Physical Therapy Health Human Resource Ratios: A

Comparative Analysis of the United States and

Canada
Michel D Landry, Thomas C Ricketts, Erin Fraher and
Molly C Verrier
PHYS THER. 2009; 89:149-161.
Originally published online January 8, 2009
doi: 10.2522/ptj.20080075

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 Research Report

Physical Therapy Health Human

Resource Ratios: A Comparative
Analysis of the United States and
Canada
Michel D Landry, Thomas C Ricketts, Erin Fraher, Molly C Verrier
MD Landry, PT, PhD, is Adjunct
Assistant Professor, Department of
Health Policy and Administration,
Background and Purpose. Health human resource (HHR) ratios are a mea- University of North Carolina at
sure of workforce supply and are expressed as a ratio of the number of health care Chapel Hill, Chapel Hill, North
practitioners to a subset of the population. Health human resource ratios for physical Carolina, and Assistant Professor,
therapists have been described for Canada but have not been fully described for the Department of Physical Therapy,
United States. In this study, HHR ratios for physical therapists across the United States Faculty of Medicine, University of
Toronto, Rehabilitation Sciences
were estimated in order to conduct a comparative analysis of the United States and Building, 8th Floor, 160 500 Uni-
Canada. versity Ave, Toronto, Ontario,
Canada M5G 1V7. Address all cor-
Methods. National US Census Bureau data were linked to jurisdictional estimates respondence to Dr Landry at:
of registered physical therapists to create HHR ratios at 3 time points: 1995, 1999, and mike.landry@utoronto.ca.
2005. These results then were compared with the results of a similar study conducted TC Ricketts, PhD, is Professor, De-
by the same authors in Canada. partment of Health Policy and Ad-
ministration, and Director, North
Carolina Rural Health Research
Results. The national HHR ratio across the United States in 1995 was 3.8 per Program, Cecil G Sheps Center for
10,000 people; the ratio increased to 4.3 in 1999 and then to 6.2 in 2005. The Health Services Research, Univer-
aggregated results indicated that HHR ratios across the United States increased by sity of North Carolina at Chapel
61.3% between 1995 and 2005. In contrast, the rate of evolution of HHR ratios in Hill.
Canada was lower, with an estimated growth of 11.6% between 1991 and 2005. E Fraher, MPP, PhD Candidate, is
Although there were wide variations across jurisdictions, the data indicated that HHR Director, NC Health Professions
ratios across the United States increased more rapidly than overall population growth Data System, Cecil G Sheps Cen-
in 49 of 51 jurisdictions (96.1%). In contrast, in Canada, the increase in HHR ratios ter for Health Services Research,
University of North Carolina at
surpassed population growth in only 7 of 10 jurisdictions (70.0%).
Chapel Hill.

Discussion and Conclusion. Despite their close proximity, there are differ- MC Verrier, PT, MSc, is Associate
ences between the United States and Canada in overall population and HHR ratio Professor, Department of Physical
Therapy and Graduate Depart-
growth rates. Possible reasons for these differences and the policy implications of the ment of Rehabilitation Sciences,
findings of this study are explored in the context of forecasted growth in demand for University of Toronto.
health care and rehabilitation services.
[Landry MD, Ricketts TC, Fraher E,
Verrier MC. Physical therapy
health human resource ratios: a
comparative analysis of the United
States and Canada. Phys Ther.
2009;89:149 161.]

2009 American Physical Therapy

Association

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Physical Therapy Health Human Resource Ratios
H
ealth human resources (HHR)
continue to emerge as critical
factors in health care policy
planning.13 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 pol-
icy 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 peo-
ple 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 practitio-
ners 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 de-
veloping 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 physicians6 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 Cana-
dian HHR ratio for physical thera-
pists to be 5.0 per 10,000 people in
2000, which represented a 16.3% in-
crease 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% in-
crease in the HHR ratio between
1991 and 2005, there was an alarm-
ing decline in the HHR ratio between
150 f Physical Therapy Volume 89 Number 2
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2000 and 2005. Although the rea-
sons for this decline were not dis-
cussed, 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 analy-
sis regarding HHR ratios for physical
therapists, and the existing data con-
cern ratios at the state or county lev-
el.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 thera-
pists across the United States at 3
time points: 1995, 1999, and 2005.
The second objective was to com-
pare the HHR ratio estimates in the
United States with those in Canada
to explore trends in the 2 countries.
this study was to compare US data
Method
The method used in this study was
similar to that previously applied by
Landry12 and Landry et al13 to esti-
mate HHR ratios for physical thera-
pists in Canada. In brief, for the de-
termination of HHR ratios across the
United States, 2 sources of data were
linked to generate estimates of the
number of physical therapists rela-
tive to the population. First, publicly
available historical population data
from the US Census Bureau were re-
trieved for the years 1995, 1999, and
2005 in each of the 50 states and the
District of Columbia.15 Second, pub-
licly available estimates of the total
number of active and inactive regis-
tered physical therapists in each US
jurisdiction were obtained from the
American Physical Therapy Associa-
tion (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 juris-
diction 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 peo-
ple 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 de-
termined by calculating the percent
changes between 1995 and 1999, be-
tween 1999 and 2005, and between
1995 and 2005.
In this study, both active physical
therapists (defined by APTA as cur-
rently practicing) and inactive phys-
ical therapists (defined by APTA as
not practicing) were included in the
sample of physical therapists for 3
reasons. First, APTAs publicly avail-
able files collapse both categories,
making it difficult to distinguish be-
tween them. Second, an objective of
with Canadian data, and a compara-
tive Canadian study13 included both
active and inactive physical thera-
pists in the data analysis. Third, the
overall goal of this study was to pro-
vide a macro-level perspective on
the number of physical therapists rel-
ative to the population, and much of
the reviewed literature included the
total numbers of active and inactive
health care professionals as a mea-
sure 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 thera-
pists in the United States. The APTA
gathers data on human resources
across the United States through an-
February 2009
 Physical Therapy Health Human Resource Ratios

Table 1.
Total Population by State or Jurisdiction in 1995, 1999, and 2005
Population in: % Change

State or From 1995 From 1999 From 1995

Jurisdiction 1995 1999 2005 to 1999 to 2005 to 2005

Alabama 4,253,000 4,369,000 4,548,000 2.75 4.08 6.94

Alaska 604,000 619,000 663,000 2.57 7.06 9.81

Arizona 4,218,000 4,778,000 5,953,000 13.28 24.58 41.13

Arkansas 2,484,000 2,551,000 2,775,000 2.71 8.79 11.74

California 31,589,000 33,145,000 36,154,000 4.93 9.08 14.45

Colorado 3,747,000 4,056,000 4,663,000 8.25 14.97 24.45

Connecticut 3,275,000 3,282,000 3,500,000 0.21 6.66 6.89

Delaware 717,000 753,000 841,000 5.10 11.71 17.40

Florida 14,166,000 15,111,000 17,768,000 6.67 17.58 25.43

Georgia 7,201,000 7,788,000 9,132,000 8.15 17.26 26.82

Hawaii 1,187,000 1,185,000 1,273,000 0.13 7.40 7.27

Idaho 1,163,000 1,251,000 1,429,000 7.63 14.19 22.90

Illinois 11,830,000 12,128,000 12,765,000 2.52 5.25 7.91

Indiana 5,803,000 5,942,000 6,266,000 2.41 5.44 7.98

Iowa 2,842,000 2,869,000 2,965,000 0.96 3.35 4.35

Kansas 2,565,000 2,654,000 2,748,000 3.47 3.55 7.14

Kentucky 3,860,000 3,960,000 4,172,000 2.61 5.35 8.10

Louisiana 4,342,000 4,372,000 4,507,000 0.69 3.09 3.81

Maine 1,241,000 1,253,000 1,318,000 0.97 5.20 6.22

Maryland 5,042,000 5,171,000 5,589,000 2.57 8.08 10.86

Massachusetts 6,074,000 6,175,000 6,433,000 1.67 4.18 5.92

Michigan 9,549,000 9,863,000 10,100,000 3.30 2.40 5.78

Minnesota 4,610,000 4,775,000 5,126,000 3.59 7.35 11.21

Mississippi 2,697,000 2,768,000 2,908,000 2.66 5.05 7.84

Missouri 5,324,000 5,468,000 5,797,000 2.71 6.02 8.90

Montana 870,000 882,000 934,000 1.47 5.89 7.44

Nebraska 1,637,000 1,666,000 1,758,000 1.77 5.53 7.40

Nevada 1,530,000 1,809,000 2,412,000 18.25 33.33 57.67

New Hampshire 1,148,000 1,201,000 1,306,000 4.63 8.80 13.83

New Jersey 7,945,000 8,143,000 8,703,000 2.50 6.87 9.54

New Mexico 1,685,000 1,739,000 1,925,000 3.25 10.70 14.30

New York 18,136,000 18,196,000 19,315,000 0.33 6.15 6.50

North Carolina 7,195,000 7,650,000 8,672,000 6.33 13.35 20.53

North Dakota 641,000 633,000 634,000 1.14 0.15 1.00

Ohio 11,151,000 11,256,000 11,470,000 0.95 1.90 2.87

Oklahoma 3,278,000 3,358,000 3,543,000 2.44 5.52 8.10

Oregon 3,141,000 3,316,000 3,638,000 5.58 9.73 15.85

Pennsylvania 12,072,000 11,994,000 12,405,000 0.65 3.43 2.76

Rhode Island 990,000 990,000 1,073,000 0.08 8.35 8.44

South Carolina 3,673,000 3,885,000 4,246,000 5.79 9.30 15.63

South Dakota 729,000 733,000 774,000 0.57 5.69 6.29

(Continued)

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Physical Therapy Health Human Resource Ratios

Table 1.
Continued
Population in: % Change

State or From 1995 From 1999 From 1995

Jurisdiction 1995 1999 2005 to 1999 to 2005 to 2005

Tennessee 5,256,000 5,483,000 5,955,000 4.33 8.61 13.31

Texas 18,724,000 20,044,000 22,928,000 7.05 14.39 22.46

Utah 1,951,000 2,129,000 2,490,000 9.17 16.93 27.64

Vermont 585,000 593,000 622,000 1.49 4.82 6.39

Virginia 6,618,000 6,872,000 7,564,000 3.85 10.06 14.30

Washington 5,431,000 5,756,000 6,291,000 5.99 9.30 15.85

Washington, DC 554,000 519,000 582,000 6.32 12.15 5.06

West Virginia 1,828,000 1,806,000 1,814,000 1.15 0.40 0.76

Wisconsin 5,123,000 5,250,000 5,527,000 2.49 5.28 7.90

Wyoming 480,000 479,000 508,000 0.08 6.09 6.00

United States 262,755,000 272,690,000 296,507,000 3.78 8.73 12.85

nual requests to all licensing bodies
in each of the 50 states and the Dis-
trict of Columbia. In large measure,
the licensing bodies provide HHR in-
formation to APTA; however, be-
cause a physical therapist can be li-
censed to practice in more than one
state, relying solely on individual
state-level data would overestimate
the number of licensed physical ther-
apists in the United States. There-
fore, each states 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 phys-
ical therapists in each state. Al-
though there is an error rate associ-
ated with these estimates, APTA has
estimated HHR data by using the
same methodology at the 3 time pe-
riods of interest in this study, and
these data represent the only pub-
licly available national-level data.
Population growth, absolute num-
bers of physical therapists, and HHR
ratios obtained from the US sample
were used, along with published Ca-
nadian data, in a comparative analy-
sis 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 differ-
ences resulted from the availability
of publicly available data from the
original sources. The first and sec-
ond 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 dif-
ferences and policy implications of
our findings are presented in the
Discussion section.
Results
Population Growth in the
United States
The population of the United States
in 2005 was 296.5 million, represent-
ing 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 be-
tween 1995 and 2005, the positive
growth was not equal across all ju-
risdictions. 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.
Growth in the Absolute Number
of Physical Therapists in the
United States
The data indicated that the absolute
number of physical therapists in the
United States increased from 98,696
in 1995 to 167,810 in 2005, repre-
senting an increase of 70.0%. As
shown in Table 2, the growth in the
number of physical therapists was
not equal across the United States;
there were differences among juris-
dictions. Although each of the 51
jurisdictions experienced overall
positive growth in the absolute num-
ber of physical therapists from 1995
to 2005, there was a range from a
low of 13.7% in Florida to a high of
151.0% in West Virginia. However,
in the latter 5-year period
(1999 2005), Michigan and the Dis-
trict of Columbia experienced de-
creases of 2.5% and 11.7%,
respectively.

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 Physical Therapy Health Human Resource Ratios

Table 2.
Number of Physical Therapists by State or Jurisdiction in 1995, 1999, and 2005
No. of Physical Therapists in: % Change

State or From 1995 From 1999 From 1995

Jurisdiction 1995 1999 2005 to 1999 to 2005 to 2005

Alabama 942 1,218 1,524 29.30 25.15 61.78

Alaska 246 258 391 4.88 51.55 58.94

Arizona 1,670 1,772 2,655 6.11 49.83 58.98

Arkansas 723 765 1,308 5.81 70.98 80.91

California 11,400 13,511 16,402 18.52 21.40 43.88

Colorado 2,516 3,716 3,955 47.69 6.43 57.19

Connecticut 2,467 2,720 3,198 10.26 17.57 29.63

Delaware 289 329 713 13.84 116.72 146.71

Florida 8,072 6,113 9,178 24.27 50.14 13.70

Georgia 1,880 2,072 3,825 10.21 84.60 103.46

Hawaii 425 449 699 5.65 55.68 64.47

Idaho 432 520 863 20.37 65.96 99.77

Illinois 4,552 4,576 6,877 0.53 50.28 51.08

Indiana 1,840 2,100 3,715 14.13 76.90 101.90

Iowa 822 1,218 1,444 48.18 18.56 75.67

Kansas 707 959 1,423 35.64 48.38 101.27

Kentucky 1,128 1,335 2,032 18.35 52.21 80.14

Louisiana 1,194 1,547 1,958 29.56 26.57 63.99

Maine 644 765 1,224 18.79 60.00 90.06

Maryland 1,948 2,791 3,562 43.28 27.62 82.85

Massachusetts 4,259 4,490 6,622 5.42 47.48 55.48

Michigan 3,036 6,454 6,291 112.58 2.53 107.21

Minnesota 2,048 2,281 3,140 11.38 37.66 53.32

Mississippi 573 943 1,146 64.57 21.53 100.00

Missouri 1,851 2,390 3,357 29.12 40.46 81.36

Montana 428 501 778 17.06 55.29 81.78

Nebraska 554 703 1,101 26.90 56.61 98.74

Nevada 374 374 846 0.00 126.20 126.20

New Hampshire 674 786 1,315 16.62 67.30 95.10

New Jersey 2,785 3,976 6,221 42.76 56.46 123.38

New Mexico 589 745 984 26.49 32.08 67.06

New York 7,448 7,209 14,098 3.21 95.56 89.29

North Carolina 2,382 3,119 4,365 30.94 39.95 83.25

North Dakota 272 266 453 2.21 70.30 66.54

Ohio 3,191 3,713 5,848 16.36 57.50 83.27

Oklahoma 1,002 1,210 1,489 20.76 23.06 48.60

Oregon 1,700 1,655 2,314 2.65 39.82 36.12

Pennsylvania 5,404 5,613 9,201 3.87 63.92 70.26

Rhode Island 567 616 925 8.64 50.16 63.14

South Carolina 873 1,155 1,775 32.30 53.68 103.32

(Continued)

February 2009 Volume 89 Number 2 Physical Therapy f 153

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Physical Therapy Health Human Resource Ratios

Table 2.
Continued
No. of Physical Therapists in: % Change

State or From 1995 From 1999 From 1995

Jurisdiction 1995 1999 2005 to 1999 to 2005 to 2005

South Dakota 278 390 586 40.29 50.26 110.79

Tennessee 1,671 2,422 3,055 44.94 26.14 82.82

Texas 5,336 7,074 8,863 32.57 25.29 66.10

Utah 542 723 1,259 33.39 74.14 132.29

Vermont 383 532 652 38.90 22.56 70.23

Virginia 2,071 2,800 4,939 35.20 76.39 138.48

Washington 1,988 2,732 3,888 37.42 42.31 95.57

Washington, DC 316 429 379 35.76 11.66 19.94

West Virginia 361 468 906 29.64 93.59 150.97

Wisconsin 1,676 2,602 3,766 55.25 44.73 124.70

Wyoming 167 247 304 47.90 23.08 82.04

United States 98,696 117,352 167,810 18.90 43.00 70.03

HHR Ratios for Physical
Therapists in the United States
For exploration of trends over time,
HHR ratios for physical therapists
per 10,000 people in each of the 50
states and the District of Columbia
were determined for 3 time points:
1995, 1999, and 2005. The national
averages for physical therapists per
10,000 people across the United
States were 3.8 in 1995, 4.3 in 1999,
and 6.2 in 2005. The trend for HHR
ratios thus represented an aggre-
gated increase of 61.3% between
1995 and 2005. As shown in Table 3,
the increases in HHR ratios between
1995 and 2005 ranged from a low of
6.6% in Florida to a high of 153.9% in
West Virginia. However, during the
period from 1995 to 1999, 7 of 51
jurisdictions showed decreases in
HHR ratios. These states included Ar-
izona (6.3%), Florida (29.0%), Illinois
(2.0%), Nevada (15.4%), New York
(3.5%), North Dakota (1.1%), and Or-
egon (7.8%). Moreover, during the
period from 1999 to 2005, Michigan
and the District of Columbia experi-
enced decreases of 2.5% and 11.7%,
respectively. In aggregate, even
through some jurisdictions showed
periods of decline, HHR ratios across
the United States showed positive
growth over the 10-year period from
1995 to 2005.
Change Scores for Population
Growth and HHR Ratios for
Physical Therapists in the
United States
To more fully appreciate the associ-
ation between trends in overall pop-
ulation growth and trends in HHR
ratios over time, we plotted change
scores for population growth and
change scores for HHR ratios for
physical therapists per 10,000 peo-
ple between 1995 and 2005 for each
of the 9 US Census Bureau regions
(Fig. 1). We decided to present these
data according to US Census Bureau
regions rather than the 51 individual
jurisdictions to provide a macro-level
perspective on the relationship be-
tween HHR ratios and population
growth. The data indicated that the
increase in HHR ratios surpassed
population growth in all US Census
Bureau regions. However, analysis at
the state level demonstrated that the
increase in HHR ratios surpassed
population growth in all but Arizona
and Florida. In Arizona, the popula-
tion grew by 41.1%, whereas HHR
ratios increased by 40.3%; in Florida,
the population grew by 25.4%,
whereas HHR ratios increased by
only 6.6%. Moreover, the data indi-
cated that HHR ratios across the
United States increased more rapidly
than overall population growth in 49
of 51 jurisdictions (96.1%). In con-
trast, in Canada, the increase in HHR
ratios surpassed population growth
in only 7 of 10 jurisdictions
(70.0%).13
Comparison of Overall
Population Growth in the
United States and Canada
To contextualize the US data, we
compared the data from the present
study with those of a similar study
conducted in Canada.13 The popula-
tion of Canada in 2005 was 32.6 mil-
lion, representing 19.5% growth
from 1991 and 5.9% growth from
2000.17,18 Like that of the United
States, the population of Canada in-
creased during the study period, but
positive population growth was not
found across all individual provincial
jurisdictions. Although the 15-year
period from 1991 to 2005 generally
showed a positive growth pattern in
all jurisdictions, population growth

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 Physical Therapy Health Human Resource Ratios

Table 3.
Health Human Resource (HHR) Ratios for Physical Therapists per 10,000 Population by State or Jurisdiction in 1995, 1999, and
2005
HHR Ratio in: % Change

State or From 1995 From 1999 From 1995

Jurisdiction 1995 1999 2005 to 1999 to 2005 to 2005

Alabama 2.21 2.79 3.49 25.84 25.12 57.46

Alaska 4.07 4.16 6.31 2.25 51.55 54.97

Arizona 3.96 3.71 5.56 6.33 49.83 40.34

Arkansas 2.91 3.00 5.13 3.02 70.98 76.14

California 3.61 4.08 4.95 12.95 21.40 37.12

Colorado 6.71 9.16 9.75 36.44 6.43 45.21

Connecticut 7.53 8.29 9.74 10.02 17.57 29.35

Delaware 4.03 4.37 9.46 8.32 116.72 134.75

Florida 5.70 4.05 6.07 29.01 50.14 6.59

Georgia 2.61 2.66 4.91 1.90 84.60 88.12

Hawaii 3.58 3.79 5.90 5.78 55.68 64.68

Idaho 3.71 4.15 6.89 11.84 65.96 85.61

Illinois 3.85 3.77 5.67 1.95 50.28 47.36

Indiana 3.17 3.53 6.25 11.44 76.90 97.15

Iowa 2.89 4.24 5.03 46.76 18.56 73.99

Kansas 2.76 3.61 5.36 31.09 48.38 94.52

Kentucky 2.92 3.37 5.13 15.34 52.21 75.56

Louisiana 2.75 3.54 4.48 28.67 26.57 62.86

Maine 5.19 6.11 9.77 17.65 60.00 88.24

Maryland 3.86 5.40 6.89 39.68 27.62 78.27

Massachusetts 7.01 7.27 10.72 3.70 47.48 52.94

Michigan 3.18 6.54 6.38 105.80 2.53 100.60

Minnesota 4.44 4.78 6.58 7.52 37.66 48.01

Mississippi 2.12 3.41 4.14 60.32 21.53 94.83

Missouri 3.48 4.37 6.14 25.71 40.46 76.57

Montana 4.92 5.68 8.81 15.36 55.29 79.14

Nebraska 3.38 4.22 6.61 24.68 56.61 95.27

Nevada 2.44 2.07 4.68 15.43 126.20 91.29

New Hampshire 5.87 6.54 10.95 11.46 67.30 86.47

New Jersey 3.51 4.88 7.64 39.29 56.46 117.93

New Mexico 3.50 4.28 5.66 22.50 32.08 61.80

New York 4.11 3.96 7.75 3.53 95.56 88.66

North Carolina 3.31 4.08 5.71 23.14 39.95 72.33

North Dakota 4.24 4.20 7.15 1.07 70.30 68.47

Ohio 2.86 3.30 5.20 15.27 57.50 81.55

Oklahoma 3.06 3.60 4.43 17.88 23.06 45.06

Oregon 5.41 4.99 6.98 7.79 39.82 28.93

Pennsylvania 4.48 4.68 7.67 4.54 63.92 71.37

Rhode Island 5.73 6.22 9.34 8.55 50.16 63.00

South Carolina 2.38 2.97 4.57 25.06 53.68 92.19

(Continued)

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Physical Therapy Health Human Resource Ratios

Table 3.
Continued
No. of Physical Therapists in: % Change

State or From 1995 From 1999 From 1995

Jurisdiction 1995 1999 2005 to 1999 to 2005 to 2005

South Dakota 3.81 5.32 7.99 39.50 50.26 109.60

Tennessee 3.18 4.42 5.57 38.93 26.14 75.24

Texas 2.85 3.53 4.42 23.84 25.29 55.16

Utah 2.78 3.39 5.91 22.19 74.14 112.78

Vermont 6.55 8.96 10.98 36.86 22.56 67.73

Virginia 3.13 4.07 7.19 30.19 76.39 129.64

Washington 3.66 4.75 6.75 29.66 42.31 84.52

Washington, DC 5.70 8.27 7.30 44.91 11.66 28.02

West Virginia 1.97 2.59 5.01 31.15 93.59 153.90

Wisconsin 3.27 4.96 7.17 51.48 44.73 119.25

Wyoming 3.48 5.15 6.34 48.03 23.08 82.19

United States 3.76 4.30 6.15 14.57 43.00 63.83

in the latter 5 years of this period
(2000 2005) showed a slightly neg-
ative trend in 5 of 10 provincial ju-
risdictions.13 As shown in Figure 2,
the change in the total US population
was 12.9% (19952005), and the
change in the total Canadian popula-
tion was 19.5% (19912005)13; these
data indicated that growth rates in
Canada surpassed those in the
United States. Although the Cana-
dian population showed greater pro-
portional growth, the study period
did include an additional 4 years.
Comparison of Absolute
Numbers of Physical Therapists
in the United States and Canada
As in the United States, the absolute
number of physical therapists in Can-
ada also increased between 1991 and
2005. The total numbers of active
and inactive physical therapists in-
creased from 11,794 in 1991 to
15,772 in 2005, representing a 33.7%
increase in Canada.19 As in the
United States, all 10 provincial juris-
dictions experienced positive
growth in the absolute number of
physical therapists from 1991 to
2005.13 However, growth rates be-
tween 2000 and 2005 represented a
different scenario, with the prov-
inces of Newfoundland & Labrador
and Ontario showing declines of
0.5% and 3.1%, respectively. Overall,
the aggregated national increases in
the absolute numbers of physical
therapists were 70.0% in the United
States and 33.7% in Canada. Table 4
shows a summary of the compari-
sons of the 2 countries with regard
to proportional changes in popula-
tion growth, absolute numbers of
physical therapists, and HHR ratios.
Comparison of HHR Ratios for
Physical Therapists in the
United States and Canada
The US data indicated a 63.8% in-
crease in HHR ratios for physical
therapists between 1995 and 2005.
In Canada, the national averages of
HHR ratios for physical therapists
per 10,000 people were 4.3 in 1991
and 5.0 in 2000; however, in 2005,
the ratio dropped to 4.8. The overall
increase in HHR ratios in Canada be-
tween 1991 and 2005 was 11.6%. As
shown in Figure 3, the trend for HHR
ratios was an upward slope in the
United States from 1995 to 2005; in
contrast, the data for Canada showed
an initial upward slope between
1991 and 2000 and a slight down-
ward slope between 2000 and
2005.13 Therefore, it appeared that
the growth trends for HHR ratios
were similar in both countries until
the midpoint of our study period, at
which time HHR ratios continued to
increase in the United States but be-
gan to decrease in Canada.
Discussion
The results of the present study high-
light macro-level trend data for HHR
ratios across the United States and
provide an interpretive context for
exploring the meaning of these data
through a comparative analysis with
Canadian data. Our analysis suggests
that the numbers of physical thera-
pists relative to the overall popula-
tion have increased in the United
States and Canada, but the propor-
tional increase appears to be much
higher in the United States. The find-
ings of the present study also indi-
cate that most jurisdictions in the
United States showed increased HHR
ratios for physical therapists relative
to the overall population but that
jurisdictions had different rates of
growth. Although the research de-
sign does not enable an exploration

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 Physical Therapy Health Human Resource Ratios

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
EnglandConnecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont; Middle AtlanticNew Jersey, New York,
and Pennsylvania; East North CentralIllinois, Indiana, Michigan, Ohio, and Wisconsin; West North CentralIowa, Kansas,
Minnesota, Missouri, Nebraska, North Dakota, and South Dakota; South AtlanticDelaware, Florida, Georgia, Maryland, North
Carolina, South Carolina, Virginia, Washington, DC, and West Virginia; East South CentralAlabama, Kentucky, Mississippi, and
Tennessee; West South CentralArkansas, Louisiana, Oklahoma, and Texas; MountainArizona, Colorado, Idaho, Montana,
Nevada, New Mexico, Utah, and Wyoming; and PacificAlaska, California, Hawaii, Oregon, and Washington.

of causation, future investigations
with the concept of small-area anal-
ysis in health care services are criti-
cal for a greater understanding of the
policy and environmental drivers in
individual jurisdictions.20 25
To our knowledge, there are no
need-based, evidence-based targets
or benchmarks for the number of
physical therapists relative to a pop-
ulation across clinical settings, dis-
ease conditions, countries, or a com-
bination of these. That is, we were
not able to determine whether the
national average of 6.2 physical ther-
apists per 10,000 people across the

The implications and policy interpre-

tations 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 ques-
tions regarding the optimal number
of physical therapists in a given juris-
diction emerged from the present
study. For instance, in our view, it
would be inappropriate to conclude
that the United States is doing bet-
ter or doing worse than Canada in
terms of HHR ratios because the Figure 2.
benchmark for the optimal number Population growth in the United States and Canada. Times were as follows: 11995 for
of physical therapists relative to a United States and 1991 for Canada; 21999 for United States and 2000 for Canada;
population has not been established. and 32005 for United States and for Canada.

February 2009 Volume 89 Number 2 Physical Therapy f 157

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Physical Therapy Health Human Resource Ratios

Table 4. downey and Berry29 would indicate a

Summary of Comparative Analysis of Physical Therapy Health Human Resource (HRR) 25.6% increase over a 30-year period.
Ratios Across the United States and Canada The trend for an increase of 61.3%
% Growth in % Growth in HHR across the 10-year period for physi-
% National Absolute Number Ratios for Physical cal therapists in the United States
Population of Physical Therapists Relative
represents much more impressive
Location (Time Span) Growth Therapists to Population
growth for therapists than for nurses
United States (19952005) 12.85 70.03 61.29
or physicians in the United States.
Canada (19912005) 19.50 33.70 11.60

As mentioned elsewhere, the rea-

United States in 2005 was high, low,
or just right because there are no
established human resource bench-
marks. We suggest that until bench-
marks across the care continuum are
established, the usefulness of HHR
ratios in the policy planning cycle is
likely to be somewhat limited. De-
mand for health care and rehabilita-
tion services is projected to increase
in the next decade as a result of fac-
tors such as an aging population, in-
creased public expectations, and
advances in technology.18,26,27 Ensur-
ing that there is a sufficient human
resource supply to meet future de-
mand 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 bench-
marks regarding appropriate HHR ra-
tios are not yet known, the propor-
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: 11995 for United States and 1991 for Canada; 21999 for United States and
2000 for Canada; and 32005 for United States and for Canada.
tional 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 de-
cade 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 fore-
casted trend suggested by McEl-
sons for such increases in HHR ratios
for physical therapists were not di-
rectly 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 educat-
ing new practitioners, there were 13
education programs in Canada dur-
ing the period from 1995 to 2005. In
1995, the production of new physi-
cal 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 ed-
ucation program was developed in
the province of Quebec, and some
training programs have doubled
their enrollment since 2005. In con-
trast, in the United States, there are
210 physical therapist education pro-
grams that graduate approximately
6,000 physical therapists per year
(Marc S Goldstein, EdD, Director of
Research Services, American Physi-
cal Therapy Association; personal
communication; September 24,

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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 ap-
preciably higher production of phys-
ical 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 out-
line national trends in new physical
therapist graduates in the United
States.
The entry-to-practice physical ther-
apy degree in the United States dur-
ing 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 Mas-
ter of Science in Physical Therapy.
The level of education or training
may not have a direct effect on the
supply of physical therapists in ei-
ther country, but the United States
may ultimately be attracting more
potential students into a doctoring
profession, whereas Canadas pro-
grams grant masters degrees. Al-
though it is speculative and surely
requires further research, the pres-
ence of doctorate-level training may
ultimately increase demand by po-
tential students and result in higher
production.
Other factors related to HHR produc-
tion include rates of attrition (rates at
which practitioners leave the profes-
sion), the movement of practitioners
into and out of the workforce, and
the influx of foreign-trained practi-
tioners.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 pro-
grams move out of the workforce
(and how many move into the work-
force) is not known, and the rates of
February 2009
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Physical Therapy Health Human Resource Ratios
foreign-trained physical therapists
entering the profession and contrib-
uting to the overall professional pop-
ulation in either country are not
known. The absence of data on these
2 important factors related to HHR
production represents an opportu-
nity 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 Bud-
get Act (BBA) of 1997 was a monu-
mental policy shift that altered Medi-
care reimbursement. The history and
impact of the BBA on publicly
funded physical therapy reimburse-
ment have been described by Ench-
elmayer 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 expendi-
tures, including chronic care ser-
vices 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 ther-
apists in Florida in 1999 and con-
cluded that implementation of the
BBA resulted in reductions in em-
ployment settings and human re-
sources 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 de-
cline in physical therapist services
for people with conditions for which
rehabilitation services were indi-
cated in the United States.
We suggest that, on the basis of our
macro-level findings, the BBA may
have had different effects depending
Volume 89 Number 2
on the age distributions of residents
in certain jurisdictions, particularly
states with higher proportions of
people eligible for Medicare. Juris-
dictions such as Florida may have
been most likely to have been af-
fected 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 physi-
cal therapist-to-population ratio be-
tween 1995 and 1999. However, this
period of decline was followed by an
increase of 50.1% between 1999 and
2005 and an aggregated overall in-
crease 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 Or-
egon (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 Ne-
vada. The BBA may have had a short-
term effect on HHR ratios in some
states with higher proportions of
people eligible for Medicare, but be-
tween 1995 and 2005, all jurisdic-
tions experienced aggregated posi-
tive growth at rates that surpassed
those in Canada. Our data offer sup-
port 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 fac-
tor that may have complicated the
suggested relationship between re-
imbursement and HHR ratios was
the 1999 Balanced Budget Refine-
ment Act, which delayed the cap on
outpatient physical therapy services.35
In previous policy research in Can-
ada, Gordon et al36 and Paul et al37
explored the outcomes of a policy
shift that may not have been as dra-
matic as the shift resulting from the
BBA but that nonetheless signifi-
cantly altered reimbursement for
Physical Therapy f 159
Physical Therapy Health Human Resource Ratios
publicly funded physical therapy ser-
vices in the Canadian province of
Ontario. Overall, the published find-
ings regarding the partial delisting of
publicly funded, community-based
physical therapy services provided
within a network of designated phys-
ical therapy centers in Ontario sug-
gests that when policy changes are
initiated to reduce reimbursement
for publicly funded physical therapy
services, the protective rebound ef-
fect may be a shift from public to
private financing, resulting in some
degree of human resource preserva-
tion. Although we believe that more
research is needed to explore the
short- and long-term effects of reim-
bursement policies, such as the BBA,
on HHR strategies, we suggest that
significant policy shifts affecting
publicly funded physical therapy ser-
vices may ultimately create the nec-
essary underlying structure to en-
courage a shift from public to private
financing for physical therapy
services.
Limitations of US/Canada HHR
Comparative Analysis
There are a number of inherent lim-
itations of the present study and, al-
though this research represents a
foundation for additional research,
there are details that must be consid-
ered. The sample of physical thera-
pists in the present (US) study (as
well as the sample in the Canadian
study) included active and inactive
physical therapists. We acknowl-
edge 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, be-
cause 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 method-
ological approach of including active
160 f Physical Therapy Volume 89 Number 2
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and inactive registrants has been
used by others to estimate HHR ra-
tios.2,4,7 We concede that there are
limitations associated with this par-
ticular inclusion criterion, most no-
tably, that active and inactive thera-
pists would have different workloads
and that therapists working full time
also would differ in terms of produc-
tivity. Nevertheless, the integration
of both groups allowed for more-
direct comparisons of the 2 coun-
tries. Once again, we argue that this
research provides the foundation for
future research in an emerging inves-
tigative field.
Another important limitation may
have been the ways in which juris-
dictions 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 repre-
sents 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 effectthat is, a
slight change in the denominator can
have an important effect on the nu-
merator 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 instruc-
tive in future research to separate
the change in the ratio into its com-
ponent parts in order to more fully
interpret the outcome.
Conclusion
We have found that there are 6.2
physical therapists per 10,000 peo-
ple across the United States. The
findings of the present study also in-
dicate that there are differences be-
tween 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 in-
dicated that despite policy shifts and
changes in education or training,
there has been a larger increase in
the HHR ratios for physical thera-
pists relative to the population in the
United States than in Canada. More-
over, our results underscore the
need to examine the policy and en-
vironmental factors that drive the
supply of physical therapists, to de-
velop 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 rehabilita-
tion demands across the United
States and Canada.
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.
This article was submitted March 12, 2008,
and was accepted November 10, 2008.
DOI: 10.2522/ptj.20080075
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Physical Therapy f 161
 Physical Therapy Health Human Resource Ratios: A
Comparative Analysis of the United States and
Canada
Michel D Landry, Thomas C Ricketts, Erin Fraher and
Molly C Verrier
PHYS THER. 2009; 89:149-161.
Originally published online January 8, 2009
doi: 10.2522/ptj.20080075

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