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Physical Therapy Health Human Resource Ratios: A Comparative Analysis of the United States and Canada

MD Landry, PT, PhD, is Adjunct Assistant Professor, Department of Health Policy and Administration, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, and Assistant Professor, Department of Physical Therapy, Faculty of Medicine, University of Toronto, Rehabilitation Sciences Building, 8th Floor, 160–500 University Ave, Toronto, Ontario, Canada M5G 1V7.
TC Ricketts, PhD, is Professor, Department of Health Policy and Administration, and Director, North Carolina Rural Health Research Program, Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.
E Fraher, MPP, PhD Candidate, is Director, NC Health Professions Data System, Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.
MC Verrier, PT, MSc, is Associate Professor, Department of Physical Therapy and Graduate Department of Rehabilitation Sciences, University of Toronto.

Address all correspondence to Dr Landry at: mike.landry{at}utoronto.ca

Submitted March 12, 2008; Accepted November 10, 2008

	Abstract

 
Background and Purpose: Health human resource (HHR) ratios are a measure of workforce supply and are expressed as a ratio of the number of health care practitioners to a subset of the population. Health human resource ratios for physical therapists have been described for Canada but have not been fully described for the United States. In this study, HHR ratios for physical therapists across the United States were estimated in order to conduct a comparative analysis of the United States and Canada.

Methods: National US Census Bureau data were linked to jurisdictional estimates of registered physical therapists to create HHR ratios at 3 time points: 1995, 1999, and 2005. These results then were compared with the results of a similar study conducted by the same authors in Canada.

Results: The national HHR ratio across the United States in 1995 was 3.8 per 10,000 people; the ratio increased to 4.3 in 1999 and then to 6.2 in 2005. The aggregated results indicated that HHR ratios across the United States increased by 61.3% between 1995 and 2005. In contrast, the rate of evolution of HHR ratios in Canada was lower, with an estimated growth of 11.6% between 1991 and 2005. Although there were wide variations across jurisdictions, the data indicated that HHR ratios across the United States increased more rapidly than overall population growth in 49 of 51 jurisdictions (96.1%). In contrast, in Canada, the increase in HHR ratios surpassed population growth in only 7 of 10 jurisdictions (70.0%).

Discussion and Conclusion: Despite their close proximity, there are differences between the United States and Canada in overall population and HHR ratio growth rates. Possible reasons for these differences and the policy implications of the findings of this study are explored in the context of forecasted growth in demand for health care and rehabilitation services.

	Introduction

Top Abstract Introduction Method Results Discussion Conclusion References

 
Health human resources (HHR) continue to emerge as critical factors in health care policy planning.^1–3 An overall measure of supply within a workforce, the HHR ratio, is generally expressed as the number of health care practitioners relative to the population or a subset of the population.⁴ The origins of the use of HHR ratios for workforce policy can be traced back to the 1930s, when pioneering work done in the United States reported that a target of 134.7 physicians per 100,000 people was a desirable benchmark (TC Ricketts, unpublished data, 2003). Since that time, the use of HHR ratios has become a common measure of the density of health care practitioners in a given geographical area. In Canada, according to the Pan-Canadian Health Human Resource Strategy, "appropriate planning and management of HHR are key to developing a health-care workforce that has the right number and mix of health professionals."⁵ Overall, the published literature has focused on estimating the HHR ratio for larger groups of health care practitioners, such as physicians^6–8 and nurses,^9–11 across multiple time periods. The publication of such workforce ratios has created an evidence base from which health care disciplines have drawn for public policy discussions and professional advocacy activities.

In contrast, international estimates for physical therapists are relatively sparse. Landry¹² estimated the Canadian HHR ratio for physical therapists to be 5.0 per 10,000 people in 2000, which represented a 16.3% increase from the value in 1991. Landry et al¹³ followed up on this earlier work and estimated that the Canadian HHR ratio for physical therapists dropped to 4.8 per 10,000 people by 2005. They reported that although there was an 11.6% increase in the HHR ratio between 1991 and 2005, there was an alarming decline in the HHR ratio between 2000 and 2005. Although the reasons for this decline were not discussed, their research demonstrated that the increase in the HHR ratio outstripped overall population growth in only 7 of 10 provincial jurisdictions (70.0%) between 1991 and 2005.

In the United States, there has been no similar national-level trend analysis regarding HHR ratios for physical therapists, and the existing data concern ratios at the state or county level.¹⁴ To address the gap in national-level analyses of HHR ratios across the United States, we carried out this study with the aim of achieving 2 objectives. The first objective was to estimate HHR ratios for physical therapists across jurisdictions by combining US Census Bureau data with the total numbers of active and inactive registered physical therapists across the United States at 3 time points: 1995, 1999, and 2005. The second objective was to compare the HHR ratio estimates in the United States with those in Canada to explore trends in the 2 countries.

	Method

Top Abstract Introduction Method Results Discussion Conclusion References

 
The method used in this study was similar to that previously applied by Landry¹² and Landry et al¹³ to estimate HHR ratios for physical therapists in Canada. In brief, for the determination of HHR ratios across the United States, 2 sources of data were linked to generate estimates of the number of physical therapists relative to the population. First, publicly available historical population data from the US Census Bureau were retrieved for the years 1995, 1999, and 2005 in each of the 50 states and the District of Columbia.¹⁵ Second, publicly available estimates of the total number of active and inactive registered physical therapists in each US jurisdiction were obtained from the American Physical Therapy Association (APTA) for the years 1995, 1999, and 2005. For calculation of the number of physical therapists per 10,000 people in each jurisdiction for each year, a simple mathematical equation was applied: The number of physical therapists in each jurisdiction was multiplied by 10,000, and the result was divided by the overall jurisdictional population. This equation yielded the density of physical therapists per 10,000 people in each jurisdiction at 3 time points. Change scores for the overall population, absolute numbers of physical therapists, and HHR ratios for each jurisdiction then were determined by calculating the percent changes between 1995 and 1999, between 1999 and 2005, and between 1995 and 2005.

In this study, both active physical therapists (defined by APTA as currently practicing) and inactive physical therapists (defined by APTA as not practicing) were included in the sample of physical therapists for 3 reasons. First, APTA's publicly available files collapse both categories, making it difficult to distinguish between them. Second, an objective of this study was to compare US data with Canadian data, and a comparative Canadian study¹³ included both active and inactive physical therapists in the data analysis. Third, the overall goal of this study was to provide a macro-level perspective on the number of physical therapists relative to the population, and much of the reviewed literature included the total numbers of active and inactive health care professionals as a measure of the density of health care professionals.^6–11

The APTA does not represent all physical therapists in the United States, but this national professional organization triangulates multiple data sources to estimate the total number of licensed physical therapists in the United States. The APTA gathers data on human resources across the United States through annual requests to all licensing bodies in each of the 50 states and the District of Columbia. In large measure, the licensing bodies provide HHR information to APTA; however, because a physical therapist can be licensed to practice in more than one state, relying solely on individual state-level data would overestimate the number of licensed physical therapists in the United States. Therefore, each state's licensing board is asked to report the total number of physical therapists licensed and the total number of physical therapists residing in that state. The APTA then cross-references these data sources to estimate the total number of physical therapists in each state. Although there is an error rate associated with these estimates, APTA has estimated HHR data by using the same methodology at the 3 time periods of interest in this study, and these data represent the only publicly available national-level data.

Population growth, absolute numbers of physical therapists, and HHR ratios obtained from the US sample were used, along with published Canadian data, in a comparative analysis of the neighboring countries. For the comparative analysis, the US data in this study ranged from 1995 to 2005 (the 3 data points were 1995, 1999, and 2005), but the Canadian data ranged from 1991 to 2005 (the 3 data points were 1991, 2000, and 2005). Although the final data points were the same for both countries, there were slight differences in the first and second points. The differences resulted from the availability of publicly available data from the original sources. The first and second data points were within 4 years of each other, a fact that in and of itself introduces complexity to the analysis, but these data were the best available. The data from the United States and the comparative analysis of the United States and Canada are presented in the "Results" section. Explorations into the reasons for differences and policy implications of our findings are presented in the "Discussion" section.

	Results

Top Abstract Introduction Method Results Discussion Conclusion References

 
Population Growth in the United States

The population of the United States in 2005 was 296.5 million, representing an increase of 8.7% from 1999 and an increase of 12.9% from 1995.^15,16 Although the population of the United States increased between 1995 and 2005, the positive growth was not equal across all jurisdictions. As shown in Table 1, 49 of 51 jurisdictions had positive growth between 1995 and 2005; however, West Virginia and North Dakota reported slight decreases in their populations—0.8% and 1.0%, respectively.

View larger version (23K): [in this window] [in a new window]   Figure 1. Comparison of the change in population with the change in health human resource ratios for physical therapists (PTs) per 10,000 people in the United States from 1995 to 2005. Jurisdictions included in each US Census Bureau region were as follows: New England—Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont; Middle Atlantic—New Jersey, New York, and Pennsylvania; East North Central—Illinois, Indiana, Michigan, Ohio, and Wisconsin; West North Central—Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota; South Atlantic—Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington, DC, and West Virginia; East South Central—Alabama, Kentucky, Mississippi, and Tennessee; West South Central—Arkansas, Louisiana, Oklahoma, and Texas; Mountain—Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming; and Pacific—Alaska, California, Hawaii, Oregon, and Washington.

View larger version (7K): [in this window] [in a new window]   Figure 2. Population growth in the United States and Canada. Times were as follows: 1—1995 for United States and 1991 for Canada; 2—1999 for United States and 2000 for Canada; and 3—2005 for United States and for Canada.

View larger version (8K): [in this window] [in a new window]   Figure 3. Trends in physical therapy health human resource ratios in the United States and Canada (number of physical therapists [# PT] per 10,000 people). Times were as follows: 1—1995 for United States and 1991 for Canada; 2—1999 for United States and 2000 for Canada; and 3—2005 for United States and for Canada.

	Discussion

Top Abstract Introduction Method Results Discussion Conclusion References

The implications and policy interpretations of our findings are complex and not linear. As in the study of Landry et al,¹³ the data collected within this research do not establish causation. However, critical questions regarding the optimal number of physical therapists in a given jurisdiction emerged from the present study. For instance, in our view, it would be inappropriate to conclude that the United States is "doing better" or "doing worse" than Canada in terms of HHR ratios because the benchmark for the optimal number of physical therapists relative to a population has not been established. To our knowledge, there are no need-based, evidence-based targets or benchmarks for the number of physical therapists relative to a population across clinical settings, disease conditions, countries, or a combination of these. That is, we were not able to determine whether the national average of 6.2 physical therapists per 10,000 people across the United States in 2005 was high, low, or "just right" because there are no established human resource benchmarks. We suggest that until benchmarks across the care continuum are established, the usefulness of HHR ratios in the policy planning cycle is likely to be somewhat limited. Demand for health care and rehabilitation services is projected to increase in the next decade as a result of factors such as an aging population, increased public expectations, and advances in technology.^18,26,27 Ensuring that there is a sufficient human resource supply to meet future demand is a critical policy issue for which further research on health care services is required; the next step is to establish benchmarks.

Although evidence-based benchmarks regarding appropriate HHR ratios are not yet known, the proportional growth for physical therapists in both the United States and Canada is impressive compared with that for other disciplines. Although other health care disciplines in the United States tend to have a higher absolute ratio of practitioner to population, their rates of growth in the last decade have been modest compared with the results obtained in the present study. For instance, Shih²⁸ reported that, in the United States, the national ratio for nurses per 10,000 people was 78.2 in 2000; the ratio increased to 82.5 in 2004, a change representing a 5.5% increase between 2000 and 2004. Moreover, McEldowney and Berry²⁹ reported that there were 22.4 physicians per 10,000 people in 1992 and suggested that should that trend continue, there would be 30.0 physicians per 10,000 people by 2020. The forecasted trend suggested by McEldowney and Berry²⁹ would indicate a 25.6% increase over a 30-year period. The trend for an increase of 61.3% across the 10-year period for physical therapists in the United States represents much more impressive growth for therapists than for nurses or physicians in the United States.

As mentioned elsewhere, the reasons for such increases in HHR ratios for physical therapists were not directly explored in the present study. However, according to Alameddine et al,³⁰ HHR ratios may be affected by production variables (eg, education and training) and policy variables (eg, health system change). In terms of production, or the rates of educating new practitioners, there were 13 education programs in Canada during the period from 1995 to 2005. In 1995, the production of new physical therapist graduates in Canada was 665; this value dropped to 620 in 2000 and then slightly rebounded to 631 in 2005.¹⁹ Thus, there was a 5.1% overall decline in the number of new graduates between 1995 and 2004.¹⁹

Although the precise reasons for these findings are not yet fully known, they may be related to the transition toward masters degree entry-to-practice programs, in which university programs decrease or limit enrollment during a transition period. The production of physical therapists in Canada in the period from 2005 on may be quite different because a new physical therapist education program was developed in the province of Quebec, and some training programs have doubled their enrollment since 2005. In contrast, in the United States, there are 210 physical therapist education programs that graduate approximately 6,000 physical therapists per year (Marc S Goldstein, EdD, Director of Research Services, American Physical Therapy Association; personal communication; September 24, 2008). Although the populations of the United States and Canada are vastly different (ie, the population of Canada is 10% that of the United States), the United States has an appreciably higher production of physical therapists than Canada, and the number of educational programs in the United States also far exceeds the number in Canada. We found no publicly available reports that outline national trends in new physical therapist graduates in the United States.

The entry-to-practice physical therapy degree in the United States during the period from 1995 to 2005 shifted from a Master of Physical Therapy to a Doctor of Physical Therapy. In contrast, in Canada, the entry-level degree shifted from a Bachelor of Physiotherapy to a Master of Science in Physical Therapy. The level of education or training may not have a direct effect on the supply of physical therapists in either country, but the United States may ultimately be attracting more potential students into a "doctoring" profession, whereas Canada's programs grant master's degrees. Although it is speculative and surely requires further research, the presence of doctorate-level training may ultimately increase demand by potential students and result in higher production.

Other factors related to HHR production include rates of attrition (rates at which practitioners leave the profession), the movement of practitioners into and out of the workforce, and the influx of foreign-trained practitioners.³¹ No national-level analysis that explored these factors within the physical therapy profession was found in either the United States or Canada. As such, the extent to which graduates of physical therapy programs move out of the workforce (and how many move into the workforce) is not known, and the rates of foreign-trained physical therapists entering the profession and contributing to the overall professional population in either country are not known. The absence of data on these 2 important factors related to HHR production represents an opportunity for further research.

There are several relevant policy changes that may have affected HHR. A particularly relevant policy shift occurred in the United States during the study period. The Balanced Budget Act (BBA) of 1997 was a monumental policy shift that altered Medicare reimbursement. The history and impact of the BBA on publicly funded physical therapy reimbursement have been described by Enchelmayer et al³² and Latham et al³³ and will not be repeated here; however, it is important to remark that the BBA has been described as the most important change in Medicare since its inception in 1965.³⁴ In brief, the BBA was implemented as a way in which to reduce rapid growth in Medicare post-acute-care expenditures, including chronic care services provided by physical therapists (and other health care professionals, such as occupational therapists and speech-language pathologists), in various settings across the health care continuum. Enchelmayer et al³² conducted a survey of physical therapists in Florida in 1999 and concluded that implementation of the BBA resulted in reductions in employment settings and human resources in physical therapy. Latham et al³³ used national-level data that seemed to refute the findings of Enchelmayer et al³² by reporting that, in aggregate, there was no decline in physical therapist services for people with conditions for which rehabilitation services were indicated in the United States.

We suggest that, on the basis of our macro-level findings, the BBA may have had different effects depending on the age distributions of residents in certain jurisdictions, particularly states with higher proportions of people eligible for Medicare. Jurisdictions such as Florida may have been most likely to have been affected by the BBA because of a higher proportion of people over the age of 65 years. The data from the present study indicated that Florida had a 24.27% decrease in the physical therapist-to-population ratio between 1995 and 1999. However, this period of decline was followed by an increase of 50.1% between 1999 and 2005 and an aggregated overall increase of 6.6% between 1995 and 2005. Six other states experienced declines in HHR ratios between 1995 and 1999: Arizona (6.3%), Illinois (2.0%), Nevada (15.4%), New York (3.5%), North Dakota (1.1%), and Oregon (7.8%). Like Florida, all of these states rebounded in the period from 1999 to 2005 and showed positive growth, ranging from a low of 29.9% in Oregon to a high of 91.3% in Nevada. The BBA may have had a short-term effect on HHR ratios in some states with higher proportions of people eligible for Medicare, but between 1995 and 2005, all jurisdictions experienced aggregated positive growth at rates that surpassed those in Canada. Our data offer support for the findings of Latham et al³³ in that there appeared to be no long-lasting effects of the BBA on physical therapist HHR ratios across the United States. However, a policy factor that may have complicated the suggested relationship between reimbursement and HHR ratios was the 1999 Balanced Budget Refinement Act, which delayed the cap on outpatient physical therapy services.³⁵

In previous policy research in Canada, Gordon et al³⁶ and Paul et al³⁷ explored the outcomes of a policy shift that may not have been as dramatic as the shift resulting from the BBA but that nonetheless significantly altered reimbursement for publicly funded physical therapy services in the Canadian province of Ontario. Overall, the published findings regarding the partial delisting of publicly funded, community-based physical therapy services provided within a network of designated physical therapy centers in Ontario suggests that when policy changes are initiated to reduce reimbursement for publicly funded physical therapy services, the protective rebound effect may be a shift from public to private financing, resulting in some degree of human resource preservation. Although we believe that more research is needed to explore the short- and long-term effects of reimbursement policies, such as the BBA, on HHR strategies, we suggest that significant policy shifts affecting publicly funded physical therapy services may ultimately create the necessary underlying structure to encourage a shift from public to private financing for physical therapy services.

Limitations of US/Canada HHR Comparative Analysis

There are a number of inherent limitations of the present study and, although this research represents a foundation for additional research, there are details that must be considered. The sample of physical therapists in the present (US) study (as well as the sample in the Canadian study) included active and inactive physical therapists. We acknowledge that future investigations must separate active and inactive physical therapists, along with other factors, such as productivity measures, to yield more robust data regarding the clinical workforce. However, because the present study is the first, to our knowledge, to generate national-level data in the United States, it was most feasible to include both active and inactive registrants across the United States in our estimates of HHR ratios. Moreover, the methodological approach of including active and inactive registrants has been used by others to estimate HHR ratios.^2,4,7 We concede that there are limitations associated with this particular inclusion criterion, most notably, that active and inactive therapists would have different workloads and that therapists working full time also would differ in terms of productivity. Nevertheless, the integration of both groups allowed for more-direct comparisons of the 2 countries. Once again, we argue that this research provides the foundation for future research in an emerging investigative field.

Another important limitation may have been the ways in which jurisdictions reported their data over the same time period. Further research should validate the ways in which national HHR ratios are calculated and reported; for instance, we do not know whether, over time, more physical therapists were registered in multiple jurisdictions. The fact that APTA provides the only publicly available consolidated list of physical therapists in the United States represents an inherent limitation of the present study. It also is important that the starting points for the trend analyses were different in the 2 countries.

Another important limitation in the interpretation of HHR ratios is the "denominator effect"—that is, a slight change in the denominator can have an important effect on the numerator and thus the overall ratio. For instance, the HHR ratio can change because the numerator (physical therapists) increases at a higher or lower rate or because the denominator (population) increases at a higher or lower rate. A slight change in the denominator can have a greater effect than a change in the numerator. Thus, it will be instructive in future research to separate the change in the ratio into its component parts in order to more fully interpret the outcome.

	Conclusion

Top Abstract Introduction Method Results Discussion Conclusion References

 
We have found that there are 6.2 physical therapists per 10,000 people across the United States. The findings of the present study also indicate that there are differences between the United States and Canada in terms of population growth, growth in the absolute number of physical therapists, and HHR ratios for physical therapists relative to the population. Overall, our analysis indicated that despite policy shifts and changes in education or training, there has been a larger increase in the HHR ratios for physical therapists relative to the population in the United States than in Canada. Moreover, our results underscore the need to examine the policy and environmental factors that drive the supply of physical therapists, to develop evidence-based targets or benchmarks regarding optimal HHR ratios, and to explore the effects of public and private funding on HHR ratios. Novel research methods must be developed within a health policy framework to plan for a future stable supply of physical therapists to meet emerging health care and rehabilitation demands across the United States and Canada.

	Footnotes

 
All authors provided concept/idea/research design, writing, and data analysis. Dr Landry and Ms Verrier provided data collection.

Dr Landry holds a Career Scientist Personnel Award through the Ontario Ministry of Health and Long Term Care.

	References

Top Abstract Introduction Method Results Discussion Conclusion References

 

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