ASEPNewsletter
Vol 1 No 12
August, 1998
ISSN 1097-9743
The ASEPNewsletter
is devoted to informative articles and news items about exercise physiology.
It is a monthly magazine of news, opinions, exercise physiology professionals,
and events that shape exercise physiology. While it contains views and
opinions of the Editorial
Staff who oversee the ASEP Internet Websites, visitors can have a voice
as well. We welcome interested practitioners, researchers, and academicians
to e-mail the Publisher their thoughts and ideas or to respond directly
via the ASEP
Public Forum.
Fitness and health
promotion in the managed care setting: The emerging role for exercise and
health care
ERIC P. DURAK and ANTHONY J. PALMIERI, JR.
Introduction
For the past 7 years, fitness and health programs have been interfacing with insurers and managed care organizations in terms of providing health and exercise services to the public under a health plan benefit. Recently, the concept of exercise and managed care benefits packages has expanded into capitation and subsidy packages. This article will explore the relationship between the utilization of exercise benefits for employees and health plan subscribers, and look at the economics of providing this type of package through managed care organizations, using existing facilities such as hospital wellness programs or health clubs as the conduit for providing such a service to the general public.
Background
The origins of subsidized health memberships started in the corporate world, where companies such as Tenneco, Ford Motor Company, and Steelcase have shown cost savings of up to 40% from the implementation of wellness and exercise programs (13). These programs were the genesis for the first subsidized health club memberships that were negotiated through the International Health and Racket Sports Clubs Association (IHRSA) in the late 1980s (5). The subsidies paved the way for employees to take advantage of health and fitness programs at a reduced cost or for free.
In the decade of the 1980s another trend, that is, the incorporation of health and fitness centers within hospitals began to grow (1,10). By 1991, the first year of the Association of Hospital Health and Fitness, there were approximately 150 hospital fitness centers. By 1997, there were over 500! Also, during the first decade of development, there was little start up capital for hospital fitness centers, and they rarely made profits in the first years. At the present, start up costs for many hospital based centers exceeds $5 million, and every center is profitable in its first year.
There are several trends happening currently that point to the fact that fitness is becoming a more powerful force within the managed care world (10-12). The following table highlights the level of participation between fitness and managed care over the last decade. The growth of this relationship may serve as impetus for individual health professionals and health club chains to create a health care business venture in their communities.
Date Liaison Ramifications 1965 Dr. Win Paris developed the first
medical health club in Torrance, CAInitial liaison between fitness and medicine 1983 Dr. Paris coins the phrase "fitness therapy" No ramifications, as teh industry has not
embrached the post rehab concept yet1985 Julie Danielson created the After Care
Fitness Manual movement in her
Minnesota health clubThe official beginning of the post-rehab
fitness1989 International Health and Rachet Sports
Association signs the first insurers and
HMOs to subsidize health club
membershipsGrowth in 5 states in the N.E. region,
and over 12 states nation-wide1992 PacifiCare's Senior Fit program developed
in Southern California, Arizona, and
OregonProviding free subsidized health club
memberships to thousands of PacifiCare
members over the age of 65 in 3 states1994 Formation of the Arizona Fitness Network
- 9 clubs using capitation services with
HMOsDevelopment of capitation nework
covering over 200,000 lives in fitness and
health club setting1995 Formation of Colorado Fitness Therapy
Network - Providing preventive and post
rehab to patients in a five state areaDeveloped standards of practice and
provides computer-based outcomes for
all physician-referred patients. Has
contracts with over a dozen HMOs for
preventive and rehab services1996 First annual personalized Health
Management Conference in San Diego, CAFirst national conference dealing with
fitness and managed care issues. Over
300 industry leaders in attendance1997 Formation of National Fitness Therapy
AssociationBranch-off from Colorado F.T. Network,
the NFTA will develop club-based post-
rehab and contract with HMOs nation-
wide1997/98 Contracts between 24 Fitness Health
Club and PacifiCareProvide post-rehab in California-based
health clubs, expanding nation-wide in
1998Outcomes Management
In his Shattuck lecture, Paul Ellwood, MD defined outcomes management as a tool to improve the quality of health care (7). A more complete definition that is more applicable to clinical exercise physiology is as follows. Outcomes can be defined as the systematic change/improvement in the health status of persons, groups, or communities by implementation of a health and/or rehabilitation program and the measurement of that status by some or all of the following elements (4):
Physiological variables.................change in aerobic capacity, strength, ROM, body composition Psychological variables................change in self-esteem, improved mood Patient satisfaction.......................about program, therapy, practitioner Cost containment.........................per session vs other treatment Statistical procedures...................% improvement, statistical comparison Based on what we now know about outcomes in general, the strength of exercise outcomes is the ability to record a positive change in health status directly related to exercise conditioning (2,9,12-17). The chart below details changes in physical function and quality of life that one should expect to see from the implementation of an exercise conditioning program for persons with the following diagnosed medical conditions:
Condition Outcomes Measures Expected Improvements Diabetes Self-glucose monitoring, A1c, body
composition, general fitnessImprovements in acute and long term blood
glucose, lipids, and waist/hip rationWeight Body weight/composition 1-1.5 lb weight loss per/week Management BMI, blood lipids, QOL survey For the first 10 weeks. Improve lean body
mass along with fat lossCancer Pain rating scale, quality of life,
overall body strength, and stress
managementImproved pain-free movement, self-esteem,
ADL's, range of movement, outlook on the
future/survivability, strength and overall
fitnessHypertension Systolic and diastolic blood
pressure, body weight, lipid levelsImproved resting SBP and DBP, exercise
SBP, body weight and exercise tolerance,
and reduction in medicationsPulmonary
DiseaseTidal volume, maximal, expiratory
volume, spirometry, oximetry
exercise time, intensity, chest
inspirationVO2 at rest and during exercise, breathing
rate, O2 saturationOsteoporosis Strength, range of motion, DEXA
scan, postural assessmentImproved bone density in the radius, lumbar,
and femoral neck areas, overall improved
strength, reduced kyphosis and/or scoliosis
(if present)Hyperlipidemia Body weight, stress scale,
cholesterol and lipid profileReduced body weight, blood pressure, lipid
levels (increased HDL-cholesterol), stress
management scoresHIV/AIDS Immune function (natural killer
cells, CD4, CD8 ratios,
macrophages, lymphocytes),
general strength and enduranceImproved immune function, better quality
of life, maintained or increased body weight,
increased muscle size and strength, improved
appetite (8)Orthopedic Plum line/grid tests, BAPS board,
ROM, muscle imbalances, general
and muscle-specific strengthImproved posture, balance, coordination,
specific strength increases, improvement in
performance and ADLs, reduced painLEGEND: (ADL = activities for daily living; SBP = systolic blood pressure; DBP = diastolic blood pressure; HDL = high densisty lipoprotein; DEXA = duel energy X-ray apsorptiometry; QOL = quality of life)
Managed Care Fitness Contracting
Managed care contracting has mostly benefited the payors. The first round of contracting between Southern California health clubs and major HMOs didn’t benefit clubs at all. Under these capitation contracts, the clubs were paid a lump sum for any and all subscribers who were eligible for club participation. Once clubs realized that the more people who came, the more money they lost, the contracts came to an end.
However, in the latest round of negotiations some clubs (such as the Orchard Hill AC in Lancaster, MA) are getting capitation money based on the number of HMO subscribers who choose their health club. They therefore receive more money based on increased enrollment - not less. Members also must pay a discounted membership dues so the club won’t lose money when enrollment increases.
This trend of making capitation contracts work to the advantage of health clubs, and the concept of negotiating for subsidized contracts (paying for one HMO member’s health program at a time) will be very beneficial in terms of health clubs truly being a player in the managed care system.
Conclusions
The relationship between exercise and managed care is coming out of its infancy. The next phase in this evolution is to negotiate for not just health club memberships (which may only total $3-500 per year), but to also factor in the costs of clinical exercise services. These services may add an additional $3-1,000 to the costs of health care, but based on the research on costs savings, the cost benefits certainly outweigh the initial investments.
Exercise programming should also take a cue from the alternative medicine world, which is growing exponentially, and is contracting for a multitude of services in many states (6). As managed care organizations continue to struggle to maintain cost savings, and other provider groups surface in order to take advantage of regional economic conditions, it is important for those in clinical exercise to understand and be able to communicate the following elements to managed care:
- Professional status as an allied health care provider (certified, understand clinical exercise and outcomes, cost savings versus other types of rehab services).
- Can work within a referral network (other exercise professionals in your community who may work with overflow subscribers).
- Long term cost savings of exercise vs medicine. You will be in essence competing against other medical providers (3).
If you can show outcomes (9,17), and price your services to be competitive, you will be in the running for contracts that go beyond a simple club membership (5). This is the true beginnings of a creation of an exercise health care profession.
References
1. Abraham, A.S. Delagi, E.F. The contributions of physical activity to rehabilitation. Research Quarterly. 31;2:365-75, 1960.
2. Banja, J.D. Ethics, outcomes, and reimbursement. Rehab Management. 1994, Dec./Jan. pp. 61-65.
3. Borzo, G., McCormick, B., Somerville, J., Voelker, R. Pulling for a piece of the health care market. American Medical News. pp-3,9,47, April 19, 1993.
4. Durak, E.P., Shapiro, A.A. The Ins and Outs of Medical Insurance Billing: A Resource Guide for the Health and Fitness Profession. 2nd Edition. Medical Health and Fitness Publications, Santa Barbara, CA, 1996.
5. Durak, E.P. The bottom line: Outcomes and the future of rehabilitation. Physical and Occupational Therapy Today. 4;45:10-12, November 4, 1996.
6. Eisenberg, D.M. Kessler, R.C., Foster, C., Norlock, F.E., Calkins, D.R., Delbanco, T.L. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. New England Journal of Medicine. 328;246-52, 1993.
7. Ellwood, P.A. The Shattuck Lecture - Outcomes Management. New England Journal of Medicine. 318:23:1549-56, 1988.
8. Fries, J.F., Green, L.W., Levine, S. Health promotion and the compression of morbidity. Lancet. 1989, March 4, pp. 481-83.
9. Jette, D.U., Downing, J. Health status of individuals entering a cardiac rehabilitation program measured by the medial outcomes study 36-item short form survey (SF-36). Physical Therapy. 74;6:521-27, 1994.
10. LaForge, R. Health reform and the future of fitness and health promotion. ACE Insider Newsletter. 1993, 3;3:1-4, Winter.
11. Nasibitt, J. The wellness re-dux. Trends Newsletter. pg. 1-4, October 13, 1994.
12. Pashkow, P. The application of outcomes to the clinical exercise physiologist. Presented at the American College of Sports Medicine Meeting, June, 1, 1996, Cincinnati, OH.
13. Pellitier, KR. A review and analysis of the health and cost effective outcome studies of comprehensive health promotion and disease prevention programs at the worksite: 1993-95 update. American Journal of Health Promotion. 10;5:380-88, 1996.
14. Reece, R. Keynote presentation at the annual Orthopedic Managed Care Conference, May 19, 1997, Washington, DC.
15. Schuck, C. Outpatient outcomes. Rehab Management. 1996, April/May, pp. 105-07.
16. Shephard, R.J., Corey, P., Renzland, P, et al. The impact of changes in fitness and lifestyle upon health care utilization. Canadian Journal of Public Health. 1983. 74:51- 54.
17. Ware, J.E. Sherbourne, C.D. The MOS 36-item short form health survey (SF 36). Medical Care. 1992, 30:473-83.
ASEPNewsletter (August, 1998)
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