President Obama signed the Patient Protection and Affordable Care Act (ACA) into law on March 23, 2010. The ACA represents the most significant transformation of the American health care system since the Medicare legislation of 1965.1 It has been suggested that the Congressional Budget Office (CBO) and the Obama administration have used creative accounting to arrive at an alleged deficit reduction following implementation of the ACA;1 furthermore, according to several recent economic health policy analyses,1-5 if the employer mandates, individual mandates, Medicare cuts, state health insurance exchanges, and Medicaid expansion are each fully implemented, there will likely be a significant increase in deficits rather than a reduction.1 Additionally, it is accepted that the ACA will provide greater demand for mid-level primary care clinicians such as nurse practitioners, physician assistants, or even physical therapists; however the extent to which the ACA will impact these professions within the U.S. health care workforce has received little attention.6
The 2014 Medicaid expansion was the single biggest budgetary increase in the Medicaid system since its inception in 1965. Moreover, the impact that the ACA will have on access to care, in part will largely depend on whether the newly eligible individuals choose to participate in the Medicaid enrollment process.4 The subsidies provided by the ACA are available to those purchasing health insurance through state-based exchanges that have incomes up to 400% of the poverty level ($93,700 for a family of four in 2014). At 138% of the poverty level, an individual is responsible for the cost of health insurance up to a level of 2% of their income; however, for incomes above this level, the maximum percentage of income that an individual should pay increases in increments to 9.5% of income at 400% of poverty level. This all costs money of course. For 2011 to 2013, US health spending grew on average at 4.0% with a historical rate of 3.8%; however, since the implementation of the ACA in 2014, health spending growth is expected to accelerate to 7.4% as both the state-based health insurance subsidies and Medicaid expansion are fully implemented. Thus, the healthcare share of the gross domestic product (GDP) is projected to rise from 17.9% in 2010 to 19.6% by 2021.2,3 Comparatively, the UK, Canada and Germany have been able to maintain health care spending levels between 8.2% and 9.8% of GDP for several decades.7-10
As the U.S. healthcare system continues to expand and rapidly evolve as a result of the implementation of the many aspects of ACA, so must physical therapists if they truly want to become the first choice providers for Americans with neuromusculoskeletal disorders. The profession has historically prided itself on its ability to improve pain, disability and general health with exercise. However, in the past decade, Physician-Owned Physical Therapy Services (POPTS) and/or “contract-management” PT operations have reached new heights. Furthermore, as a result of the implementation of the provisions in the ACA, and in many larger metropolitan markets, “big” healthcare, hospital and network mergers have effectively turned off the tap for referrals from medical physicians to independently owned physical therapy clinics. It has become much more difficult for the independent, private practice physical therapist to make a living over the past decade. Additionally, with DPT student loan levels at record highs and the aforementioned changes in healthcare, it is difficult to fathom how the new crop of physical therapists will be able to afford to open up their own clinics and become their own bosses—as we believe it should be for a growing, not diminishing, portion of a doctoring profession.
As U.S. healthcare moves towards a pay-for-performance, or outcome-based system, physical therapists will need to recognize that they need to be more than exercise specialists. Yes, exercise is medicine, but many professions (e.g. athletic trainers, personal trainers, chiropractors, massage therapists, osteopaths, medical physicians, oriental medical doctors, podiatrists, and even surgeons) prescribe or utilize exercise in the management of their patients—exercise is a shared procedure among many professions and no single profession can lay exclusive claim on such. We are not the only profession that claims to be movement specialists; furthermore to date, the majority of the American public may not even recognize us as the primary authorities on exercise or movement. Interestingly and contrary to the belief held by many physical therapists for two decades, it is now clear from the literature that the transverse abdominus is not the only muscle authorized by God to “stabilize” the spine;11-14 that is, for low back or neck pain, specific or core stabilization exercises targeting the deep neck flexors or the transverse abdominus are no better than general exercise.11-14
In short, skyrocketing health care costs (partly due to the implementation of the ACA) combined with dwindling reimbursement rates have left patients, referral sources and insurance companies demanding better patient outcomes in less time. We believe the need for advanced training in Orthopaedic Manual Physical Therapy has never been more crucial for the successful operation of your own fully independent, outpatient physical therapy clinic that isn’t at the mercy of “big” healthcare or overly dependent on referrals from medical physicians.
As three relatively new private practice owners in outpatient orthopaedic physical therapy, we investigated a number of APTA-accredited Fellowship programs that would allow us to gain the skills necessary to help grow our new practices. While we found a number of quality programs throughout the United States, the American Academy of Manipulative Physical Therapy (AAMT) Fellowship in Orthopedic Manual Physical Therapy appeared to be more focused than other programs on the actual psychomotor development of advanced procedural skills in spinal manipulation and dry needling, along with a focus on exploring the scientific evidence underpinning such. The 12-month, accelerated AAMT Fellowship does not require relocation and this was advantageous for us in order to continue working in each of our respective practices. Moreover, the evidence-based curriculum was both comprehensive and directly applicable to the management of patients with neuromusculoskeletal conditions. In particular, the training we received in non-thrust mobilization, high-velocity low-amplitude thrust manipulation of the spine and the extremities, tool-assisted therapy, dry needling, manual techniques related to vestibular disorders, and differential diagnosis appears to have facilitated a dramatic expansion in our referrals and patient population, as we are now able to treat a greater number and variety of patient diagnoses in less time. Within just three months of entering the AAMT Fellowship program, each of our clinics went from standard or general physical therapy providers (seeing predominantly post-op patients) to specialty clinics with the ability to diagnose and treat much more complex patients, including: cervicogenic headaches, migraine, tension type headaches, post-partum pelvic pain, plantar fasciitis, second and third rib syndrome, cervicothoracic myofascial pain syndrome, and a variety of maxillofacial pain syndromes.
The American Academy of Manipulative Therapy Fellowship in Orthopaedic Manual Physical Therapy is accredited by the American Physical Therapy Association (APTA) as a post-professional fellowship program for physical therapists in Orthopaedic Manual Physical Therapy. Therefore, after graduation from the 12-month AAMT Fellowship program, we will be awarded the FAAOMPT credential (i.e. become Fellows of the American Academy of Orthopaedic Manual Physical Therapists) via AAOMPT, the official Member Organization of IFOMPT (International Federation of Orthopaedic Manual Physical Therapists). In addition, we also earned the Certification in Spinal Manipulative Therapy (Cert. SMT), the Certification in Dry Needling (Cert. DN), and the Diploma in Osteopractic while completing the AAMT Fellowship curriculum. We believe this has been paramount in our ability to effectively market our services directly to the consumer (i.e. potential patients) and to specialist physicians (headache neurologists, gynecologists, maxillofacial surgeons, physiatrists, podiatrists, dentists etc.) as these specialty certifications demonstrate the ability to provide treatment and/or diagnoses that are above and beyond what a “general” physical therapist has been educated and trained to do.
The AAMT Fellowship curriculum is particularly strong in clinical research. In addition to an online journal club whereby we continuously appraise the latest literature on manual therapy, exercise, dry needling and Western acupuncture, we receive intensive training in research design, research methodology, biostatistics, grant writing, emerging technologies in physical therapy research, and the biopsychosocial and pharmaceutical aspects of pain management. We were blown away by the lectures provided by Dr. Stacy Fritz, the head of the University of South Carolina Doctor of Physical Therapy Program. Moreover, the hands-on instruction with fMRI, non-invasive brain stimulation, gait-rite technology and diagnostic ultrasound more than surpassed our expectations. We particularly enjoyed the advanced musculoskeletal imaging course with Dr. Paul Beattie and the applied musculoskeletal anatomy course (with real cadavers!) at the third week-intensive in Columbia, SC.
Nevertheless, regardless of the didactic coursework and all of the scientific literature that we have critically appraised over the past year in the AAMT Fellowship, evidence-based medicine is not restricted to randomized controlled trials, systematic reviews and meta-analyses.15 In the seminal article “Evidence-based medicine: what it is and what it isn’t”, Sackett et al15 stated, “Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient.” In short, the technical skill and mastery that we have each gained during the AAMT Fellowship, specifically in the sub-specialty areas of spinal manipulation and dry needling, and the practical clinical training (both diagnostic and management based) has allowed us to work from a platform that rests on all three pillars of evidence-based practice.
We believe the curriculum, hands-on training, and osteopractic approach to patient care offered through the AAMT Fellowship program is second to none. Dr. Dunning has truly created a team of faculty members that are both academic and clinical experts. For example, each AAMT faculty member is adept at manipulating or adjusting the upper cervical spine16,17 and masterful in the use of the 9-point semi-standardized dry needling protocol for the management of knee osteoarthritis18-34—thus, you can learn by seeing as well as by doing. With over 140 applicants to the AAMT Fellowship program within its first two years of existence, Dr. Dunning has also been able to handpick the most qualified and well-suited fellows-in-training. We have particularly enjoyed the camaraderie with exceptionally talented physical therapists throughout the United States. It has been a privilege to be a part of such a fine group of individuals that have the ability to move the profession forward. We are thankful for the friendship and professional connections that we have made through the AAMT Fellowship program.
As Albert Einstein once said, “Education is what remains after one has forgotten what one has learned in school.” For those of you considering an APTA-accredited post-professional fellowship program in Orthopaedic Manual Physical Therapy, we believe the 12-month, accelerated AAMT Fellowship is your best option!
Casey Bush, PT, MSc, Cert. DN, Cert. SMT, Dip. Osteopractic
Owner & Physical Therapist, Body, Heart & Spine, Jonesboro, AR
Fellow in Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Dr. Amy Brannon, PT, DPT, Cert. DN, Cert. SMT, Dip. Osteopractic
Owner & Physical Therapist, T.O.P.S. Physical Therapy, Phoenix, AZ
Fellow in Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Todd Koos, PT, Cert. MDT, Cert. DN, Cert. SMT, M.Div., Dip. Osteopractic
Owner & Physical Therapist, Physical Therapy Center, Monroe / Waxhaw, NC
Fellow in Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy
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