Walk into almost any outpatient clinic since 2018 and the story feels the same: 30-minute slots stacked back-to-back, concurrent treatments squeezed in to hit productivity, and insurers approving care in three- and four-visit rations—if they approve it at all. Some clinics have closed or transitioned to cash-based models to survive. OTAs, once the backbone of access and continuity, are frozen out by hiring pauses and a 15% “assistant differential” that punishes teams for using them. Meanwhile, federal payment models keep ratcheting down what OT services are “worth,” even as patient needs get more complex.

Now put that reality next to AOTA’s recent tax filings. In 2022, 2023, and 2024 the association ran operating deficits (-$321k, -$2.52M, and -$1.49M). Net assets slid from $26.8M (2021) to $21.3M (2024). Liabilities jumped from $9.36M (2022) to $17.9M (2024). “Contributions”—the philanthropic fuel that powers strong advocacy—fell to $48k (2022), $5k (2023), and $0 (2024). And the eye-popping “good year” in 2020? It was driven by a one-time $13.17M asset sale, not by dues, programs, or fundraising strength. In short: while clinicians felt squeezed from every direction, their national association looked and behaved less like a crisis-time nonprofit and more like an organization protecting its internal footprint—higher payroll, higher liabilities, and virtually no philanthropy—while the field absorbed the blows.

The profession’s slide, in plain terms

Congress did repeal the notorious therapy cap in 2018, but it bolted on the OTA/PTA modifiers that triggered a 15% cut whenever assistants provide a meaningful portion of a timed service (implemented 1/1/2022). In Home Health, PDGM took effect in 2020 and removed therapy visit thresholds; agencies now get a lump sum and often cut therapy utilization to conserve that payment. The Medicare conversion factor (CF)—the base price for most codes—kept slipping: $34.89 (2021) --> $33.59 (2022) --> $33.06 (2023) --> $32.7375 (2024) with a small mid-year patch, then $32.35 (2025). On September 30, 2025, the Medicare telehealth waivers for OT expired, ending Medicare payment for OT telehealth unless Congress acts (currently in a government shutdown). And looking ahead, CMS has proposed an additional 6.4% cut to Home Health payments in CY 2026, citing “behavioral adjustments” under PDGM—at the very moment agencies are already pressuring therapists to cut visits and even letting algorithms, not clinical judgment, decide how much care a patient gets. CMS’s own data show visit counts per 30-day episode declining across disciplines since 2018, with OT visits dropping from 1.02 to 0.73 per period through 2024.

That is the current state of the profession: fewer visits authorized, lower pay per unit, assistant devaluation, shrinking telehealth authority, and growing administrative burden.

So, what is going on with the organization charged with the promotion of the occupational therapy profession?

Some would be of the opinion that a profession-first association should get more nimble when its members are apparently under siege. This would look like -- cutting internal costs, boosting fundraising, concentrating spend where rules and rates are set, and proving the value of OT with tough, payer-ready outcomes. That’s not what AOTA’s 990s read like.

• Three straight operating losses (2022–2024) while payroll stayed high (other salaries and wages at ~38–46% of expenses).

• Executive pay continued at roughly ~6% of total expenses (e.g., $1.4M in 2022 and again in 2024), even as members’ own wages stagnated or fell out in the working profession. 

• Philanthropy flatlined to nearly nothing. The association reported no professional fundraising costs and collected $0 in contributions in 2024. This is extraordinarily shocking for a national body chartered to advance a profession through advocacy, research, and public education.

• Revenue quality weakened. The 2020 surplus was a one-time asset sale. “Other revenue” bolstered the organization for a while, then turned negative in 2024. Rental/inventory highly fluctuated - but little details have been provided to membership base. 

It appeared like the association didn’t pivot while the profession got hammered. 

How we got crossed up

Occupational therapy has always wrestled with identity: are we a craft of hands-on function or a science of measurable outcomes? The best periods in OT’s history married both: activity analysis, graded occupation, rigorous measurement, and clear, occupation-based outcomes that medicine and payers could respect. Since 2018, the pressures have been overwhelmingly economic. That is, policy levers have been a driving force in the devaluation of therapy visits, assistants, and time. That demands an association that thinks like a scrappy public-interest firm: data-rich, litigation-ready, coalition-building, and laser-focused on the handful of rules that make or break access and wages. What we’ve had instead is an organization running deficits while clinging to the same cost structure and almost no philanthropic muscle to fund big fights...but apparently continued to have a million-plus dollars to pay for obscene executive salaries that do not match the profession they serve. 

A better way forward (and absolutely doable)

Imagine an AOTA that publishes a plain-English quarterly dashboard that includesr evenues, expenses, advocacy goals, and scorecarded wins so that members can see exactly how each dues dollar turns into policy pressure. Picture a board policy that says no more deficit budgets and executive pay moves only when member wages and advocacy outcomes move. Consider a three-year plan to build real fundraising (5–10% of revenue) earmarked for the things that save the profession money and dignity: OTA differential relief, permanent telehealth authority, PDGM guardrails, and outcomes research that makes payers take notice of the work we are doing as a profession.

Then aim spending where it counts most:

• Federal levers: conversion-factor relief; fix or carve-out the 15% assistant cut; restore and stabilize OT telehealth in Medicare; stop PDGM from indirectly punishing therapy visits; hard-wire ADL/IADL and home-safety measures into quality programs so OT’s wins are visible (this would require providing grants to clinicians and clinician-researchers who are doing the work!) 

• State levers: prior-authorization reform, Medicaid rate parity (Medicaid rates pale in comparison to Medicare rates -- and no, this has nothing to do with the Trump administration), timely payment standards, and rapid-response teams for local payer abuse.

• Proof: fund multi-site studies that translate OT into outcomes that CFOs and actuaries respect : fewer falls and readmissions, faster functional gains in bathing/dressing/meds, lower caregiver burden, safer discharges. Package those results for CMS and commercial plans in their language.

Finally, rebuild the pipeline (especially OTAs) by quantifying their cost-effectiveness for health systems and investing in scholarships, residencies, and employer toolkits that make team-based care the obvious choice despite CO/CQ.

Why this is worth fighting for

OT’s distinct value (i.e., turning capability into participation) saves money and transforms lives. Policymakers are not hostile to that; they’re hungry for clean data and clear stories. The profession has both. We need an association that behaves like it: transparent, member-indexed, and outcomes-obsessed.

Until then, here’s what you can do right now:

• Ask for the dashboard. Respectfully demand quarterly transparency and a “dues-to-wins” ledger.

• Show up for the big levers. Use AOTA and your state association to contact Congress on CF relief, OTA differential reform, and telehealth; comment on PDGM and Home Health rules; push your state on prior-auth and Medicaid parity.

• Feed the evidence. Track falls, readmissions, ADL/IADL changes, caregiver burden, and discharge safety—and share those data with your associations and lawmakers.

The association was created to promote the profession. not to preserve its own balance sheet while members struggle. The good news is that course corrections are completely within reach. If we align dollars with mission, measure what matters, and keep our story focused on participation and outcomes, OT won’t just survive this era, it will lead.