A Vision for Society: Physical Therapy as Partners in the National Health Agenda

The American Physical Therapy Association's (APTA's) Vision 2020 statement1 provided the stimulus our profession needed to develop a stronger self-awareness and broader public perception of physical therapy as a doctoring profession. Health service delivery in the United States is being refined and shaped by current sociopolitical events. In addition, changes in the demographics of our society, technological advances in medicine that continue to decrease mortality yet increase morbidity, and the critical need for more affordable health care will have an impact on the demand for physical therapy services. In 2001, the Institutes of Medicine (IOM) recognized the urgent need for fundamental change in the American health care delivery system due to the existing “chasm” between the care delivered and the health of the children and adults who reside in the United States today,2 especially for those with developmental or acquired disability.3 On March 23, 2010, US President Barack Obama signed into law the Patient Protection and Affordable Care Act (Public Law 111–148) (PPACA).4 The PPACA focuses on the initial steps needed to reform a health care delivery and reimbursement system that is not consistently meeting the health needs of children and adults across the US population. Healthy People 2020 (HP2020) is the science-based, 10-year national public health agenda for improving the health of all Americans as determined by the US Department of Health and Human Services.5 Healthy People 2020 is the road map between the PPACA (the law that mandates health care reform) and the reform needed in both health services delivery and the national health-science research agenda. There are unique opportunities for physical therapists to participate in the process of health care reform, which includes the stewardship of health care dollars. Through advances in the science and practice of physical therapy, physical therapists have earned the public's trust and recognition as health care professionals. The 2010–2011 edition of the US Department of Labor's Occupational Outlook Handbook6 describes the physical therapist as part of the health care professional workforce, qualified to practice as one of the “health diagnosing and treating practitioners.” Today, the public recognizes the essential value of physical therapy for episodic care provided within the current health care delivery system. However, we envision that the physical therapist of the future will provide primary care that includes rehabilitation, primary and secondary prevention, disease mitigation, and health promotion to protect the physical health and mobility of the population. Currently, our profession confronts major challenges as our association responds and adapts to a changing, and yet to be defined, health care delivery and reimbursement system. Forty years ago, our professional leaders anticipated the need to advance professional preparation of the physical therapist to the clinical doctorate in order to prepare practitioners for direct access and autonomy of care. The short-term practice challenges we face today do not recuse us from preparing for the demands society will make on physical therapy in the next 40 years. As Jules Rothstein reminded our profession in 2002, the pursuit of direct access was not to ensure our professional autonomy but to “seek unfettered practice that allows us to use our skills, knowledge, and compassion to our maximal potential.”7(p751) Physical therapy has earned the distinction as one of the health care professions; however, along with professional autonomy comes professional responsibility that includes the ethical and moral duty of a profession to meet the needs of the society that has granted that trust. Health care professions are granted certain privileges in society, such as self-regulation and financial earning power, in exchange for meeting societal needs.8 Recognition of professional autonomy is not something the profession claims for itself but is bestowed upon the profession from society in exchange for meeting those societal needs. A fundamental, mutual expectation and shared understanding (quid pro quo) between health care professions and society is that health and health improvements are primary needs of our social contract with society.9 It is eminently important that every constituent group that represents the interests of the physical therapy profession, whether physical therapists or not, fully comprehend the rights, privileges, and responsibilities of this social contract. Building upon the observations of others,10–14 this health policy perspective provides additional evidence that our profession must evolve beyond the tenets of Vision 2020. Through open discussion among our professional leaders, a new vision statement that is relevant to the challenges of today, yet prepares for the future, is a logical step in the evolution of physical therapy as a health care profession. Current events provide the impetus our profession needs to: partner in the national health agenda; respond to the societal need for accessible, affordable, and effective health care; and shape the future of physical therapist practice beyond 2020. The objectives of this health policy perspective are to: (1) increase awareness—within our association and among practitioners, educators, and researchers—of the public expectation for the physical therapy provider workforce, (2) introduce the public health concepts of population-based, life-stage health promotion/risk reduction and individual life course management as a health and wellness model for physical therapy, and (3) describe the looming shortage in the physical therapy workforce and identify areas of educational reform needed to prepare an adequate number of qualified physical therapists and physical therapist assistants to meet the demand society will make on physical therapy in the next 40 years. Within this decade, the profession will be called upon to address the demand for physical therapy health services that extend beyond our historical roots as one of the “allied health professions.”15 Demographic and health care trends and the need to improve the nation's health without increasing health care costs will affect the future role of the physical therapist and physical therapist assistant. The US Census Bureau's National Health Interview Survey* projects that starting in 2007 and extending to 2050, the population 65 years of age and older will outpace the rate of rise in the younger populations.16 The population 18 years of age will remain at 23% to 25%, and the populations 18 to 44 and 45 to 64 years of age are projected to decline. Starting in 2010, the population over 65 years of age is increasing from 12% to 13% to reach 20% of the total population by 2030 to 2050. For adults 65 years of age and older, decline in physical and cognitive ability increases the likelihood of progressive disability or increased risk of unintentional injury. With each decade, basic or complex activity limitations† progressively increase (percentages of people reporting activity limitations: 26% of those 65–74 years of age, 36% of those 75–84 years of age, and 62% of those 85 years of age and over).16 The decrease in the proportion of working-age adults compared with the increasing growth rate of the older-age sector has never been experienced in the US population. Affordable, accessible care for the younger populations is constrained due to the imbalance in health care resources consumed by the older population. The imbalance in health services delivered, compounded with the poor overall physical health of children and working-age adults today, has profound, long-standing implications for the health and wellness of younger populations. The most recent US health statistics highlight the poor physical health of children and adults. Childhood obesity affects approximately 12.5 million children and teens, with a prevalence of approximately 17% for children 2 to 19 years of age17 and with higher rates based on race or ethnicity.18 Obesity affects nearly 73 million adult men and women, with the prevalence of obesity at 32.2% among adult men and 35.5% among adult women.19 Furthermore, physical inactivity has reached unprecedented levels among children and adults of all ages. The range of physical inactivity varies by US region.20 A large proportion of American children and adults do not meet the minimum activity standards recommended by the Centers for Disease Control and Prevention (CDC).20 Yet, physical activity is a modifiable health behavior and one of the most effective health promotion and disease mitigation/prevention strategies to reduce multiple comorbidities, physical disability, and premature death.21 In our opinion, physical therapy has a professional responsibility to partner in several of the recently announced HP2020 objectives, particularly in the areas of safe physical activity across the life span, especially for children or adults with comorbid health conditions. However, one of the major objectives that should not be ignored by the physical therapy profession is to “promote the health and well-being of people with disabilities.”5 Historically, physical therapy emerged as the health care profession that addressed the physical mobility needs of children and adults when disability resulted from injury (eg, World War I and II veterans) or disease (eg, survivors of paralytic poliomyelitis). Physical therapists are health care professionals trained to address the health consequences of pain, weakness, and impaired mobility through physical therapy interventions that are restorative and preventive. The unique value of physical therapy to societal health includes the following: (1) rehabilitation that returns working-age adults to preinjury or pre-illness function to resume participation in everyday activities such as employment or homemaking; (2) early intervention and home modification that prolongs safe, independent living in the home for the elderly population; (3) health risk monitoring with chronic disease management if needed when physical inactivity affects the physical health of young and middle-aged adults; (4) secondary prevention for physical health that includes safe, effective physical activity interventions for sedentary children or adults at risk for premature onset of chronic diseases and physical disability; and (5) education and screening that promote healthy lifestyles and the consequences of high-risk activity such as serious injury and disability in adolescents, teenagers, and young adults. In our view, one of the greatest challenges for our professional and association leaders today is to combine our collective knowledge and experiences into one vision that defines our social contract between physical therapy and any child or adult who needs our care. A renewed vision will lead physical therapy beyond autonomy toward partnerships where our skills, knowledge, and compassion will merge with those of others to protect the health of the US population. In so doing, the value of physical therapy will be judged by our contribution to societal health, and any financial reward will be earned, and not demanded, by our profession. Physical therapists are recognized by the public as practitioners in the areas of physical health and rehabilitation, as are chiropractors, occupational therapists, speech-language pathologists, athletic trainers, and exercise specialists.6 The scope of physical therapist practice as licensed health care professionals is distinct from our colleagues in rehabilitation or community-based exercise settings. Due to specialized professional training in movement dysfunction and physical health, physical therapists have unique knowledge, skills, and abilities that fulfill the qualifications and responsibility for health decisions across the continuum of health care delivery settings, from emergency department to long-term chronic care. The clinical doctorate in physical therapy was a necessary evolution in the training of the physical therapy workforce. Physical therapists have knowledge in systems physiology and pathophysiology and the effects of disease or injury on human movement across the life span. 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