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.
621330 (Offices of Mental Health Practitioners (except Physicians))
621340 (Offices of Physical, Occupational, and Speech Therapists and Audiologists)
621399 (Offices of All Other Miscellaneous Health Practitioners)
The offices and clinics of health care providers in this industry are characterized by their contrast and competition with offices and clinics of medical doctors. In America, many sectors of this industry have not enjoyed the public acceptance given to medical doctors. As a whole, this industry has become more accepted during the latter part of the twentieth century as a result of various social and economic factors.
This industry earns income from the tens of thousands of health providers in private practice who are either self-employed or employed through health maintenance organizations (HMOs).
Since the mid 1980s, the "graying" of America has helped to fuel the growth of offices and clinics of respiratory therapists, physical therapists, and nurses, with a substantial number employed by home health care services.
Offices and clinics in this industry belong to either hospitals, where the practitioners may be employed by the hospital or those 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 profession associations, as a tool to ensure a steady flow of self-funded patients.
Common to the background of many of the professions represented by this industry, such as acupuncturists, is their long global history. 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 America, outside Chinese communities, until the 1960s. Today acupuncture and other forms of Oriental medicine are among the fastest growing segments of health care in America. According to the National Acupuncture and Oriental Medicine Alliance, at the end of the 1990s, thirty-eight states and the District of Columbia had recognized the practice of acupuncture, and legislation had been introduced in eight additional states. The number of licensed acupuncturists in the United States rose from 5,525 in 1992 to 10,512 in 1998. Nearly all full-time acupuncturists in the United States are self-employed. Others, mostly medical doctors, have been trained in acupuncture and use the technique mostly as a form of anesthesia.
Audiologists and Speech-language Pathologists. Audiologists work in the diagnosis and treatment of hearing problems; in addition, these practitioners work in public health, providing instruction and counseling for the hard of hearing. By 2005, a doctoral degree may be required to enter audiology practice. 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 eight million Americans sought treatment from speech-language pathologists. Of those, more than three million were children undergoing therapy for speech impairments, primarily stuttering.
In 1997, there were about 87,000 speech-language pathologists and audiologists practicing in America. The median annual salary in 1997 for speech-language pathologists was $44,000 and $43,000 for audiologists. One half provided services in preschool, elementary, secondary schools or in colleges and universities; 10 percent worked in hospitals. Both of these fields are expected to grow because of the aging population and also federal laws that guarantee special education for all eligible children.
Christian Science Practitioners. These practitioners, in 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 perished under the care of a medical doctor. These incidents were highlighted by legislation brought about 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—which excludes spiritual healing—for a child 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, while another case was dismissed due to freedom of religion acts; other cases remain 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 as it placed the blame upon the practitioners and not the parents. Legal battles continue in this area, which involves 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 1996, there were approximately 133,000 dental hygienists working in America, of which the majority 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," noted the New Age Encyclopedia. Modern hypnosis is used for treating smoking, alcoholism, weight control, disorders related to stress, and many phobias.
According to the American Association for Professional Hypnotherapy, in 1997 nearly all of the 13,300 hypnotists practicing in America 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; this factor has hindered the growth of this profession within the medical community.
Midwives. Midwifery, the profession providing care and assistance for delivering babies, has a long history. The dominance of obstetrics in America, however, has significantly diminished this profession from the role it enjoyed earlier in the country's history. However, the practice enjoyed something of a revival in the late 1980s and 1990s. Midwifes delivered 3.7 percent of all births in 1989, but eight years later, in 1997, that figure had nearly doubled to 7 percent. As of 1999, the American College of Nurse-Midwives reported its membership had topped 6,700, of whom about 5,700 were in clinical practice. Of these, less than 500 were self-employed, while the majority of midwifes worked at birth centers or clinics or as nurses to medical doctors.
Historically, midwives were not licensed to use instruments, such as forceps, and they 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 has 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 consequent development of the field of obstetrics. It was also during this time that European immigration to America had a negative impact on the midwives' profession. In Europe, midwives usually belonged to the middle classes, and since the Europeans who immigrated to America 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 America were carried out by midwives, a precipitous drop from an estimated 90 percent during colonial times.
Midwifery in America was to see another major setback during the 1920s and 1930s, as medical procedures for childbirth in hospitals improved dramatically, as did 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.
Midwives practicing in America cared for less than 10 percent of childbirths by 1960. However, during the 1960s and 1970s, interest in women's rights and the women's liberation movement brought renewed interest in natural childbirth and the services of a midwife. Between 1975 and 1980, the number of American babies delivered by midwives doubled. In 1993, CNMs attended 188,370 deliveries, which accounted for 4.5 percent of all U.S. births. By 1997, midwife-assisted births had climbed to 7 percent of total U.S. births.
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 it out). Naturopathic physicians are only licensed in eleven states: Alaska, Arizona, Connecticut, Hawaii, Maine, Montana, New Hampshire, Oregon, Utah, Vermont, and Washington.
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. In 1997, there were an estimated 2,300 offices and clinics of naturopathic physicians in the United States.
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 serviced by medical doctors. According to Business Week, registered nurses with advance training can provide 60 to 80 percent of all primary care. Given that nurses' salaries are considerably less than those of doctors, these services are provided at a savings and are filling a niche in the health care industry. A study by the American Nurses Association found that primary care provided by a nurse practitioner costs an average of 60 percent less than that provided by a medical doctor. For these reasons, nurses are 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 1994, there were about 1.97 million registered nurses practicing in the United States. Of those, nearly two-thirds worked in hospitals, while the remaining third worked in nursing homes, home health care agencies, schools, government agencies, and the offices and clinics of physicians. The median annual salary for a RN was $36,240. In 1996, there were roughly 700,000 licensed practical nurses (LPNs) with a median annual salary of $24,336.
Nutritionists and Dietitians. Nutritionists plan and supervise meals in state and government health departments, social service agencies, residential care facilities, and at schools. They may also counsel individuals on aspects of nutrition and ways to prevent diseases. In 1996, there were 58,000 dietitians and nutritionists. According to a Hay Group survey of acute care hospitals, their median annual salary was $34,400 in early 1997.
Occupational Therapists. Occupational therapists treat people with physical or emotional illnesses that affect their abilities in a day-to-day work or home environment; this type of therapy emphasizes 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 1996, there were roughly 57,000 occupational therapists practicing in the United States, earning a median base salary of $40,560 a year. Most occupational therapists worked in hospitals, with school systems being the second largest employer. A small but rapidly growing segment works in private practice.
The offices and clinics of occupational therapists originated in Europe and America 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 United States federal government. This governing body reviewed occupational therapy programs and established accreditation standards for therapists and their assistants.
This sector of the health care industry witnessed 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 work force.
The profession has changed in recent years in the types of services offered. Fewer occupational therapists have been working with mental health patients and patients with cerebral palsy and arteriosclerosis; these trends can be explained in part by the increase in the number of psychotherapists and psychiatric social workers and 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 turned to 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 late 1990s, there were about 150,000 paramedics and EMTs working in the United States. One-third of them worked with police, fire, and rescue squad departments; two-fifths worked for private ambulance companies and one-fourth in hospitals. The average salary of a paramedic was $30,407, while an EMT made $25,051. Many work on a voluntary basis.
Physical Therapists. Similar to the work of occupational therapists, physical therapists provide treatment for the physically or developmentally disabled; their patients include victims of strokes and accidents and 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 1996, there were roughly 115,000 physical therapists working in the United States, earning a median base salary of $39,364 a year. Most of these therapists worked in general hospitals, rehabilitation hospitals, and nursing homes. 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 America. 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; however, 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; this prompted private insurers to offer wider coverage again—a key factor in the industry's recent economic improvement.
In addition to increased insurance coverage, this sector of this 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 set up 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 1997, there were about 143,000 psychologists employed in the United States. Nearly 40 percent of them worked in educational institutions while 30 percent were employed in health services, and one-sixth worked in government agencies. The U.S. Department of Veterans Affairs and the Department of Defense used 80 percent of the federally employed psychologists.
Respiratory Therapists. 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. Out of the 82,000 respiratory therapists working in 1996, more than 9 out of 10 worked in hospitals.
Like other sectors of the health care industry, establishments in this industry entered the 1990s expecting growth due primarily to the maturing American population, but at the same time held concerns about health care costs and government reforms affecting the management and insurance coverage of their services.
The needs of the aging population of the United States have contributed to the rapid growth of home health services, which primarily employ physical and occupational therapists, respiratory therapists, and nurses. Other sectors of this industry which entered the 1990s to service the needs of the elderly include audiologists and paramedics.
According to Business Insurance, the changes expected with more managed care have been of particular concern to psychologists and psychotherapists, as these professions have been negatively affected by existing managed care systems; which have favored the use of psychiatric social workers over psychotherapists and clinical psychologists as the least expensive outpatient mental health provider. By 1996, some managed care organizations were beginning to cover certain alternative treatments, including acupuncture and hypnosis.
With cost-cutting changes in health care moving the health care industry away from inpatient treatment and toward more outpatient treatment, the offices and clinics of occupational and physical therapists have increasingly moved from hospital settings to more private offices and outpatient clinics.
Some of the leaders in this industry in the late 1990s included HEALTHSOUTH Corp., NovaCare Inc., Comprehensive Care Corp., and Tenet Healthcare Corp.
HEALTHSOUTH, headquartered in Birmingham, Alabama, is the largest provider of outpatient surgery services and rehabilitative health care in the United States, operating nearly 2,000 health care facilities in this country, Australia, and the United Kingdom. With more than 51,000 employees worldwide, HEALTHSOUTH posted 1998 net income of $46.5 million on sales of $4 billion. Although the company's sales were up more than 32 percent from 1997, net earnings were nearly 86 percent below the level achieved the previous year.
NovaCare, one of HEALTHSOUTH's leading competitors in the field of rehabilitative health care, was in the process of extricating itself from the business in late 1999. The company suffered a net loss of $189.5 million on revenue of $1.48 billion in fiscal 1999, the 12 months ending on June 30, 1999. NovaCare, which provided rehabilitation services to nearly 3,000 hospitals and nursing homes, employed 54,800 worldwide as of late 1999.
Comprehensive Care Corporation provides inpatient and outpatient mental health and substance abuse therapy and counseling. It contracts with hospitals and also operates free-standing facilities. Its subsidiary, Comprehensive Behavioral Care Inc., provides the same care for employers, HMOs, PPS, government organizations, third party administrators, and other group purchasers of healthcare. Headquartered in Tampa, Florida, the company posted net income of $42.0 million on revenue of $46.1 million in fiscal 1998, the 12 months ending on May 31,1999.
Although its main business is the operation of hospitals, Tenet Healthcare Corp. also runs a number of outpatient surgery centers and rehabilitation centers. With more than 125,000 employees worldwide, Tenet posted net income of $249 million on revenue of $10.9 billion in fiscal 1999, the 12 months ending on May 31, 1999.
The various professions represented by this industry are on the whole expected to grow well into the end of the century. The fields that involve home health care and health care conducive to managed care systems are expected to do best; nurses and physical and occupational therapists represent three of the fastest growing areas of the health care industry. According to the U.S. Bureau of Labor Statistics, by the year 2005, there will be a 55 percent increase in the number of self-employed nurses and occupational therapists; the job market for physical therapists is expected to grow by more than 25 percent.
During the latter half of the 1990s, the average salaries for practitioners in this industry were as follows: audiologists and speech-language pathologists, $43,000 and $44,000, respectively; dental hygienists, $39,468; registered nurses, $36,244; licensed practical nurses, $24,336; occupational therapists, $40,560; occupational therapy assistants, $27,442; paramedics, $30,407; physical therapists, $39,364; psychiatric social workers, $35,000; psychotherapists, hospital/clinic, $51,000; psychotherapist, government, $62,120; and respiratory therapists, $32,500.
With the exceptions of midwives and occupational therapist assistants, the occupations listed above 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 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.
Many of the professions represented by this indus try 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 the government-run health programs. Hypnosis, naturopathy, and various forms of spiritual healing have also been more widely accepted overseas than in the United States.
America's approach to midwifery has also been significantly different from approaches 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.
However, 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.
Like other sectors of the health care industry, establishments in this industry are greatly affected by medical research and technology. Technological developments since the mid 1980s such as computerized infusion therapy and smaller physical therapy apparatus have helped home health care services grow. In addition, at-home monitoring devices for the elderly have increased the efficiency and use of paramedics.
Information technology has brought about new developments in computer-assisted healthcare, including psychotherapy. Computer systems, such as the Therapeutic Learning Program, developed by a California psychiatrist, provide therapeutic advice to employees at their work site, meeting the concerns of employers over employees' psychological well-being. Such systems can be operated by the patient, although mental health practitioners see such systems as working in conjunction with services provided by a practitioner for personalized diagnoses.
The National Institutes of Health have also begun research on alternative therapies, such as naturopathy and hypnotism. The institute is offering grants for private studies on such therapies. The outcome of these studies will either help promote or reduce the number of people interested in using these kinds of healing methods.
American Association of Naturopathic Physicians, 1996. Available from http://www.infinite.org/naturopathic .
American College of Nurse-Midwives. "A Brief History of Nurse-Midwifery in the U.S., " 1996. Available from http://www.acnm.org/HISTORY.HTM .
——. "Basic Facts About Certified Nurse-Midwives." Available from http://www.midwife.org/press/basicfac.htm .
American Dental Association. "Fact Sheet — Dental Hygiene Today," 1997. Available from http://www.ada.org .
Meckler, Laura. "The Doctor's Still In." Associated Press, 2 December 1999.
National Acupuncture and Oriental Medicine Alliance. "Quick Facts About Acupuncture and Oriental Medicine in the U.S." Available from http://aacuall.org/usaccept.htm .
U.S. Department of Labor. Occupational Outlook Handbook. 1996-97. Washington, D.C.: GPO, 1996.
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