Chapter 34
Exercise Physiology and Healthcare – Where Does the Exercise Physiologist Fit into the Current Healthcare System?
Eric Durak, MSc
For students of Exercise Physiology – there is a humble acknowledgement of some of the tremendous advances in medicine by persons trained in the course work of exercise physiology. Even at the turn of the 20th century, some medical advancements (such as treadmill testing and pulmonary assessments) had some level of involvement from exercise physiology. The 1928 Nobel Prize in Medicine was awarded to Dr. AV Hill for his work in muscle physiology.
When we look to exercise in the healthcare system – we refer to cardiac rehabilitation programs, which have been part of the standard of care for heart disease patients since the 1970s. Information on exercise physiology and its adaptation to medical situations have been eloquently presented in the medical literature since Dr. Ken Cooper wrote his best-selling book “Aerobics ” in 1968. Information about exercise and heart disease (Pritikin, Ornish), diabetes (Devlin, Bogartus), hypertension (Hagberg), cancer (Winningham), and a host of other disease and metabolic conditions points to the tremendous strength of the association between inactivity and various diseases and and, in many cases, the cause and effect relationship between regular physical activity and the prevention and therapy for many conditions as well.
However, over the past decade and a half, a series of events have turned the tide against exercise as a part of mainstream medical practice in this country. This chapter is dedicated to explaining some of the more current ramifications in health care and their impact on the prescription of exercise. This chapter ends with information that may change the course of exercise as it relates to healthcare issues. It will also offer pertinent suggestions on how exercise can become and remain a viable part of healthcare without having all of the trappings of the current healthcare system become intertwined with its prescription.
As we enter the bear beginning of the 21st century of medical care in the US, we should ask the definitive question: "What has happened to exercise as part of the health care system?” Cardiac rehabilitation, once a staple clinical program, has been reduced in its third party payments in most regions by over 60%. Programs that boasted 30 to 40 sessions of reimbursable cardiac sessions are now lucky to receive 10 payments in total.
The advent of managed care may or may not have impacted exercise growth and proliferation in the current system. In other words, did the "growth and proliferation" start or exacerbate the problem? Managed care actually started in Minnesota in the mid-1970s. It came into prominence in the late 1980s in California, Arizona, New York, and Florida. The reason was simple enough (i.e., contract out for a fixed sum of money for payment of services to physicians, hospitals, and other providers). They, then, had the responsibility to treat patients in a business fashion (meaning, not too many sessions) or their profit margin would be in jeopardy. For many physicians, managed care was dubbed “incentive not to treat.” That way their profit margins from the old fee for service (FFS) method of reimbursement would not be cut into by a large amount.
However, the problem is that the patients suffered by not receiving the best type of care. Patients were released from hospitals in some cases in half the time as usual stays. Programs such as cardiac rehabilitation were also cut. At the same time, HMOs were limiting the types of “pre-existing conditions” that they would cover. Although managed care was based on prevention as a means of cost controls (Chenowith), in reality, it cost savings meant cost-cutting measures. Many patients with pre-existing conditions were not allowed in certain plans. As a result, the managed care scenario to “not treat” specific types of diseases or only seek out the healthiest members lead to important and significant problems in the health care system. Medicare – the largest funder of medical interventions, has found its burden greater since more private insurers are not covering some of the major medical claims.
Interestingly, HMOs and the managed care system should work well for wellness and fitness-orientated programs. One case in particular is the Silver Sneakers Wellness Program produced by Healthcare Dimensions in Phoenix, AZ. This program, which has been in operation since 1995, has venues nationally. It does business with over 20 HMOs and PPOs. The premise of Silver Sneakers is to contract with the payor for a regional wellness program. Staffed by certified fitness professionals, the program is on-going, and provides an option for persons over 65 years to improve their health status. The theory is that their improved health will reduce the incidence of falls, osteoporosis fractures, diabetes complications, and general degenerative problems associated with aging in general. This well-funded model could (and should) be a model for other exercise-related programs for disease management, corporate wellness, and general prevention.
Current Reviews on Health Promotion and Cost Savings
At this time, most HMOs in this country dedicate a very small percentage of their total budget to prevention and exercise programming. Despite the proven effectiveness of exercise to cut costs in many large companies, most of the payments of wellness-type programs are from their own in-house insurance premiums. Companies such as General Electric cut healthcare costs by 38% in 18 months with their in-house fitness program, Traveler’s Insurance reduced sick leave by 19%. Dupont, Coors, Bank of America and Traveler’s found a return on investment from their fitness programs on average of $4.40 (Wellness Council of America). Also, the majority of the nation’s 70 million Medicare recipients are provided little in terms of “prevention” services. Title 18 of the Social Security Act, which governs Medicare laws, has no preventive aspects in its guidelines. According to Gordon (2001), if health promotion is going to play an ever-increasing role in improved overall health, and cost-savings, then specific aspects of Medicare laws need to be updated.It is clear that the application of health promotion components such as smoking cessation, nutrition, and especially exercise play a role in improving overall health status of employees and clinical patients. It is also clear from a recent review of health promotion strategies that more governmental interaction is necessary to create changes in our healthcare system to allow for a higher percentage of payments for prevention and health promotion services.
The Growth of Alternative and Complementary Medicine
One interesting aspect of the fiscal impact of health promotion is the increase in the amount of money spent on alternative medicine programs. Over the past eight years the money spent by the NIH alternative medicine section has risen from 7 million to almost 70 million dollars. This represents a significant increase to look at specific complementary treatments currently being practiced in the United States.In his book on alternative medicine, James Gordon, MD makes the strong case that alternative medicine has its place in mainstream healthcare. Most doctors such as Dean Ornish, Deepak Chopra, and Andrew Weil are not only in favor of expanding alternative and complementary medicine, they wish to see it fully reimbursed from private insurance and Medicare. Many types of alternative medical practices, such as herb therapy, acupuncture, spiritual healing, the Gerson Method for cancer treatment, and chiropractic care for low back pain have all shown some level of efficacy as reported in peer review studies (Gottlieb). However, the cost-benefit analysis of these programs has not been analyzed. The 1993 report from Eisenberg mainly reported who was using alternative medicine in the United States, compared to traditional medical services. No attempt was made to look at cost savings or a ROI from monies spent on alternative medicine services.
It is not the purpose of this chapter to either approve or condemn alternative medicine. Its growth and diversity is testament to those who wish to use it to improve or maintain their health status. It is a model that should be viewed by those in exercise physiology as one that could be replicated in many clinics, hospitals, and health facilities nationally. As many Exercise Physiologists struggle for traditional reimbursement or rely on out-of-pocket payments for their services, it is interesting to note the formation of state alternative medicine provider networks and the beginning stages of reimbursement for alternative medicine programs. For example, in California, over seven major insurers now pay for alternative medicine – from massage to acupuncture. The reimbursements are not large (average $25 per session with a mandated $5 to 15 co-pay). For alternative practitioners who charge more per session and don’t want to be locked into a fixed payment schedule, they simply chose not to become a provider in the network.
Is Reimbursement a Viable Option for Exercise Services?
Should exercise physiologists seek reimbursement for their exercise therapy services? One point of contention is that groups like the American Physical Therapy Association have mandated in a number of states that is it illegal to practice physical therapy services without a license. This simply means that any non-PT providers may face fines or jail time for providing therapy services and submitting bills to Medicare. The obvious flaw in this argument is that it is not defined as illegal to provide services to patients on a cash-only basis or to secure contracts with Worker’s Compensation or HMO groups through a contract. The good news is that since reimbursements are capped by the Medicare Reform Act (see below), then even many PTs are going to a cash-pay basis for their services. Time will tell as to whether HMOs will truly get on the wellness bandwagon and provide these services as part of their contracts to patients and provider groups.However, there are pockets of exercise professionals across the United States who do receive referrals from physicians for medical patient recovery programs, submit prior authorization forms to insurance companies, and receive a specific amount of insurance money for their therapy services. It is therefore enlightening that services referred by doctors can be reimbursed to the practitioner (similar to those of alternative practitioners). It is simply a matter of understanding the system, and working through it (Durak, 1997). In the future more types of exercise therapy services will be reimbursable to practitioners who are not “traditional” therapists in the sense that they are recognized by state licensing laws. Much of these reimbursements will be dependent upon outcomes and healthcare cost savings attributable to these services performed.
The Medicare Reform Act of 1997
In 1997 Medicare decided to cap the amount of money it spent on rehabilitation services. This bill was designated to limit the reimbursement of traditional rehabilitation services to $1,500. For many physical and occupational therapists, this meant a cut in pay, hours, or both. It did, however, dictate to those in the rehabilitation world that there is a limited amount of reimbursement dollars available for therapeutic intervention with specific types of patients. The results of this legislation have seen two areas of reverberation from the therapy world. First, treatments to most rehabilitation patients have been dramatically cut. This may have been good news for fitness and health professionals, as some patients who would have spent more time in acute therapy sought other types of health programs at lower costs.The second aspect is that the therapy world has intensely lobbied to reverse the MC Act. Although this has not happened at this writing, there are signs of a reversal as MC has implemented for some medical services a Òmodified fee for serviceÓ format that would allow for extended billing procedures at pre-determined rates. This may be of benefit to physicians and therapists who are used to extended billing procedures, but again may place more financial constraints on the already over-burdened MC system.
The Medicare Wellness Act of 2001
An interesting twist in the reimbursement and funding sector came about in 2001 when Senator Bob Graham from Florida co-sponsored the Medicare Wellness Act (Senate Bill 2332 / House Bill 2058). This act looked at funding of specific prevention programs for the following types of conditions:• healthy seniors prevention programThe goal for the MC Wellness Act is to reduce health care costs by preventive and educational interventions. Although still in committees, the MC Wellness Act may provide more than 30 million dollars for health and exercise services through government-sponsored financial assistance. One aspect of this bill is that it is lobbied for by the American Dietetics Association, and the Physical Therapy Association; both of whom would stand to gain the majority of funding through this program if implemented. The APTA has developed a wellness certification program at the same time as the MC Wellness Bill was being introduced. It is no coincidence that PTs would like to have a share of the wellness market. It is likely the fastest growing aspect of healthcare delivery. It is incumbent upon all exercise professionals to look to their local and regional representatives to have a stake in the development and implementation of this new aspect of Medicare sponsored health programs.
• behavioral health
• smoking cessation
• lack of physical activity
• nutritional interventionPartnerships
One area of investigation in terms of assisting patients to attend health club and medically based clinical programs is the aspect of corporate sponsorship. This may take place from programs such as Worker's Compensation which routinely pays for clinical exercise programs, or seeking sponsorship for specific programs from corporations which have a stake in partnering with exercise and health promotion in general. One example would be working with local or regional representatives from Eli Lilly for a diabetes and exercise program. Lilly may sponsor educational components or guest lectures for a program, and donate a specific amount for exercise "scholarships" for underserved diabetics who may not be able to afford specific services. A number of pharmaceutical companies are partnering with health programs, such as web sites, hospitals, and clinics who provide information, technologies, or complementary services that may be in the best interest of that company to do so. This is a fast growing area of healthcare and business development, and one that clinical exercise professionals should consider in terms of bringing in revenue sources to their programs independent of current or future insurance reimbursement.Future Exercise and Healthcare Relationships
For Exercise Physiologists to not make a claim in current and future healthcare and reimbursement policies is not appropriate. Healthcare has undergone extensive change over the past 10 years and, in some ways, is leaning towards lifestyle issues as a major reimbursable avenue especially for cost containment models. If the exercise profession can provide quality outcomes and continue to develop relationships with physicians, physician groups, governmental agencies, HMOs, and other managed care organizations, the possibility of being a part of third party funding is closer to a reality.There are many questions that remain to be answered. First, there is the question of licensure. Is it a prerequisite for receiving reimbursement? Or, is the ability to understand healthcare relationships the most important element? Second, how will clinical exercise programs create a ROI or cost savings mechanism for payors? Although this has been addressed sufficiently in the health promotion literature, continued analysis is important with regard to clinical studies of diabetes, cancer, hypertension, and weight management. Third, will exercise professionals be able to distinguish their services from physical therapy, personal training, yoga, and otheres to a degree by which they can truly be accepted as healthcare providers? I believe this last aspect has more to do with providing quality outcomes measures in individual and multi-center programs than it does what licensure status or terminal degree an exercise physiologist credential has earned.
References
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