With the passage and implementation of the Affordable Care Act, U.S. healthcare policy is placing an unprecedented value on prevention—a field that fitness professionals know well.
Yet prevention is not only about averting the onset of disease. We also have to figure out how to keep health care from bankrupting our country. The U.S. healthcare system must address a crisis in costs that are far out of sync with results. Although we spend substantially more money on care than any other country, our health status is relatively poor (OECD 2013). The U.S. spends about $3 trillion per year on health care, about $8,900 for every man, woman and child
in the country. This puts us well above the next-highest spender, Norway, which spends $5,670 per person (OECD 2013).
For all that spending, the U.S. ranks only fifth out of 11 developed countries for healthcare quality, according to the Commonwealth Fund; and in overall rankings, which factor in not only quality but also access, efficiency, equity and indicators of healthy lives, the U.S. comes last (Davis et al. 2014). The system struggles with a seemingly unsolvable puzzle: How do we achieve the triple aim of providing high-quality care at an affordable cost to as many people as possible? The ACA represents our nation’s attempt to confront that riddle.
As the bumps get worked out in the implementation of the ACA, one reality is emerging: The healthcare system is placing a higher priority on prevention and lifestyle approaches to chronic-disease management. This creates opportunities for fitness professionals who are well-versed on the ACA and the changing healthcare landscape.
10 Important Facts About ACA and Healthcare Reform
These 10 facts serve as a starting point for fitness professionals who want to play a larger role in helping a healthcare system shift from focusing on sick care to supporting wellness:
1. The ACA Is a Rough End to a Generation of Political Stalemate
Passage of the ACA in 2010 followed nearly half a century of political stalemate in healthcare reform. The ACA resulted from political compromise, with many hard-won and hard-lost legal battles along the way. Far from perfect or ideal, this law tries to move the country forward to decrease healthcare costs and increase quality of health care. However, it is complex, difficult to understand and challenging to implement.
What it means to you. While fitness professionals don’t need to grasp every intricacy, a basic understanding of the law is important. You can start with the Kaiser Family Foundation’s easy-to-understand and entertaining 7-minute animated overview of the ACA at http://kff.org/health-reform/video/youtoons-obamacare-video/.
2. ACA Encourages Workplace Wellness
The ACA provides incentives for employers to promote employee health, largely through worksite wellness programs. While many large companies had such programs before the ACA, more employers have now started or enhanced their programs. According to a 2013 Rand report, about half of companies offer wellness programs, and more than 75% of employers with wellness programs offer a lifestyle management program, most often as a group program (Mattke et al. 2013).
The most common themes of these programs are nutrition and weight control, fitness, smoking cessation, stress management, and alcohol and drug abuse. Programs with the highest employee engagement include yoga, guided meditation and exercise programs (Mattke et al. 2013). Many employers offer disease management programs for diabetes, asthma, heart disease, depression, cancer, chronic obstructive pulmonary disease and back pain. Often, these disease management programs are offered through telephone-based health coaching provided by the company’s health plan (Mattke et al. 2013).
What it means to you. Fitness professionals—particularly those who are also trained as health coaches—are well positioned to provide these programs to employers.
3. ACA Requires Insurers to Pay for Prevention
Under the ACA, insurers must cover preventive services with no copay. Recommended preventive services are clearly defined and are graded as either “A” or “B” by the U.S. Preventive Services Task Force.
- Grade A recommendations have a high certainty of benefit.
- Grade B recommendations have a high certainty of moderate benefit, or a moderate certainty of moderate to substantial benefit.
These recommendations include screenings and interventions for obesity and tobacco use.
The most significant recommendation for fitness professionals is the Grade B recommendation finalized in August 2014, “Behavioral Counseling to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors.” This recommendation advises primary care physicians (themselves or through referrals) to offer nutrition and exercise counseling to individuals who are overweight or obese and have a cardiovascular risk factor such as high cholesterol, smoking or a sedentary lifestyle. Exercise professionals are specifically mentioned as possible providers for such interventions.
The complete list of Grade A and B preventive recommendations is at www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm.
What it means to you. Increasingly, insurance companies will cover preventive services that fit in the domain of some fitness professionals, such as providing obesity management or exercise counseling for those at high risk of cardiovascular disease. The challenge is being in the position to capitalize on this opportunity.
4. ACA Encourages Value-Based Care
ACA is helping to pilot new models of value-based care, including patient-centered medical homes, medical neighborhoods, accountable care organizations and accountable care communities (see the sidebar “Key Terms in Healthcare Reform”). Each of these entities aims to provide a higher quality of care that
improves health outcomes while cutting healthcare costs. The new models focus heavily on team-based efforts to engage patients in disease prevention and management. These systems share risk, and they reward high quality of care rather than high volume of care, which the traditional fee-for-service system rewards.
What it means to you. As the role of exercise in preventing and treating chronic diseases evolves, fitness professionals will have to gather data showing that their programs improve health outcomes. Healthcare systems and providers may engage fitness professionals to help them define quality-of-care metrics.
5. ACA Devotes Money to Prevention
While ACA funding strictly for prevention has decreased from what was initially allocated, the ACA has increased the focus on prevention and provided support to communities through the Prevention and Public Health Fund. This fund awards grants to states and communities for the prevention of diabetes, heart disease and stroke. It also provides funds for workplace wellness programs, obesity research, tobacco cessation, and reduction of health disparities related to chronic diseases.
The PPHF also directs $3.5 billion toward prevention research to build evidence supporting various community-based interventions.
What it means to you. While PPHF grants are typically awarded to public health departments, universities and other large entities, disbursements may trickle down to create opportunities for fitness professionals to engage in community-based prevention efforts.
6. Healthcare Reform Implementation Is Mostly Local
It’s up to states and local communities to implement healthcare reform. While the law says certain services must be covered, how they are covered may differ substantially from one location to the next. While an insurance company in one community may address obesity counseling requirements by offering telephone health coaching, another may reimburse for Weight Watchers® participation, while yet another may pay for the services of a registered dietitian.
Although fitness professionals may be well-equipped to provide these services, to date the opportunities have been limited, at least in part owing to the lack of regulation and licensure in the profession, which makes it difficult to vet fitness pros.
What it means to you.
Developing local relationships and understanding the local landscape are important steps in pursuing opportunities afforded by healthcare reform.
7. “Mom-and-Pop” Providers Are Going Away
While independent private medical practices still exist, the trend is for larger healthcare systems to buy out smaller practices and employ the physicians. Though it is still important for fitness professionals to develop referrals through personal relationships and contacts with local providers, this change increases the potential for healthcare systems to include a fitness professional in their broader network.
However, systems may have a high bar when contracting with exercise professionals and may opt to work with vetted organizations such as respected medical fitness and wellness centers in their communities.
What it means to you. Fitness professionals should keep developing relationships with individual physicians and other healthcare providers when seeking referrals. However, aligning with respected establishments such as wellness and medical fitness centers may provide an even more powerful play.
8. Patients Are Paying More Out-of-Pocket Costs
As insurance companies strive to control costs, the ACA has triggered reform in the makeup of health plans, including larger copays in many plans. This means patients are paying more out of pocket for visits to a physical therapist or registered dietitian, for example.
What it means to you. Patients paying more out of pocket for services may consider other options, such as programs offered by personal trainers, group fitness instructors and private health coaches. Even though insurance companies do not reimburse for these services, they may not cost much more than the out-of-pocket share of services covered by insurance.
9. Nonprofit Hospitals Must Document “Community Benefit” Health Needs
The ACA requires nonprofit hospitals to meet several community benefit requirements, including completing a community health needs assessment with the input of key community stakeholders at least every 3 years. The written report must be available to the public on the hospital website. These hospitals must also develop an implementation strategy to meet the needs identified in the community health needs assessment.
What it means to you. Reviewing the local nonprofit hospitals’ community needs assessment can help you identify gaps in community health that represent areas of opportunity. The assessment may also provide a starting point for you to help with the implementation strategy to meet the community needs most relevant to your area of expertise.
10. Opportunities for Proven Programs Are Emerging
Programs proven effective at helping to improve health at a reasonable cost have increased appeal to payers and employers. The most obvious example is the Diabetes Prevention Program, a research-based lifestyle intervention guided by a trained lifestyle coach for people diagnosed with
prediabetes, the precursor to type 2 diabetes. This program is offered in a growing number of communities across the country and is increasingly reimbursed by insurance companies.
What it means to you. Payers and employers want evidence that the programs they support are effective. Fitness professionals who can deliver these types of programs may find increased success when pursuing opportunities with employers and healthcare plans and providers.
Seizing the Opportunities
The ACA is creating opportunities for well-qualified, proactive fitness professionals. While we do not yet have a clear path to seize all the opportunities, these tips should help when working with physicians, healthcare plans and employers:
Gain Appropriate Credentials
Lack of regulation and licensure makes it difficult to vet fitness professionals. Earning a certification from the National Commission for Certifying Agencies is a necessary first step. The NCCA is the accrediting body for many healthcare professions and is the minimum bar for fitness professionals interested in pursuing opportunities in health care.
Additional credentials may include a medical fitness credential, such as the ACE Advanced Health and Fitness Specialist, ACSM’s Clinical Exercise Specialist or the ACE Health Coach. ACSM also offers three Exercise is MedicineTM designations that qualified fitness professionals can earn. The goals are to gain the knowledge and skills required to provide the best care to clients, and to support the fitness professional’s credibility.
Offer a Program That Works
Fitness professionals will have more success connecting with a clinic and workplace if they offer a program that is likely to work, with evidence supporting its efficacy. Fitness professionals may want to consider offering programs such as the Diabetes Prevention Program or designing exercise programs that closely align with what the evidence suggests works best for specific conditions. The Diabetes Prevention Program curriculum is available free of charge on the Centers for Disease Control and Prevention website (www.cdc.gov/diabetes/prevention/recognition/curriculum.htm).
Speak Their Language
When working with physicians and healthcare systems, fitness professionals need to be able to “speak the language” of the clinical environment. Specifically, they should develop programs consistent with what has been shown to work in peer-reviewed, published evidence. They should recognize the evolving landscape of the healthcare system; understand models like the patient-centered medical home and accountable care organizations; and value the importance of privacy, confidentiality, professionalism and written communication.
Likewise, fitness professionals interested in pursuing opportunities in workplace wellness should understand why these
programs are offered. Employers have several motivators for wellness programs, including return on investment (ROI), improved health outcomes, employee retention, employee participation and employee satisfaction (Kaiser Family Foundation 2013). While many employers do not routinely evaluate their wellness programs in a systematic way, employers are driven by results. If a fitness professional makes a compelling case that a program can improve the metrics above, an employer is more likely to become interested in learning more.
Understand Disease Management
The medical community is becoming increasingly aware of the potent role of exercise in the treatment of numerous diseases. In many cases, exercise is as effective as medications at a fraction of the cost. Fitness professionals should understand the medical goals for managing common chronic conditions such as obesity, type 2 diabetes and hypertension, and be able to explain how exercise can help to achieve goal metrics.
Many clinicians are cautious about partnering with an unknown provider. Fitness professionals should approach providers in a highly professional manner, taking extra care to exude competence.
Develop Relationships With Clinicians
Clinicians will be most willing to collaborate with professionals they know well. In many cases, the best place to start is with one’s own physician or the physician of a family member such as a child or a parent. Fitness professionals can engage in networking events and community coalitions, and seek out opportunities to work with clinicians.
Be Part of a Respected Team
Many providers feel more comfortable referring a patient to a medical fitness center, wellness center or gym that they trust and respect rather than to an individual fitness professional. Fitness professionals interested in pursuing a career in medical fitness may best succeed in obtaining referrals and regular clients by becoming affiliated with a local fitness or wellness center that is well respected by the local medical community.
The Affordable Care Act has sparked a historic change in the way health care is delivered in the United States. Public health and medical systems are working more closely together, not only to
treat disease, but also to improve overall health and support prevention. While the possible roles of a fitness professional in this system are not clearly defined, healthcare reform has the potential to give qualified fitness professionals a larger role in pursuing the triple aim of providing the best care to the most people at the lowest cost.
Davis, K., Schoen, C., & Stremikis, K. 2014. Mirror, mirror on the wall, 2014 update: How the U.S. health care system compares internationally. The Commonwealth Fund. www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirrow; accessed Sept. 7, 2014.
Kaiser Family Foundation and Health Research & Educational Trust. 2013. Employer health benefits 2013 annual survey: Section 12 wellness programs and health risk assessments. http://daiserfamilyfoundation.files.wordpress.com/2013/08/8465-employer-health-benefits-2013_section_121.pdf; accessed Aug. 11, 2014.
Mattke, S., et al. 2013. Workplace wellness programs study. RAND Corporation. www.rand.org/pubs/research_reports/RR254.html; accessed Aug. 11, 2014.
OECD (Organisation for Economic Co-operation and Development). 2013. Health at a glance 2013: OECD Indicators. www.oecd.org/els/health-systems/Health-at-a-Glance-2013.pdf; accessed Aug. 5, 2014.