Evidence-Based Practice Proposal – Final Paper

The Problem of Debt and Geriatric Physical Therapy David B. Gillette, PT, DPT; Todd E. Davenport, PT, DPT; Alicia Rabena-Amen, PT, DPT

The cost of higher education con­ tinues to rise: student loan debt has pro­ gressively become a greater concern. In the United States, the price of a public and private non-profit “4-year” (under­ graduate) college degree has increased at a rate much greater than predicted by inflation.1 An analysis of self-reported student loan debt from a cohort of graduating college seniors in 2015 indi­ cated almost 70% of graduates reported a debt balance that averaged a record value of $30,100; almost 20% of the debt “was in private (nonfederal) loans” that tends to be associated with higher costs and fewer protections.2 In 2012, those graduating with a doctoral degree in professional practice had $120,000 or more in cumulative student loan debt.3

IMPACT ON THE INDIVIDUAL AND THE PROFESSION

Student loan debt greatly affects the individual borrower. Student loan debt correlates with subjective well-be­ ing,4 mental health,5,6 and substance use disorders.7 Student loan debt is also associated with life choices including living with parents,8 formation of their own family (getting married9 or hav­ ing children10), saving for the future, and availability of discretionary spend­ ing.11 Increased overall debt can have a negative impact on physical and mental health, including stress, depression, and high blood pressure.12

Student loan debt can affect the profession through the borrower. Stu­ dent loan debt is known to associate with career choices, including complet­ ing further training for pharmacists13 and nurses,14 reducing likelihood of specialization for dentists,15 and influ­ encing the choice of specialty for medi­ cal school graduates.10,16'18 Thus, the issue of student loan debt has great relevance to the financial, physical, and psychological well-being among gradu­ ating students, and the potential future of the profession. Most of the data available are for undergraduate students and medical students, so trends and po­

tential impacts on physical therapists of their educational costs remains unclear.

Many health professions in the United States, including physical ther­ apy, require a graduate degree for licen­ sure. The process of professionalization in physical therapy has involved an increase in level of the first professional degree required to enter the field and obtain licensure to a professional doc­ torate. Additional education up to 3 to 4 years post baccalaureate are required to accommodate the Doctor of Physical Therapy degree. This increased training time represents more direct and indirect costs of education to students. Direct costs include tuition and fees associated with the educational experience. Indi­ rect costs include living expenses and lost time for remunerative employment. Thus, although surveys specifically re­ lated to United States physical therapy education have not been conducted over time, it seems reasonable that increased training costs also may have resulted in an increased accumulation of stu­ dent debt among practicing physical therapists. Physical therapy graduate education is largely self-funded through savings, limited work, and loans.

Because physical therapy graduate education is self-funded through savings and loans, there may be a correlation between the cost of education and stu­ dent debt. Understanding the cost of physical therapy education helps to un­ derstand the debt burden in the profes­ sion, with potential impact on not only graduates but the profession as a whole. Graduates may experience physical and mental health ramifications, may make decisions of where to practice based on salary,11 and may choose not to pursue further training such as residencies or research doctorates. Additionally, there are indications that new graduates in physical therapy may be overleveraged with educational debt too high for the salary of a new graduate.19 This may impact the profession by creating areas of practice either in specialty or geogra­ phy with a dearth of physical therapists,

reducing the number of residency or fel­ lowship trained therapists, and reducing the number of research therapists even further, weakening academic institutions and progress in rehabilitation research.

A BRIEF LOOK AT HISTORICAL DATA

To understand the concern of stu­ dent debt and geriatric physical therapy, one should look at the historical trends of 3 things in relation to the Consumer Price Index (CPI): tuition, salary, and Medicare expenditures (Table 1). The CPI records the price paid for various goods and services and is used to cal­ culate inflation. We took the value for each September starting in 2009.20

Students have limited opportunity to work during school. Funding must come through savings or loans, so tu­ ition could be viewed as a proxy for the estimate of student debt. Using CAPTE’s annual reports since 2009 when 86% of the programs were award­ ing the DPT,21'23 it can be observed that tuition has increased annually for both public and private institutions.

In looking at the historical data of the salary of physical therapists during the same time period, the assumption was made that the 10th percentile is a new grad, 25th is a new professional, and mean is the mid-career salary.19 Comparing these annual changes to the change in tuition, one can see that salary is not rising as quickly as tuition.24

Geriatric physical therapy is in all settings - acute, skilled nursing, home health, and outpatient. What is con­ sistent is the payor source-Medicare. However rules, diagnosis codes, and payment criteria change every year, which creates a challenge when trying to collect historical data. No studies have been conducted to look at the changes in payment for physical therapy services across multiple settings. It would be a fair assumption however to say that the relative amount that physical therapy receives as a whole for Medicare expen­ ditures has not significantly increased. Historical data for Medicare expendi-

26 GeriNotes, Vol. 26, No. 2 2019

Table 1. Table 2.

Education Cost, Salary, Medicare Expenditure, and CPI

$120,000

$100,000

$80,000

$60,000

$40,000

$20,000

* v / *

s - 2009-2010 2010-2011 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016 2016-2017 2017-2018

• ‘ Total Cost: Public $34,979 $39,082 $45,750 $50,294 $55,997 $48,135 $59,210 $60,627

.... .. Total Cost: Private $84,564 $85,289 S85.289 $94,251 $99,797 $105,229 $105,857 $109,099

«h > mm Salary: 10th percentile $53,620 $54,710 $55,620 $56,280 $56,800 $57,060 $58,190 S59.080

Salary: 25th percentile $64,230 $65,860 $66,950 $67,700 $68,690 $69,620 $70,680 $71,670

$77,990 $79,830 $81,110 $82,180 $83,940 $85,790 $87,220 $88,080

* Medicare per enrollee expenditure $11,146 $11,442 S11,462 $11,514 $11,702 $11,904 $12,046

— - CPI (Sept) 215.861 218.275 226.597 231.015 233.544 237.452 237.467 241.017 246.392

"Tota l Cost: Public

' Salary: 10th percentile

' Salary: Mean

•CPI (Sept)

"•■To ta l Cost: Private

Salary: 25th percentile

' " Medicare per enrollee expenditure

tures per person was examined; that has increased at a slower rate than salaries during this same timeframe.25,26

WHY SHOULD WE CARE ABOUT DEBT?

When all these changes to the CPI are compared as a measure of inflation, there are several disconcerting observa­ tions that can be made when looking at the annual rate of growth (Table 2). First, salaries are not keeping up with the rise in tuition. If students are taking on the majority of their tuition as loans, this can become a problem where they become overleveraged in debt.19,27

Second, Medicare expenditures are not keeping up with salaries. If physical therapy reimbursement is keeping steady as a percentage of Medicare expen­ ditures, this will increase productivity pressures to keep company profits and salaries up. This may lead to increased burnout of new graduates. Third, sala­ ries are also not keeping up with infla­ tion. This is a concern not just for the student or new graduate, but also for the profession.

Rising student debt among early ca­ reer physical therapists eventually could limit participation in residency, fellow­ ship, and research training programs in

geriatric, neurologic, orthopedic, and other areas of physical therapy. In turn, there will be fewer clinical specialists available to serve patients and train new specialists. In addition, there may be future adverse effects of physical therapy education total program costs on the number of rehabilitation scientists who can inform geriatric physical therapy practice.

Taken together, these observations raise several concerns. First, the current trend of tuition in relation to salaries, re­ imbursement, and the CPI is unsustain­ able for individuals and the profession. Second, post-graduate training opportu­ nities only will be accessible to physical therapists who can afford them, which also could lower the representation of physical therapists from economically disadvantaged backgrounds in clinical specialist roles and the academe.

WHAT WE CAN DO Advocate: be involved with the

American Physical Therapy Association, and contact your legislators with the Action Center when called upon about reimbursement. This will not fix the problem as debt is rising too faster, but it can help.

Financial markers Annual rate of growth, 2009-2016

Consumer Price Index

1.60%

Public cost 5.50%

Private cost 3.70%

Salary - 10th 1.40%

Salary - 25th 1.60%

Salary - mean 1.90%

Medicare expenditure 1.30%

Be fiscally responsible. As a stu­ dent, limit your use of credit and stick to a budget, and use any resources or assistance your program may have. As a physical therapist, diligently pay off your student loans. See if your employer has an assistance program. Both students and licensed therapists should call on the American Physical Therapy Associa­ tion and its components, including the Academy of Geriatric Physical Therapy, to assist their membership in seeking and obtaining debt management and financial counseling services, in order to maintain optimal financial health.

Call on the American Physical Therapy Association and physical ther­ apy education programs to examine not only the efficacy of their educational modalities, but also their cost effective­ ness. There is a great diversity in the length and nature of physical therapy education programs, which primarily appears driven by judgments of face va­ lidity. It is time for physical therapy educators to weigh the costs of their educational modalities to students with their effectiveness. Perhaps even more importantly, administrators in charge of setting physical therapy tuition and fees should consider the cost burdens with regard to managing student debt following graduation, in addition to the relative size and competitiveness of applicant pools. Universities should consider if continuing to increase the cost per credit is responsible and sustain­ able, particularly as programs have been lengthened to accommodate the doctor­ al degree. Programs need to decide if it truly is in their best long-term interest to continue leveraging supply and demand economics to achieve increasing profits

GeriNotes, Vol. 26, No. 2 2019 27

considering the detrimental effects on our profession discussed above.

As indicated earlier, there is no systematic survey of student loan debt in physical therapy. Other professional organizations, such as the American Psy­ chological Association, conduct periodic surveys of graduate students to measure the financial health of their profession­ als. The American Physical Therapy Association and its components should develop a similar mechanism to sur­ vey student physical therapists, physical therapist graduates, and practicing clini­ cians at various time points. Potential variables of interest to measure would be the amount of student loan debt; the originator, guarantor, and servicer of student loan debt; income, affect, and mental health related to debt manage­ ment; and career choices related to debt management. Analyses from these data would allow for a deeper discussion of the potential issues facing physical thera­ pists as they relate to paying for their training costs.

REFERENCES 1. National Center for Education

Statistics. Fast Facts - Tuition costs of colleges and universities. https://nces.ed.gov/fastfacts/dis- play.asp?id=76. Accessed December 7, 2018.

2. The Institute for College Access and success, student debt and the class of 2015. 11th Annual Report. Oc­ tober 2016. https://ticas.org/sites/ default/files/pub_files/classof2015. pdf._Accessed December 7, 2018.

3. The College Board. Trends in high­ er education: cumulative debt for undergraduate and graduate studies over time. https://trends.colleg- eboard.org/student-aid/figures-ta- bles/cumulative-debt-undergradu- ate-graduate-studies-time,. Accessed December 7, 2018.

4. Tay L, Batz C, Parrigon S, Kuyk­ endall L. Debt and subjective well­ being: the other side of the income- happiness coin. / Happiness Stud. 2017; 18(3):903-937.

5. Walsemann KM, Gee GC, Gentile D. Sick of our loans: Student bor­ rowing and the mental health of young adults in the United States. SocSci Med. 2015;124:85-93. doi: 10.1016/j.socscimed.2014.11.027.

6. Richardson T, Elliott P, Rob­ erts R, Jansen M. A longitudinal

study of financial difficulties and mental health in a national sam­ ple of British undergraduate stu­ dents. Community Ment Health J. 2017;53(3):344-352. doi: 10.1007/ s i0597-016-0052-0. Epub 2016 Jul 29.

7. Jackson ER, Shanafelt TD, Hasan O, Satele DV, Dyrbye LN. Burn­ out and alcohol abuse/dependence among U.S. medical students. Aca­ demic Medicine. 2016;91(9):1251- 1256.

8. Houle JN, Warner C. Into the red and back to the nest? Stu­ dent debt, college completion, and returning to the parental home among young adults. So- ciolEduc. 2017;90(1):89-108. doi: 1 0 .1 1 7 7 /0 0 3 8 0 4 0 7 1 6 6 8 5 8 7 3 . Epub 2017 Jan 5.

9. Addo FR. Debt, cohabitation, and marriage in young adulthood. De­ mography. 2014;51 (5): 1677-1701. doi: 10.1007/s 13524-014-0333-6.

10. Rohlfing J, Navarro R, Maniya OZ, Hughes BD, Rogalsky DK. Medical student debt and major life choices other than specialty. Med Educ Online. 2014;19(1):25603. doi: 10.3402/meo.vl9.25603.

11. Thompson K, Coon J, Handford L. Financing physical therapy doc­ toral education: methods used by entry-level students and the finan­ cial impact after graduation. J Allied Health. 2011 ;40(4): 169-173.

12. Sweet E, Nandi A, Adam EK, Mc- Dade TW. The high price of debt: household financial debt and its im­ pact on mental and physical health. Soc Sci Med. 2013;91:94-100. doi: 10.1016/j.socscimed.2013.05.009. Epub 2013 May 16

13. Hammond DA, Oyler DR, Devlin, JW, et al. Perceived motivating fac­ tors and barriers for the completion of postgraduate training among American pharmacy students prior to beginning advanced pharmacy practice experiences. Am J Pharm Educ. 2017;81(5):90.

14. Jones-Schenk J, Leafman J, Wallace L, Allen P. Addressing the cost, val­ ue, and student debt in nursing ed­ ucation. Nurs Econ. 2017;35( 1):7- 13, 29.

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career decisions. J Am Dent Assoc. 2015;l46(ll):800-807.

16. Rosenblatt RA, Andrilla CH. The impact of U.S. medical students’ debt on their choice of primary care careers: an analysis of data from the 2002 medical school gradu­ ation questionnaire. Acad Med. 2005;80(9):815-819.

17. Phillips JP, Weismantel DP, Gold KJ, Schwenk TL. Medical stu­ dent debt and primary care spe­ cialty intentions. Fam Med. 2010;42(9):616-622.

18. Phillips JP, Petterson SM, Bazemore AW, Phillips RL. A retrospective analysis of the relationship between medical student debt and primary care practice in the United States. Ann Fam Med. 2014;12:542-549.

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20. United States Department of Labor, Bureau of Labor Statistics. Con­ sumer Price Index. https://www. bls.gov/cpi/data.htm. Accessed De­ cember 7, 2018.

21. Commission on Accreditation in Physical Therapy Education (CAPTE). 2011-2012 Fact Sheet - Physical Therapist Education Pro­ grams. http://www.capteonline.org/ uploadedFiles/CAPTEorg/About_ C A PT E /R esources/A ggregate_ Program_Data/Archived_Aggre- gate_Program_Data/CAPTEPTAg- gregateData_2012.pdf . Accessed December 7, 2018. “CAPTE bears no responsibility for interpretations presented or conclusions reached based on analysis of the data.”

22. Commission on Accreditation in Physical Therapy Education (CAPTE). Aggregate program data 2 0 1 5 -2 0 1 6 physical therapist edu­ cation programs fact sheets, http:// w w w .capteonline.org/uploaded- Files/CAPTEorg/About_CAPTE/ Resources/Aggregate_Program _ D ata/A rchived_A ggregate_Pro- gram_Data/PTAggregateData2016. pdf . Accessed December 7, 2018. “CAPTE bears no responsibility for interpretations presented or conclu­ sions reached based on analysis of the data.”

23. Commission on Accreditation in Physical Therapy Education (CAPTE). Aggregate program data 2 0 1 7-2018 physical therapist edu-

28 GeriNotes, Vol. 26, No. 2 2019

cation programs fact sheets, http:// w w w .capteonline.org/uploaded- Files/CAPTEorg/About_CAPTE/ Resources/A ggregate_Program _ Data/AggregateProgramData_PT- Programs.pdf. Accessed December 7, 2018. “CAPTE bears no respon­ sibility for interpretations presented or conclusions reached based on analysis of the data.”

24. United States Department of Labor Bureau of Labor Statistics. Oc­ cupational employment statistics. h ttps://w w w .bls.gov/oes/tab les. htm. Accessed December 7, 2018.

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American Geriatrics Society Unveils Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

With more than 90% of older people using at least one prescription and more than 66% using 3 or more in any given month, the AGS Beers Criteria®— a compendium of medications potentially to avoid or consider with caution

because they often present an unfavorable balance of benefits and harms for older people— plays a vital role in helping health professionals, older adults, and caregivers work together to ensure medications are appropriate.

Read more at https://www.americangeriatrics.org/media-center/news/older-people- medications-are-common-updated-ags-beers-criteriar-aims-make-sure

PDPM and PDGM Resources A new MLN Matters Article MM 11081 on Home Health Patient-Driven Groupings M odel (PDGM)—

Spilt Implementation is available. Learn about the payment reform requirements.

A new MLN Matters Article M M 11152 on Implementation o f the Skilled Nursing Facility (SNF) Patient Driven Payment M odel (PDPM) is available. Learn about the required changes.

A New SNF PD PM Webinar Recording is Now Available An Overview of the Skilled Nursing Facility Patient-Driven Payment Model

webinar is now available at http://apta.adobeconnect.com/pch0i3flszlw/ The webinar was put together by the Post-Acute Care Educational Collaborative and was done by AGPT and

HPA members along with APTA staff. The webinar recording is open to all members and non-members.

CMS has a PDPM webpage at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html

2016: spending and enrollment growth slow after initial coverage expansions. Health A ff (Millwood). 2018;37(1): 150-160.

27. Shields RK, Dudley-Javoroski S. Physiotherapy education is a good financial investment, up to a cer­ tain level of student debt: an inter­ professional economic analysis. J Physiother. 2018;64(3):183-191. doi: 10.10 l6/j.jphys.2018.05.009. Epub 2018 Jun 15.

David Gillette, PT, DPT, GCS, is an Assistant Profes­ sor at University of the Pacific where he teaches several class­ es including geriat- rics. Dr. Gillette is

a board certified clinical specialist in geriatric physical therapy. He has had experience in skilled nursing and outpa­ tient care, and is now seeing patients in the home.

Todd E. Davenport, PT, DPT, MPH, OCS, is Professor and Program Direc­ tor with the Depart­ ment of Physical Therapy at Univer­ sity of the Pacific in

Stockton, California. Dr. Davenport is a board certified clinical specialist in orthopaedic physical therapy.

Alicia Rabena- Amen, PT, DPT, is an Assistant Profes­ sor and the Director of Clinical Educa­ tion for the Depart­ ment of Physical Therapy at the Uni­

versity of the Pacific in Stockton, Cali­ fornia. Dr. Rabena-Amen also serves as a board member to the Physical Therapy Board of California, as well as a volun­ teer for the Federation of State Boards of Physical Therapy.

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GeriNotes, Vol. 26, No. 2 2019 29

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