Moving from Efficacy of Exercise to Cost Effectiveness

This paradox , as I view it , is the trust , interaction and communication gap 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 this brings us to episode number one of the new year , 2025 , which is be a year for the podcast .

That would be marked by monthly updates and insights from my role as the president of the Physical Activity Alliance and you've probably heard me talk about the Physical Activity Alliance before , but I just wanted to provide a reminder of who the Alliance is for those of you that maybe haven't been quite clear on in the past , or maybe those of you that are coming

across it for the first time . So the Physical Activity Alliance , the nation's largest coalition dedicated to advancing regular participation in physical activity . The coalition uses its collective voice to lead efforts that create , support and advocate for policy and systems changes necessary to empower all people to enjoy physically active life .

So we are the group of people that work at the national level with federal agencies on how to increase physical activity levels in the population . I know everyone that's listening to this podcast certainly wants to increase population-wide physical activity .

We know that underactivity and inactivity is not only a very real public health threat , but it's also a threat to our economy and to our military preparedness , and I know this is something that everyone who's listening is very passionate about .

And the goal of 2025 for me is to really lift up the curtain on some of the work that the Physical Activity Alliance is doing , under my presidency and with our board organizations and with our staff , to help increase physical activity in the population .

But most specifically , as it relates to you , our audience , which largely are exercise professionals , but I know we do have some healthcare professionals and healthcare leaders that listen to this podcast . I also am well aware that we have some researchers and academics that listen to the podcast .

So really , my hope , in every episode in 2025 , I'd like to be able to give all of those stakeholders a very specific call to action based upon the insights from the work that we're doing at the Physical Activity Alliance to address the policy and system environment around physical activity in this country , and a lot of what I'm going to talk about relates to the

Physical Activity Alliance it's Time to Move initiative . And it's Time to Move has the goal of making physical activity assessment , prescription and referral the standard of care in medicine , and this initiative has had several signature wins . It's a very complex , multi-pronged , multi-year effort .

One of the biggest wins we've had most recently is getting the physical activity vital sign to be a required field and feature in certified electronic health records . That's critically important because you cannot prescribe for physical activity until you know someone is underactive or insufficiently active or inactive , for that matter .

So having that field inside of EHR was a massive win , and that was work that the Alliance did with the federal agencies that mandate what go inside EHR was a massive win , and that was work that the alliance did with the federal agencies that mandate what go inside EHRs .

And so that's one example , but really what I want to focus this conversation around was something that happened in mid-December in Washington DC and it was the first benefits design roundtable that the Physical Activity Alliance conducted , and this was done in conjunction with Tiviti Health , as well as the firm Alston Bird .

That's a DC-based lobbying firm that does a lot of great work on healthcare policy , and in this roundtable we had close to 50 stakeholders that were both in-personC and virtually from around the country , and the breadth and depth of the stakeholders were significant .

We certainly had people from the Physical Activity Alliance staff myself , we had people from the major certification organizations such as the ACSM , we had people from the American Medical Association . We had people from the American Medical Association , we had physicians , we had individuals from CMS , the Centers for Medicare and Medicaid Services .

So all the critical stakeholders were physically or virtually around the table to have a conversation around benefits designed for supervised exercise therapy . Now , what exactly does that mean ? Well , to put it in layman's terms , this is how we go about designing what supervised exercise therapy will look like to get insurance reimbursement from public and private payers .

Now , just to level set on what I just said there , the public payer , the person that pays for health insurance , that's the public entity is the Centers for Medicare and Medicaid Services .

They pay through it for individuals who are seniors in the form of Medicare , and they pay for it for low-income people who are on the Medicaid program and that's done at both the kind of a combination of the state and the federal level . And then there's a bunch of private payers out there that you've heard of Most recently in the news .

You've heard of UnitedHealthcare , you've also probably heard of Blue Cross , blue Shield , anthem , elevance .

There's many , many private payers in this country , and so , basically , what this conversation was about is how do we structure the benefits for supervised exercise therapy that are administered by a qualified exercise professional to someone that has a chronic disease that exercise will impact , which is basically all chronic disease ?

How do we design that effectively to garner the support that we need to get coverage from those public and private payers ? In other words , how do we get insurance reimbursement for supervised exercise therapy ?

And I'm not going to get into the deep healthcare economics and the wonky policy aspects of this , because that's really not necessary for this discussion and it's also not very instructive to you in our audience in terms of what you should be doing .

The couple of things I will say is that this is a path that we are pushing towards very aggressively as an alliance .

We already have seen an organization moving through cancer , led by Katie Schmitz at the University of Pittsburgh , who's a past ACSM president , submit a national coverage determination to Centers for Medicare and Medicaid Services for cancer and exercise , and she has been supported by the alliance in that work and she has been supported by the Alliance in that work and

she's been advised by the Alliance in that work . But she's really been a pioneer and a thought leader on how to make this a reality and she's a great partner of the Alliance . But that's just the first shoe to drop .

There are other opportunities in a whole host of chronic conditions Fall prevention , depression , cardiovascular disease you go on and on and on down the list . You'll find that there are almost innumerable chronic conditions that supervised exercise therapy could be helpful for . Now that's kind of the state of play of where things are at .

We're working on a policy level . We're working with these federal agencies to determine what they need to hear and what they need to see in order to make a broad-based benefit available for supervised exercise therapy , first at the condition level and then , hopefully , for all individuals at some point who are insufficiently active or inactive .

Now , how this relates to all of you that are listening is something that I really want to connect the dots on .

Because , in order for what we're talking about to become a reality , for us to receive insurance reimbursement , another form of compensation that kind of unloads the cost burden of supervised exercise therapy from the individual consumer , from the patient themselves . And the umbrella that I want to put over the top of all of this is the concept of cost effectiveness .

And bear with me for a moment while I talk about the economics of this , because I think it's critically important to understand , first and foremost , an apparently healthy individual who is very active . No insurance company is going to be paying for supervised exercise therapy . No insurance company is going to be paying for supervised exercise therapy .

That's just not happening because there is no ROI to doing it . Myself , who's very active and doesn't have any chronic diseases probably many of you who are listening that are very active and don't have any chronic diseases there would be no benefit from a return on investment standpoint for an insurance company to pay for us to do exercise .

So I think the first notion we need to divorce ourselves from is that everyone in America , at some point in time , could be getting their gym membership or their personal training covered by some sort of insurance company . That is not going to happen .

The way the algorithm is going to work is first , do you have a chronic disease that physical activity and exercise can help ? If so , are you insufficiently active ? Are you not exercising and you're not doing the right kind of exercise to address that condition ? If yes to both of those , then that individual would be a candidate for supervised exercise therapy .

This is also not something that will be an indefinite benefit . All of us know this from just health insurance in general . They're not looking to pay for something in perpetuity or they want to try to limit that as much as possible . Physical therapy is a great example .

You only get so many physical therapy visits covered by your insurance company on a year-by-year basis , so I think we have to level set with some reality around that .

But really , what this conversation is around is around the cost effectiveness of supervised exercise therapy or , to put it another way , the ROI , the return on investment in supervised exercise therapy . Why the return on investment in supervised exercise therapy ?

If I invest $100 for Sally patient in supervised exercise therapy , how much of a cost savings will I be able to accrue as an insurance provider from that $100 ? Is it only $50 ? Well then , that's a bad deal . I've lost $50 . Is it $100 ? Well then , I net out even seems like a bunch of administrative burden for not a lot of benefit .

Is it $200 , $300 , $1,000 ? What is it ? What is the cost effectiveness ? What is the ROI ? And this is the vexing question that we have to answer , because I want to be abundantly clear . We know exercise works . We know it works when you do it and you do it for long enough to derive a health benefit .

The two things that we don't know and we certainly don't do a great job at one is getting the people that need to do it to do it for long enough to derive that benefit . So there's an adherence and compliance challenge , make no mistake about it , and exercise professionals will talk about that in a second .

But we also don't really know how much money an insurance company will save if they invest in exercise for an individual , and the amount of money they will save is a bit of a complex question to ask , and I feel it's important to touch on this before we start to talk about actionables .

When we think of saving money on particularly chronic diseases and when we think about saving money from exercise , the time horizon is very important for us to consider , and the time horizon is something that insurance companies think about quite a bit . What many of you may not know intellectually but intuitively might know is people change insurance a lot .

We have a odd insurance system in America where about 50% of Americans are insured through their employer and people change employers frequently . I've seen statistics that suggest people change employers as frequently as every three years . Employers change their insurance provider with some degree of frequency , shopping for a lower price .

So the time horizon for ROI can be very , very short in some cases , meaning if this person is going to switch their insurance plan in a year for any number of reasons , then the ROI that they derive from any medical intervention that is covered , including supervised exercise therapy it needs to be a very rapid and robust return because they might not be on that

plan years later . Now that's for the non-governmental payers . It is a little bit different with the Centers for Medicare and Medicaid Services , particularly people that are on Medicare , the aging population . I think there's a great opportunity there , because once those people get on the rolls they don't come off . You stay on Medicare until the day you die .

So I do think there's a slightly different value prop for the public payer in CMS than there is with all of the individual private payers . But there is this interesting notion of time horizon . I think all of us . When we think about , should somebody exercise to be healthier ? The answer is unequivocally yes .

Well , if they start to exercise to be healthier , how soon does that actually manifest itself in their health to a great enough degree that it reduces healthcare spend ? And we really don't have that answer right now . So , without getting too deep into the weeds of everything I just talked about , let's move the conversation to actionables as I see them .

For all of you that are listening right now , what can all of you do , individually and collectively , to drive our understanding of cost-effectiveness and ROI ? Let me start with the exercise professionals .

Let me start with the people that I feel like I know best in this conversation and for all of you , this goes back to a concept I've talked about many times before we have to be very good at producing consistent , clinically meaningful outcomes in the broad swath of the population .

I'm not just talking about that 10 to 20% of people you work with that are already exercisers , that are already highly motivated or that are coming to you to fine tune things . I'm not even talking about that person who is not an exerciser , who got a major health scare , that comes to you and is very intrinsically motivated .

I'm talking about everybody you work with the people who are ambivalent about what they're doing from an exercise perspective , the people who aren't quite so sure , the people who sheepishly come through your door . For those people , how do we ensure that we produce consistent , clinically meaningful outcomes ? And there's other podcasts that I've done on that topic .

There are certainly articles that I've written on that topic . I'll link up to those in the show notes page so you can check some of those articles out as well as some of those podcasts .

But the bottom line is this where the rubber meets the road for what we're trying to do to advance the exercise profession and to get people more physically active and healthier through exercise , it is the individual exercise professional him or herself that must take it upon themselves to produce those outcomes .

So certainly that means being good with the nuts and bolts of exercise prescription , but that also means being very good with the nuts and bolts of how you conduct a consistent and reliable health and fitness assessment , how you collect all of those metrics that actually show that you're substantively improving somebody's fitness .

But then it also has a lot to do with how you coach the individual you're working with towards behavior change . And we've talked about coaching many times on the wellness paradox and really , at the end of the day , somebody comes to you with that spark of motivation .

They want to do something about their health through physical activity and exercise and ultimately it's your job as the exercise professional to coach them appropriately to adhere and comply to the program that you co-create together . So my call to action for exercise professionals that are listening is threefold .

One , get very , very good at being able to evaluate somebody's fitness , all of the metrics that you're trying to improve , not just body composition but aerobic capacity , muscular endurance , muscular strength , flexibility and mobility . Get good at being able to evaluate that consistently to be able to show change over time . So that's call to action number one .

Call to action number two is understand the evidence-based protocols that drive the outcomes that we're looking for with the populations that we're working with . There is a specific way you work with somebody who has cancer . There's a specific way you work with somebody who has depression or diabetes or heart disease . Know those protocols , be educated .

And then , lastly , be a coach , not a coach like your old high school football coach or your old high school basketball coach .

Be like a health coach , where you work collaboratively with somebody and you shift their motivation from extrinsic to intrinsic using the appropriate coaching tactics like motivational interviewing , using the ORS , skills of open-ended questions affirmations or skills of open-ended questions affirmations , reflections , summaries .

Learn coaching psychology to drive those outcomes consistently and sustainably . Collect the data , know it for the individual , know it for all the individuals you work with and hold yourself accountable to those outcomes . Ultimately , patient or member or client whatever the term is you want to use outcomes are the accountability of the exercise professional .

If you take that radical approach to accountability , it will drive a level of outcomes that will allow the downstream effect to be . We're seeing a reduction in healthcare spend for individuals . Now I want to move on to the researchers and the academics that are listening and we need to move beyond . In the academic research .

We need to move beyond just purely efficacy . Does a program work to improve someone's fitness ? Does it work to improve someone's health ?

Not that we can't continue to pull on that thread and publish and conduct research on that , but there's a decently large , established body of evidence out there right now that exercise pretty much improves almost any chronic health condition that exists . The next step that needs to happen is we need to look at cost effectiveness .

We need to start to collaborate and get out of our own research silos and work with health systems , work with healthcare providers , to actually look at how this bends the cost curve from a medical expense perspective . That's the big jump that we need to take .

There's very little research right now , although there will be a paper published very soon that's coming out of some of the Physical Activity Alliance's work on cost effectiveness for supervised exercise therapy , and Katie Schmidt has some of that data with exercise and cancer .

And that's one of the reasons that that is such a great opportunity for us to seek insurance reimbursement is we have that cost effectiveness data but we need it for as many chronic conditions as we can get it . And this is just the next iteration of research that's being done .

It goes beyond the what and the how and speaks to the why , and certainly the why on a very foundational level is we want people to be healthy , but the why that's going to get the attention of policymakers and insurance companies is going to be the economic why , and that is if you spend a dollar on supervised exercise therapy , it saves several multiples of that

dollar . That's how we move the needle . So I would encourage all of the researchers that are out there that listen to this , or those of you that know researchers , communicate this to them . It's great to do efficacy research . It's great to do research that develops the protocols , but now let's advance that .

The next step , let's take that to the step of how does this save on healthcare spend ? What is the cost effectiveness ? What is the ROI ? That's a massive game changer . Next , I want to talk to people in the healthcare ecosystem , and I'm going to break this up into two groups . First is healthcare executives and then is healthcare providers .

So first to the healthcare executives those of you that are in the C-suites of your health systems A couple things I would ask you to consider . First , do you have exercise professionals that are working in your healthcare system ? I would bet you do , in the form of exercise physiologists working in cardiac rehab .

Can you start to look at the cost-effectiveness of the work that those individuals are doing ? When they spend X on a certain amount of cardiac rehab after a cardiac event , as someone is more adherent and compliant , what happens to their healthcare costs .

How can we connect people that are involved in revenue cycle management and the financial side of the healthcare system with individuals that are actually providing supervised exercise therapy ? And how can we get creative about how we can look at reductions in healthcare spend from a lifestyle intervention like supervised exercise therapy ?

Healthcare executives have the ability to break down silos through conversations , and this is not something that takes a monumental amount of work . I just think it takes a little bit of forethought , but , more importantly , it takes awareness that this is something that needs to happen .

I think that we all understand that health care is moving away from fee-for-service and towards value-based care . That is unequivocally true and , without getting into the nuance , right now , we pay for volume in health care . We don't pay for value , meaning outcomes .

Eventually , health care systems are going to have to move to pay for outcomes or value rather than pay for volume or for service , because the current system just doesn't work . We all know that this is a critical pillar in the transition of value-based care . We do it in the nutrition and the food as medicine world .

Now we need to do it in the exercise as medicine world . So I'd strongly encourage healthcare leaders that are out there to really think about how you can help drive some of this understanding of cost effectiveness and ROI with the work that's currently happening .

I mentioned cardiac rehab , but certainly peripheral artery disease and a whole host of other programs that you may offer in your health systems . How can we tie the efficacy of those programs to the reduction in healthcare spend for the participants ? That's powerful , powerful data . Healthcare providers , two calls to action for you here .

First call to action is develop great relationships with qualified exercise professionals in your community . Use the United States Registry for Exercise Professionals , which can be found on usrepsorg , to find exercise professionals in your community who are highly qualified to work with your patient populations .

If those providers aren't within the same healthcare system or within the same practice , go outside of your practice . Go outside of your healthcare system . Make that referral Primary care physicians , particularly talking to you right now , who are so overburdened and overwhelmed by all the patients that you have to see managing their chronic disease .

There are exercise professionals out there in the community that can help with that chronic disease management and if you are to make that referral , it can have a profound influence on that individual's health .

It can certainly have a profound influence on your workload , allowing you to work at the top of your license instead of trying to sketch out an exercise prescription in 30 seconds in an office .

And , most importantly , as we make this transition to value-based care and you can get involved with direct-to-employer arrangements and you can get involved with cost-sharing arrangements , aco models it actually stands to make you additional money . Now , the other half of that is the same thing that I said to the healthcare executives that are listening .

When you have the opportunity to connect a patient with an exercise professional , helping to understand how the fitness outcomes that the exercise professional is producing relate to their health outcomes and then their claims , data is critically important .

I think at the health system level the executives I was talking to we can look at very large swaths of data , massive data sets to look at this cost effectiveness , but there's value to looking at it at the individual patient level , there's value to case study observations .

So I would encourage physicians that are listening , when they have the opportunity , to think about how we capture case study data . Maybe you can even capture case study data on a large number of individuals . It doesn't necessarily have to be a published research paper . It could be a blog that you put out .

It could be information you provide to the Physical Activity Alliance , but there's an opportunity there .

The last group of people I want to talk to are the business leaders that are listening , and if there's not business leaders listening at mass , then I would encourage those of you who know some business leaders in your life to maybe send them this podcast , particularly business leaders that are in organizations that self-insure . A little bit of context here .

There are some smaller companies . Most smaller companies go into a shared risk pool for insurance . They don't pay for health care . They pay a company to cover the cost of the health care of their employees . Other companies larger companies normally more than 250 , 300 employees they choose to self-insure .

They use an insurer to manage their insurance , but then they pay out of their own pockets , so they're directly on the hook for healthcare expenses of their employee population .

Those business leaders that are listing , consider how you can find a direct-to-employer relationship with a healthcare system where you can not only negotiate the cost of their care but you can also inquire about how they can integrate exercise professionals into your employees' care , because we unequivocally know that exercise does improve chronic disease and you as an

employer have the opportunity to not only make your workforce healthier , happier , more productive , which improves retention and that also improves profitability for your company , but you also have the ability at the same time to contribute to this body of knowledge we have on cost effectiveness , because at the end of the day , employers are looking at cost effectiveness of

healthcare spend about as much as anything else . Employers see this on their financial statements on a month-by-month basis , how much they are spending on healthcare . Hr representatives and leaders know how much chronic disease costs an organization .

So business leaders are in an amazing position to help to move the needle on the work that we're doing , but also have the very real ability to make their employees healthier and happier and more productive and make their organizations more profitable at the same time . Big win-win-win there .

So , in closing , we are at a very neat inflection point in the exercise profession . We're at this point where we are having the active conversation about how we elevate the services we provide to that of a healthcare service , where we actually see that if we spend a certain amount of money , we get a certain return on investment .

Everyone who's listening has a call to action . Exercise professionals produce the outcomes . Researchers work on cost-effectiveness research . Healthcare executives figure out how to pair your exercise professionals with your people that are involved in finance , to help with some of that cost-effectiveness data .

Healthcare providers do it on the micro level , do it on a slightly larger level , do it at any level you can do it , and then business leaders demand opportunities for working with healthcare systems that do provide some form of exercise counseling to your employees . I think we all have a very important part to play in this process .

Certainly , for those of you that are listening , sharing this message can be absolutely critical . Getting this out here so other people can see it is a great way to advance the cause but , most importantly , to keep our country healthier and to maintain the economic stability of not just our health care system but also really the economic stability of our nation .

So this is just a little look under the hood of some of the work that's happening with the Physical Activity Alliance . As I said in that end of year podcast from 2024 , I'll be coming back at the end of every month to give you an update on the work that the Alliance is doing .

And since we have a new Congress in Washington , we have a new administration in Washington . There's a lot of moving parts . I actually don't know the topic for the February podcast right now . I know there's a lot that's going to happen between now and the end of February when I record , so I think that'll be a great opportunity to inform all of you again .

If you found this conversation valuable and insightful , as I said , please share with your friends and colleagues . Those shares are a great way to advance this collective journey that we're on . Any information I'd like to share with you from today's episode can be found in the show notes page . That's by going to wellnessparadoxpodcom . Forward slash episode 139 .

Please be on the lookout for our next episode when it drops the last Wednesday of February , and please don't forget to subscribe through your favorite podcast platform Until we chat again next month . Please be well .