Compensating Exercise Professionals: Navigating Insurance Reimbursement and Future Opportunities with Christina Badaracco

As always , I'm your host , michael Stack , an exercise physiologist by training and a health educator and health entrepreneur by trade , and I'm fascinated by a phenomena I call the wellness paradox . This paradox , as I view it , is the trust , interaction and communication gap that exists between exercise professionals and our medical community .

This podcast is all about closing off that gap by disseminating the latest , most evidence-based and most engaging information in the health sciences , and to do that , in this 11th episode of our podcast series , we're going to talk with Christina Badaracco .

She was the lead author of an article for the themed issue entitled Compensation for Exercise Professional Services , and this is such a thorny topic , such an unknown area , and Christina and her co-authors did such an amazing job breaking down the different forms of reimbursement or payment for exercise professional services , that is , cash pay , health savings accounts as

well as insurance reimbursement . Now this podcast is going to get into some conversations around some things that we might not always talk about in our field and some terminology that you may need to look a little closer into the article to really understand .

But I think this is such an important conversation and it's really why we saved it to last , because everything we've talked about thus far kind of builds to what we need to do to get reimbursement and increase accessibility and what that might look like in the future . So there's a lot of great information to share in this episode .

I think Christina does a great job encapsulating all of the important things that we need to know about this . Any information we'd like to share with you from today's episode can be found on wellnessparadoxpodcom . Forward slash , episode ACSM 11 . That's forward slash episode , acsm 11 . Please enjoy this conversation with Christina Badaracco .

Today I'm here with one of the lead authors from one of our articles , christina Badaracco . Christina , thank you so much for joining us .

I talked to a lot of people about writing on this topic and not a lot of people were excited to do it , and I think that speaks to the complexity and the unknown area that exists around this topic .

So I'm super excited that we got you and your writing team to do it and do the great job that you did , and we're going to dive into that article in this conversation . But first , why don't you tell our audience a little bit more about your background , just to provide some context for the discussion ?

I'm based in Washington DC and you and I actually met through my most recent full-time job .

I was working at a healthcare advisory firm called Avalere when I was working on a project for the Physical Activity Alliance , which will probably come up later in our conversation , and I worked on various other projects while at Avalere involving research policy and strategy work for different healthcare industry clients . I'm currently working in independent consulting .

Just to offer a few examples of my work working with healthcare organizations to develop and evaluate new programs regarding lifestyle and culinary medicine . Also directing trainings about lifestyle and culinary medicine for professional associations like the Obesity Medicine Association .

Also food companies to help them understand healthcare markets and develop food as medicine strategies . Healthcare markets and develop food as medicine strategies . Writing cookbooks , writing peer-reviewed articles and educating healthcare and public health professionals about the Farm Bill and ag policy and how that relates to health , and so I'd say across many of these areas .

An overarching theme in my work is educating and training healthcare providers and other professionals about policy issues and program development and helping to connect the dots between a lot of the different issues that are impacting their work and the environmental factors that our patients and our clients are facing as they're going about trying to be healthy in their

daily lives .

A lot of times I tend to find people that are in the fitness and exercise space don't quite understand all the mechanics of the different forms of reimbursement , the pros and the cons , and so coming at this from a bit of an outsider's perspective that was really able to dive deep with your work with Avalere , I think , provides a very unique perspective to this

topic . And your article that you wrote with your writing team was Compensation for Exercise Professional Services .

That you wrote with your writing team was compensation for exercise professional services , and you had three other authors on the article Eric Durek , doug Ribley and Christina Ward-Retico and you guys kind of dove into all the different forms of reimbursement that existed the most common form , which we all get on a day-by-day basis , which is cash pay , the one that

our industry is yet to capture , which is insurance reimbursement from the public and the private payers and everything in between . So I'm gonna give the baton over to you and just ask you the simple but not easy question of why do you feel this was such an important topic to cover and what were the most important topics that we covered in the article ?

It's not part of our education , it's not part of our training .

I learned about coverage and payment policies as a healthcare consultant at Avalere , really on the job , as I was interpreting policies and giving recommendations to clients , and those clients were typically more on the payer side , or life sciences or digital health companies are on the payer side , or life sciences or digital health companies .

I've also learned more so on the provider side as a dietitian .

As you pointed out , my own professional association , the Academy of Nutrition and Dietetics , has been really actively involved in advocacy for improved reimbursement for our services and kind of related to that or part of that has been the last several years the enormous growth in the food as medicine movement , which in many ways I know sort of parallels a lot of

the work in this field around exercise as medicine and physical activity as medicine . That has led practitioners and other community partners to need to better understand payment models and standards and quality measures and all these other factors that affect third-party reimbursement for services .

So I've also sort of learned on the job and through my own you know , professional engagement and advocacy as a healthcare provider .

So in our article we're definitely trying to write from the perspective of a practitioner , like an exercise professional , but also trying to help them understand the perspective of the patients , the clients , the audiences whom we're serving .

So just sort of briefly to go through the main topics , as you pointed out , we're starting off with the sort of most traditional , most common form of payment for these services , which is paying out of pocket or cash pay .

We also walk through the use of health accounts like health savings accounts or HSAs , hras , fsas , and how those can be used for different forms of exercise programming . And then insurance reimbursement .

We talk about various models like capitation or shared savings , and so there aren't many individual services in physical activity and exercise that are actually covered by insurance today , although we do offer a couple examples like cardiac rehab , the Silver Sneakers Program , and talk a little bit about Medicare Advantage and employer-sponsored insurance plans .

We offer some of the pros and cons for accepting each form of payment , again largely from the professional's perspective . What are the pros and cons ? Just to offer a couple of examples when we think about insurance reimbursement , just to offer a couple of examples .

When we think about insurance reimbursement whether I guess you know you're speaking from a dietician perspective or the exercise professional perspective it expands the pool of patients who are able to see you and maybe opens opportunities for those who can't afford to pay out of pocket .

But from our perspective as a professional , it also means more paperwork and it's more of our precious time and very often means less payment per patient .

And then , as we move toward the conclusion of the article , we talk about some growing trends and emerging opportunities , like the rise of health and fitness clubs affiliated with health systems and the push toward advancing health equity and addressing more health-related social needs throughout the health care system .

And then we offer some calls to action to the audience . So you know , I think there are many important educational points that we include in this article that are probably new to readers , or maybe they've heard some of these buzzwords but don't really know what they mean or how to apply to practice .

So we want to help sort of elucidate and clarify what these concepts mean and help them understand , either today or in the future , why they're affecting or why or how they're affecting our work .

You know we also want it to be um action oriented , like I was saying before , so offering recommendations for actual actions that readers can take to contribute to some of the ongoing um progress , to expand access to our valuable services .

Um , so often when I attend , maybe , a webinar or a presentation that's focused on different areas of healthcare policy , I feel like the main call to action or takeaway point is call your member of Congress , you know , and speak in favor of a certain bill or against a certain bill .

Well , I personally , as I said , I live in Washington DC , so that doesn't mean anything to me , you know , given my representation in Congress , and I also really think it's important that we make sure people understand there are so many ways that they can take action and I know you've had other people speak about this on your podcast in the past , but whether

it's through , maybe , research that we're doing to generate evidence and we'll probably talk a little bit more later in this podcast but just really think it's important to highlight that there are so many ways that we can be contributing to the momentum to move our field forward , and so we tried to bring that across in our article .

So I think those are a few ways . Those are the topics we're focused on in the article and a few reasons why I think they're really important to include in the conversation in this special issue .

It is the vastly predominant way we're paid and I think everyone looks at that as an inferior form of payment that it kind of sits outside of the healthcare tent and we kind of tend to think , I think in the fitness industry sometimes that insurance is just this panacea and , oh man , once we get insurance reimbursement , everything will be right with the world and

physical activity levels will increase . So let's you talked about the pros of yes , it increases accessibility , it broadens the pool , it reduces the economic burden on the patient . But talk a little bit more about some of the cons you know , particularly as someone who was , you know , accepting and is accepting insurance reimbursement .

You mentioned , you know , paperwork . There's timelines , there's , you know , reduced reimbursement amounts . I think people that don't accept insurance don't realize these kinds of things . So zoom in on that a little bit for us .

So I guess something I want to clarify too , and not just in this field , I think in many fields is kind of a common misconception just because you know , maybe a code is created and CMS the Centers for Medicare and Medicaid Services basically makes it allowable for plans to cover a certain benefit , doesn't actually mean that they will .

I'm thinking like a lot of the food is medicine movement that we're seeing lately . It is possible for Medicare Advantage plans , medicaid plans , others in many instances to cover , like medically tailored meals , for example , or produce prescriptions , but that doesn't necessarily mean they all are .

And in fact the last couple of years last I saw data , I believe actually from Avalere and others is that in the last couple of years fewer plans are . So there are many other factors that cause plans to decide which benefits they're going to cover and at what amount , which vendors they're going to work with or which providers .

So just wanted to point out again , like , even if legally you know these plans are allowed to provide or cover these benefits , doesn't actually mean they will . It doesn't actually mean it will be at a what we would argue to be , I guess , a reasonable rate .

But to dig in on some of the cons , as you pointed out , a little bit more , so definitely there is going to be more paperwork required , which also means more time and a lot of exercise . Professionals may not have the expertise or the skills or the time to be able to fill out that paperwork .

So that might mean maybe you're obligated to hire an assistant , hire additional staff to help coordinate with , communicate with the health insurance plans , manage all the billing . Many times claims are denied as well , so you'll have to go back and forth about claims that may be denied .

I mentioned that the reimbursement rates may be substantially lower than those paid out of pocket , especially when we think of Medicare and Medicaid . I know in the case of many dietitians well , those , I guess especially who work in private practice it's always a decision do we want to accept insurance or not ?

And maybe they will just decide to stick with the private insurers rather than Medicare and Medicaid , because the reimbursement is substantially lower . I guess another factor is you need to speak the lingo and understand all of the details about what must be included in the benefit , what must be included in your service offering ? When is it going to start ?

Does this start in 2024 , 25 ?

And so , as I was kind of saying before in our motivation for writing this article , this content is new for most exercise professionals , and so , even before they can learn how to fill out the paperwork and negotiate with the payers , they need to understand what all these terms mean , and so there's just a really enormous learning curve .

You know , there may be a lot of technology infrastructure that's needed to aggregate claims and submit claims , and you know I talked a little bit before about one of my sort of calls to action , which I think is so important , is collecting data and tracking improvements in health outcomes for our patients and our clients .

Whether it's that , or even again kind of back to the claims and corresponding more with the insurance companies , there may be a lot of technology infrastructure that you may not already have , technology infrastructure that you may not already have . So there are costs there and another learning curve , and so I think those are just several examples .

Oh , one other thought that comes to mind , too , is there will also be a delay . So if you're accepting cash pay maybe , whether it's credit card or even check or whatever form , you'll probably be getting the payment fairly immediately from your client or your patient .

But if you're submitting to an insurance company and then waiting for that payment , it could take quite some time and especially if you know , depending on your available resources , that may put a lot of strain on your business if you're not able to receive that reimbursement right away .

You're definitely paid later . So what we're not saying here is that we shouldn't be striving towards reimbursement and trying to figure out a way to make it work . I just think what we are saying and what you and your co-authors said so well in the article is hey , this is one way to be paid and it's only one way .

Cash pay is another way , HSA , FSAs are another way , and we just need to be informed on everything .

With that said , as you mentioned in your introduction , we met at the Physical Activity Alliance Symposium last year to talk about some of the work that you were doing with Avalere for the Physical Activity Alliance , and this does require a little bit of level setting , Although if you've been listening to this podcast series , you've probably heard the PAA come up a

couple of times . Paa is the nation's largest group of stakeholders in the physical activity space . We primarily focus as an organization on policy and systems change , and a lot of the complexities you talked about with insurance reimbursement have a lot to do with modifying the policy and systems environment to be more favorable to being able to get reimbursement .

And Avalere was brought in to do work on the PAs . It's Time to Move initiative , which has the goal of making physical activity assessment , prescription and referral the standard of care in medicine . And we're not going to dive super deep into the great work that you and your colleagues at Avalere did , but on a high level . What did that research tell us ?

And maybe how can that inform some of the things that we need to be thinking about going forward ?

In largely the we were looking at the payer perspective and conducting interviews with representatives from payers but also a couple of stakeholders more from the medical fitness industry , so that we could better understand priorities , challenges , future opportunities , recommendations for advancing opportunities for healthcare , integration for physical activity .

And I remember included in some of our interviews we were asking about food as medicine as well , because there are a lot of parallels , and insurance reimbursement was one topic that we addressed in our conversations , but also talking about things like quality programs and sort of other payment incentives and sort of all the different potential levers that could be pulled

. And so we had several , I guess , sort of summary findings I know we mentioned very briefly in this article , one of which would be seeking and striving toward more public insurance coverage , so like Medicare and Medicaid , enhancing employee wellness programs , solving some of these ongoing issues , technical issues , communication , issues related to payment and reporting ,

finding better ways to engage with healthcare providers and I know , again , you've had other folks in your podcast in the past talk about sort of that collaboration between the health care providers and the exercise professionals and then increasing opportunities for adoption of exercise prescriptions and making that more kind of a common practice .

And again , there I'm sure we see some parallels with the healthy food prescriptions and the produce prescriptions that are growing , disruptions that are growing .

So yeah , based on our diverse set of conversations , which I know we really enjoyed and we learned so much from all of those folks , we tried to sort of pare things down and summarize some general recommendations , and I don't know , actually , if you're even able to share in the call , if PAA knows how that any of our findings might be impacting some of the work

going forward , if largely you found they were sort of reinforcing a lot of the work that you were already doing or sparked any new ideas .

We really need to do a much better job of being very clear about the outcomes we're producing from our programs and how that relates to health and then how that relates to claims data , and that's kind of the through line that we've yet to establish is . Everyone universally agrees that exercise is a good thing . No one says exercise doesn't work .

We don't need any more white papers on that . But what we've not been able to do is tie kind of someone's fitness outcomes to their health outcomes , to the cost of their care , and particularly do it with the populations that need it the most .

The commercial fitness industry and I talk about this quite often does a very good job of getting the fit , fitter and the healthy healthier , the fit , fitter and the healthy healthier , and we're not really moving the needle from economic perspective . You know , getting somebody from , you know , 15% body fat to 10% body fat with a six pack .

But we are moving the needle when we get someone who's not physically active at all to start being physically active for 30 minutes a week .

And so I think the findings of Avalere , a lot of the things you said in this conversation that's what we need to solve for right now is you know what are our quality measures , you know what are the evidence-based , outcome-oriented programs we're developing and implementing to produce those quality measures , and if we could start doing that then I think we could

start to gain some traction .

But , just like you know , in the field of nutrition and changing your behavior on foods that you're eating and cooking and any aspect of lifestyle , the behavior change takes a long time and to be able to conduct these studies , to generate this evidence , it takes a long time .

These prospective long-term studies , well , they're also very expensive because they're very long and so obviously it's very difficult to go about doing this research . But it's necessary to make it kind of common practice when we think about this concept of prescriptions and generating evidence to show payers that it's going to be valuable to reimburse for the services .

So it's not an easy task but it's necessary . So I'm definitely excited to see in coming years through whether it's PAA , other listeners definitely excited to see in coming years through whether it's PAA , other listeners you have who are interested in digging into the research a little bit more to help build this evidence base .

It pales in comparison to the funding that physical activity has behind its initiatives and I think some way , somehow our communities working together to make sure we're advancing lifestyle medicine as a whole is really important .

I do find it really interesting just the disparity in the kind of the coffers of the organizations that are involved in it , and that's not a bad thing per se .

I'm excited that food is medicine is moving in the right direction , but , as you well know , it is costly to play in the policy space , and so I think that's just a word of advocacy to everyone who's listening on this is that we need to support the research that does the things we're talking about on the physical activity side just as much as the research is

being supported for food as medicine .

And so I I would love to see and you know we were talking before we came on the call today about the upcoming ACLM American College of Lifestyle Medicine conference .

Maybe there will be an opportunity there to start to think with anybody there who's interested about integrating sort of the food as medicine interventions with the physical activity lifestyle medicine more broadly these being two of the key ACLM pillars and kind of building the evidence base together .

I think we all fundamentally believe that and talk about all of these aspects of lifestyle together . But I'd say I guess it's not too common in the research to see those interventions included together and then to see the interventions detailed sufficiently in the published literature so that it's sort of reproducible .

So that would be a great conversation I think to start to have . Yeah .

Obviously , in a 30-minute conversation , you know , christina can't summarize everything . I wanted to spend the most time talking about insurance reimbursement , but the health savings account is an important conversation , understanding the benefits of cash pay compared to the benefits of some of these other methods . They're important to know .

Read the article , but there still is a lot more work that we have to do in this area . So , christina , before we hop off and I get to our final question , where can people go to find out more about you and the work you're doing ?

Some of my work over the past couple of years in the culinary medicine and lifestyle medicine space has been through a company called Rewire Health , so people can also find some of my work there , and then if anybody's interested in collaborating , they're welcome to contact me , whether it's through LinkedIn or through my website .

So I would love to talk about ways to collaborate and advance a lot of these , as we were just talking about these interrelated areas of lifestyle medicine .

However , I think the price of a membership is well worth the price of admission for this issue . Christina , before I let you go , I'd like you to give our listeners , from your perspective , one piece of advice you feel that they should be focusing on to advance and elevate the exercise profession .

So write in the journals and websites and go to the conferences that are outside of your industry , where the stakeholders that you're trying to reach go for their information .

So that gives you a chance to learn how to convey the implications of your work , whether you know , regardless of your setting or the type of audience , or you know , client population you work with .

Learn how to convey the implications of your work to those audiences and that might be policymakers , that might be healthcare providers , that might be healthcare administrators and then understand the language that you need to convince them of the need to change accordingly .

You know we I'll use the term we very broadly are so used to being in echo chambers and silos in this modern era and you know , even like posting and cheering for others in our own field on LinkedIn .

But I think to really make the broader change and move the profession forward , as I said , we need to learn to speak others' languages and have productive conversations with them . So I think writing op-eds can be a good way to start .

Maybe you could also , for your own professional audience , explain a lesser known issue , a lesser known concept , Like if somebody on the line knows about or listening in today knows about a certain aspect of insurance , reimbursement or other aspects of healthcare policy . Maybe write an op-ed to educate some of your fellow professionals .

And I've really tried to do this myself in my profession in recent years as I've been , as a nutrition professional , trying to reach more of the physician audience or the policymaker audience , so writing in , like Health Affairs or New England Journal of Medicine , to try to reach those audiences , not just only ever writing for the dieticians , and so again , I think

that can help to help me to convey my message and convey the need to change the current system to these other stakeholders or audiences . So I think that can be a great way it's not easy again , but I think a really important , powerful way for listeners to be able to help move their profession forward .

Forward slash episode ACSM 11 . That's forward slash episode ACSM 11 . This is the second to last episode in this special podcast series . Next week we'll be back with a consolidation of all the critical points from our guests leading up through this episode .

I think it's a great summary that'll put a real bow on this themed issue of the ACSM Health and Fitness Journal on professionalization and advocacy . Until we chat again next week , please be well .