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Are Secondary Outreach Contracts Killing Our Profession? Also Are They Killing Our Profession?

As an athletic trainer with a strength coach niche - I've primarily worked in the secondary school settings for multiple organizations that provide athletic training services to high schools at a discounted rate. Having worked with more than one organization - I feel it is safe to conclude that these organizations are causing more harm than good within our profession.

Here are the issues I see with secondary school contracts:

- ATC are usually held to referral quotas and their primary role is to generate a source of revenue for the company they work for... It is not to provide the best quality of care for their athletes. (I was often told, not to treat my athletes injuries that were in my scope of ability because the business wanted the money from the referral.)

- Often contracts are at a discounted rate for limited hours. This is a false sense of savings for the school because the parents are the one's footing the bill because ATC's are require to refer the student athletes out.

- PT clinics/hospitals hire entry level ATC's to decrease their overhead each year and cycle through new grads every 1-2 years because they burn out. (Note - if you want to grow the profession it is best to keep the professional you have than try to produce new ones every year.)

How does this make you feel? Also do you think our profession should take a stand and make secondary contracts a thing of the past?


  • Michael, I think you raise very good points, but are pointing the finger at the wrong problem. I think that the point is that they should be well-paid, low-turnover, high quality of care positions. If a group is promoting those things by providing outreach, then there should be no issue. I work outreach and while I have been witness to the things you discuss in several different states, it comes down to ethics, best practices, and quality access. I have personally seen problems in quality of care, high turnover, low salaries at almost every level in every setting (pro, college, high school, clinical) so I don't think it's an "outreach" problem, it's a profession problem.

    My current employer will turn down an "affiliation" if it comes down to money and the school/club/organization isn't interested in educating coaches/athletes/parents, developing a long-term plan to include a full-time AT, etc. We also charge a competitive rate for our AT's and will say no to tournaments, etc. offering less than $30/hr (which in my opinion should be a much higher rate). We also don't have quotas. We do evaluate how we are benefiting from our affiliates and vice-versa every year, but there is never a quota and the pressure is never put on the staff "in the trenches". If they aren't providing quality care in their scope then we don't want them representing us as part of our staff!

    Yes, I have the luxury of working with bosses who believe in running our department the right way, but even in my years doing camps, working at the University level for 8 years, etc. I have never faltered on my ethical standards for care or compensation! I know it sounds naive, but you can only control you and set an example for others to follow. Whether that's turning down a 8hr camp for $120 when you need a new tire, or treating a mild ankle sprain yourself rather than referring "to meet a quota" eventually others will follow.

    Gerard, you are absolutely right about not only internships, but the university levels general lack of respect for our profession in general. That's why I "hung up the cleats" and am happily make a difference in a new population setting (with a respectable salary and benefits to boot!). I loved the universities I worked with, the athletes, and my colleagues however that level is by far doing our profession more of a disservice than outreach! Good discussion though guys and great points!
  • Agree with many of the comments above. In my area, the hospital provides free AT services to most of the area secondary schools. Many injuries can be treated on-site, however most are referred to orthopedic physicians and are sent to outpatient PT. Time loss is significant.
  • I am a contract athletic trainer employed by a hospital to cover area schools (and by area schools, I mean that I cover 4 area high schools and a collegiate rec sports program in the area). I provide injury eval and treatment clinics semiweekly for three of those schools (one of the four schools has a full-time staff athletic trainer who was hired due to our initial coverage of their school). I also cover football games as well as provide contracted athletic trainers to cover the other schools that I cannot cover. I understand the hesitation to encourage and promote this style of athletic trainer coverage; however, I ask that you consider the alternative: should these small schools not accept our coverage, they would rather have no coverage at all than to pay for a FT athletic trainer. We, as athletic trainers, demand a certain pay-grade, but some of these school districts simply cannot afford to pay a minimum of $40k, $50k, etc., especially when their athletic directors are barely making that much. Instead of targeting contracted athletic trainers and hospitals that provide such services, perhaps we should target school districts and their school boards to increase property tax rates so as to increase revenue enough to provide a salary for a full-time athletic trainer.

    Secondly, you are blatantly mistaken when you cite that we are required to refer at all, much less to refer to our own physicians/hospitals. As an athletic trainer who was taught in college never to refer unless absolutely necessary, I rarely refer unless I'm sure they need X-rays or further evaluation/treatment with tools/modalities that I, myself, cannot provide. I am even currently providing rehabilitation to an injured athlete, spending extra time to perform rehab exercises with the athlete to save his family traveling time and money as well as time away from school they would have to forfeit to obtain formal PT.

    Thirdly, I am not planning on "cyclying out" of this hospital any time soon. I am the director of sports medicine, making a higher pay than I could at any area high school as a full-time staff athletic trainer. If anything, I think this type of coverage should expand to provide services to those schools who simply cannot afford a full-time staff athletic trainer. I politely disagree with your premise, but I do understand why you and many others support that point of view. I just ask that you consider the PRACTICAL alternative. Schools will not "cave in" and hire a full-time AT for coverage; they will go without.
  • I agree with all of what the OP said. I am no longer a practicing AT. I lost my job twice as a contracted AT to the largest and, arguably, richest school district in IL. Each of these were the result of our employer asking for more money and the district denying it. After the second time, I fought hard to see if we could convince the district to hire ATs as full-time district employees. I sought help from the IATA BOD only for the president to throw me under the bus since he is the director of AT services for Athletico. The result was the head ATs were hired by an orthopedic physical group and the assistants were hired by ATI. I worked really hard at and spent a lot of CE money gaining clinical rehabilitation skills that I was getting scolded for using because my assistant wasn't getting enough referrals. It was a double-edged sword. Either I used the skills I was licensed and educated to and put our jobs on the line but made parents and athletes happy or we would just be walking marketing for ATI. Ultimately, the district did end up hiring their head ATs, but didn't hire an AT with 20+ years in the district. They hired a bunch of young, inexperienced, and inexpensive ATs and then use Athletico for the assistants. I think we need to put our foot down as a profession and quit allowing our services to be 'pimped' out to the lowest bidder. I tried to fight for this, but with a president with a vested interest in the success of contract positions, I was dismissed. To the argument that schools can't afford it, that's ridiculous! Have you ever noticed how much wasteful spending happens in a school? The last AT position I had, one of my assistants was also a teacher AND the aquatics director. I can't even tell you how many times the after school rush was in full swing and she'd leave because they needed her at the pool. Seriously? This woman made more than me in stipend pay alone and barely worked. She was either in the pool or had to leave early for one reason or another. Tell me that makes sense... If, as a profession, we put our foot down to this, then it won't happen anymore. We say we want to be respected as health professionals yet we give away our services for next to nothing or enjoy just providing coverage instead of care and referring the rest out. Am I bitter? You bet I am! But only because I loved what I did and was forced out. I worked hard to be good at what I did but, in my area, that didn't matter because that meant I wasn't cheap enough. It's a shame! It's to the point that when one of my students says they want to go into AT I certainly don't encourage it. There's nowhere to go in the profession and it doesn't seem the profession cares to do much about it. Rant over.. :)
  • This is one of the fundamental issues that has not changed in my 30 years as an Athletic Trainer. I am fortunate to have a full time, tenured faculty high school athletic training job. In my 29 plus years, I've seen very little movement in my area toward hiring more full time positions in the high schools. Clinical outreach AT's make up the vast majority of AT's working in high schools around me. These are entry level positions, some part time, some full time, but include work at a PT clinic. They are definitely placed in the high schools to build referrals for the particular practice that is doing the placements. Most, if not all of these positions would be more beneficial to both the student-athletes, as well as the AT's themselves if they were employed as full time staff at the specific high schools that they are assigned to.
    This is one area where I believe NATA needs to step up, as well as state organizations to force schools- at least the larger school districts, to fund and support employing a full time AT, who is a paid employee of that school district, rather than the school districts paying a third party provider to provide valuable AT services. Seldom would a fulltime school based AT be in a worse position than a clinc based AT.
    When an AT is placed into a secondary school for free, then that school district has placed a value of Zero dollars on athletic training services. Do we as secondary school AT's have no value? Like it or not, this is the value those particular school districts have assigned to the health of their student athletes.
    One last point- a school district could save plenty of money by employing full time substitute teachers to teach English, Math, History. The subjects would be taught, but would the students get the highest quality education? Of course not, yet this is what happens when a clinical outreach AT is employed by the school. There is an AT at the school, but the student-athletes may not be provided with the best possible care. High turnover rates, entry level AT's, AT's who must answer to their clinic first are all issues for clinical outreach ATs.
    Thank You, Michael, for bring this topic to light and opening this discussion.
  • I totally disagree that it is killing our profession. Many smaller and private schools cannot afford hiring an Athletic Trainer to care for their athletes. Hospital or clinic based AT's fill that void and provide high quality care to athletes that normally would not have that luxury.
    While I am not lawyer there are laws that prevent an individual from referring patients to a particular clinic or hospital for revenue. I believe they are Anti-kickback laws and to some extent they are covered under the Stark regulations. I work for a large hospital system. We are trained yearly on this type of activity and it expressly forbidden where I work. We have outreach contracts with many private and public schools along with various sports clubs. All of them are extremely happy and grateful we are there for the athletes. Self referral and quotas are not an option. Parents decide where the athlete is treated.
    By doing outreach I believe we expose more people to what we do and our value as a credentialed health care provider.
    Also it provides more job opportunities to Athletic Trainers.
  • As an AT, parent, former school board member, etc, I see this from several perspectives. I do agree that contract AT positions haven't helped our professions but they have helped our kids. When serving on the local school board, I advocated for a full time AT for our high school - ended up with a contract position 30 hrs / week thru the local hospital group. Not what I'd hoped for but certainly better than the 8 hr/wk the position previously provided. The young lady they hired has done an outstanding job - the toughest part for her was getting the coaches to buy in. As a parent, I was glad to no longer have to be called out of the stands when there was in injury on the court/field - I could actually enjoy watching my own kids play. Do I think our local district will ever employ a full time AT? Not unless it is to become a state mandate. That is why schools have nurses, OT's, PT's, speech therapists, social workers, etc - they are positions mandated by the state.
    It is really no different at the college level - while most have full time AT's on staff, there are still some NCAA schools that use contract AT's - and I do not know of very many NCAA D-III schools that have an adequate number of AT's on staff - that won't change until the NCAA and the NATA get their heads out of the sand and start to seriously work together.......or we unionize.
    There is a current job posted on the NATA career center site - University of Buffalo Ortho / Sports Medicine - a full time position, working in the city schools, compensation (though not listed, I called.......$25K PER YEAR. The NATA shouldn't allow a job to be posted on the career center unless:
    1. The salary is posted
    2. The salary posted meets the 50th percentile for the geographic region the job is located
    3. The salary posted meets the 50th percentile for the demographic profile the are asking the candidate to meet (yrs experience, educational level, etc)

    My point is, while I don't think the contract AT positions have helped our position to advance, they certainly are not to blame for where our profession is as a whole.
  • Mr. Thompson,

    As a colleague, it is appreciated for your insight and personal feelings\thoughts on what you perceive as the norm among secondary schools. I agree with a few of the previous commentators as not all contract\outreach programs fall under the same scenarios as you have mentioned above. Many of us have worked long and hard to make strides in promoting our profession and the needs of having our services available for our schools. With those grass root efforts, I'm just one of many across this nation that have promoted our profession and the understanding of what we are qualified to do and the value we bring to each of our communities.

    By following the NATA Secondary School Model and Plan, we have established an outstanding partnership with our school system and now have developed an Athletic Healthcare Team(AHT) that never existed prior to having our services on campus, full-time every day. This AHT, created by an AT, has involved into the following: Athletic Trainer (employed by local Hospital), School Superintendent, Hospital CEO, Athletic Director, Coaches, Emergency Room Director\Supervisor, Team Orthopedic, EMS Director and Team, Sheriff, Principal, Teachers, Parents, as well Student Athletes. As you might see, if it weren't for a AT to plant a flag and cast a vision of creating a Healthcare Team, nobody in in our community would understand what we do and what services we can provide.

    The NATA has made major strides in the development of the focus on the Secondary School Setting. However, The NATA only is our leader in providing mere Models and Plans for us to incorporate in each of our own communities and helping in building relationships and partnerships with school systems and each individual healthcare facility in our area. Its is up to each of us as AT's to build and mold that partnership as we are the front line combat for promoting our profession.

    It is once again great to see where you may think the Secondary School Setting\Clinical Outreach may be hurting the profession, and in some situations\areas, it might need some focused attention and assistance. However, We are all not bringing situations down for the entire profession and continue to work in making the Secondary School\Outreach Setting a great area for entry level students to enter.

    Appreciative of your veiwpoint.

  • null

    With all do respect Danny - I disagree. Answer this, if most "outreach" practices/hospitals truly cared about the schools/ATs why do they make them sign non-compete agreements? As we know most ATs barely make 40k... So what is in it for the "outreach"? Basically suppression and control of a profession that controls the referrals! (*note - non competes can be beaten by ATs - I've done it myself.)

    Next, why have myself and many other ATs been help to referral quotas? Someone mentioned about about "stark laws", but I can tell you most hospitals/practices are ignoring them. (i.e. the need for quotas.) I've even personally seen organizations make athletes pay $50 dollars to receive their baseline ImPact test if they choose to go out of network. Keep in mind these same athletes are forced into taking these test preseason or they can't play which is extortion.

    Now most of the "outreach" directors above disagree with my point of view. Yet I think we all know "why", their very job is dependent on the fact that until now there hasn't been a movement to remove the infection of "outreach" contracts that are slowly killing our profession.

    Make no mistake it already has made the career of a secondary AT something that cannot be viable long-term because of the conflict of interest the above issues are creating. The numbers don't lie because we are going through young ATs at an alarming rate still.

    In conclusion the "straw man" you put up when you said, "I'm blatantly mistaken" is null. Have you lived a moment in my shoes or any other ATs that have had to put up with these injustices? It is my opinion that it must and should be a primary concern of all athletic trainers that we need actively work and find viable options to removing "outreach contracts" from our local schools.
  • Agreed! I have worked for 3 different contract companies just to stay at the high school I currently work for. Most other schools in our district have had anywhere from 5-9 different athletic trainers in the last 9 years. Our athletes are the ones that suffer because of such high turnover rates. School districts will continue to choose the lowest bidder to save money. If you have athletic trainers that are willing to speak to the district office about the concerns, it can be improved, but I think with constant turnover and new grads, that doesn't happen as often as it should.

    We were with a company for about a month or 2 before another AT and I scheduled meetings with out district AD in an attempt to reconsider the choice they made. We had to stay that year, but at the end of the year, the district chose another group. We were required to do 15 hours a week in a clinic doing rehab for PTs before we were off to the high schools. If our schools had a day off of school or a week off for break and practices were in the morning, we were not allowed to go to the school if it was a day we were supposed to be in the clinic. I had coaches cancel football practice because I wasn't allowed to be there, and they were afraid to have football practice without coverage.

    The last 2 contract companies I worked for didn't have quotas for referrals because that isn't allowed, but we were constantly pressured and put down for not having enough referrals. We had to report whatever injuries we had seen or referred to physician for X-rays or consultation and were asked monthly why those athletes hadn't gone in for PT. There was no consideration for our athletes and what their family and financial situation was. Some have very high deductibles and co-pays and don't have the money to pay. We were told by our supervisor that any injury lasting longer than 3 days should be sent to PT to let the "experts" do the rehab and return to play. Every monthly meeting was a time for us to be told how we were worthless, brought in no money, shown how much money we were costing the company, how much we should be bringing in, and so on.

    Luckily, our district moved on from that company and now has a contract through a hospital group that seems much better. ATs work for physicians rather than a PT company. It's a lot easier to refer to a physician than hope that the physician you refer to will send them to your PT company. I work for the district now so I don't have to worry about referrals at all and can just work directly with my directing physician.

    This argument has been going on for a few years and I don't know that there is a way to fix it. The problem is that a district will accept a contract from a company to pay out as little as possible if they don't have anyone that understand these companies well. Companies will continue to pay low salaries if ATs continue to accept them. I understand that sometime we need to take a job, but even if we take a lower paying job, we should be working towards better salaries or changing contracts. Educating our schools and those in charge of the decisions should be of great importance to those in these settings. If you don't know how these decisions are made or the people that will be making the decisions, that should be step 1.
  • Mr Thompson I totally agree with what you have said. One commenter, Mr Hamilton is full of baloney. The job of the NATA and state organizations is to help us not just give out advice. We have no power in getting this changed but the NATA has a lot of power to do that and to help us. We need the states to mandate our profession, just like the nurses. The rest of the commenters who say that their business doesn't put pressure on them, are full of it too. The only reason the companies are there is for the money.
    I work as a full time ATC for a school district and we are currently in a war with an orthopedic group who wants to be our school's team physician. He even enlisted our contract trainers (from a PT group) to help him become the team physician. They said they wanted him in here, because their PT group didn't get referrals from the other orthopedic group in town. The only reason he wants to do it is because of the money he can make from referrals. That is the driving factor in these places.
    Our current team physician has been with us for 25 yrs and is a general practitioner. He makes no money on referrals, he is here because he cares for the students.
    The focus for secondary schools should be on the care of the student athlete, and it should not be about money, The main problem is "ITS ALL ABOUT THE MONEY!"
  • I've worked as a secondary school outreach ATC for 11 years and we are definitely the exception to the rule. I have full benefits, don't work in the clinic (unless I want to use the equipment that I don't have at the school), and am able to provide my athletes the best care. I also make more than any of the local division one college ATCs.

    The problem I think is that these clinics try to underbid the contracts for fear of losing them, so perhaps I'm lucky because no one else ever bids our contract every three years. Here's why: my AD loves me and together we put together specific items in the contract that only we can provide. No one else can bid because no one else has an established ATC with a masters in nutrition as well as a CSCS and a part time ATC who is a teacher at the school. That's how we're both able to make decent and livable wages
  • Michael - you raise some great points. But I know a LOT of ATCs who would be out of a job if we made secondary contracts a thing of the past. So my question is: do you have any suggestions on how this situation can be improved? Maybe these contracts are slowly killing our profession. But the truth is that this is how THOUSANDS of ATCs are able to have employment. If we just did away with them, I know it would be a bullet to the heart for a lot of us out there.
  • I would like to make the case that outreach athletic training has substantially made athletic training better in our area of Western Pennsylvania. I am a manager for a large health system. We have over 80 full time staff and total over 100 staff with casual calls. We provide FULL TIME athletic training services to over 50 high schools, colleges, and professional organizations. If you look at the Western PA area, you will find that nearly ALL high schools have an athletic trainer. Not only do they have an athletic trainer, they have MULTIPLE athletic trainers. It is safe to say that athletes in Western PA have some of the best care by athletic trainers in the country. We have moved beyond providing our services to high school is becoming more and more common that we are providing staff to the middle schools now. It's my opinion that the saturation of athletic training services in our area is the result of quality care at a reasonable cost to our districts by outreach organizations. Our clients want more and more of our services.

    As far as having a career in our organization...I have none of the concerns in the original post. We don't have quotas. Our belief is if your provide quality athletic training care and have the system resources to provide quality care beyond that, patients will utilize your services. It's the customer's choice. Be the best and they will come to you. We don't have limited contract hours. Our staff are there before the end of the day bell and are there until the last event of the night. We have put some work-life balances in place by putting into the contract certain holidays and Sundays as non-work days in certain situations. We are fortunate to receive over 100 applicants every summer for the open positions that we have and we select the best candidates...not just entry level candidates. This year we have hired multiple staff with years experience in the double digits.

    In my opinion, the turnover of staff that we have is a result of some of our problems with the profession. It's a tough job. Demanding hours and relatively low pay compared to other medical professionals. All too often we lose staff because they go back to PA school, nursing school, or just switch gears with their career. When we recruit to backfill those position, we receive applications from people all over the country. We are able to draw a diverse group of athletic trainers from different regions of the country. And we are providing good careers for these people that want to maintain their career as an athletic trainer... all in the outreach setting.

    We would all like to make more money. But our total compensation package is excellent when you look at retirement (we have a pension and 403k match program), health insurance (very low premiums), as well as other great benefits such as life insurance, employee assistance program, discount perks, etc. We have an outstanding career ladder where there are leadership opportunities and professional growth. I've been with my organization for 15 years and plan to remain with it until I retire. We have multiple staff with 20+ years experience with us.

    I am proud to work for an outreach athletic training organization. I truly believe as a result of our work, the athletes of Western PA are receiving some of the country's best health care. And by working for our organization, we have a very large group of athletic trainers who are having great engaging careers as athletic trainers.

    Having said that...perhaps there are some areas of the country with organizations who are doing it wrong...
  • As an AT for 20 years in a contracted outreach position, here is my 2 cents. What would be our perfect world. For many it would be the full time secondary school postion with all the benefits. And I would sign up for that in a minute. But it may come with consequences. So let's say they pass a law that does just that. That every school needs an AT on staff. There are only so many schools, even with many districts being underserved, many ATs would or could lose their jobs. What do we do for the New grads that are coming in and others like myself who would have another 10 years before retirement? They would be out of work and if ATs don't obtain reasonable reimbursement on the insurance front for our skills, hospitals and clinics won't hire ATs. That is why, and the NATA should have kept moving forward with this, 3rd party reimbursement is still so critical. But as far as what you are getting paid by your clinic or hospital, I urge all of you to search your schools board of education Minutes and the contract should be there in black and white. I know what every school pays where I come from and use it as a comparison tool when negotiating.
  • As an AT in Utah, working outreach through a physical therapy clinic, I think you hit the nail on the head!!! After 3 years, I'm about burned out. There's no respect from the PTs, I'm underpaid, and they wont allow me to treat at the school, everything must be referred to the clinic. There needs to be change!
  • Hang in there Liz....I was burnt out too at one I am 20 years later.
  • Clinic/outreach ATC here for 11 years. I don't work in the clinic, and I get a cash bonus for patient referrals to the clinic, as well as referrals to my favorite orthopedist as well. In addition, I have a part time assistant and I get paid very well relative to other local ATCs. I think what's killing our profession is the fact that ATCs will still take any amount of money as a salary because it's a job and they need a job.

    We aren't going to get paid more by billing to insurance. We aren't going to get paid by being directly hired by schools. We are going to get paid more BY GETTING PAID MORE. Stop accepting $25/hour when the local going rate is $40/hour.

    Also, I'm a firm believer that an extra year of tuition wil kill the profession more than anything else. One of my clinical students just graduated and is about to have student loans of $1500/month, and had to accept a clinic/outreach high school job of $33,500/year. Do the math, that leaves her $600-$700/month to pay rent, car, insurance, phone, eat. Good luck to her.

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