Eric P. Durak MSc In the October, 1994 issue of the NSCA bulletin, the status report of the proposed California Fitness Instructor Act was given (22). For those who are unfamiliar with this bill or the status of licensure movement for fitness professionals in the US, this article is written to shed some light on the subject. The debate of licensure has recently been addressed in one professional periodical (27), and will be addressed in the future on a larger scale as future types of licensure bills are submitted to state legislatures. With the demise of the California Licensure bill, and that of health care reform on both the federal and state levels (Prop 186 in California in November of 1994), the effects on licensure may be a blessing in disguise for fitness and health promotion professionals.
It is well documented that exercise and improved fitness has a positive impact on the lives of participants (18, 19, 24-26). The joint pronouncements on the benefits of exercise from the American College of Sports Medicine, the Centers for Disease Control, and the National Institutes of Health with continued media publicity have led to more participants into the fitness market. Because market demands for quality health clubs and instructors, the profession has designed certification programs, presumably to give the public a perception of quality for those instructing the public. Several professional fitness organizations including the National Academy of Sports Medicine (NASM), National Strength and Conditioning Association (NSCA), International Sport Sciences Association (ISSA), Aerobics and Fitness Association of America (AFAA), and the American Council on Exercise (ACE) have certification programs, each varying in the levels of competency with no apparent concensus for a baseline level. Because of the varying levels and quality of these certifications, the public is being sent mixed messages on instructor certifications.
The California Fitness Instructor Act, although well-intended, was an ill-fated attempt as a consumer protection act to exclude from practice those instructors who presented the highest risk to the public (those with the least education or who are negligent). This bill made no reference to published reviews on the topic of licensure, or scope of practice within the exercise profession (6,9). Further, it did not have the support of the organizations it was designed to regulate. This bill would have come under the guise of “Sunrise” legislation – meaning there would have to be documented proof that fitness instruction was inherently dangerous to the public safety and thereby need state regulation. To date, there is little documentation concerning injuries or court judgements against personal trainers or fitness staff who do not perform their jobs well and post a consumer risk. Until further documentation is published, any form of licensure at the state level may be premature and destined to fail in any state.
The Clinton bill and others on national health care reform may be dead, but private sector reform is not. Before the Feds began their push for reform, private insurers and corporations had already begun to set limits on how much they were going to pay and were demanding proof that the interventions being provided were delivering a quality outcome. Enter the world of managed care and capitation. These market forces and the public’s demand for the best health care available have forced a critical appraisal of prevention and wellness services as a means of containing costs (15, 21, 23).
Health care in the United States is dictated by these market forces. The substantial growth in HMO’s and PPO’s in the past decade is testament to the fact that the primary “gatekeeper” in medicine may very well be the insurer who is footing the bill, rather than the physician providing acute medical services. The insurer is now paying for prevention and wellness services, even though wellness per se is not part of the medical model at all – it is part of the health model (public health, physical education, holistic health programs, etc.). It is because the combination of the evidence of enhanced fitness and that wellness programs have been shown to have the ability to save insurers and corporations money and will save more in future health care expenditures (10, 15, 19, 23, 25).
The October, 1994 issue of the Naisbitt Trends Newsletter states that the “wellness reflux” may have potential cost savings of $188 billion dollars in the coming years (16). Insurers are betting that a small portion of their yearly expenditures on wellness will help defer future costs of major medical intervention and hospitalization. It is a gamble that is paying off for some insurers, such as California’s PacifiCare Corp., whose Senior Fit program is growing exponentially in the past few years. Seeing this trend, other insurers in California such as Take Care and Health Net are considering or have already implemented similar health promotion programs. A recent agreement between MetraHealth and the Arizona Fitness Network to provide wellness services on a capitated basis is further evidence of this trend.
Licensure Feasibility
Licensure is a state-mandated quality assurance marker. However, the fitness industry in its foresight has instituted its own quality assurance marker in the form of certifications. The wide variety and lack of concensus in quality of certifications are not indicative of the lack of direction and leadership, but are a testament to the diversity of the profession, and the entrepreneurship of those who administer the tests. Unfortunately, there are no internal regulations on those who are negligent or who are un-knowledgeable. At present, most Americans are dissatisfied and distrustful of the way our government is run. Over 60% of American’s think that local, state, and federal governments are too bureaucratic and move like dinosaurs, and with good reason. Take for example, the recent debacle of the California State Assembly spending three months of partisan wrangling just to choose a speaker; or the 1993 California budget process causing millions of dollars in delays and the eventual issue of IOU’s. Why should the fitness industry lobby for a licensure bill (which is costly, time consuming, and has the possibility of fighting a turf war with other allied health professions) only to have the control of who is labeled a fitness instructor taken out of their hands? Issuance of a certification is a visible sign of recognition of the organization. It is a privilege of that organization. Institutionalization by the state of some form licensure would be contrary to the changing environment off allied health medicine and to the long term public interest.
This may be difficult to believe, but if a law were passed a law that states, for example, that no one person or organization could give prudent nutritional advise other than those designated by law as being qualified, then persons with insight such as Nathan Pritikin (originally an electrical engineer) would have been barred by law from practicing and counseling persons about nutritional habits and prescribing nutritional advice. The revolution he helped create in the medical and nutritional world would have been delayed or prohibited. As it was, it took the profession more than twenty years to realize his concepts as having benefit to disease control and health lifestyle.
In general, establishment of licensure laws moves to exclude individuals from a stated form of health practice. These licensed individuals cast a dim view of education and enhancement of a particular school of thought that may be contrary to their basic structure. Therefore, the very act of licensure may exclude those for whom it may serve the best purpose. Because of the present lack of demonstrated increased risk of injury or death from exercise instruction, we must assume this risk is low. Given this, responsibility for seeking out qualified exercise instruction to deal with the client’s preferences and personal medical condition(s) is with the client. To date, market forces are already moving in this direction faster than most realize. Professional fitness organizations are publicizing the qualifications of their certified instructors and setting up guidelines for the facilities they work in.
To further legitimize their professional standing and give the public an appearance of quality assurance, some fitness professionals have turned to the American Kinesiotherapy Association, based in Washington state. Since 1954, the AKA has been a fully accredited, state recognized licensed organization that provides therapeutic exercise as part of the health care system. They operate primarily within the Veteran’s Administration system, but are expanding their markets to private practice, rehab settings, and sports medicine practices. Persons who wish to sit for the AKA board exam must have a BS degree in a related field, and over 1,000 clinical internship hours in certain health care areas (counseling, orthopedics, pediatrics, exercise physiology, and adapted exercise). If is is licensure that fitness professionals are seeking, then the AKA may be a “best-fit” option for them. Why re-invent the wheel?
Secondly, health care reform spurred great changes in the way people think about insurance in this country. If you ask any licensed professional, they will state that, in part, their licensure means they can bill insurance companies for their services, although it doesn’t necessitate payment. It is the type, quality, and outcome of service that counts. Since this is one area that many fitness professionals are seeking to enter, awareness of facts concerning third party reimbursement are needed. 1) Fee for service is changing rapidly, and moving to a “capitated fee structure”, meaning that insurers will pay providers a certain amount of dollars per patient to take care of their needs and a limited number of dollars per procedure, regardless of the degree of health or illness of the patient. The patient is responsible for whatever fees not paid for or the provider “makes due” with the length of service dictated by the insurer to help the patient achieve functional status. The provider must provide justifying documentation proving that extended or different types of treatment will provide the desired outcomes in order to be paid any further (5, 17). In many cases, this patient is referred to community health/fitness programs, because it is economically unfeasible for the health professional to see the patient for an extended period of time. This is a blessing and can be very lucrative for the fitness industry, as many health clubs and instructors have come to realize. Most personal trainers are used to working under a fee-for-service arrangement. Insurance reimbursement is seen as supplemental income. Many allied health care centers that rely solely on third party reimbursement have drastically changed their business arrangements to keep ahead of the changing market. Some have gone exclusively to a capitate fee arrangement.
Since wellness programs are gaining momentum, fitness professionals may be able to collect insurance money for wellness services they provide. Since one does not have to be licensed to provide wellness programming, the ability to receive money must come from the following factors:
A) The ability to negotiate with insurers and achieve reimbursement will be based on provider’s demonstrated ability to provide services that will have a positive outcome on the client’s health or limit the future incidence of a medical condition. Fitness and health promotion programs are feeling increased pressure to be cost effective and not to repeat the same mistakes of the present health care system, such as overspecialization, overbuilding, and overspending (14). “Outcomes Management”, “Managed Care”, and “Lifestyle Case Management” are the buzzwords for the 1990’s. Health care is now viewed as a team approach taking into account all aspects of a patient’s care. Any fitness professional who truly wants to be a part of the team must understand and be able to demonstrate proper outcomes criteria to insurers, medical, and other allied health practitioners who refer to their program for continued reimbursement. A listing of health promotion-type programs is in Table I.
B) Understand what type of financial arrangement to make with insurers. Just as you set fair market rates for clients, you must be able to manage a profitable program in your facility and not overbid yourself. The insurers sole objective is to keep it’s bottom line profitable, as much as possible. The ability to negotiate with insurers is essential to the growth and maturation of the entire fitness industry. For facilities and professionals who land contracts (many already have), they represent important inroads to the fitness profession becoming more legitimized as members of the health care team. They provide essential services to asymptomatic individuals for health improvement to delay the onset of disease and to diagnosed individuals for reversing or limiting the disease process, the ultimate goals being health improvement and decreased costs. This represents a tremendous challenge for the industry, which in the view of 20th century medicine has long been regarded as a health care outsider. Because of this, the industry has not asserted itself in the past and has watched many health and rehabilitation jobs fall into the hands of other allied health professionals.
Recent trends over the past few months may see a resurgence in both the market forces with fitness and health care, and government inclusion. First – A group from Arizona called Health Care Dimensions has forged into health care with a business that will link existing health care agencies with hospitals, and fitness clubs. Their goal is to expand exercise and health promotion services into the corporate and medical work environments. They are starting in the Southwest, and moving around the country. In the next couple of years it may be possible to enlist a health club or other type of exercise program (home fitness training, hospital programs, etc.) into your health insurance plan.
Secondly – The issue of government inclusion and state licensure debate may indeed be coming to a close in the next year or so. In July of 1995, the state of Louisiana passed a bill (Senate Bill No. 597) licensing clinical exercise physiologists who practice in the cardiopulmonary area of care (29). Upon obtaining the baseline criteria (Master’s degree from a an accredited school, one year experience in a clinical setting, one national certification, two physician recommendations, plus a three hundred hour internship) the licensed physiologist is eligible to: formulate, develop, and implement exercise programs, administer graded exercise tests, provide patient education regarding exercise, and disseminate information to patients with deficiencies in the cardiovascular system, diabetes, lipid disorders, hypertension, cancer, COPD, arthritis, renal disease, organ transplant, peripheral vascular disease, and obesity.
This bill is the beginning of a national movement toward licensure in the US for persons in the exercise world. It will start with state-by-state bills for exercise physiologists, but will also encompass other members of the exercise profession within a short period of time. It will mean that the government will take a more pro-active role in the development of the profession.
What will this mean for those who call themselves exercise professionals? With the current push for HMO contracts, and the inclusion of exercise in certain types of health care plans, this may mean more marketing power for those who already work in the rehab and clinical areas of exercise instruction. Sadly, it may exclude competent fitness professionals who do not possess the academic background necessary to have this advanced certification. With the information provided in this article, it may spur these professionals to inquire about continuing education and future opportunities within the upcoming fitness/health care world.
It is up to the profession with its many types of practitioners, and the general public to mandate the direction of fitness. Positive changes will happen when fitness professionals read and recognize the current health care system, and trends affecting their professional status. They must establish relationships with medical and allied health professionals and insurers. Most importantly, they must have a universal outcomes-managed health promotion program that can assure long-term success of participants (2, 4, 8, 21). Health care providers are most likely to value the need for individualized exercise programs and the variety of prevention services that are provided. Organizations can foster this growth by providing education and certification programs that fill this need. They can go a step further to insure this recognition by performing their own form of regulation by: a) establishing a basic competency and code of ethics (1); b) providing a form of registry that all certified personnel can be listed under and give the public one view of a fitness professional is (28), and; c) certify health and fitness facilities that hire those personnel who are certified and registered. If these steps can be achieved within the near future, the profession will position itself as a viable productive part of the “health” care system.
Table I : Future Health Promotion Programs
- Exercise Rehabilitation/Therapeutic Exercise (3, 6)
(Cancer, Osteoporosis, Hypertension, Diabetes,
Metabolism, HIV/AIDS, End Stage Renal Disease,
Lipid Disorders, COPD, PVD, Post-Rehab Orthopedic)
- Pre Natal, Post Partum Exercise (16)
- Cardiac Rehabilitation (phase III and IV) (14, 15)
- Low Back Prevention and Safety classes
- Water Exercise Therapy
- Smoking Cessation Programs
- Weight Management Programs
- Body Composition Assessment
- Fitness Assessment
- Nutritional Programming
- Stress Management Programming
- Senior Fitness Programming
- Youth Fitness Programming
References
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26. Wood, PD. Stefanick, ML, et al. The effects on plasma lipoproteins of a prudent weight-reduction diet, with or without exercise, in overweight men and women. New England Journal of Medicine. 1991, 325:461-66.
27. Davis, P., Davis, K. What is the meaning of licensure? IDEA Personal Trainer. Pg. 2, August, 1994.
28. Herbert, DL. Certification of health and fitness facilities. Exercise Standards and Malpractice Reporter. 8;2:17-20, April, 1994.
29. Hines, T. Louisiana Clinical Exercise Physiologists Licensing Act. Senate Bill No. 597 (¤ 3421-33), July, 1995.
Eric Durak, MSc – is the director of Medical Health and Fitness in Santa Barbara, CA. He is the author of: The Ins and Outs of Medical Insurance billing, and has performed therapeutic exercise for many special population groups. He is currently writing about exercise and the health care system, and has written Scope of Practice for Exercise Physiologists, presented at the 1993 American College of Sports Medicine meeting in Seattle, WA.
Phillip GA Leake , MA – is director of Preventive Health Systems in Sacramento, CA. He is currently contracting wellness and rehabilitation services with Mercy Hospital. His emphasis is on health promotion, and cardiac rehabilitation. He is a member of the health promotion section of the Southwest American College of Sports Medicine, and co-authored the original Standards of Practice document in 1993.
Maryon Stewart
Jim Strohecker
Tom Ferguson MD
Daniel Redwood DC