Eric P. Durak MScA Historical Perspective On Health and Medicine
What if….at the turn of the century the Flexner report* had included research in physical fitness, and the profession of physical culture (the precursor to physical education) had formed a relationship with medicine? Perhaps the past ninety years may have seen a dramatic change in the way this country views health, exercise, and longevity.
Much of the Flexner report at the beginning of this century dealt with validating medical procedures, and had a strong relationship with medicines that were tested on humans and animals. Much of the prescription medication in this country that undergoes controlled trials is done, in part, because of the early work by medical researchers after the report was published in 1910 (Payer).
At the same time, physical culture was becoming a driving force in the educational system. Students (both boys and girls), were participating in regular physical movement courses as part of their curriculums. However, this participation, as with most physical education programs throughout this century, have concentrated on sports and skill training. Although this type of exercise is important, it is transient from the standpoint that it is specific to a sport, and may not transcend itself into a lifetime activity to participate in for most.
*The Flexner report was commissioned in 1909 as a statement on the status of medical education in the US. It’s contents inspired medical schools to standardize their curriculums, and opened the doors for philanthropists such as JD Rockefeller to donate large sums of money for medical research. This also opened the door for pharmaceuticals to work with medical schools in this research, and this aspect of medicine grew rapidly over the course of the next forty years.
In the 1950’s the first epidemiological investigation of London bus drivers (Morris, Buskirk) showed an association between daily activity and heart disease (bus ticket-takers who walked up and down the buses had a lower incidence of health problems than the bus drivers). Since that investigation, many types of reports on exercise have shown strong evidence that regular moderate exercise may increase longevity, by lowering risk factors for premature morbidity and mortality, enhance physiology by lowering body fat, improving lipid and muscle metabolism, and bone density.
Since the late 1950’s, sports medicine research has become intertwined with public health, medicine, general physiology, medical pathology, and gerontology research to attempt to answer basic questions about how acute and chronic exercise effects the human body, and what types of adaptations are made by its practice.
Current Tends In Health and Fitness
The 1970’s marked a dramatic turn-around for the health and fitness world, as Frank Shorter won the 1972 marathon in Munich, and Dr. Ken Cooper coined the word “aerobics”, and its system became wide spread through this decade. Nathan Pritikin came into notoriety for his program of low fat eating to help reduce the effects of “the typical American diet” on heart disease, cancer, and other lifestyle diseases. Nobel laureate Linus Pauling and colleague Ewan Cameron were performing investigations on large doses of Vitamin C and its effects on improving health with cancer patients. Governmental policies regarding health were implemented, and grant money for health issues was becoming more available. It seemed that more people were interested in health, and a new direction was about to occur within the movement (Fries, Weinstein).
But was it? According to publisher Marshall Ackerman (who founded Prevention Magazine with editor J.I. Rodale in 1954), the health movement in the US has seen relatively little change in the past 30 years. People move into its philosophy, and others move away, so the net effect is fairly stable. What are the reasons for such a small segment of the population being interested in health and fitness.
In her book, “Disease-Mongers” author Lynn Payer suggests that medicine is merely marketing people into sickness by diagnostic tests, and slick advertising campaigns. Indeed, in Dr. John MacDougall’s book ” The MacDougall Plan”, the AMA, along with meat and dairy virtually created the four basic food groups as part of a sales program. The true health benefits of this way of eating has been debated and questioned by many alternative practitioners.
Has exercise been subject to the same type of segmentation as aspects of nutrition? Perhaps not, as the role of physical education was primarily to teach athletic skills. The aspect of activity and fitness as a lifetime endeavor, and to protect against certain diseases later in life was not introduced, and hence was not accepted as important. Medical practitioners actually advised against exercise for heart patients, pregnant women, and others with medical conditions because they felt that exercise had no substantial benefits (Fries, Ibrahim).
Any revolution that was suppose to happen in exercising for the general public never materialized during most of this century (Goldstein). There are many reasons, such as facilities available, type of instruction available on a mass scale (such as qualified health club workers), and suggestions made by doctors to patients. This brings us to perhaps the biggest reason for the lack of exercise “en masse“. Fitness is not, and has never been, part of the health care system.
Although many aspects of rehabilitation include specific exercise routines, (physical therapy, occupational therapy, back to work services, recreation therapy, etc.), the concept of exercise for health has never been part of the physician’s practice, or an aspect of major medical centers.
What if… exercise had been included in the Flexner Report? Would the demographics of health be different today? It is estimated by health club statistics that 82% of the American public is deconditioned, and they feel it represents a tremendous opportunity for the fitness profession to get them into regular exercise programs. How will this happen? What changes are necessary in order to create such a major change in our health care system, and health care thinking? This article explores the 10 paradigm shifts that will need to happen in order to dramatically change the way exercise and fitness programs are perceived by persons. These shifts will cause a tremendous increase in fitness participation by Americans, leading to an overall change in lifestyle, improvements in general health, and a cost savings in our health care dollars.
Paradigm 1: EXERCISE AND HEALTH PROMOTION SERVICES WILL BE REIMBURSABLE THROUGH INSURERS.
This may be the single biggest reason that most people do not participate in health-related exercise programs. Although most of us know that even a moderate amount of exercise is beneficial, we don’t participate because of costs. In 1994, Dr. C. Everett Koop, speaking to a fitness conference in Reno, NV, stated that one of the reasons we may never achieve true health care reform is that patients have come to expect too much from their health care system for too little a price.
What Dr. Koop meant was that insurance reimbursement had cut the cost of the medical service to the patient, so they did not know in many instances what the price actually cost, but that most of the inflated cost was passed on to other insurance subscribers.
The elements of health care reform suggest that HMO’s may lead the way for “capitated health subsidies” for health club memberships, and health promotion programs in a medical setting.
California’s PacifiCare HMO has a program called Senior Fit, whereby senior citizens may participate in a health club exercise program at a pre-determined cost, to improve their health. The program is capitated through the insurer, and a specific contract is reached with individual health clubs. It is a trend that is growing very fast.
Arizona and Colorado Fitness Networks have negotiated with regional HMO’s for health promotion packages that include traditional services (stress reduction, smoking cessation), along with therapeutic exercise, physical therapy, pre natal exercise, and yoga and meditation as part of a package that was purchased by the insurers. They feel that this unique concept in “one stop shopping” for health services is comparable to a medical clinic where many types of services are performed. Many health clubs are following this lead, and within the next two to three years, it will not be uncommon for seniors, diabetics, and those with high blood pressure to receive a physician’s referral to their local health club for a six month membership to work on their specific medical need.
Future Implications:
If managed care embraces wellness and health promotion programs in the coming 1-3 years, we will expect millions of Americans to take advantage of certain health program within their place of employment, or from their insurance agent. This may lead to a dramatic utilization decrease in clams, as a percentage of subscribers avert a disease or its complications through exercise and education. Like the Steelcase report, showing a decrease of over 50% of medical claims over an 8 year period through wellness participation. There may be a substantial savings seen through engaging in regular exercise by large numbers of people.
Paradigm 2: CREATE RELATIONSHIPS BETWEEN PHYSICANS AND EXERCISE PROFESSIONALS
Many physicians have a general knowledge of the benefits of exercise, but many are reluctant to refer patients to exercise programs because they do not understand the specific elements of exercise prescription, or the qualifications of the staff. In almost all instances, they do not understand how these services can be profitable.
The concept of education of health professionals is touched on below, but the concept of educating physicians is an important one. In many areas of the country, they are gatekeepers, and their referral is important for the success for many allied health practitioners. The way for exercise to be an important part of the health care system is to convey specific research on the effects of exercise in medical conditions to the general public, and be able to convince physicians that this program will be beneficial for their patients.
A prime example is the concept of exercise during pregnancy for improved labor and delivery. Although there are hundreds of medical publications in the area of exercise, it is not routinely part of the advise given as part of an obstetricians pre-natal health visits (Clapp). However, the effects of poor health are known (gestational diabetes, neural tube defects, fetal alcohol syndrome, premature birth). If one can extrapolate that exercise as part of a health promotion package is effective on birth outcomes, then it may be universally accepted as part of a regular obstetrical visit.
The concept of profitability is touchy, because many do not believe that the only reason to create a relationship with medicine is to create profits. However, fitness professionals can generate money for the medical practice. By seeing patients 2-3 times per week for a regular exercise program, the practice increases profits based on the fee for service for therapeutic exercise, or capitated rate negotiated at with the HMO. Thus, fitness becomes as essential to the practice as the nurse educator, or the physician’s assistant.
Paradigm 3: IMPROVING THE CONTINUING EDUCATION REQUIREMENTS OF EXERCISE PROFESSIONALS
As consumers, we expect that professionals who work for us have a minimum level of competency in their field of expertise. In health care, most professionals receive their initial education, and must sit for a state board exam that has set the minimal level of competencies for their particular job. They must on a yearly basis receive continuing education credit so they can keep up in their field.
At present, there are no requirements to become a personal fitness instructor. The fastest growing aspect in fitness, it has no minimum entry level requirements, and no mandatory continuing education. Trainers are for the most part business owners who work with clients in a fee for service mode, and are not required to receive any education in order to perform their jobs. They may have experience in terms of being an athlete, or have spent a lot of time training in a gym.
The future exercise professional will have to have a certain level of academic preparation, and will need at least one type of fitness certification in order to practice their craft. Some outside the fitness industry suggest that exercise instruction by its nature contains a certain amount of risk to the general public by practicing what is essentially an adjunct health trade with no entry level competency. Within the next 3-5 years, there will be mandatory certification within the field, and it will be looked upon favorably by the industry, the medical profession, and the public at large. Why? Because certification and continuing education gives credibility to any profession where health issues are concerned. People know that physicians and nurses all take continuing education courses. By having a system of continuing education in place for the fitness profession, the public has a sense of assurance that quality is maintained.
Future Implications:
Within the next decade, all fitness professionals will be required by their profession, or state law, to be certified by one or more agencies. Although this will never insure total quality, it will bring the profession up to standards with other allied health professions.
Paradigm 4: IDENTIFY OUTCOMES MEASUREMENTS FOR HEALTH PROMOTION SERVICES
Outcomes measures is the buzzword for rehabilitation in the ’90’s. Outcomes may be described as applying improvement measures (either by statistics, or temporal trends) to elements of patient care. How did their weight change each month? What were their changes in blood pressure after each yoga class? The numbers are the crucial factors in helping to show the importance of any exercise program on certain physical functions. It is the way rehab specialists will receive reimbursement money in the future. It is also something that the fitness industry must learn quickly if they are to compete in tomorrow’s marketplace. In rehab, outcomes represents getting the patient back to functional status in a reasonable time frame. For health promotion and therapeutic exercise, the outcomes may be very different. An example would be treating a patient with a knee injury, which may take 6-10 visits to orthopedic rehab. A weight management patient with yo-yo diet syndrome may need a year’s worth of services from a dietitian, exercise specialist, and counselor in order to facilitate emotional growth, and a long-term weight loss. Outcomes must be based on the patient’s ability to stick with the program (detailed below), and their improvement at specific intervals during the regime.
Future Implications:
Why are outcomes important to consumers? There is a feel with many insiders that many types of rehab programs are too expensive (an average visit to the physical therapist is $100.00), and may not be that effective. Historically, many rehab practitioners have not had to show success with their programs. With the advent of managed care contracts, all health care practitioners will be required to provide proper outcomes for their services. This is the highest level of quality assurance that any consumer can expect.
Paradigm 5: STANDARDIZE ASPECTS OF EXERCISE PROGRAMMING
Is strength training good for cardiac patients? Can osteoporotic women engage in vigorous water workouts? What is the difference between mall walking and treadmill exercise?
Fitness is many things to many people. And for the most part it should be that way. In order to work successfully with the health care industry, the fitness profession should at least have some basic way of performing its functions for specific medical patients. This may entail having a general outline for exercise programs for each type of medical condition served. It starts with an evaluation. The basic aspects of exercise should be outlined for specific medical conditions. An example would be a program for adult onset diabetic patients. The goal is weight loss and metabolic control (reducing blood sugar and lipid levels). If these goals are achieved through a 3 day per week health club membership, or a 6 day per week home walking and stretching program, its not important as the overall physical and psychological results. However, since the goal is better metabolic control, the structure of the program should be fairly constant. An example is:
- Assessments (pre program)
- Supervision (at every session)
- Regular monitoring (blood pressure, blood sugars,
body weight, body fat, heart rate, etc.)
- Program compliance (maintaining regular workouts)
- Follow-up assessments
This program may include a non-traditional component (such as T’ai Chi, Yoga, Qigong, etc.), but as long as the above structure is standardized, the outcomes should be the same.
Paradigm 6: UNDERSTAND EXERCISE AS PART OF AN HOLISTIC APPROACH TO HEALTH AND WELLNESS
In 1994, American Western Insurance Company started offering insurance premiums for alternative therapies for patients. Some of these practices include: Acupuncture, Ayurvedic Medicine, Homeopathics, massage, Midwifery, Reflexology, Trager Work®, Wellness Medicine, and yoga (Firshein). This type of insurance reimbursement is a giant step forward in thinking towards insurance, physician gatekeepers, and what constitutes a medical necessity.
Exercise may be the critical link between alternative therapies and conventional medicine. The reason for this is in research. For the past 40 years, exercise physiology research has crossed over into general medicine, epidemiology, molecular biology, and a host of other areas. It has strengthened the relationship between regular physical activity and longevity, reduction of disease risk, increase in the quality of life, and reduction in economic costs associated with a sedentary lifestyle.
Although exercise has formed a close link with medicine and the medical way of research, exercise is still part of the health model, and views the body not by segments (medical viewpoint), but as a whole (holistic viewpoint).
It should be remembered that a patient who is in treatment for a specific condition (high blood pressure), will receive a total exercise package designed not just to reduce blood pressure, but to reduce body weight, teach proper exercise performance, posture enhancement, and lifestyle management. Exercise may be the liaison between the allopathic and holistic communities if in the next few years the numbers of people who participate in exercise increase.
Paradigm 7: HEALTH PROMOTION MUST NOT REPEAT THE SAME MISTAKES AS THE CURRENT MEDICAL PROFESSION
In his 1993 article, LaForge points out three areas of the current health care system that have contributed to rising health costs, and a decrease in the quality of care. They are listed as the three “O’s”:
- overspecialization. In the past 15 years, the amount of medical specialists has grown more than the per-capita population. This has created a glut of services in areas where the niche may not be large enough to fill. One in particular is the orthopedic surgeon who only performs knee or shoulder surgery. This type of practice has diminished the role of the family practitioner (both medically and financially), and has shifted the emphasis of medicine from hands-on patient care, to high technology procedural care.
At the present, there is no such thing as a “specialist’ in the exercise profession. Some may have training in cardiac rehab, or work hardening, but the basic principles of exercise are universal, and most exercise professionals have the ability to work with a wide variety of fitness conditions.
- overbuilding. It is not uncommon to see construction happening at many hospitals in any given city in the US. This may not be as applicable to the exercise profession as the other components of the three “O’s”, but it may serve as a guide post as to the fact that many hospitals have forced layoffs of employees, and had a resurgence of building happen.
- overspending. This may be the biggest area of health care cost inflation. In many areas, new MRI machines have dictated a portion of the clinic or hospital’s costs in hopes of recouping that investment within one or two years of continued service. According to Payer, this has led to efforts at cost controls (in the form of DRG’s), and have even changed the way physicians diagnose disease.
There is a tendency to think that if the fitness industry could become more high-tech and have in increased sophistication, it may attract more members to its clubs, and increase its market share overall. This is not true. Historically, those who provide the best service, and the best results to clients in fitness and health programs have been, and will continue to be successful in attracting new types of clients and programs to their businesses.
Future Implications:
How is this beneficial? By feeling better and maintain normal medical symptoms (blood pressure, blood sugar, cholesterol, etc.). This shows the effectiveness of the health club program, and the potential cost savings versus other medical programs. If fitness is to compete in tomorrow’s health care market, they must be able to attract and MAINTAIN members in both prevention and post rehab programs. This leads us to the next trend.
Paradigm 8: REMEMBER THAT FITNESS IS A SERVICE INDUSTRY
Where health promotion and fitness differ from medicine is that, in most instances, the member never leaves a health club with anything tangible in their hands (unless it is a protein bar). This is because exercise has never been a drug, and it can never be accurately measured in terms of its total effects. Therefore, the professional must keep in mind that in the future they must promote and provide health and fitness programs that will do what they proporte to do – lose weight, improve sports performance, help increase functional strength, among others. Since the product is not tangible, and the effects are transient, then it is only through diligence and perseverance that people make and keep the gains that they have worked for during their program’s tenure. This leads us to the next trend.
Paradigm 9: KEEP PARTICIPANTS ADHERANT TO LONG-TERM EXERCISE PROGRAMS
One reason that over 90% of weight loss programs fail to maintain results with clients is that they provide services for patients at the onset, and the follow-up is minimal. Education and handouts for a 10 week program will not help with questions and motivational lapses at 35 weeks.
The new element in the profession of fitness is to make sure that patients keep on track with their exercise programs. This entails having a quality program for them to attend in the first place – good instructors, an element of fun, able to see some short term results, and personal attention. Also, it is up to the instructor to make sure that patients are called on the phone if they miss a few sessions, or arrangements are made for exercise instruction during vacations and business trips, and everyone who is part of a fitness program, be they seniors, or new mothers, or cancer patients, receives an element of permanence to their participation. This will be key to the success of all future health and exercise programs within the health club industry. An important element of adherence was discussed by Funnel (1991) in her article on diabetes patient empowerment. Her message confirms that when patients/clients are given their share of the responsibility for their own health care, they will do better over the long run vs. patients/clients who have little to say in their medical and health decisions. If this philosophy is applied to exercise programs, clients will (after a period of instruction), become part of the health team, and hopefully they will have acquired the skills to continue exercise and health habits even when they are not exercising at the club.
Paradigm 10: READ CHANGES IN MEDICINE, BUSINESS AND HEALTH, AND PREPARE FOR THEM.
The last, and perhaps the best forecast that consumers need to see happen for the fitness profession is that they should be looking at the current trends in health care. Futurist John Naisbitt recently wrote that wellness programs may have a tremendous cost-savings for American citizens. Therefore, the influx of these types of programs into hospitals, health clubs, and rehab facilities seems a logical extension of a cost savings plan.
The Clinton health care plan was hailed by some, and criticized by others, but never made it to passage governmentally. It did, however, spur a reform within certain elements of the health industry to create their own incentives for change that directly impact health and exercise programming.
The Dean Ornish Health Heart Trial has been sponsored by Mutual of Omaha plan nation-wide. Dr. Ornish plans to expand his program in 1995-96 to over forty sites nation-wide. Fitness gurus Jack LaLanne and Richard Simmons have also been in negotiation with health insurers for senior exercise and weight management program reimbursement. This could have major ramifications on the concept of paying for long term lifestyle management through exercise and health education.
Other programs are springing up across the country are paving the way for the use of exercise and “wellness medicine” in hospitals and rehab clinics, as many HMO’s (as mentioned), are paying for these types of prevention services.
Conclusions
It is estimated by leaders in the health industry that the next two years will show profound changes in the way exercise is viewed by both medical professionals and consumers. Relationships between fitness, health promotion, medicine, and the insurance industry will become closer. There will also be a “weeding out process” for those in the field who do not understand coming trends, and are able (or willing) to make necessary changes within their businesses in order to survive within tomorrow’s health care and wellness markets.
For those who are planning for the future, it looks bright. Perhaps the benefits will be seen within the next year, as more exercise programs are formed with medical practices, and deals are made with third party insurers.
Practical Tips for Tomorrow’s Health Consumers
1. Pick an insurance plan that provides health promotion as part of its basic benefits package. This will insure you some affordable wellness services through your work, or community program.
2. Pick a health club that offers alternative programs (weight management, nutrition classes, smoking cessation), in addition to basic exercise services. These are the programs that are reimbursable.
3. Ask your doctor for referrals in other areas of health (educators, massage, chiropractic, exercise). Also, choose another practitioner as your “secondary provider” outside of traditional medicine. In the future, they may be part of our allopathic health care system.
A Future Forecast For Health Promotion and Exercise
Within the next 1-2 years.
- Major contracts will be signed with HMO’s by select fitness providers.
- Employers select insurance companies based on the inclusion of health promotion and exercise programs, and the potential cost savings to their companies.
- Outcomes reports will become standard to the first-line health clubs that do business in the health care arena.
Within the next 2-5 years
- Consumers will be aware of medically-based health clubs through their work, insurance company, or through the media.
- Major contracts between fitness and insurance companies will be completed (no new programs will be incorporated).
- Certification will be mandatory for employment in the health club industry.
- Most (if not all) clubs will have programs for special/medical population groups.
Within the next millennium
- We may find physician offices (or branch offices) within health clubs.
- Large volumes of health research will come from the health club setting, as opposed to hospitals and universities.
- We may also realize Naisbitt’s prediction of a potential $188 billion a year savings in health care through health promotion programs.
References
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Maryon Stewart
Jim Strohecker
Tom Ferguson MD