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Pettitt, Cherie D. Ed.D., FACSM, ACSM-EP, NBC-HWC, PAPHS, CSCS, CHWC, EIM Level II; Joy, Elizabeth M.D., M.P.H., FACSM

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ACSM's Health & Fitness Journal: 3/4 2020 - Volume 24 - Issue 2 - p 9-15
doi: 10.1249/FIT.0000000000000554
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There is extensive evidence that engaging in regular physical activity prevents chronic diseases and facilitates treatment paradigms. In part I of this article series, we discussed current challenges and barriers to connecting health care and health and fitness. The barriers reviewed included 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 this article, we will discuss current efforts and potential solutions that may increase the likelihood for well-qualified fitness professionals becoming members of the health-care team to positively affect a patient’s prevention or treatment plan. First, we discuss potential strategies at the policy and organizational levels. Second, we highlight an exercise referral case study. Third, we discuss current gaps and needs within health care and the fitness industry and end with a call to action given the consensus that increasing physical activity participation is a public health imperative.


Regular physical activity is recognized by health care providers (1) and payers (2) (insurance companies) as a key health-enhancing behavior. People who engage in regular physical activity have lower rates of chronic disease and, as such, lower health care utilization and lower total health care costs (3). Several health care policies are aimed at the assessment and promotion of physical activity by physicians. The National Committee for Quality Assurance develops and measures adherence to health care quality measures, referred to as the Health care Effectiveness Data and Information Set (HEDIS) measures. Adherence to these quality measures identifies gaps in health care delivery and influences reimbursement and payments to health care providers and insurance companies, respectively (4).

Several HEDIS quality measures specifically address the assessment and promotion of physical activity. The first measure addresses physical activity in older adults, and specifically measures “the percentage of Medicare members 65 years of age and older who had a doctor’s visit in the past 12 months and who received advice to start, increase, or maintain their level of exercise or physical activity” (5). These data are collected using a survey of Medicare members. Aligned with this measure in older adults is a “fitness benefit” that may be offered by managed care Medicare (or Medicare Advantage plans) plan members (6). Typically, this “fitness benefit” is defined as a per member per month financial benefit (e.g., $20 per member per month for fitness-related activities), or access to specific fitness services (e.g., Silver Sneakers). A study examining the effect of Silver Sneakers participation on health care costs found that members participating in the fitness program at least 2 times a week over 2 years incurred at least $1,252 less health care costs compared with those that attended less than 1 time per week (7).

Another HEDIS measure is aimed at physical activity counseling for children and adolescents and assesses the proportion of youth who received assessment and counseling related to body mass index, nutrition, and physical activity by their health-care provider (8). This physical activity counseling HEDIS measure promotes adherence to best practices in preventing childhood obesity but is not currently tied to reimbursement. Other measures include recommendations to promote physical activity as part of disease prevention and management.

Another organization that influences health care delivery is the U.S. Preventive Services Task Force (USPSTF). The USPSTF makes recommendations regarding preventive care services that obligate commercial insurance companies to pay for certain services (9). Although the delivery of physical activity services (e.g., fitness classes and personal training) is not, as a consequence of these recommendations, required, these recommendations often include the promotion of physical activity as a strategy to prevent disease and improve health.

Lastly, the National Physical Activity Plan (NPAP) was developed to support the implementation of the Physical Activity Guidelines for Americans. The NPAP has nine sectors that have developed strategies, tactics, and objectives with a goal of increasing physical activity. The health care sector includes four strategies linking physical activity and health care (10). These strategies include the following:

  1. Health care systems should increase the priority of physical activity assessment, advice, and promotion.
  2. Health care systems and professional societies should recognize physical inactivity and insufficient physical activity as treatable and preventable with profound health and cost implications.
  3. Health care systems should partner with other sectors to promote access to evidence-based physical activity-related services that increase health equity.
  4. Universities, postgraduate training programs, and professional societies should include basic physical activity education in the training of all health care professionals.

Strategy 3 as stated above includes an associated tactic to “Partner with providers of community physical activity services to form referral networks that increase opportunities for physical activity and ensure equal access of their patients to community resources, including patients living in rural areas.” Although there are no requirements that governmental and nongovernmental organizations implement these strategies and tactics, it is hoped that stakeholders in health care will adopt these strategies and tactics to improve the physical activity of their patients, employees, and communities.

Many tactics cited in the health care section of the NPAP address many of the barriers previously discussed in part I of this article regarding referral schemes/programs and reimbursement. The referral schemes/programs and reimbursement recommendations were specific to evidence-based programs and not necessarily fitness professionals per se. Also, the NPAP makes a strong case overall, including funding at the government levels, of the high need for research in assessment and surveillance of physical activity in and outside of health care and additional research in determining inclusive, evidence-based programs.

Many tactics cited in the health care section of the NPAP address many of the barriers previously discussed in part I of this article regarding referral schemes/programs and reimbursement. The referral schemes/programs and reimbursement recommendations were specific to evidence-based programs and not necessarily fitness professionals per se.


Expanded organizational work to increase and improve the efforts of health care in physical activity promotion have emerged in the past decade. In 2008, the American College of Sports Medicine (ACSM), in partnership with the American Medical Association, launched Exercise is Medicine® (EIM). EIM is a global initiative with chapters in 43 countries that “encourages primary care physicians and other health care providers to include physical activity when designing treatment plans and to refer patients to evidence-based exercise programs and qualified exercise professionals” (11). EIM has three main areas of focus: health care and health care providers, fitness professionals, and EIM on Campus. For health care and health care providers, EIM encourages health care providers to implement in their electronic health records and clinical workflow a physical activity vital sign (PAVS) to assess physical activity at every visit. The PAVS assessment serves as a reminder or prompt to the health care provider and care team that physical activity should be discussed at most if not every clinical visit, similar to how blood pressure and weight are checked at every visit. In addition, EIM has developed physical activity prescription pads, and patient education materials regarding physical activity and various common health conditions, to assist the provider in personalizing and promoting physical activity (

For fitness professionals, ACSM and EIM have developed an EIM credential that aims to prepare the exercise professional to work with clients who have underlying health conditions, such as diabetes or osteoarthritis, and effectively communicate and coordinate care with health care providers. The EIM credential directly relates to addressing some of the barriers discussed previously in referral schemes/programs and fitness professional credibility and competence. Unfortunately, the dilemma remains that the wages of well-educated fitness professionals are often inadequate and are subject to market demand and a patient’s ability to pay out of pocket.

Most recently, the American Council on Exercise (ACE) launched the Prescription for Activity (PfA) Task Force and developed a “systems-change map that charts a course to a U.S. culture transformed to prioritize and celebrate physical activity and thus reduce the prevalence of inactivity-related diseases” (12). The comprehensive plan maps how to get 50% of Americans to recommended levels of physical activity by 2035.

The PfA Task Force plan identified three core paths to achieve its goal:

  1. Care delivery: assessing, prescribing, and tracking physical activity as a path to enhanced patient outcomes.
  2. Community: recruiting communities to make physical activity a priority and a source of fun, enjoyment, and socialization.
  3. Clinic-community Integration: building a bridge of trust and collaboration between health care providers and community resources to encourage physical activity.

In describing the work of the PfA Task Force, ACE Chief Science Officer, Cedric X. Bryant, Ph.D., was quoted as saying, “Within the Task Force was the palpable sense that health care has almost limitless capacity to influence the adoption of physically active lifestyles and facilitate a new understanding of the degree to which regular physical activity can enrich lives.”

The PfA plan includes specific strategies to address reimbursement and health care provider-fitness professional trust issues outlined in part I of this article. Some of the recommendations included the following:

  • Existence of seamless, accessible payment/funding systems that cover medically necessary physical activity counseling and interventions, including current procedural terminology and codes, alternative payment models with value-based incentives, and shared savings programs
  • Incentivizing or mandating providers and health care systems to assess, counsel, and conduct surveillance
  • Evidenced-based interventions become standard insurance benefits for all populations
  • Trusted providers, programs, and places are identified, verified, readily accessible, and established in the community

In the PfA care delivery sector, it is recommended that “systems are in place to support a team-based approach to physical activity assessment, counseling and follow-up, and the role of each care team member is clearly defined.” Based on this recommendation, it seems reasonable to assume there is potential for strategies within health care teams to include fitness professionals.

In addition, it would be important that there also are opportunities to include collaboration within education paradigms between health care provider curricula and exercise science curricula. The Institute of Lifestyle Medicine and the American College of Lifestyle Medicine advocate for physical activity competencies within medical education. Taking this concept to the next level, there is opportunity to include health care provider students exposure to primary care teams that include fitness professions to enhance integration and competencies of new health care professionals.

Efforts like those of EIM and the PfA Task Force are key in mobilizing health care to play a meaningful role in physical activity promotion. Connecting patients to fitness professionals who can instruct, coach, and guide people to more active lives is the next step. Health care is poised to take that step, as the evidence is overwhelming that physically active people are healthier people.

Efforts like those of EIM and the PfA Task Force are key in mobilizing health care to play a meaningful role in physical activity promotion. Connecting patients to fitness professionals who can instruct, coach, and guide people to more active lives is the next step. Health care is poised to take that step, as the evidence is overwhelming that physically active people are healthier people.


June Kahn is founder of June Kahn’s Bodyworks, LLC and the owner of Center Your Body Pilates, a full-service Pilates studio in Louisville, Colorado. In addition, June also works as a Pilates rehabilitation practitioner with Allied Health Chiropractic & Rehabilitation. Ms. Kahn has partnered with a variety of health care providers to develop a referral system for patients with chronic disease. Ms. Kahn receives more than 40% of her business from health care provider referrals and is well known in her community of Boulder, Colorado. She currently has a network of 10 health care providers referring patients to her and about one third are getting reimbursed by their insurance companies for Pilates prescribed by their physician.

Ms. Kahn developed relationships with health care providers by writing them letters and meeting with them. She reached out to those providers that were advocates for exercise prescription and partnered with them to approach the insurance companies. June has met with insurance companies to describe how she and the health care provider work together to improve the patient’s condition or disease. These meetings sometimes resulted in reimbursement for her Pilates services, based on clauses in the policy. Ms. Kahn continues to maintain documentation for their reimbursement consideration on behalf of her patients and includes information about the how the patient’s condition or disease has improved. Through her grassroots efforts and developing relationships with those in her community, Ms. Kahn is continuing to see increases in referrals from health care providers. Below, Ms. Kahn provides her strategies and recommendations for building relationships with health care providers.

  1. Begin with your own network of health care providers.
    1. Discuss during your own visit or
    2. E-mail; follow up with a phone call or
    3. Walk in — this strategy works well if you are familiar with front desk staff.
    4. Set up appointment — 30 minutes max (time is a commodity for primary care providers).
    5. Once appointment is set up,
      1. Offer a demonstration/explanation of your services to your health care provider’s staff
      2. Identify how your services can pick up where physical therapy leaves off and how your services can assist the client to continue to thrive
      3. After your visit, follow up with a thank-you note and a menu of services that falls in line with the health care providers’ patient needs

Examples may include the following:

    • Benefits of everyday functional movement for the general practitioner for all patients
    • Benefits of movement every day for the active/older adult
    • Benefits of movement for the patients with cancer/survivors for cancer centers/oncologists
    • Benefits of pelvic floor strengthening for the OB-GYN provider
    • Benefits of general strength training for the pre- and postnatal mother for the OB-GYN provider
    • Benefits of core training for chiropractors, orthopedic surgeons, etc.
  1. B. Collect recommendations and reviews from existing clients.
    1. Ask for reviews from current clients who have had success with your services.
    2. Request the names of their primary care providers that you can reach out to.
    3. Reach out to their health care provider explaining briefly how your services have enhanced your client’s well-being with documentation of their progress. Request if there is anything more specific you should be adding or other related open-ended questions seeking their input.
    4. This becomes the beginning of building your relationship and therefore leads to gaining referrals.
    5. This process can be done with physical therapists and chiropractors in addition to physicians, physician assistants, and nurse practitioners.
  2. C. Align yourself with your business community.
    1. Seek out your local Chamber of Commerce.
    2. Create or join a “leads group” of like wellness-based businesses.
    3. Invite primary care providers and other medical professionals and wellness businesses to join.
    4. Create one-on-one meet-and-greets to exchange and learn about each business and determine how your business can best service them.
    5. Support your community by finding referrals for their business. The more reciprocity, the more referrals are created.
  3. D. Insurance reimbursement: Is it possible?
    1. Fitness professionals are not licensed wellness practitioners.
    2. Some insurance providers offer a clause for chiropractic care and/or physical therapy. It may be possible for a percentage of reimbursement to be applied to fitness professional services when a primary care provider offers a written prescription for the service.
    3. Accurate and detailed reports must be maintained by the fitness professional.
    4. Client pays for fitness professional services on their own with an understanding that not all insurance companies will approve partial reimbursement. The client provides the fitness professional with the written prescription from the primary care provider. A letter, detailed reports, and a copy of the prescription is given to the client who in turn submits this information to their insurance company for reimbursement. Depending on the insurance company, a percentage may or may not be refunded to the client by the insurance company.
    5. Assist your clients in communicating with their insurance providers.
  4. E. Maintain a related credible certification.
    1. Certification should be through organizations recognized by the U.S. Registry of Exercise Professionals (USREPS) (ACSM, ACE, Cooper Institute, NSCA, PMA, NCSF, CSCC, and AAPTE).
    2. This provides verification of credentials of fitness professionals for referring health care providers.
  5. F. Maintain comprehensive documentation.
    1. Document clearance for exercise (e.g., PAR-Q), waivers, and informed consent documentation
    2. Detailed summaries of services rendered
    3. Copies of all communication with the client
    4. Copies of all communication with health care providers/wellness providers
    5. Copies of all communication with insurance providers (if applicable)
  6. G. If at first you do not succeed, try again.
    1. Avoid interpreting a lack of response as a lack of interest.
    2. If after a follow-up there is no response, try once again as there may have been a technical glitch.
    3. Avoid reaching out repetitively — let some time pass, then try again.
    4. On second try, perhaps include a short client success story or client review.
    5. Do not give up! With follow-through and determination, bridging the gap between fitness professionals and the health care community will continue to change lives.

Ms. Kahn holds a B.S. degree, an ACSM certification, and is a certified Pilates Master Trainer and Rehab Practitioner. She is an award-winning international speaker for fitness/Pilates and wellness conferences, a published author with Human Kinetics, and serves on the ACSM Summit program selection committee. A two-time cancer survivor, she has authored the Cancer Exercise Specialist’s Pilates Manual.


Many policy initiatives, plans, and organizational efforts highlighted in this article include strategies to address barriers identified in part I of this article. It appears that efforts are moving forward with additional research and funding calls to develop and evaluate physical activity referral schemes, develop new payment models, address health disparities, and evaluate the effect of physical activity programming to address the quadruple aim: 1) better outcomes, 2) lower cost, 3) improved patient experience, and 4) improved clinician experience.

Unfortunately, the role fitness professionals will play in designing and implementing these initiatives remains unclear, and a dedicated call to develop policies, guidelines, or research agendas regarding the practice of fitness professionals within health care remains elusive. Very little is known about the effectiveness and competencies of fitness professionals needed to work alongside primary care teams, their interactions with patients, and the professional development pathways. Indeed, within the entire documents, the NPAP mentions fitness professionals one time, and the PfA plan mentions them twice. It is clear that a focus on fitness professionals’ development, practice, and role implementing these plans is highly needed and should be a major focus moving forward. Many of the strategies included in these plans such as “assessment, prescribing, counseling and promoting physical activity” within health care seems fitting for the discipline of exercise science and its professionals.


Although only one case study was highlighted in this article, there are numerous fitness professionals who have embarked on similar efforts in their communities to enhance the relationship between health care providers and fitness professionals. Fitness professionals are the lynchpin of the success of the initiatives highlighted in this article. We recommend that fitness professionals wanting to connect with health care engage in the following strategies:

  • Engage in ongoing training to increase competency in exercise prescription for individuals with chronic disease and varying abilities.
  • Develop an understanding of health disparities and their role in the NPAP and PfA plan.
  • Increase competency in behavior change theories and strategies, coaching and motivational theories, and population health.
  • Reach out to health care providers, attend networking opportunities, and approach decision makers within health care to establish rapport and trust to increase provider referrals to your services.
  • In partnership with health care providers, begin or increase communication with your local insurance plans to discuss opportunities for reimbursement, use of health savings accounts, etc., for physical activity programs and services within your community by intentionally exploring opportunities offered through the Affordable Care Act as well as other value-based care initiatives.


There has been incredible effort and progress made by many committed policymakers, influencers, researchers, and organizations to expand the efforts and effect of health care on physical activity to improve the health and well-being of our communities. Many of the efforts of the organizations included in this article discuss the importance of referrals to community evidence-based physical activity programs. However, very little mention is given of the role of the fitness professional in leading and implementing these programs which is concerning. Indeed, more research is needed to address a gap in knowledge about fitness professionals’ practice, professional development pathways, and effectiveness within referral scheme and reimbursement models within health care.

In addition to the aforementioned organizational efforts, fitness professionals can and should reach out directly to health care professionals in their communities. The vast majority of primary care providers have limited experience partnering with the health and fitness industry. As such, educating physicians and other health care providers about the role of fitness professionals in health promotion and disease prevention and management is important and a key strategy. Ultimately, developing trusting relationships and providing high value services to patients/clients and to referring providers is an imperative.


By understanding the current efforts to connect fitness with health care, fitness professionals can become dynamic team members to develop and implement strategies that directly affect patient health and well-being through increasing engagement in physical activity.


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Exercise Reimbursement; Exercise is Medicine; National Physical Activity Plan; Prescription for Activity

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