Vanichkachorn, Greg MD; Roy, Brad A. Ph.D., FACSM, FACHE
President Barack Obama's landmark Patient Protection and Affordable Care Act was signed into law on March 30, 2010. Although debate continues on the effectiveness of this historic legislation, it is certain that this unparalleled overhaul in the U.S. health care system will result in sweeping changes for health care providers. With the reform's expanded coverage of preventive services and increased emphasis on healthy lifestyles, medical fitness facilities and related providers of wellness programs can expect to serve a more expanded and integral role in the delivery of U.S. health care.
THE CURRENT DILEMMA IN PREVENTIVE CARE AND WELLNESS PROMOTION
Despite our best efforts, the delivery of preventive medical care and the promotion of healthy lifestyles in the United States falls short of ideal. Based on data from 2007, only 50% of patients received recommended preventive care and screenings. As staggering as this underserved percentage is, so too is the documented benefits of preventive care that are not being used. A 2007 study by the National Commission on Prevention Priorities shows that delivery of just five preventive services - breast and colorectal cancer screening, flu vaccinations, smoking cessation counseling, and promotion of regular aspirin use - could prevent as many as 100,000 deaths per year. The U.S. Centers for Disease Control and Prevention estimates that 80% of heart disease and stroke, 80% of Type 2 diabetes, and 40% of cancer could be prevented if patients quit smoking, ate a balanced diet, and exercised appropriately. Indeed, proper exercise prescription and counseling in itself can combat many of the chronic conditions plaguing the United States.
Optimal delivery of preventive and wellness services also has ramifications for the exorbitant cost of health care in the U.S. obese patients, who comprise an increasing percentage of the U.S. population and have 39% greater health care costs than the average nonobese patient. Results of a 2005 study showed that completion of recommended vaccinations can result in a net savings of 9.9 billion dollars in direct health care costs and 43.3 billion dollars of societal costs.
The barriers impeding the effective delivery of preventive and wellness services are numerous. First and foremost, the lack of health care insurance is a major financial obstacle for many patients. For the uninsured, the cost of simple preventive physical screenings and counseling can be insurmountable. The continued poor delivery of preventive services in the insured population indicates that the disparity in health insurance coverage is not the only impediment to preventive care. In the current health care structure, an increasing focus is placed on higher patient volumes as opposed to higher quality care. Providers are faced with an ever-decreasing amount of time available with their patients, and it is often unfeasible to adequately discuss preventive care topics such as cancer screening, diet, and exercise within such time constraints. Another major impediment is the lack of efficient protocols for referring patients to medically sound wellness services. Within the wellness industry, a myriad of titles, areas of specialty, and qualifications exist that can prove to be a daunting challenge for the busy provider to navigate. Moreover, in the few scenarios where patients are successfully referred for preventive and wellness services, collaboration and sharing of valuable clinical information between providers are limited by the underutilization of electronic medical record systems by the wellness industry.
The barriers to preventive care and wellness services, crucial components in changing the standard of healthy living in America, have been long endured. Fortunately, an end to these barriers may be near as they are addressed in part within the Patient Protection and Affordable Care Act.
AN ANSWER TO THE DILEMMA: THE PATIENT PROTECTION AND AFFORDABLE CARE ACT
This spring, President Obama signed into law the Patient Protection and Affordable Care Act. This historic legislation significantly expands the availability of health care insurance and increases the scope of covered services. Recognizing the benefits of investing in preventive care, an emphasis has been placed on preventive services and wellness. In addition, the Act created a National Prevention, Health Promotion, and Public Health Council. Composed of senior government officials, this council is tasked with designing a national health strategy in collaboration with communities. In addition, a Public Health Fund, with a planned investment of 15 billion dollars within 10 years, has been developed. Fund resources will be used to increase the number of primary care professionals, the expected frontline providers of the expanded preventive services.
A NEW ERA FOR MEDICAL FITNESS FACILITIES
The changes put forth by health care reform allow for a robust increase in the effectiveness of wellness programs.
Medical fitness facilities represent a key strategy that effectively integrates health promotion, preventive medicine, and fitness into wellness programs. Facilities, especially those certified by the Medical Fitness Association, are dedicated to medically sound health promotion and prevention. A typical facility offers a gamut of medical treatments, including physical therapy, cardiac rehabilitation, clinical dieticians, disease management, and wellness coaching, in addition to traditional gym services. Since 1985, the number of facilities has increased from 79 to just more than a thousand in 2010.
As major providers of wellness services, medical fitness facilities are poised to take on an unprecedented role in U.S. health care. By the end of 2010, 31 million people in new employer plans and 10 million people in new individual plans will benefit from the expanded preventive medicine coverage. By 2013, this number is expected to rise to 78 million. As previously discussed, the pending surge in demand for health care and preventive services will fall first on primary care physicians, a group already struggling with a shortage of providers and time with patients.
REFERRAL-BASED WELLNESS PROGRAMS
With the need to alleviate the burden on primary care and to raise the bar in health promotion, referral-based wellness programs within medical fitness facilities represent an exciting opportunity. In referral-based wellness programs, medical fitness facilities partner with community physicians and hospital systems to provide care. In such a system, patients and providers are presented with an all-encompassing suite of services in one location. Benefits of such a program paradigm include simplicity of use by providers; availability of increased collaboration between counselors, therapist, and clinicians; and convenience for patients. Requiring a referral ensures that the patient understands the critical nature of wellness and establishes the groundwork for future reimbursement.
An example of the effective delivery of a wellness program via a referral-based model is the Journey to Wellness Program at The Summit Medical Fitness Center in Kalispell, Montana. The Journey to Wellness Program provides patients who are physically inactive and/or diagnosed with chronic medical conditions a means of achieving a healthy lifestyle. Examples of medical conditions addressed by the program include diabetes, cancer, low back pain, other chronic pain conditions, heart failure, hypertension, and others. Once a hospital or community physician refers a patient to the program, counselors meet with the patient to develop specific personalized healthy living goals to identify barriers to a healthy lifestyle and methods for overcoming them and to design an exercise program. Regular follow-up sessions help patients attain their maximum improvement. All services take place within The Summit Medical Fitness Center, part of the Northwest Healthcare Hospital System. By consolidating the necessary therapists, counselors, exercise professionals, and even physicians in one location, participants in The Journey to Wellness Program enjoy both an extensive collection of resources and a high level of collaborative care. Services can include full gym access, nutrition and dietary counseling, athletic trainers, physical therapy, and supervised exercise programs.
In our experience, the success of the Journey to Wellness Program and other similar programs is dependent on adequate alignment with medical providers, financial support of services, and return of information to referring providers. The Affordable Care Act enhances each of these factors and results in a new era of program effectiveness.
REASONS TO COLLABORATE: ACCOUNTABLE HEALTH CARE ORGANIZATIONS
Understandably, a close relationship with local hospital systems and providers promotes continued program utilization and improves the health of the served community. Recognizing the benefits of collaborative care on the quality of care rendered, The Affordable Care Act includes initiatives and incentives to increase integrated care among providers. An example of such an initiative is the support of Accountable Care Organizations. The Accountable Care Organizations entities are composed of health care providers and systems combined to improve the efficiency and quality of care by creating financial incentives for members. Although the exact organization, performance variables, and payment structures remain to be defined, the new emphasis on cooperative health care organizations supports the development of integrated wellness programs aligned with health systems and community providers. Facilities with collaborative programs in place or in development will be positioned to enjoy the most success.
EXPANSION OF PREVENTIVE SERVICES COVERAGE
Currently, services rendered through many wellness programs are not typically covered through insurance. Within the Journey to Wellness Program, the fees for rendered services are paid for by patients. Although the program's current fee, a dollar a day for 90 days, is priced to be maximally affordable, even this amount may be a barrier to participation. With new health insurance plans starting on or after September 23, 2010, a defined selection of preventive services must be covered without having patients pay a copayment, coinsurance, or meet a deductible when services are rendered by a network provider. Covered services include counseling for a variety of wellness topics, including alcohol and tobacco use, blood pressure reduction, mental health care, diabetes management, diet control, obesity, immunizations, and aspirin use. With the expansion of covered preventive services, medical fitness facilities with well-designed and staffed wellness programs will be much more readily accessible by patients. In addition, medical fitness facilities, benefiting from increased revenue, will have more resources available for further promotion of healthy lifestyles.
IT'S TIME: ELECTRONIC HEALTH RECORDS
Yet another component of the Affordable Care Act that increases the use of medical fitness facility health programs is its support for electronic health record systems. With the new legislation, health systems will be required to adopt electronic medical records. Historically, transfer of information between referring providers and wellness programs has been hindered by lack of efficient communication methods. Several software options currently exist that are tailored for wellness programs, and others are in development. These online platforms are capable of storing wellness information, providing health risk assessments, providing education and counseling, and sharing information among treating providers. Although the use of such systems is clear, factors such as investment costs have limited their adoption. With the health care reform's mandates and incentives for electronic medical records, wellness programs and medical fitness facilities will have increased capability to adopt these new technologies and thereby improve program integration, communication, and success.
HEALTH AT WORK: CORPORATE WELLNESS PROGRAMS
Similar to referral-based wellness programs, corporate wellness programs are designed to improve the health of a work force. Studies have consistently shown that a healthy work population leads to increased productivity, decreased health care costs, decreased lost work time, and decreased injuries. In a time when businesses are struggling to cut costs, corporate wellness programs have seen a dramatic increase in use. With the expanded insurance coverage of preventive services, corporate wellness programs will become more affordable for large and small businesses. Medical fitness centers are the logical venue of choice for administering such programs in the future.
NEW OPPORTUNITIES: THE COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS PROGRAM
Although the expansion of preventive medical service coverage increases the existing ability of medical fitness facilities to develop wellness programs, the Affordable Care Act also has created new areas of potential health care services. One particularly exciting component of the new legislation is the creation of the Community Living Assistance Services and Supports (CLASS) Program. The CLASS program is a national voluntary insurance program that provides financial support for services that allow patients with disabilities to live independently at home. Covered services include assistants to help with activities of daily living and instrumental activities of daily living, home modifications, assistive technologies, and home care aides. With many medical fitness facilities already encompassing therapy and rehabilitation services and other wellness services, expansion into home-care settings represents an exciting opportunity to further serve their communities.
CONDENSED VERSION AND BOTTOM LINE
The Patient Protection and Affordable Care Act will usher in a new era of preventive care and wellness programs. By maximizing physician/hospital system alignment, investing in information-sharing technologies, and exploring novel service venues, medical fitness facilities and wellness programs will become an integral component in setting a new standard for healthy living in America.
© 2010 American College of Sports Medicine.