Offices and Clinics of Health Practitioners, NEC

SIC 8049

Companies in this industry

Industry report:

This industry consists of establishments of health care practitioners engaged in the practice of health fields not elsewhere classified. Practitioners may or may not be licensed or certified, depending on the state in which they practice. Establishments operating as clinics of health practitioners, not elsewhere classified, are included in this industry. Specific health care practitioners included in this industry include acupuncturists (except M.D.s), audiologists, Christian Science practitioners, dental hygienists, hypnotists, respiratory therapists, midwives, naturopaths, nurses (except home health service nurses), nutritionists, occupational therapists, paramedics, physical therapists, physician's assistants, psychiatric social workers, clinical psychologists, psychotherapists (except M.D.s), speech clinicians, and speech pathologists.

Industry Snapshot

Since the mid-1980s, the "graying" of America has helped fuel the growth of offices and clinics of respiratory therapists, physical therapists, and nurses, with a substantial number employed by home health care services. Whereas certain segments are integral parts of the overall U.S. healthcare system, such as nurses, paramedics, nutritionists, and physical therapists, other segments, including hypnotists, midwives, and Christian Science practitioners, worked on the fringes of modern medicine.

Organization and Structure

Offices and clinics in this industry belong to either hospitals, where the practitioners may be employed by the hospital, or that work independently of hospitals. Occupational and physical therapists, psychologists, and acupuncturists often work, to some extent, with hospitals. Occupational and physical therapists are frequently employed by general and rehabilitation hospitals, and many psychotherapists work at psychiatric hospitals treating the mentally ill.

Unlike the offices of medical doctors and dentists, establishments in this industry do not rely on payments made through insurance companies or government programs like Medicare and Medicaid as their main source of income. However, occupational and physical therapists receive the largest portion of their incomes from employee compensation plans. Practitioners in this industry use referral services, such as those of professional associations, as a tool to ensure a steady flow of self-funded patients.

Background and Development

A long global history is common to the background of many of the professions represented by this industry, such as acupuncturists. Many of these practices, however, have gained acceptance in the United States only during the twentieth century. Another common feature of these professions has been their rapid growth since the 1970s, when "natural" and Eastern medicine gained popularity. At the same time, the rising costs of traditional health care spurred patients to seek new approaches to health care.

Acupuncturists.
Acupuncture is a system of medicine that uses needles on nerve and "energy" points to cure disease and modify certain behaviors. Developed in ancient China, acupuncture was not widely practiced in United States outside Chinese communities until the 1960s. By the twenty-first century, acupuncture and other forms of Oriental medicine were among the fastest growing segments of health care in the United States. There were more than 5,000 licensed acupuncturists practicing in the United States at the end of the first decade of the 2000s. Nearly all full-time acupuncturists in the United States were self-employed. Others, mostly medical doctors, were trained in acupuncture and used the technique mostly as a form of anesthesia. According to a 2007 National Institutes of Health survey, approximately 3.1 million people visited an acupuncturist in the prior year.

Audiologists and Speech-Language Pathologists.
Audiologists work in the diagnosis and treatment of hearing problems, as well as in public health, providing instruction and counseling for the hard of hearing. This sector of the health care industry has grown steadily since the 1970s, in part because of a maturing patient base and in part because of technological advances that allow increasingly effective treatment of patients with hearing difficulties.

Speech-language pathologists treat and counsel people with communication disorders caused from hearing loss, brain injury, learning disability, mental retardation, or emotional problems. These practitioners are mostly self-employed and work at rehabilitation hospitals and clinics and out of private offices. In 1993 the American Speech-Language-Hearing Association reported that nearly 58,000 speech-language pathologists were established in the United States. In 1992 it was estimated that nearly 8 million Americans sought treatment from speech-language pathologists. Of those, more than 3 million were children undergoing therapy for speech impairments, primarily stuttering.

According to the U.S. Census Bureau, in 2010, 286,570 people were employed at offices of physical, occupational and speech therapists, and audiologists. Of these, about 20,000 were speech/language pathologists, who earned an average annual salary of $79,210 and 2,610 were audiologists earning an average wage of $74,720 a year. About half of speech/language pathologists and audiologists provided services in preschool, elementary, or secondary schools or in colleges and universities, and 10 percent worked in hospitals. Both of these fields were expected to grow because of the aging population and federal laws that guaranteed special education for all eligible children.

Christian Science Practitioners.
These practitioners, following the Christian Science faith, use spiritual healing to cure ailments. This form of healing, which relies on prayer and Bible reading, dates back to the start of the Christian Science religion, founded by Mary Baker Eddy in 1866. Throughout this profession's history, efforts have been made, mostly by governing bodies, to prohibit this form of health care. However, laws guaranteeing the right to religious practices have continually fought this opposition. Some states have passed laws specifically designed to protect the rights of this profession.

Nationally, this profession suffered negative publicity in the 1980s following several incidents where children died under the care of a Christian Science practitioner. In these cases, medical experts testified that the children would not have died under the care of a medical doctor. These incidents were highlighted by legislation in 1983 that drew the public's attention to spiritual healing. That year, the federal government defined a parent's failure to provide medical care for a child, which excludes spiritual healing, as child neglect. Additionally, the government had the right to intervene if a parent's actions prohibited medical treatment. Consequently, the parents of children who died under the care of Christian Science practitioners faced criminal charges.

Most of these cases were dismissed on the basis of lack of due process, and one case was dismissed due to freedom of religion acts, while other cases remained in the appeals system. In 1993, however, a landmark decision was made against the Christian Science Church itself that returned a $5.2 million wrongful death judgment to the biological father of a diabetic boy who died under a Christian Science practitioner's care. This decision was important to this industry because it placed the blame upon the practitioners and not the parents. Legal battles continued in this area, involving issues ranging from children's rights to religious rights.

Dental Hygienists.
Dental hygienists provide treatment and education for oral hygiene and prevention of gum disease. The offices and clinics of dental hygienists, independent from employment by a dentist, involve working for public health agencies, industrial plants, and independent dental clinics. In 2010 there were approximately 176,670 dental hygienists working in the United States, the majority of whom worked for general dentists.

Hypnotists.
The practice of putting a person into a trance, or sleep-like state, in order to influence their actions and behaviors, was long regarded as a form of trickery. Its origins are unclear, although the first reliable form of hypnotic induction was reported in the eighteenth century. Research continued during the nineteenth century and the hypnotic state came to be increasingly attributed to physiological and psychological factors. By 1893 the British Medical Association "officially recognized hypnotism in a report that found the hypnotic state to be real and of value in relieving pain and alleviating certain functional ailments. The report was not approved by the American Medical Association until 1958, and acceptance of it among medical doctors continues to be slow," according to the New Age Encyclopedia. Modern hypnosis is used for treating smoking, alcoholism, weight control, disorders related to stress, and many phobias.

Nearly all hypnotists practicing in the United States were self-employed, and a considerable number were licensed in other health fields, such as psychotherapy or medicine. Hypnotherapy has been developing as a treatment used in conjunction with more traditional health practices. However, even when hypnosis is used by a medical doctor, it is rarely covered by insurance, which has hindered the growth of this profession within the medical community. In 2008 there were 5,171 psychologist, psychotherapist, and hypnotist offices, employing 14,450 workers and 1,359 hypnotist firms, employing 2,362 workers.

Midwives.
Midwifery, the profession providing care and assistance for delivering babies, has a long history. The dominance of obstetrics in the United States, however, has significantly diminished the role this profession had earlier in the country's history. However, the practice enjoyed something of a revival in the late 1980s and 1990s. Midwives delivered 3.7 percent of all births in 1989, and by the middle of the first decade of the 2000s, midwives attended more than 10 percent of all vaginal births, according to the American College of Nurse-Midwives. Between 1998 and 2008, the number of births attended by certified nurse-midwives and certified midwives grew 33 percent. In 2008 membership in the American College of Nurse-Midwives topped 6,500.

Historically, midwives were not licensed to use instruments, such as forceps, and had to call upon a medical doctor if there were any complications with a birth. Despite these restrictions, prior to the seventeenth century, midwifery was a lucrative profession for women. In Europe during the seventeenth century, a male-dominated medical profession sought to include childbirth as part of their practice. Since then, the scientific advances available to women through the established medical profession have kept pregnant women away from the natural methods of childbirth usually employed by a midwife.

In colonial America, midwifery was still a prosperous profession and remained so until the expansion of medical schools and specialties in the nineteenth century and the subsequent development of the field of obstetrics. It was also during this time that European immigration to the United States had a negative impact on the midwives' profession. In Europe, midwives usually belonged to the middle classes, and since the Europeans who immigrated to the United States belonged mostly to the lower classes, midwives were left behind. According to the 1910 census, after a wave of European immigration, 50 percent of births in the United States were carried out by midwives, a precipitous drop from an estimated 90 percent during colonial times.

Midwifery in the United States suffered another major setback during the 1920s and 1930s, as medical procedures for childbirth in hospitals improved dramatically, along with medical training in the field of obstetrics. It was also during this time that some states decided to prohibit the practice of midwifery, while many other states enforced strict supervision. Many historians (of medicine and women's studies) have explained this change from midwifery to obstetrics as a male takeover of the profession of assisting childbirth.

Naturopathic Physicians.
Naturopathic physicians specialize in the use of natural therapeutics and are primarily concerned with overall health instead of alleviating specific symptoms or illnesses. The types of treatments and medical practices used by these physicians include Herbology; acupuncture; natural childbirth; and homeopathy, which employs drugs that reproduce the symptoms of a disease as a way of canceling out the disease. Naturopathic physicians are only licensed in 14 states, including Alaska, Arizona, California, Connecticut, Hawaii, Idaho, Kansas, Maine, Montana, New Hampshire, Oregon, Utah, Vermont, and Washington, as well as Washington, D.C.; Puerto Rico; and the U.S. Virgin Islands. Their offices and clinics are operated in ways similar to those of primary care physicians, with the assistance of medical secretaries and medical assistants. These health care providers routinely perform physical examinations, lab tests, and minor surgery.

Nurses.
The offices and clinics of nurses, independent from medical doctors, have had long histories in institutions and large industrial sites where first aid facilities are needed. This role has evolved since the 1960s into the job of occupational health nurse. In addition to administering first aid, occupational health nurses develop health promotion programs related to fitness and well-being, as well as safety regulations for the work site. Regulations passed by the Occupational Safety and Health Administration (OSHA) during the 1980s have greatly expanded the roles of occupational health nurses, whose responsibility it is to see that regulatory standards are met.

Establishments of nurse practitioners outside of institutions and industrial work sites have also evolved into new, more challenging roles. With the rise in health care costs and the shortage of family doctors, nurses have been providing primary care previously offered by medical doctors. According to Business Week, registered nurses with advanced training can provide 60 to 80 percent of all primary care. Given that nurses' salaries were considerably less than those of doctors, these services were provided at a savings and were filling a niche in the health care industry. A study by the American Nurses Association found that primary care provided by a nurse practitioner cost an average of 60 percent less than that provided by a medical doctor. Consequently, nurses were expected to benefit from government-imposed health care reform designed to expand primary care and cut costs.

However, the move into primary care for nurses has been challenged by the medical profession and state governments. These groups have expressed concern over the qualifications of nurses seeking to expand their roles into primary care. Moreover, in some states, such as California, controversy has arisen over whether nurses should legally be allowed to fill prescriptions.

In 2010 there were about 2.7 million registered nurses practicing in the United States, approximately 60 percent of whom worked in hospitals. However, the growth rate was expected to be highest in physicians' offices and home health care. The mean annual salary for a registered nurse in 2010 was $64,690. Employment of nurses was expected to grow faster than average at 26 percent annually between 2010 and 2020.

Nutritionists and Dietitians.
Nutritionists plan and supervise meals in state and government health departments, social service agencies, residential care facilities, and schools. They may also counsel individuals on aspects of nutrition and ways to prevent diseases. In 2010 there were 64,400 dietitians and nutritionists earning a median annual salary of $53,250.

Occupational Therapists.
Occupational therapists treat people with physical or emotional illnesses that affect their abilities in a day-to-day work or home environment, emphasizing treatment of work-related behaviors and skills. According to the American Occupational Therapy Association, the most common problems among patients of occupational therapy in the 1990s were strokes, developmental disabilities, arthritis, hand injuries, depression, and schizophrenia. In 2010 there were roughly 108,800 occupational therapists practicing in the United States, earning a mean salary of $72,320 a year. Most occupational therapists worked in hospitals, with school systems being the second-largest employer. A small but rapidly growing segment worked in private practice.

The offices and clinics of occupational therapists originated in Europe and the United States after World War I, with the emergence of rehabilitation hospitals for the long-term disabled. By 1925 the Council on Physical Therapy was created by the U.S. federal government, which reviewed occupational therapy programs and established accreditation standards for therapists and their assistants.

This sector of the health care industry reported steady growth from the 1930s through the 1970s. Since the 1980s, growth in occupational therapy has accelerated with the aging population and increased efforts to integrate more disabled people into the workforce.

The profession has changed in recent years in terms of the services offered. Fewer occupational therapists have been working with mental health patients and patients with cerebral palsy and arteriosclerosis partly as a result of the increase in the number of psychotherapists and psychiatric social workers, as well as by the development of better medications. At the same time, following increased public awareness of learning disabilities, such as dyslexia and slow cognitive processing, occupational therapists have increasingly worked with patients with learning disabilities.

Paramedics and Emergency Medical Technicians (EMTs).
Paramedics and EMTs are medical technicians who give on-site medical treatment in place of a physician. These health care practitioners provide treatment most commonly for heart attack and accident victims. Paramedic services were introduced in the United States in the 1960s. During the early 2010s, there were 226,500 paramedics and EMTs working in the United States. One-third of EMTs worked with police, fire, and rescue squad departments; two-fifths worked for private ambulance companies; and one-fourth worked in hospitals. The average annual salary of paramedics and EMTs in 2010 was $30,360.

Physical Therapists.
Similar to the work of occupational therapists, physical therapists provide treatment for the physically or developmentally disabled, including victims of strokes and accidents, as well as the elderly. These practitioners carry out programs of testing, massage, exercise, and other therapeutic treatments to increase their patients' muscular strength and range of motion and to relieve pain.

In 2010 there were roughly 198,60 physical therapists working in the United States, earning a mean salary of $76,310 a year. About one-third worked in independent offices or offices of other health practitioners and about one-third worked in hospitals. Approximately 11 percent worked in home health care, and the remainder worked for long-term care facilities and in physicians' offices. Since the mid-1980s, the aging population has resulted in an increase in the number of physical therapists working in patients' homes or out of their own private practices.

Psychotherapists and Clinical Psychologists.
The offices and clinics of psychotherapists and clinical psychologists began with the emergence of psychotherapy in the late 1800s in Europe. Like psychiatrists, psychotherapists and clinical psychologists treat patients with mental disorders and emotional problems. According to American Demographics, 76 percent of the patients of psychotherapists, including clinical psychologists who practice psychotherapy, were being treated for emotional conditions, such as anxiety disorders, neuroses, and relationship problems. However, unlike psychiatrists, psychotherapists and clinical psychologists do not prescribe medication and are not licensed as medical doctors. Another notable difference between these two related professions is that psychoanalysis requires more frequent patient visits, and treatment outcomes are less predictable than those of psychiatric treatment.

These differences have made it more difficult for psychotherapists and clinical psychologists to gain wide acceptance in the United States. The insurance industry traditionally limited its coverage for mental health patients not under a psychiatrist's care. The role of the insurance industry has played a large part in the growth of this industry. It was not until after World War II that this industry was given a boost by commercial insurance companies offering coverage of mental healthcare for the first time. At first such insurance coverage provided for psychiatric and nonpsychiatric care, but by the 1970s, insurers started restricting coverage of non-psychiatric mental health care, mainly because of the difficulty of diagnosing such ailments and the uncertain amount of time needed to treat disorders. In 1989 federally-funded insurance provided through Medicare expanded its coverage policy to include treatment by psychotherapists and clinical psychologists, which prompted private insurers to offer wider coverage again, a key factor in the industry's subsequent economic improvement.

In addition to increased insurance coverage, this sector of the industry has been aided by employers' increased awareness of work-related psychological disorders, such as stress and fatigue. Many companies have set up Employee Assistance Programs (EAP). The involvement of psychotherapists and clinical psychologists in treating such problems in corporate environments has seen rapid growth since the mid-1980s. Many government agencies also mandated the setup of EAP programs for their employees.

The offices and clinics of psychotherapists and clinical psychologists compete for business with the establishments of psychiatrists, psychiatric social workers, and primary care physicians who counsel their patients. In 1989 there were a considerably greater number of clinical psychologists than psychiatrists. However, psychiatrists held a considerably larger portion of the mental health market.

In 2010 there were about 174,000 clinical, school, and counseling psychologists employed in the United States. Approximately 42 percent of them worked in educational institutions while 11 percent were employed in health services. The average annual salary was $68,640.

Respiratory therapists treat patients with cardiopulmonary (heart and lung) problems that obstruct breathing. These health care practitioners work primarily in hospitals and nursing homes, but have also filled a growing need in home health services. More than 75 percent of the nearly 113,000 respiratory therapists worked in hospitals in 2010 earning an average salary of $54,280.

Like other sectors of the health care industry, establishments in this industry expected continued growth due primarily to the maturing U.S. population, but at the same time had concerns about health care costs and government reforms affecting the management and insurance coverage of their services.

At the end of the first decade of the 2000s, health care reform was at the top of President Obama's political agenda. Everyone in the health care industry was lobbying hard for their particular interest, which often put different segments of the industry at odds as multiple sectors sought funding from the same pool of funds. Health care reform had the potential to open the door for significant increases in certain segments of the health care industry. In addition, several sectors, such as the acupuncture industry, were lobbying to be included as reimbursable under Medicare and Medicaid guidelines.

Current Conditions

The cost of staying healthy in the United States continued to increase in the second decade of the twenty-first century. According to a report from Bryant University, health care expenditures rose at an annual rate in the double digits in the first decade of the 2000s, reaching a high of 17.6 percent in 2010, when Americans spent more than $3 trillion on health care. The employment outlook in the industry was good, and as of 2010, those working in health care made up approximately 9 percent of the total U.S. workforce.

As baby boomers began to reach retirement age, numerous segments of this industry were expected to grow at a faster than average rate. The need for nurses, which continued to experience shortages, was expected to continue to build, especially for physicians' offices and the home health care industry. However, the competition was expected to be the stiffest in these areas as they tended to offer the most stable work environment and working hours. The need for professional EMTs and paramedics was also anticipated as municipalities found it more difficult to recruit and retain an adequate number of volunteers. Therefore, communities that had long depended on volunteers had begun to hire a professional staff. Occupational therapists also expected very good career opportunities through the 2010s due to the aging of the baby boomer generation.

Industry Leaders

Select Medical was a leader in the field of rehabilitative health care in the early 2010s. The company owned 111 long-term acute care hospitals that were commonly located in leased space within a major hospital. Select also operated five inpatient rehabilitation clinics and more than 950 outpatient rehabilitation clinics in 32 states. The company posted revenues of nearly $2.8 billion in 2011 and employed 21,300 workers.

HealthSouth, headquartered in Birmingham, Alabama, was another one of the largest providers of rehabilitative health care in the United States, operating approximately 100 health care facilities. Following a 2003 investigation by the Securities and Exchange Commission that alleged accounting fraud, HealthSouth's chairman and CEO, Richard Scrushy, was terminated. Afterwards, the company was restructured, shedding its outpatient surgery services. Nevertheless, HealthSouth posted revenues of $1.8 billion in 2008.

Physiotherapy Associates, located in Exton, Pennsylvania, provided occupational, physical, and speech therapy at approximately 650 locations in 30 states. The company merged with Benchmark Medical in 2007 and its majority ownership was held by Water Street Healthcare Partners, an investment firm.

Workforce

With the exceptions of midwives and occupational therapist assistants, the occupations in this industry require at least four years of training, usually in conjunction with a bachelor's degree. Midwives can practice with two years of training and certification in the state in which they work. Occupational therapist assistants undergo two years of training through an associate's degree program and have to be certified by the American Occupational Therapy Association.

America and the World

Many of the professions in this industry have had larger and often more profitable markets overseas, especially practitioners of "alternative medicine," such as acupuncture and natural therapies. Acupuncture is not only a standard form of medicine in China, but is also widely practiced all over the world. In Great Britain and Germany, acupuncture is covered by government-run health programs. Hypnosis, naturopathy, and various forms of spiritual healing have also been more widely accepted overseas than in the United States.

The United States's approach to midwifery has also been significantly different from overseas. In most other industrialized countries, midwifery has been blended into the medical profession, while in the United States the use of obstetricians and gynecologists has taken precedence. Midwives from overseas, unlike many other nurse-practitioners in the health care industry, do not tend to seek employment or set up practices in the United States.

The better salaries offered in the United States for nurses and physical and occupational therapists have brought many practitioners in these professions to the United States. Nursing professionals, in particular, are apt to secure work overseas because their credentials are easily transferable and because of the worldwide shortage of nurses.

© COPYRIGHT 2018 The Gale Group, Inc. This material is published under license from the publisher through the Gale Group, Farmington Hills, Michigan. All inquiries regarding rights should be directed to the Gale Group. For permission to reuse this article, contact the Copyright Clearance Center.

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