Back pain? Bum knee? Be prepared to wait for a physical therapist

At no point along his three-year path to earning a degree in physical therapy has Matthew Lee worried about getting a job.

Being able to make a living off that degree? That's a different question – and the answer is affecting the supply of physical therapists across the nation: The cost of getting trained is out of proportion to the pay.

"There's definitely a shortage of PTs. The jobs are there," said Lee, a student at California State University-Sacramento, who is on track to receive his degree in May. "But you may be starting out at $80,000 while carrying up to $200,000 in student debt. It's a lot to consider."

As many patients seeking an appointment can attest, the nationwide shortage of PTs is real. According to survey data collected by the American Physical Therapy Association (APTA), the job vacancy rate for therapists in outpatient settings last year was 17%.

Wait times are generally long across the nation, as patients tell of waiting weeks or even months for appointments while dealing with ongoing pain or post-surgical rehab. But the crunch is particularly acute in rural areas and places with a high cost of living, like California, which has a lower ratio of therapists to residents: just 57 per 100,000, compared with the national ratio of 72 per 100,000, according to the APTA.

The reasons are multifold. The industry hasn't recovered from the mass defection of physical therapists who fled as practices closed during the COVID-19 pandemic. In 2021 alone, more than 22,000 PTs – almost a tenth of the workforce – left their jobs, according to a report by the health data analytics firm Definitive Healthcare.

And just as baby boomers age into a period of heavy use of physical therapy, and pandemic-delayed procedures like knee and hip replacements are finally scheduled, the economics of physical therapy are shifting. Medicare, the members of which make up a significant client base percentage of many PT practices, has cut reimbursement rates for four years straight, and the encroachment of private equity firms – with their bottom-line orientation – means many practices aren't staffing adequately.

According to the APTA, ten companies, including publicly held and private equity-backed firms, now control 20% of the physical therapy market.

"What used to be small practices are often being bought up by larger corporate entities, and those corporate entities push productivity and become less satisfying places to work," said James Gordon, chair of the Division of Biokinesiology and Physical Therapy at the University of Southern California.

There's a shortage of physical therapists in all settings, including hospitals, clinics and nursing homes, and it's likely to continue for the foreseeable future, said APTA CEO Justin Moore. "Not only do we have to catch up on those shortages, but there are great indicators of increasing demand for physical therapy," he said.

The APTA is trying to reduce turnover among therapists, and is lobbying Congress to stop cutting Medicare reimbursement rates. The Centers for Medicare & Medicaid Services (CMS), the federal agency that administers Medicare, plans a 3.4% reduction for 2024 to a key metric that governs pay for physical therapy and other health care services. According to the APTA, that would bring the cuts to a total of 9% over four years.

Several universities, meanwhile, have ramped up their PT training programs – some by offering virtual classes, a new approach for such a hands-on field – to boost the number of graduates in the coming years.

"But programs can't just grow overnight," said Sharon Gorman, interim chair of the physical therapy program at Oakland-based Samuel Merritt University, which focuses on training health care professionals. "Our doctoral accreditation process is very thorough. I have to prove I have the space, the equipment, the clinical sites, the faculty to show that I'm not just trying to take in more tuition dollars."

All of this also comes at a time when the cost of obtaining a physical therapy doctorate, which typically takes three years of graduate work and is required to practice, is skyrocketing. Student debt has become a major issue, and salaries often aren't enough to keep therapists in the field.

According to the APTA's most recent published data, median annual wages range from $88,000 to $101,500. The association said wages either met or fell behind the rate of inflation between 2016 and 2021 in most regions.

A project underway at the University of Iowa aims to give PT students more transparency about tuition and other costs across programs. According to an APTA report from 2020, at least 80% of recent physical therapy graduates carried educational debt averaging roughly $142,000.

Gordon said the University of Southern California, in Los Angeles' urban core, has three PT clinics and 66 therapists on campus, several of whom graduated from the school's program. "But even with that, it's a challenge," he said. "It's not just hard to find people, but people don't stay, and the most obvious reason is that they don't get paid enough relative to the cost of living in this area."

Fewer therapists plus growing demand equals those long waits. When Susan Jones, who lives in Davis, California, experienced pain in her back and neck after slipping on a wet floor in early 2020, she went to her doctor and was referred for physical therapy. About two months later, she said, she finally got an appointment at an outpatient clinic.

"It was almost like the referral got lost. I was going back and forth, asking, 'What's going on?'" said Jones, 57. Once scheduled, her first appointment felt rushed, she said, with the therapist saying he couldn't identify an issue, despite her ongoing pain. After one more session, Jones paid out-of-pocket to see a chiropractor. Given her experience, she said she'd be hesitant to try for a physical therapy referral in the future, in part because of the wait.

Universities and PT programs graduate about 12,000 therapists a year, the APTA's Moore said, and representatives of several schools told KFF Health News they're studying whether and how to expand. In 2018, USC added a hybrid model in which students learn mostly online, then travel to campus twice a semester for about a week at a time for hands-on instruction and practice.

That bumped USC's capacity from 100 students a year to 150. Gordon said many of the hybrid students' professional skills are indistinguishable from those of students on campus full time.

Natalia Barajas received her PT doctorate from USC last year and was recently hired at a clinic in nearby Norwalk, with a salary of $95,000, a signing bonus, and the opportunity to earn more in incentives.

She's also managing a lot of debt. Three years of tuition for the USC physical therapy program comes to more than $211,000, and Barajas said she owes $170,000 in student loans.

"If it were about money alone, I probably would have shifted to something else a while ago," Barajas said. "I'm OK with my salary. I chose to do this. But it might not be the perfect situation for everybody."

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF -- the independent source for health policy research, polling, and journalism. KFF Health News is the publisher of California Healthline, an editorially independent service of the California Health Care Foundation.