Physical therapy's billing system was built to measure time. It has quietly started measuring thought. Ask a new grad why they're doing manual therapy for exactly eight minutes before moving to therapeutic exercise, and the answer isn't "because that's what this patient's tissue needs right now." It's "because that's a unit."

The reimbursement structure has stopped being a back-office detail and become the actual clinical reasoning. That's the problem, and it's getting worse, not better.

I work at the intersection of physical therapy operations and health and wellness consulting, which means I get to see both sides of what's happening in this industry — the clinical reality and the business reality. They are increasingly hard to reconcile. Here's what I think the next few years look like.