

to serve its members and the

profession by, identifying applicable

approaches.

* Society and the business sector will

continue to focus on quality management

and customer service. The

Association increasingly must integrate

these concepts into its structure

and management approach and

must be prepared to communicate

effectively about the issue of quality.

* All segments of health care will have

to reinforce the value of continued

learning and the need to support

problem-solving learning behaviors.

It will be important for the Association

to integrate these values into its

structure and programs.

An Opportunity for the Future

The 1990s will mark a decade of significant change within the Nation. The characteristics of our people - and of their needs - will shift. Our economic base will be modified to accommodate the needs of the country and the world. This period also will witness reshaping of our health care system.

Although change often brings moments of apparent chaos, it also brings great opportunity. The future of physical therapy might be characterized by this dichotomy. The physical therapy profession historically has dealt effectively with change. It has responded to challenge. There is every reason to believe that the profession will meet the challenges and opportunities of the future with courage and strength.

In the development of this environmental assessment, four major themes emerged:

* The profession must define "physical

therapy" more clearly for itself

and for the public.

* The profession will be responsible

for shaping its future. Physical therapy

must begin to determine its

role within a changing health care

system by understanding the needs

of our society and the complexities

of the system in which it exists.

* The profession must have confidence

in itself and its ability to meet

the challenges that lie ahead. It must

utilize effectively all the resources

available to it and must proceed as

a unified discipline.

* The profession must be willing and

prepared to pursue a role of leadership

in the health care system and

in our society. Physical therapy has

been built on a tradition of concern

and advocacy, for the public it

serves. It is gaining in status among

other professions. It must now be

willing to be proactive and bold, to

assume a leadership role, and to

take on the responsibilities associated

with leadership.

The Economics of

Health Care

In 1990, the United States entered a recessionary period. A variety of factors have contributed to economic decline, including escalating levels of governmental, corporate, and consumer debt. Although there is extensive debate about the severity and length of recession, it appears likely that economic growth in the coming decade will be relatively slow.

Health Financing - An Industry

in Crisis

Health care is the largest industry, in the United States; the country devotes more of its GNP to health than does any other nation in the world. For the past 30 years, health care expenditures have increased nearly three times faster than has the rate of inflation. In 1986, this Nation spent approximately $460 billion on health care. By 1989, the level had risen to $604 billion. Expenditures are expected to approach $750 billion in 1991, representing 12% of the GNP.[1.2] On its present course, the cost of health care could reach $1.5 trillion by the year 2000.[2] Despite these expenditures, an estimated 37 million Americans are uninsured and another 23 million are underinsured; 90% of the population lacks long-term care coverage (Health Insurance Association of America, unpublished communication).

The 1990s will represent a period of increased challenge to the availability of health care dollars. Competition for federal funds among health and social programs, defense, and international programs will heighten. In addition, health care will face a serious dichotomy: As the costs of new technology continue to drive up health care costs and the health care needs of society increase, the health care system will be faced with developing strategies to enhance access among the uninsured and underinsured. These issues will escalate amid efforts to contain health care spending.

A Changing Profile of Health

Care Coverage

Approximately 85% of the population has some form of health insurance coverage. It is estimated that 50% of the costs for physical therapy services are reimbursed through private insurers. The private health insurance sector is extremely complex and diverse: the nearly 2,000 private health insurers in the United States are regulated by 52 different state jurisdictions, and an additional half million self-administered employer health plans administer 1 million different insurance policies. The latter plans are not state regulated and have only nominal federal regulation.

During the 1980s, efforts to contain health care costs led to the rapid growth of prepaid health plans (health maintenance organizations [HMOs] and PPOs) and managed fee-for-service plans. By 1989, 59% of individuals with employer-sponsored health care insurance were enrolled in managed-care programs. Managed care will continue to grow throughout the 1990s as the influence of business and industry, on health policy increases, the trend toward self-insurance grows, and payers increase efforts to contain health care expenditures. The managed-care focus will include a consolidation of traditional HMO programs; expansion of openended HMOs (point-of-service programs that allow use of services outside the HMO network on an indemnity, basis); increased use of PPO programs; and introduction of new managed-care products, networks, and administrators.

Increasing interest in managed-care programs extends to public payers. The Health Care Financing Administration (HCFA), together with several state government agencies, is seeking to expand and improve Medicare and Medicaid coverage through managed-care programs.

In addition to increased emphasis on the managed-care approach, the move to control health care expenditures will shift the delivery of care from the inpatient to the outpatient setting and will be accompanied by more stringent pricing of and limitations on these services. These cost-containment procedures will affect all segments of the health care industry. For physical therapy, this may lead to even greater limitations on the type, frequency, and duration of services; the personnel involved in care delivery; and the total reimbursable costs for services. A vulnerable area for cuts in physical therapy coverage is likely to be workers' compensation and automobile accident medical insurers because of the profession's strong role in treating patients with industrial and automobile injuries. Physical therapy can respond to impending challenges to reimbursement and coverage by carefully undertaking well-designed effectiveness studies. Effectiveness research must be designed to provide adequate statistical significance and to address both quality and cost perspectives.

Cost containment within health care will lead to greater competition among care providers. Cost constraints in several medical services have already led many physicians to diversify into the rehabilitation area. Physicians also have sought financial interests in physical therapy practices. Growing public and legislative opposition to the latter referral-for-profit scenario is likely to lead to restrictions on physician investment in other health care services. New issues. however, may arise regarding joint venture practice arrangements and employment situations among physicians, physical therapists, and other health care personnel when such arrangements can improve the effectiveness of care delivery,

The focus on cost containment provides a strong incentive to examine critically the elements that affect the pricing of health care services. Careful assessment of what services are provided, how, they are provided, and the overhead costs associated with care delivery can provide a strong base for eliminating unnecessary bureaucracy, and cost and improving the effectiveness of service. The concept of "quality management," which has been emphasized recently within the industrial sector, will be of increasing importance to the health care industry.

The Economy of Prevention

Efforts to control health care costs will lead to a stronger focus on the economic advantages of prevention, The emphasis on prevention will extend to virtually, all facets of life. Most relevant to physical therapy will be the greatly expanded focus on physical activity and the prevention of primary and secondary disabilities. An estimated 40 million Americans live with some form of disability. Total direct costs, including health care expenditures, loss of productivity in the work force, and loss of wage-earning ability among other household members, are estimated at 6.5% of the GNP.[3] Increases in the number of individuals with disability and the economic impact of this health problem will increase if appropriate prevention and rehabilitation programs are not introduced. With the aging of the population, the proportion of people at risk for disability will continue to climb. In addition, there has been a dramatic increase in the prevalence of severe disability among persons between the ages of 18 and 45 years, with a 178% climb during the period of 1959 to 1984.[4]

Many. primary and secondary disabilities are preventable. Although there are no accurate estimates of the total cost savings that might be seen with such preventive measures, they are likely, to approach tens of billions of dollars. For example, an estimated 5.2 million Americans are disabled by low back pain; half of these individuals are chronically disabled. Low back pain is the most common cause of disability, among the population under age 45 years and the third most important cause in the population over 45 years of age. The majority of back injuries are job related among the working population. In 1986, the annual cost of compensable back pain was estimated at $11.6 billion.[5]

Business and industry will continue to focus on prevention as a means of reducing health care costs and increasing worker retention and productivity. Physical therapy can play a critical role in demonstrating the effectiveness of prevention programs.

The Economic Future

The Nation's economic profile in the 1990s, coupled with strong interests to control rapidly escalating health care costs, will reshape the financial structure of health care and physical therapy. Major economic trends facing physical therapy will include the following:

* Health care expenditures for the

Nation will continue to increase,

accompanied by heightened attention

to reducing health care costs.

Business and industry, payers, and

the government will be active participants

in cost-containment efforts.

Attempts to reduce health care costs

will lead to a continuation of the

shift from inpatient to outpatient

services.

* Managed-care programs will account

for a steadily increasing proportion

of health care coverage plans offered

by private and governmental

payers.

* Health care payers will put increasing

pressure on health care providers

to demonstrate effectiveness of

care. Effectiveness studies must be

carefully, and appropriately designed

and implemented and must include

quality and cost perspectives.

* The financial structure of health

care will lead to further aggregation

of physical therapy providers. This

trend will encompass the acquisition

of smaller practices by larger

health care conglomerates and the

expanded involvement of physical

therapy in PPOs. Small practices will

continue to exist, provided they are

able to define and respond to specific

health care niches and avoid

head-on competition with larger

health care conglomerates.

* The economic advantages provided

by prevention will be a major incentive

within the health care system.

Although physical therapy has a major

opportunity in this area, the profession

must be prepared to demonstrate

the overall effectiveness of its

prevention efforts.

* The health care industry, including

physical therapy, will benefit from

thorough evaluations of the components

of care delivery and associated

costs. The movement toward

the concept of "total quality management"

will enable the health

care industry to respond more effectively

to cost-containment mandates

and competition.

* The focus on health care cost containment

will enhance public and

legislative opposition to referral-for-profit

scenarios. Joint-venture opportunities

within the health care

system may continue in cases in

which the effectiveness of such approaches

can be demonstrated. Elements

in the environment, however,

suggest an increased possibility that

greater professional parity among

physical therapists and physicians

will emerge.

The Demographics of the

American Population

Since the 1960s, the rate of growth of the US population has declined steadily from 14% to approximately 10% in the 1980s. By the end of this decade, the rate of growth is expected to fall to approximately 7%.[6] Although the American population will expand more slowly, its demographic characteristics will undergo significant changes in terms of age, cultural diversity, economic status, and geographic distribution.

The evolution of physical therapy reflects a profession that has responded to the health care needs of the populations it serves. In looking toward the future, the profession, and the health care system in general, will be faced with new challenges resulting from the changing profile of the American population. These changes will affect the health status, care needs, and distribution of health services, as well as the future "pool" of health care providers,

Aging of the Population

As the rate of population growth continues to decline, due in large part to a drop in the birth rate, there will be dramatic shifts in the age distribution of the population. The American pollulation is aging. During the 1990s, the "baby boom" generation, nearly 76 million strong, will approach and enter middle age. By, the end of this decade, the number of individuals between the ages of 45 and 54 years will increase by 45%. At the same time, individuals who are 65 years of age or older will number 35 to 40 million. The number of persons over the age of 75 years will increase by more than 33%, to more than 17 million; the number over 85 years of age will increase by more than 30%, approaching 5 million. The increasing numbers of middle-aged and older Americans are not expected to be offset by growth in younger age groups. The number of children under the age of 5 years is expected to decline from 18 million to less than 17 million by the year 2000; a decline of approximately 10% is projected among individuals between 15 and 29 years of age.6 The aging of the US population will cause a shift in public attitudes and concerns and will introduce new challenges to the health care system.

The baby boomers will have a profound effect on shaping the nation's attitudes toward health care. This generation will continue to maintain a strong focus on healthier lifestyles and prevention as well as a keen interest in maintaining involvement in health care decision making. In addition, economic and social pressures are likely to make this group strong advocates of health care reform. Economic pressures and concerns about pension funds will force many members of this generation to continue working beyond age 65 years. In addition, economic and social issues will lead to greater involvement of baby boomers in the care of aging parents.

Perhaps the greatest challenge in health care provision will arise from the elderly population. The elderly utilize health services more frequently than do younger age groups. More than 85% of the population over the age of 65 years have one or more chronic conditions that impair function. Nearly 75% of all strokes and amputations occur in this age group. The majority of hip fractures are sustained by individuals over 70 years of age. Among individuals between 65 and 69 years of age, 10% have difficulties in performing activities of daily living. This level rises to more than 50% among persons 75 years and older and approaches 60% in the population aged 85 years and older. Disabilities in the elderly are associated with increased mortality, increased health problems, and higher costs for health care.[3,4,7,8]

Changing Cultural Patterns

Currently, 25% of the American population can be described as "minority," representing African-American, Asian, Hispanic, Native American, Alaskan Native, or Pacific Islander backgrounds. Through the 1990s, the racial and ethnic composition of the Nation will change, with these groups coming to represent 30% of the population. During the 1980s, the Hispanic population grew by more than 53%, five times faster than the remainder of the country's population. By the year 2000, this group will represent an estimated 11.3% of the US population. African-Americans will represent more than 13% of the population, while the proportion of Asians, American Indians, Alaskan Natives, and Pacific Islanders will rise to 4.3% of the total. These changing racial and ethnic patterns can be attributed to several factors, including higher birth rates among minority groups and immigration. Eighty percent of immigrants during the past 5 years have been of Hispanic or Asian origin.[6.9] In the 1990s, the American population may increase by up to 6 million as a result of immigration. Although the origin of future immigrants will be affected by international events, the trends of the previous period are likely to continue.

The expanded cultural diversiry of the population will present challenges for the health care system because of many factors. The racial and ethnic categories typically used do not reflect the subgroups within these populations. For example, Americans of Asian and Pacific Islander origin represent nearly 30 distinct cultures and languages. Hispanic subgroups include Mexican Americans, Puerto Ricans, Cuban Americans, and immigrants from Central and South America. The health histories, problems, experiences, and attitudes of these subgroups vary greatly. In addition, the poor socioeconomic status among many minority groups contributes to the health problems seen in these populations.

The Poor-Uninsured and

Underinsured

Poverty will continue to be a growing problem of American society. Nearly one in eight Americans is a member of a family with an income below the federal poverty level. An estimated 25% of children under the age of 6 years live in poverty; 40% of the poor are under the age of 18 years.[10,11] The disparity in the level of health among the poor and those with higher incomes is dramatic. The death rate among individuals with low income is double that of people with income above the poverty level. Poverty is associated with increased risk of infant death, chronic disease, traumatic injury, and significant developmental limitations. Individuals from families with an annual income of less than $13,000 are twice as likely as the remainder of the population to be limited in major activities because of their health.[12]

Many of the poor have no health insurance. In addition, many near-poor and non-poor individuals lack health insurance. In 1988 more than 37 million Americans had no health insurance coverage. There are concerns that this level will rise. The majority, of the uninsured are under the age 65 years. Nearly 80% are employed or are dependents of workers.13 The poor and uninsured are more likely to suffer from chronic conditions an illness than is the remainder of the population; however, they are less likely to seek care during illness, and they infrequent1s. make use of preventive services. This trend may be due to the fact that they cannot afford health care, as well as to the possibility that they are confused or uneducated about or distrusting of the health care system. The consequence of this trend is that these individuals may enter the health care system when their health condition is complicated and deteriorating and when the cost of treatment is thus increase dramatically.

A growing number of Americans are underinsured against chronic or catastrophic illness. With the escalating costs of health care and insurance coverage, the proportion of underinsured Americans is likely to increase.

Geographic Distribution of

the Population

Changing demographics and economic trends will effect shifts in the geographic distribution of population groups. The Southeast and West are expected to grow at much faster rate than are northeastern and midwestern areas. Economic and quality-of-living factors will foster the migration of working-age adults and their families to western and coastal areas. Although a growing number of older America will move to sunbelt areas, a large proportion of the elderly, population will not relocate. Thus, large concentrations of elderly residents will be characteristic of the Northeast and Midwest.[14] The distribution of new immigrants is likely to be disproportionate, with larger numbers settling in cities along the east and west coasts. The distribution of racial and ethnic groups and the poor also is likely to be disproportionate, with the largest concentrations in central urban and rural areas.

Implications for the Future

Through the 1990s, the rate of growl of the US population will continue t decrease as a result of the decline in the overall birth rate. During this period, however, economic expansion expected to create up to 18 million new jobs. Coming at a time of decline in the number of young job seekers, this growth will put greater pressure on maintaining a healthy, well-functioning older work force. This challenge will be complicated further by shifts in the cultural and socioeconomic profile of the population. By the end of this decade, the number minorities entering the work force will exceed the number of whites. Women of all racial and ethnic backgrounds will represent the major source of new workers-, 50% of working women will be between 35 and 54 years of age.[15]

Although the physical therapy profession can make significant contributions toward enhancing the health and well being of the American population, a changing demographic profile will present the following new challenges to the profession:

* The aging of the US population will expand the need for preventive care, acute and long-term care, and rehabilitative physical therapy care. in addition, the more complicated health characteristics of this population will present new challenges to physical therapy and other health care professions.

* The increasing racial and cultural diversity of the US population will affect the health profile of the population, as well as their needs for and attitudes toward health care services

* The continued growth of poverty, and the accompanying lack of adequate health insurance coverage will increase pressure to provide universal access to health care services, including physical therapy. The number of children living in poverty and/or without health care coverage, and the need for these children to enter the work force in the future, will place greater demands on pediatric physical therapy.

* The changing demographics of the US population will result in a greater complexity of health problems. Physical therapists, like other health care providers, will be faced with patients with multiple health problems and problems of greater severity.

* Geographic migration among the population may require redistribution of physical therapy services. In addition, the distribution of the total population and of various economic, cultural, and age groups will affect the funding of health-related programs.

Human Resources in

Physical Therapy

The 1990s will present significant dilemmas for the health care industry, in general, and for physical therapy, in particular. There will be only minimal growth in the labor force as a result of lower birth rates after the 1960s. In addition, the composition of the work force will undergo major changes. An increasing proportion of the working population will be minorities and women. Among younger entrants to the labor force, there will be growing problems because of illiteracy and lack of skills. The changing profile of the US work force will come at a time when the need for health care workers will escalate.

Projections from the Bureau of Labor Statistics indicate that health care will be the most important source of new job opportunities in the 1990s. Physical therapy is among the health care professions expected to have the greatest increase in demand for human resources.[16,17] These predictions are reinforced by the changing demographic profile of American society. The rising need for health care providers is emerging, however, amid reported shortages among several health care professions.

There are an estimated 71,000 licensed physical therapists practicing in the United States (American Physical Therapy, Association, unpublished communication). The number of PTAS involved in care delivery, is not known, It appears that the current number of personnel is insufficient, and several health groups, including hospitals, the institute of Medicine, and the APTA, have reported severe shortages of physical therapy practitioners. Further, some of these groups, specifically those in the hospital industry, perceive that APTA policies have contributed to the shortages. The nature of shortages warrants careful examination, as does development of strategies to deal with future human resource needs. Particular emphasis should be placed on the geographic distribution of practitioners, shifts in practice settings, specialization, and effective utilization of personnel.

The Changing Demographic

Profile of the Profession[18]

Physical therapy traditionally has been a female-dominated profession, The increasing number of women entering into and remaining in the work force will reinforce this characteristic. The employment opportunities, status, and salaries within the profession, however, may attract more men.

The proportion of minorities in physical therapy grew during the 1980s, but remains a small percentage of the work force. The changing racial/ethnic composition of the US population is likely to lead to a shifting pattern within the profession, Certainly, increasing cultural diversity among physical therapy personnel will enable the profession to deal more effectively with the health care needs and attitudes of the population it serves.

The age profile of physical therapists has shown gradual shifts. In 1983, the average age of active members of APTA was approximately 35 years; at that time, 52% of members were under the age of 35 years. In 1990, the average age increased to 36.5 years, with less than 49% under age 35 years, With the aging of the work force and gains in employment opportunities, the age profile of the profession will shift. A major issue that the profession must address in light of the aging of practitioners is their ability, to respond to the physical demands of providing care.

The geographic distribution of physical therapy personnel must respond to the needs of the American population. Although it appears that the distribution of physical therapy, personnel generally has matched that of the population, inner city and rural areas are underserved. The health characteristics of residents in these areas indicate a high demand for care.

Increased emphasis on outpatient care and community-based and home health services will affect physical therapy practice settings. The growth in the elderly population will result in increased need for physical therapy in extended-care and nursing home facilities. In addition, increased emphasis on work-site injury prevention will provide expanded opportunities for physical therapy services. Despite the reorientation of care deliver, the need for physical therapy services within the hospital setting will persist. The severity, and complexity of health problems among hospitalized patients, however, will put greater demands on the knowledge and skills of caregivers in these environments.

Effective Utilization of

Human Resources

The growing needs of the population for physical therapy care, coupled with the complexity, of health care problems, will challenge the human resource requirements of the profession. Clearly, there will he a need for more physical therapy personnel. The compelling importance of dealing with the complex health care demands of the population while containing health care costs suggests the urgent need to) examine how physical therapy care is provided.

Effective delivery, of health care services, including physical therapy, necessitates efficient use of a variety of personnel with different skill and training levels, It has been reported that only a small proportion of physical therapists utilize PTAS in the delivery of care.[18] Similarly, PTAs report that they, are often underutilized or are inappropriately, utilized. Although it has been difficult to determine the number of PTAS, the growth in the number of PTA education programs indicates that this group will constitute a valuable human resource in meeting the care needs and costcontainment challenges of the future. In addition, efficient and effective delivery of physical therapy care will require increased interaction with and utilization of other health care and business professionals.

Recruitment and Education of

Future Physical Therapy

Personnel

The challenge of expanding the number of physical therapy personnel will be significant. To a great extent, this difficulty will arise from the declining population of secondary-school-aged children and the growing concerns about the educational preparedness of this population. Thus, the profession must refocus its student recruitment efforts in order to compete for qualified students with other health care, science, and engineering professions.

Shifting cultural characteristics will necessitate enhanced efforts to recruit minority students. It is estimated that in the 1990s approximately 50% of the new work force will represent minority populations, with individuals of Asian and Hispanic origin constituting the largest proportion. To date, minority involvement in the profession has been limited, perhaps indicating a lack of awareness of the field and its employment opportunities and/or lack of educational preparedness,

Another important source of human resources in physical therapy will be members of the work force seeking a career change. Declining employment and growth opportunities in several segments of the economy are likely to be a driving force among change seekers.

The costs of higher education will present significant challenges to all professions and to all segments of the population. This factor will have the greatest impact, however, on the less affluent minority populations and on mid-career individuals who have family and economic obligations. Escalating costs will require the profession to seek expanded higher education training and subsidy funds and to develop creative approaches to meet the educational needs of these important resources.

The ability to meet human resource requirements in physical therapy also will be affected by the educational environment of physical therapy programs. Physical therapy, like many other areas of higher education, has been faced with an inadequate supply of faculty. The economic incentives of clinical practice, the costs and demands of doctoral training needed to prepare for a career in higher education, and the relative lack of success of many physical therapy faculty in achieving tenure rank and career advancement may continue to be deterrents to an academic career unless creative options can be developed.

Expanding the human resource pool in physical therapy also will require increasing the number of education programs and/or increasing the class size of existing programs. Both approaches will require additional funds and resources. Competition for educational resources will continue to increase over the next decade. The projected need for growth of the profession, however, may provide an opportunity to develop a stronger resource base for education programs. Other opportunities lie in application of new technology to physical therapy education and collaborative use of resources with other health and science disciplines.

Foreign-trained Physical

Therapists

Physical therapists trained outside the United States may be an important human resource. Changes in immigration laws in recent years have resulted in an increase in the number of foreign-trained physical therapists in this country. During this time, issues related to the training and licensing of these therapists continued to mount. Shortages could lead to more flexible immigration policies in the next few years; however, differences in the educational preparation of foreign-trained therapists must be addressed, and issues of licensing must be resolved.

Retention Within the Profession

Meeting the human resource needs for physical therapy will require a high rate of retention of physical therapists and PTAs. Estimates of the retention rate among physical therapists have been open to question. Increases in salary, the nature of opportunities within physical therapy practice, and the increasing demand for care are expected to contribute to increased retention in the profession It is important to note, however, that a significant number of clinicians (30% in a 1990 profile of APTA active members) have interrupted their career at least once. Nearly 75% of physical therapists in this group were women who left practice to raise a family[18] Economic issues are likely to reduce the number of physical therapists who leave the profession for extended periods. Issues of child care, flexible hours, and access to services to "refresh" the clinical skills of those who have interrupted their career, however, will have an important effect on retention.

A significant challenge relates to the retention of doctorally trained physical therapists. Anecdotal evidence has indicated that many physical therapists who pursued advanced training in basic or clinical sciences have sought research and/or faculty appointments in other fields. This has been attributed to the lack of research resources and the heavy teaching loads among physical therapy faculty. Physical therapy academic programs will continue to face competition for these researchers/academicians from other health and scientific disciplines.

Future Challenges

The opportunities in physical therapy care will grow at a rapid rate, far exceeding many other fields. Amid a work force that is growing only slightly, the profession will be faced with significant challenges. Failure to meet the needs of society will invite other segments of the health care system to develop alternative strategies for providing care. The challenges and opportunities that lie ahead include the following:

* To meet human resource needs,

physical therapy must actively recruit

minority students and members

of the work force who are

seeking mid-career changes. The

profession will face tremendous

competition from other health care

and scientific disciplines in recruiting

qualified personnel.

* Meeting society's needs for physical

therapy care will require the profession

to approach consensus on

models of physical therapy practice that will result in more efficient and effective use of physical therapists, PTAs, and other support personnel. Collaboration within physical therapy and with other segments of the health care system will become of even greater importance than it has been.

* Retention will continue to be a

critical factor. The profession must

be prepared to deal with the

needs of a predominantly female

work force, including provision of

child care services and work

schedule flexibility.

* Personnel shortages will affect immigration

policy, allowing more

foreign-trained physical therapists to

enter the country. Existing questions

related to recruiting, training, and

licensing of foreign-trained therapists

must be addressed as quickly

as possible.

* Problems in the educational system

will continue to escalate. Failure to

prepare secondary-school-aged children

adequately will affect the future

student pool The increasing

costs of higher education, including

the resources to expand educational

programs, could limit the ability to

meet human resource requirements.

Finally, the higher education system

must contend with continuing difficulties

in recruiting and retaining

faculty.

The Physical Therapy

Profession in the Health

Care Sector

The explosive growth of health care over the past 50 years resulted from rapid gains in knowledge and technology as well as a desire to serve society. During this time, new health care professions emerged; specialization within professions became a vehicle for developing new knowledge and technology, and serving the population. Growth in the health care industry led to competition within and among professions, and the scope of practice of many fields became less distinct. The evolutionary, pattern of physical therapy has not differed greatly from the remainder of the health care sector.

The American health care system is in the midst of a revolution. The changes that will occur in the 1990s are the result of many different factors. The advocates of change represent virtually every sector of our society including the public, government, business and industry, and the health professions. Change is not new to the health care system, nor is it new to the physical therapy profession. The rapidity, of that change, however, is significant. The evolution that will take place over the next decade offers an opportunity for physical therapy once again to evaluate the needs of the society, it serves, to respond to these needs, and to take a more active and visible role in the health care system.

Physical therapy traditionally has been classified as "allied health" profession. This label has tended to imply the need for guidance and direction from medicine. During the past decade, physical therapy has emerged from this directed role to one of more autonomy and parity. The shifting needs of society and the changes expected in the health care system could strengthen the role and autonomy of physical therapy. The profession must be prepared, however, to evaluate and monitor the health care revolution and to define carefully its appropriate role for today and the future. It is from this base that the profession can develop strategies to enhance the quality of practice and the development and application of new knowledge. From this base, the profession can assume a leadership role in health care.

An Evolution in Clinical Practice

The scope of physical therapy practice will continue to evolve with the changing needs of society and health care. Although there has been a continuing tendency to expand the scope of practice to accommodate the population's health care needs, this trend will he less successful in the future, due in part to cost constraints and human resource issues. Physical therapy, is facing the challenge and opportunity define clearly its realm of clinical services. Failure to do so may jeopardize the future growth of the profession.

The demographic and health characteristics of this Nation will highlight the dilemma of general practice versus specialization. A trend toward specialization has evolved in many health professions, including physical therapy in an effort to deal with the increasing complexity of health care. The public has become attuned to this trend and often seeks specialized care. This trend, however, has created problems within and among the professions and voids within the system in general. Several health care professions are beginning to evaluate the future need for and benefit of specialization and to develop strategies to avoid excessive segmentation of care services. This will become increasingly important in dealing with issues of access to care and in responding to the human resource needs in health care delivery.

The more complex health care needs of the American population and the nature of the care delivery system will require increased communication and collaboration among providers. An effective team approach to health care will become a necessity. The issue of who controls care will begin to change. as will the dominant/subservient roles among the health professions. These changes will reinforce the existing evolution of physical therapy toward greater parity with medicine.

The health care environment will place greater emphasis on critical evaluation of clinical care. In 1989, Congress established the Agency for Health Care Policy and Research (AHCPR) and charged the organization with developing clinical care guidelines. The HCFA, other government agencies, and private payers have continued their emphasis on evaluation of effectiveness of care. Physical therapy continues to be involved in quality-assurance and peer-review efforts. This involvement, however, must grow and expand. Certainly, the health needs of the public, and the projected increase in utilization of physical therapy and related services, will force active peer-review efforts. Thus, the profession has an important opportunity to become a key participant in critical evaluation of care and in development of guidelines in related areas of prevention, acute care, and rehabilitation, The profession also faces the challenge of encouraging wide-spread involvement among physical therapists who have not been active participants in the clinical care review process.

The Professional Role and

image of Physical Therapy

Public recognition of physical therapy, has continued to grow. A recent public opinion survey indicated that the profession has a strong and respected image and is viewed as making important contributions to meeting the health care needs of society. There also are indications, however, that the public remains confused about the distinction between physical therapy and related health care professions.

The self-image of the profession appears to be less solid. Professional status among physical therapists often is associated with self-employment. It appears that physical therapists practicing in other care settings may undervalue their role in the health care system and often may not view themselves as professionals. In some cases, this view may be reinforced by others in the work setting who may view physical therapists as "technicians." The emergence of physical therapy to a position of greater parity within the health care system will require a strong, positive, professional self-image. Advancement in this area must be built on a willingness to assume a leadership role in health care and on recognition of the importance of the profession in responding to the need of society, acquiring knowledge and skills that extend beyond clinical care and enhancing the ability to communicate and collaborate with other members of the health care system

The Scientific Base of

Physical Therapy

Progress in health care is built upon the quest for and application of new knowledge. Research in the basic and clinical sciences has led to great strides in understanding the machinery of the body and the origins of disease and in developing more effective prevention and treatment methods. Work in the social sciences has improved understanding of the clinician/patient interaction and has led to more effective methods for public, patient, and professional education. Studies in the area of health services research have provided insights into the complex interaction of component of health care delivery Research will continue to be the under-pinning of health care,

Although physical therapy has a history of involvement in research. the profession's recognition within the research realm has been limited. In comparison with medicine and other basic and clinical science fields, physical therapy has had limited success in reinforcing the importance of research to the profession and in developing a cadre of successful investigators. But this is changing rapidly. The importance of research to the future development of physical therapy is becoming more widely acknowledged.

Opportunities for involvement in scientific study are emerging quickly as federal research sponsors, private funding agencies, and the health care industry seek information in such areas as the prevention, management and rehabilitation of disabilities-areas that will improve the health status of our society in a cost-effective manner.

Opportunities for the involvement of physical therapists in the research process are diverse. The need to expand basic knowledge of subcellular, cellular, and physiological systems will continue. There will be an increasing focus on clinical research aimed at improved health care. Outcome and effectiveness studies will become a research focal point. This area will encompass comprehensive investigation of the appropriateness of various procedures from the clinical, cost, and patient perspectives. Closely related, health services research will gain greater prominence and provide the basis for new policy, directions as it addresses such issues as the effectiveness of different care delivery systems, elements comparing the costs of health care, and factors affecting access to care.

Active and direct involvement by physical therapy, in the research process will be vital to the evolution and growth of the profession. It will be the basis for demonstrating the effectiveness of treatment approaches and will provide a strong base for seeking appropriate reimbursement for services. Research also will advance the image of the profession among the public and with other health care professionals. Finally, it will enable the profession to assume a leadership role in the shaping of health policy.

Enhancing the research emphasis within the profession will not be without challenges. There is an existing shortage of skilled physical therapy researchers. Funds for training researchers are limited. Further, there has been a declining interest among members of many health and scientific disciplines in pursuing a research career. Although support for research related to physical therapy is expected to increase, there will be keen competition for grants. Despite these obstacles, physical therapy will be in a strong position to launch a research thrust by initiating collaborative links among researchers and clinicians within the profession and between physical therapist researchers and investigators from other scientific and health care fields.

Evolution in Education

The changes in society and in health care necessitate periodic revitalization of education. During the 1980s, physical therapist education underwent a major and somewhat controversial shift toward a postbaccalaureate entry level degree. The benefits of this change cannot yet be adequately assessed. In addition, the scope and content of entry-level education has expanded to accommodate new knowledge and technology. The latter trend will be magnified not only, by the need to incorporate new knowledge relevant to clinical practice, but also by the critical need for physical therapists to have a solid understanding of the system in which they work. To assume a stronger role in health care, the physical therapist will have to be well versed in such areas as ethics, cost and financial aspects of health care, policy formulation, health care management, and communication among health professions, all within a more culturally diverse population. In addition, the physical therapist must be educated in a manner that fosters critical thinking and decision-making skills. The need for incorporation of these elements comes at a time at which entry-level education already has a cramped and compressed curriculum.

The dilemma facing education is not unique to physical therapy. Higher education is in the midst of crisis and transition. The educational system has been subject to a steady depression resulting from funding decreases, declining interest in pursuit of academic career,s, and lack of public confidence in the higher education enterprise. In responding to crisis, the education system also will explore methods to better meet the changing needs of society. This may require a paradigm shift away from educating in a vacuum (teaching facts) to approaches that support decision analysis, problem-solving behavior, communication and collaborative skills, and the ability and desire to continue to learn.

Physical therapy can play a leadership role in fostering the transition in higher education. Opportunities will exist in establishing more collaborative links with other professions during entry-level education. These approaches will offer multiple benefits, including building communication among the professions and more effective utilization of educational resources and faculty. Basic training in the health care system and societal issues are not unique to any health care profession and need not be approached from a discipline-specific perspective. Physical therapy, also can lead efforts to incorporate effective use of technology into entry-level education as well as teaching methods that foster independent thinking and problem-solving approaches. Beyond issues of curricular design and teaching approaches, the profession must become an active participant in higher education politics and policy formulation. Physical therapy faculty typically have had limited involvement in the university enterprise beyond their own programs and appear to lack understanding of the business of higher education.

Developing effective strategies for change in physical therapy education must be based on a clear understanding of the profession, the necessary skills and knowledge of the graduate, and the role of the academic setting versus clinical training in preparing the new practitioner. In addition, the physical therapy educator must seek to understand and become involved in higher education policies and to participate actively in the reshaping of this system.

Education of the health care professional does not cease upon graduation from entry-level education. Physical therapy has a history of seeking professional development. Members of the profession have participated in training in new areas of treatment and, more recently, in programs designed to enhance understanding of reimbursement and practice management. The need for continual knowledge and skill advancement will increase in the coming years. Physical therapists and PTAs must expand their clinical abilities to accommodate advances from within the profession and from other health care fields. Further, the diverse nature of the health care system and the realities that exist within the system will require the physical therapist to broaden and continually enhance knowledge beyond the direct scope of physical therapy

The Future Evolution of

the Profession

Responsibility for the growth of physical therapy resides, to a great extent, within the profession. The evolution of physical therapy. to a leadership role within health care first will require that the profession delineates its role in the health care spectrum. It then must face development of effective strategies to enhance the research and educational base of the profession and to reinforce involvement in health care policy. and decision making. The major trends that will shape advancement in this area include the following:

* Physical therapy, will continue to

gain public recognition. Enhancing

the image and perception of the

profession, however, first will require

that the profession develop a

strong self-image, based on a clear

definition of physical therapy, and a

commitment to becoming a leader

in health care delivery.

* Physical therapists must become actively

involved in peer review and

quality. assessment. The health care

environment soon will mandate development

of practice guidelines and

demonstration of effectiveness. The

profession must become proactive in

this area, thus enhancing its professional

status and providing a base for

dealing with reimbursement issues.

* Opportunities for research involvement

will increase and will be an

important aspect of advancement of

the profession. Although needs will

exist throughout the research spectrum,

physical therapy will face the

greatest opportunities in areas related

to outcome/effectiveness studies

and health services research.

Success in the research arena will

require thorough understanding of

the research process and establishment

of strong collaborative ties

with scientists in other disciplines.

* Higher education in general will

continue to face crises in funding

and public confidence. Concurrently

the educational enterprise will undergo

major transitions, including

increased emphasis on problem

solving, decision analysis, and effective

learning behavior. Physical therapy

and its academic communities

will have an opportunity to assume

a major role in facilitating the educational

paradigm shift. This will

require a careful review of needs in

entry-level education, a focus on

developing more effective approaches

to education, and a willingness

to become involved in education

policy formulation.

* Physical therapy professional development

will become of increasing

importance. Professional development

will encompass not only acquisition

of new clinical knowledge

and skills, but also a strong focus o

enhanced knowledge of the health

care system.

The Shaping of Public Policy

The clearest statements of the public policies of this Nation ultimately reside in our laws, regulations, and court decisions. The primary formulators of public policy are in the White House and federal agencies, in state executive houses and offices, in Congress and state legislatures, and in state and federal courts. Not all public policy affects health care, and not all health care policy, affects physical therapy. To a great extent, the Association's efforts can be focused on such specific areas as the following:

* Major insurance programs (eg,

Medicare, Medicaid, workers' compensation,

national health insurance

long-term care, federal employees

health benefits program, and state

insurance codes)

* Legislation and regulation regarding

persons with disabilities (eg, Rehabilitation

Action, Americans with

Disabilities Act, Education of the

Handicapped)

* Legislation and regulation governing 

support for education and research

(eg, National Institutes of

Health funding, health care personnel

legislation)

* Legislation and regulation affecting

credentialing (eg, state licensure 

laws)

* Legislation and regulation affecting

business (eg, tax codes, mailing

subsidies)

Government is not the only formulator of public policy. Several national standard-setting organizations, such as the joint Commission on Accreditation of Health Care Organizations (JCAHO), the Commission for the Accreditation of Rehabilitation Facilities CARF), and the Council of Post-Secondary Accreditation, affect health care policy through their credentialing operations.

Integral to the development and formulation of public health care policy are the dialogue and debate that precede it. Contributors to this debate are many and diverse: other professional and health care organizations, the insurance industry, the business sector, private think-tanks," consumer groups, individuals, and spokespersons from other countries. The future of health care in the United States will reflect. to a major degree, the ideas, perspectives, and initiatives emanating from these sources.

The Challenge of

Sociopolitical Issues

During the 1990s, the Nation will face many challenges related to our social and political systems, the changing nature of our society, international affairs, and national and international economies. Each of these areas will have both direct and indirect effects on the future of health care and on the profession of physical therapy.

One of the greatest policy challenges facing the United States in the next decade will be health care reform. impetus for reform has emerged fro virtually every segment of our society: a rapidly growing population of uninsured and underinsured individuals, consumer dissatisfaction with the health care system, consistently rising health care costs and provider charges that far exceed the overall inflation rate, the rising cost of health insurance coverage coupled with decreasing and variable health care benefits, the increasing burden of uncompensated care in Medicare and Medicaid, inadequate access to comprehensive care services, and the lack of demonstrated appropriateness and effectiveness of many aspects of care. A number of groups, including health care professional organizations, private commissions, have developed models for reform. Although the APTA has been involved with several of these groups and has been active in issues related to health care reform, the organization has not developed a comprehensive position in this area. The opportunity for the profession to participate, however, will remain open, for it is unlikely that any major reform initiatives will be developed in the next 2 years. Further, the process of reform is likely to extend at least through the end of the decade.

The profession and the Association will have opportunities to pursue policy initiatives related to reimbursement, ethics in health care, research funding, and support of educational training. In addition, the profession will have an opportunity for involvement in the shaping of immigration policies, which in turn will affect human resource needs in physical therapy. Immigration laws pertaining to physical therapists have been changing and are likely to be reexamined with the dramatic political changes occurring in Eastern Europe and the Commonwealth of Independent States. Although the entry of foreign nationals is largely controlled by the Immigration and Naturalization Service, issues of licensing reside at the state level. Thus, there will be a need to link federal and state policy in this area.

The profession, through the APTA, has been involved in shaping and responding to policy directly related to physical therapy. The profession and its members have had difficulties in becoming visibly proactive on issues less directly related to the profession. These difficulties may be due to a variety of factors, including a lack of understanding of policy formulation, an underestimation of the potential power of the profession in policy, development, and a lack of time needed to be involved in public policy. Active involvement in policy formulation, however, will be an important base for shaping the future of the profession, for enhancing the status and image of the profession, and for assuming a leadership role in health care.

Although there are a variety, of socio-political issues facing the country, the profession and the Association cannot and should not become involved in all. The profession must define a policy agenda and develop policy positions that are consistent with its definition and mission. Among the areas of greatest opportunity in public policy - beyond those that will affect physical therapy, care directly - are the following:

* National health care insurance and

access to health care

* Issues of women and families in the

work force

* Prevention (of both disease and

accident)

* Reform and support of higher

education

* The educational preparation of elementary- and secondary-school children

Policy initiatives are most effectively pursued through strong collaboration with other professional and consumer groups. Coalitions are a key element in public policy beginning at the grass-roots level. It will be necessary, however, to select coalition partners carefully in order to preserve the image and integrity of the profession.

Active involvement in policy formulation will require establishing and maintaining contact with legislators and policymakers by individual members of the profession. Legislators look for and respond to personal contacts. Further, contact with policymakers through informal mechanisms is essential during early stages of drafting laws and regulations.

Key Directions in Public Policy

Policy directions of the next several years will have both a direct and an indirect impact on physical therapy, and will be shaped by the changing needs of society and the Nation. Major considerations for the profession include the following:

* Health care reform will he a key

focus for the country and for the

health care system. The process of

reform in general will move slowly,

with incremental change occurring

in areas affecting cost containment,

reimbursement, and the ethics of

health care delivery.

* The Nation will face other important

sociopolitical issues, many of which

will have direct and/or indirect effects

on physical therapy, including

prevention, education, women's and

family issues, immigration issues,

and cultural diversity.

* The issue of the emotionally/behaviorally

impaired practitioner will

pose a challenge to the public and

the health care industry. Physical

therapy has an opportunity to assume

a leadership role in this issue

by developing responsive efforts to

deal with ethical concerns and rehabilitation

programs.

* The participation of physical therapists

in the development of public

policy has been sporadic, at best.

The profession must recognize the

importance of this participation and

work to expand upon the foundation

it creates.

* Although the profession has been

involved in the shaping of public

policy related directly to physical

therapy care, there has been less

involvement in other sociopolitical

issues. The profession and the Association

can play a major, proactive

role in the public-policy arena by

carefully selecting focal issues, shaping

policy positions consistent with

its professional orientation and philosophy,

and participating within

coalitions and as individuals.

* Expanded involvement in public

policy: will enhance the image and

status of the profession and will

contribute to a more prominent

role for physical therapy. Failure to

become an active participant in the

policy arena may jeopardize not

only the growth but also the viability

of the profession.

The Role of the Association

More than 160 years ago, America was called "a nation of associations." This perspective is equally valid today. Approximately 70% of Americans are members of at least one association., 25% belong to four or more. Although the role of associations varies, these organizational entities form the basis for communication and collaboration within and among groups, develop ethical standards for the individuals or groups they represent, educate members and the public, and provide a vehicle for change in the society.

The APTA is the professional association that has represented the physical therapy profession for more than 70 years. The Association, like the profession, has undergone significant evolutionary change and will continue to do so during the next decade. In shaping its future, the Association and profession must delineate clear roles and directions.

Practitioner involvement and

Awareness

The APTA membership encompasses approximately 60% of licensed physical therapists. Although the total number of PTAs is not known, only a small fraction are members of the Association. Further, physical therapist and PTA student membership in the APTA are 39,000 and 2,800, respectively.

The Association will face continuing challenges in increasing membership and participation, it appears that many practitioners do not understand the nature of the APTA's work, the relevance to care delivery of many Association programs, or the importance )f individual membership and participation. Many practitioners also are confused about the distinction between the APTA, its state chapters, and the state licensing agencies. Promotion of membership and participation in the Association, which should begin during entry-level education, has had mixed success. Finally, ineffective communication between members and the Association on controversial issues max, have been related to declines in membership.

Factors external to the Association also will affect membership recruitment and retention. Although some may join because of it, the effects of recession and inflation will force some members to drop membership in order to meet other financial obligations. Economic factors and the need to reduce overhead costs will continue to erode the willingness of employers to pay for their staffs' professional memberships.

Association Interaction with

External Groups

The APTA has progressively strengthened its recognition and image in the external environment. The Association has sought out and established ties with consumer and advocacy groups, other professional organizations, business communities, and governmental agencies. The APTA and the profession have established a strong image in consumer/patient advocacy related to health care. The Association increasingly will be presented with opportunities to interact and collaborate with external groups, particularly on health care and other sociopolitical and economic issues. Many issues will extend beyond the Association's previous concentration on physical therapy-related areas., however, the APTA and the profession will be able to enhance significantly their leadership role and status through participation in issues relevant to the mission of physical therapy and the Association.

Shaping the Future of the

Association

The success and viability of virtually all organizations and groups will depend on careful definition of roles, resources, and strategies. The APTA has continued to strengthen its position as a professional association and has an opportunity to continue this trend. As the profession further defines its role and position in the health care realm, however, the Association must also delineate its mission in serving the profession and functioning as an effective business organization. In shaping its future, the APTA will be faced with several challenges and opportunities:

* The Association will be the major

resource for effecting the growth

and increased status of the profession.

The successful evolution of the

profession, however, will require

the commitment and active involvement

of all members of the physical

therapy community. The APTA must

be prepared to effectively communicate

with and involve its constituents

and to build leaders at national,

state, and local levels.

* A lack of understanding of the role

and importance of the Association,

and of the value of membership,

among many practitioners will continue

to impede membership

growth. The importance of Association

membership and its relevance

to the future growth and status of

physical therapy must be conveyed

initially during educational preparation

and reinforced subsequently by

professional colleagues.

* The Association must respond to the

increasing cultural diversity in the

United States. The changing demographic

profile of the population

will affect the delivery of care as

well as the composition of the profession.

The Association must be

prepared to recruit minorities to the

profession and to encourage active

participation of minority therapists,

including involvement in leadership

roles.

* The Association will be presented

with opportunities to expand its

interaction and collaboration with

external groups. Many opportunities

will focus on sociopolitical issues

related indirectly to physical therapy

care, Efforts in this area, however,

will enhance the status and leadership

role of the profession and the

APTA. Further, such efforts can serve

as the foundation for enhancing

communication and collaboration

between physical therapy and other

health-related professions.

* Information and technology will

become increasingly important to

associations and to professions. The

Association has begun to integrate

technological advances into its operation

and to access and organize

information relevant to the profession.

The APTA can play a vital role

by continuing to access and organize

information into useful entities.

The emergence of technological

advances and concepts also will provide

the Association an opportunity

to serve its members and the profession

by identifying applicable

approaches.

* Society and the business sector will

continue to focus on quality management

and customer service. The

Association increasingly must integrate

these concepts into its structure

and management approach and

must be prepared to communicate

effectively about the issue of quality.

* All segments of health care will have

to reinforce the value of continued

learning and the need to support

problem-solving leaming behaviors.

it will be important for the Association

to integrate these values into its

structure and programs.

References

[1] HCFA Off-ice of National Cost Estimates. National health expenditures. Health Care Finance Review. Summer 1991. [2] Healthcare in the 1990s: forecasts by top analysts. Hospitals. July 1989. [3] Institute of Medicine. Disability in America: Toward a National Agenda for Prevention Washington, DC: National Academy Press; 1991. [4] Task Force on Medical Rehabilitation Research. Report of the Task Force on Medical Rehabilitation Research. Bethesda, Md: National Institutes of Health; 1990. [5] Centers for Disease Control. National Agenda for Injury, Control in the 1990s Rockville, Md: US Dept of Health and Human Services; 1991. [6] Spencer G Projections of the populations of the U.S. by age, sex. and race: 1988 to 2080. In: Current Population Reports: Population Estimates and Projections. Series P-25. No. 1018. Washington, DC: US Dept of Commerce. Bureau of the Census; 1989. [7] Institute of Medicine, The Second Fifty Years: Promoting Health and Preventing Disability Washington, DC: National Academy Press; 1991. [8] National Center for Health Statistics. Health: United States, 1989. In: Prevention Profile. Rockville, Md: US Dept of Health and Human Services; 1990. [9] Spencer G. Projections of the Hispanic population 1983-2080. In: Current Population Reports Population Estimates and Projections. Series P-25, No. 995. Washington, DC: US Dept of Commerce, Bureau of the Census; 1986. 10 National Center for Children in Poverty. A Special Profile of Our Poorest Young Children. New York, NY: The Center; 1990. [11] Poverty Slates in be US. Washington, DC: US Government Printing Office; 1990. [12] La Plante MD. Data on Disability from the National Health Interview, Survey: 1983-1985. Washington, DC: National Institute of Disability and Rehabilitation Research; 1988. [13] The non-elderly. uninsured, 1988-update: Americans without health insurance. Employee Benefit Research Institute issue Brief. No. 104, July 1990. [14] Population Gains and Losses by State. Washington, DC: US Dept of Commerce, Bureau of the Census; December 1990. [15] Kutscher RE, Projections 2000; overview and implications of the projection 2000. Monthly labor Review. September 1987. [16] Silvestri GT, Lukasiewicz JM. Projections of occupational employment 1988-2000, Monthly Labor Review. November, 1989. [17] Institute of Medicine. Allied Health Services Avoiding Crises. Washington, DC: National Academy Press; 1989. [18] 1990 Active Membership Profile Report. Alexandria, Va: American Physical Therapy Association; 1991.