Physical inactivity is the fourth leading cause of death worldwide (1), and more than 80% of adults do not meet the guidelines for both aerobic and muscle-strengthening activities (2). There is extensive evidence for physical activity and exercise positively impacting chronic disease rates through primary, secondary, and tertiary prevention. Fitness professionals can play a key role in assisting people to achieve recommended levels of physical activity. These professionals are well positioned to serve as influential members of the health care team, especially in primary care. Given the profound deficits in essential physical activity, it is the patients who suffer when they do not have access to well-qualified fitness professionals as part of their treatment or health and well-being plan.
Fitness professionals can play a key role in assisting people to achieve recommended levels of physical activity. These professionals are well positioned to serve as influential members of the health care team, especially in primary care. Given the profound deficits in essential physical activity, it is the patient who suffers when they do not have access to well-qualified fitness professionals as part of their treatment or health and well-being plan.
Although some headway has been made connecting fitness professionals with health care, many barriers still exist (3,4). This article will review the following barriers that health care providers or fitness professionals may encounter in their attempts to connect health care with health and fitness: 1) navigating the ambiguity of the Affordable Care Act, 2) reimbursement, 3) referral schemes/programs, 4) fitness professional credibility and competence, and 5) research gaps. In part two of this article, we will discuss solutions to each of the barriers presented.
THE AMBIGUITY OF THE AFFORDABLE CARE ACT
The Patient Protection and Affordable Care Act (PPACT) was released in May 2010. Within this Act, increasing physical activity is mentioned 11 times, which is promising evidence of a new emphasis on physical activity. Unfortunately, the words “exercise professional” or “fitness professional” do not appear at all. On page 480 of the PPACT, it states that the Medicare Annual Wellness Visit (MAWV), under the physician, could be performed by “a medical professional (including a health educator, registered dietitian, or nutrition professional) or a team of medical professionals, as determined appropriate by the Secretary.” The inclusion of health educators was a major shift as it included allied health professionals within the reimbursement model for the MAWV.
What is not clear is the definition of “health educator.” Although formal degrees in health education exist, many allied health professionals have gainful employment as health educators across many government agencies, not-for-profits, and private industries. These allied health professionals often include fitness or exercise professionals. Thus, the lack of clarity around the definition of “health educator” may serve as a barrier to primary care practitioners viewing fitness professionals as a viable resource to assist their practices with the MAWV and follow-up visits, which they are certainly qualified to perform. In addition, fitness professionals also could participate in diabetes prevention programs and fitness assessments and teach personal and group exercise. Lastly, if the fitness professional is also a nationally board-certified health and wellness coach, they also could serve as a health care team practitioner within chronic disease management schemes.
When a patient is newly diagnosed with type 2 diabetes, a standard, evidence-based algorithm ensues to optimize patient care. The algorithm generally includes evidence-based testing to determine a proper medical diagnosis, health care provider appointments to ensure a sound diabetes management plan that includes recommendations for lifestyle changes and pharmacotherapy, and a referral to a certified diabetes educator or registered dietician. An example of this algorithm can be seen in the newly released Consensus Statement by the American Association of Clinical Endocrinologists and the American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm (5). Interestingly, the words “fitness professional” or “exercise professional” do not appear in the consensus statement. Because reimbursement for the services of exercise professionals for primary, secondary, and tertiary prevention does not exist in the health care system beyond cardiac and pulmonary rehabilitation, it is clear this is a major barrier to fitness professionals becoming a member of the health care team or receiving health care provider referrals for their services.
Currently, health care provider reimbursement for physical activity or exercise is an alphabet soup of ICD-9/ICD-10 codes, consultation, prevention, and treatment (CPT) codes, and using evaluation and management (E/M) codes for the purposes of diagnosis, documentation, and billing. There are physical activity-related ICD-9 codes (e.g., “lack of physical exercise” (V69.0) and “exercise counseling” (V65.41)) and an ICD-10 code (e.g., “lack of physical exercise” (Z72.3)); however, commercial and government payers do not recognize them as stand-alone billable diagnostic codes. In addition, there is no specific CPT code for physical activity counseling. Health care providers including physical therapists may use therapeutic exercise codes (CPT 97110) when teaching patients specific exercises to develop muscle strength and endurance, joint range of motion, and flexibility. Unfortunately, use of this code is limited.
The system of physician reimbursement in the United States is based on work relative value units (wRVUs). Providers paid on wRVUs have little financial incentive to spend time counseling patients on healthy lifestyle given the low wRVU value assigned to counseling in comparison with other medical services. For example, the wRVU for a knee joint injection is 0.79. The follow-up visits solely to assess a patient’s progress with their exercise prescription has a wRVU value of 0.
The best method for physicians to receive appropriate reimbursement for physical activity counseling is to bill for time using E/M codes. If greater than 50% of a 25-minute office visit is spent face-to-face with the patient counseling and coordinating care, the health care provider can bill using an established patient E/M code of 99214 where the wRVU is 3.01, accompanied by appropriate diagnoses in support of that coding. Unfortunately, for many patients with high deductible health plans, evaluation and management visits to discuss physical activity would likely go against a patient’s deductible — resulting in out-of-pocket costs. Given the dramatic increases in the number of people with high deductible health plans and associated greater out-of-pocket costs, patients are less likely to desire or return for a follow-up visit. Fitness professionals, while typically not reimbursed by third-party payers, provide a lower cost option for people who would benefit from physical activity counseling and support.
Fitness professionals, while typically NOT reimbursed by third-party payers, provide a lower cost option for people who would benefit from physical activity counseling and support.
Referral schemes are defined as systems where health care providers refer their patients to third-party fitness professionals or fitness facilities to encourage patients to increase their physical activity. These schemes were originally developed in the United Kingdom in the early 1990s and have expanded to Australia, New Zealand, Scandinavian countries, Spain, and the United States. They also may include referrals to parks and other outdoor spaces commonly referred to as “green prescriptions” (6). In the United States, 55% of all health care visits are to primary care physicians; thus, these health care providers are uniquely positioned to positively affect their patient’s engagement in physical activity at all visits (7). Yet, very few primary care providers participate in physical activity referral schemes or prescribe exercise to their patients. These providers report lack of time, training, self-efficacy, and reimbursement as the biggest barriers (8). In addition, the evidence reporting the effectiveness of these schemes is mixed (9). Lastly, it is important to note that these referral schemes must go both ways in that fitness professionals need to refer their clients to primary care providers when appropriate.
Researchers report positive, cost-effective, short-term outcomes related to increasing physical activity; however, little evidence exists that these schemes improve other related health outcomes such as improving blood pressure or quality of life (10). Interestingly, most studies included a period of 10 to 12 weeks, a period not long enough to impact biometric outcomes such as blood pressure, and did not describe the delivery methods, theoretical foundations, or techniques used to encourage behavior change. Initiatives, such as the American College of Sports Medicine’s Exercise is Medicine®, were explicitly designed to assist in solving these limitations to previous research and improve exercise referral schemes.
Some researchers hypothesize that more long-term research is needed, including well-established behavior change foci, to truly establish the effectiveness of referral schemes to fitness professionals (11). In other words, the effectiveness of the fitness practitioners needs evaluation too. Indeed, one factor that has been associated with low rates of referral in exercise referral schemes was the lack of trust or skepticism among health care providers about the knowledge and credibility of fitness professionals (12).
CREDIBILITY AND COMPETENCE
Fitness professionals, historically, have not been included in the health care paradigm, although it is beginning to change (e.g., exercise referrals to fitness professionals) (13). In addition to the issue of reimbursement noted above, fitness professionals also are faced with challenges to their credibility and competence. There seems to be a lack of trust between health care providers and fitness professionals (11,12). This lack of trust may stem from lack of licensure in the fitness industry, variability in the educational background of fitness professionalism ranging from certificate programs requiring only a high school degree, all the way to graduate degrees in exercise physiology. This ambiguity in credentialing may explain why health care providers may be confused about who to trust with their patients’ health and wellness.
There seems to be a lack of trust between health care providers and fitness professionals. This lack of trust may stem from lack of licensure in the fitness industry, variability in the educational background of fitness professionalism ranging from certificate programs requiring only a high school degree, all the way to graduate degrees in exercise physiology. This ambiguity in credentialing may explain why health care providers may be confused about who to trust with their patients’ health and wellness.
The American College of Sports Medicine’s Exercise is Medicine® Credential was designed to include additional competencies in working with health care systems, behavior change, and exercise prescription for chronic disease so that the health care provider community would have an indicator of a fitness professional’s competency for referral. Also recognizing the challenge of a confusing for-profit industry of certifying fitness professionals, eight leading fitness organizations are members of the Coalition for the Registration of Exercise Professionals. The registry includes fitness professionals who hold certifications from the National Commission for Certifying Agencies accredited bodies. Lastly, Warburton and colleagues (14) developed best practice recommendations for fitness professionals working with clinical populations including 1) a bachelor’s degree in exercise science, 2) nationally accredited certification, 3) practical skills, and 4) core competencies in chronic disease, behavior change, pharmacology, exercise testing, etc.
Although focus on fitness professionals’ need to gain additional competencies to work with complex patients is important, De Lyon and colleagues point out that “fitness professionals’ ability to meet the health-related needs of their clients cannot be separated from the conditions of employment that prevail within the sector” (11). The authors continue by drawing attention to the tensions that exist between the fitness industry and standards of professionalism warranted to receive referrals from the health care system.
Fitness professionals seek opportunities to share their passion for physical activity and help others adopt a healthier lifestyle. The work of a fitness professional is rewarding and for many a fulfilling career choice; however, the profession faces challenges including low or inconsistent pay, high turnover, and limited formal career development pathways (15,16). It is difficult for employers to retain well-trained fitness professionals as a result, yet there seem to be few efforts within the industry to tackle these problems, especially an industry that is generally unregulated. The unfortunate reality in the fitness industry is that wages of well-educated fitness professionals are inadequate as they are subject to market demand and to a patient’s ability to pay out-of-pocket. Without reimbursement, it is hard to imagine how fitness professionals of high quality will be able to positively impact large numbers of individuals who are currently inactive and/or experiencing chronic disease. The impact fitness professionals could make on the diabetes epidemic alone is lost.
Fitness professionals seek opportunities to share their passion for physical activity and help others adopt a healthier lifestyle. The work of a fitness professional is rewarding and for many a fulfilling career choice, however, the profession has significant downsides including low or inconsistent pay, high turnover, and few formal career development pathways.
Despite the barriers highlighted, it seems intuitive that fitness professionals play an important role as an allied-health arm of the multidisciplinary health care team to address increasingly common health issues such as depression, diabetes, and cardiovascular disease. Interestingly, little has been published in the peer-reviewed literature on the fitness professional’s effectiveness, practice, education, training, and professional development pathways. Likewise, there is very little data on the quality, nature, and types of interactions fitness professionals have with the public and how they operate within a scope of practice. This research gap lessens the understanding, recognition, and credibility of the fitness profession.
There remains considerable uncertainty regarding the practice of fitness professionals within health care. Little is known about the autonomy of fitness professionals and how it may impact patient/client health outcomes. Some would suggest that the fitness industry has benefitted from the lack of research and scrutiny other allied health professions encounter (11). Yet, little public funds exist to conduct research on the practice of fitness professionals, which is most likely the result of the industry operating primarily within the private sector. Addressing this research gap is critical to further understand the role fitness professionals play in positively impacting patients’ participation in physical activity, quality of life, and rates of chronic disease in the United States as a member or extension of the health care team. In part two of this series, we will discuss headway being made in this area by groups such as the Prescription for Activity, the National Physical Activity Plan Healthcare Sector, and Exercise is Medicine®.
Although there is consensus that increasing physical activity participation is a public health imperative, limited progress has been made within the health care sector. Five major barriers to incorporating physical activity and fitness professionals within health care have been identified: 1) ambiguity of the Affordable Care Act, 2) reimbursement, 3) referral schemes/programs, 4) fitness professional credibility and competence, and 5) a research gap. Although there has been some evidence to support fitness professionals’ involvement in health care, the barriers highlighted remain arduous. It is important to keep in mind the benefits of physical activity participation as a proven prevention and treatment strategy for millions of Americans at risk for and experiencing chronic disease, and ultimately it is the patient who loses out when exercise as medicine is not a part of the treatment plan. Solutions will be identified in part two of this article series.
BRIDGING THE GAP
Fitness professionals can play a key role in assisting people to achieve recommended levels of physical activity, especially in primary care settings. Although some initiatives have made progress in connecting primary care to the fitness industry, many barriers still exist. Understanding these complex barriers and current research gaps is an essential first step in developing more robust solutions.
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