For at least 25 years there has been sufficient scientific proof that physical activity is extremely beneficial to health and well-being, both generally and in many disease-specific scenarios. So why doesn’t our health system cover exercise management services?
I was prompted to get involved in health care policy after I opened a lifestyle medicine practice in 2003. Having a new practice, I was a target for drug reps. A succession of drug reps did an odd thing, they wouldn’t leave after they’d given me their spiel about their products. After the first couple of times, I began to expect them to sheepishly tell me they had a Master’s Degree in Exercise Science. From schools like U Mass, Univ of South Carolina (where my good friend Larry Durstine was Chair), East Stroudsburg, Appalachian State…good programs in exercise science. When asked why they had become drug reps, they replied “I couldn’t make a living”.
We had then (and still have) an epidemic of type 2 diabetes, arthritis and cardiometabolic disease, all related to inactivity, and the people educated to help address the problem can’t get a good job??
For several years in the ‘00s, I chaired a series of “Bridging the Gap” symposia at the American College of Sports Medicine’s Annual Meeting, dissecting the disconnect between the science and clinical practice. In the 2007 symposium, Roland Sturm, a Senior Economist at RAND Corporation was the first economist to present at ACSM. At that time, I was also involved in helping design a health plan for Cornell University.
Increasingly, I saw that when exercise wasn’t a covered benefit, it wasn’t for lack of proof. The problem was lack of a business model, and all the scientific evidence in the world wasn’t going to make it happen.
Eighteen YEARS later…
The Physical Activity Alliance (PAA), with the efforts of Laurie Whitsel from the American Heart Association, sponsored a roundtable discussion in Washington, D.C., to explore how to get exercise prescription as a covered benefit under health plans. After almost 2 decades of dancing around the physical activity vital sign, we’re finally getting to the heart of the matter: money.
Similar battles are being fought for health coaches and social services professionals. And, like the effort to get exercise management data into the electronic medical record (EMR), the Gravity Project is working on social determinants of health (SDoH). Data capture is a necessary, but not sufficient, element to get the health system addressing upstream factors.
The Ardmore Institute of Health funded a study, just published, showing that most family physicians are aware that unhealthy processed foods, alcohol and tobacco lead to chronic conditions, but much fewer of them are aware that literacy, employment, access to free and safe places to exercise and racism are strong risk factors in chronic disease. The authors called for “comprehensive education on SDoH with a focus on community components across all levels of medical training and practice”.
Yes, but what America really needs is a business model that values health and well-being, a model that recognizes that our ever-inflationary reliance on more and more medical technology is not a sustainable path to health and well-being. Adam Smith would have chastened us that there MUST be a viable and sustainable business model.
Here is a little thought experiment:
Imagine two societies grappling with today’s chronic and cardiometabolic disease burdens, most heavily affecting those with greater social vulnerability.
Society A relies on highly bureaucratic, centralized health care systems. Professionals certified in lifestyle and social interventions address SDoH and unhealthy behaviors, using complex tools and billing processes in a highly regulated, expensive and cumbersome EMR designed to serve the system (not the users). Medical malpractice attorneys advertise on TV for people who have experienced medical neglect. The system prioritizes "Big Data" and technology, empowers large corporations and turns health care professionals into overburdened millworkers that form unions. Patients bear the cost of these health promotion services as “personal accountability”, paying out-of-pocket with limited tax deductions and sometimes being able to use health savings accounts.
Society B fosters a decentralized, community-driven approach. Businesses compete to provide lifestyle and social intervention services, empowering consumers to choose what works best for them. These businesses being lightly regulated, tort attorneys advertise through personal injury ads on TV for people who are harmed. Instead of rigid billing codes and complex data systems, whole health software tools support local community collaboration and innovation. Society B values health as a collective priority, recognizing that healthy cultures produce more value and wealth, providing tax- or employer-supported discounts through a “Stay Well” plan. This plan provides everyone access to a limited number of discounted services annually, making wellness affordable and prioritizing prevention over treatment for better, longer lives.
We live in Society A. With that bias, Society B looks tempting (their grass looking greener), but I doubt Society B would end up fully satisfied - according to T.R. Reid, no society in the world is fully satisfied. The notion of charlatans restrained by tort is un-nerving, but – closing in on 40 years as an invested observer – I’m underwhelmed by the power of board certification and regulation to deliver cost-effectiveness and high quality. Certification primarily protects “turf” (aka scope-of-practice), regulations marginally increase safety but stifle creativity and drive up cost. Free markets foster innovation, but ill-informed and unwitting consumers can get swindled. Societies need a mix of free markets and regulations.
After 25+ years, I think it's high time we take a look at what Society B has to offer.
In your thought experiment, which society outperforms?
References
https://confluence.hl7.org/display/FHIR/2024+-+07+Physical+Activity
Accessed - 01/29/25
https://confluence.hl7.org/display/FHIR/2024+-+07+Gravity+Project+Track
Accessed - 01/29/25
Bharati R, Kovach KA, Sayess P, Polk E. Impact of Physicians' Perception of Social Determinants of Health (SDoH) on the Practice of Lifestyle Medicine. Findings From a Family Physicians Survey. Am J Lifestyle Med. 2024 Nov 15:15598276241277460. doi: 10.1177/15598276241277460.
Reid TR. The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care. New York, Penguin Press, 2009.
Starr P. The Social Transformation of American Medicine. New York, Basic Books, 1982.
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