Utilising rebatable services

– Written by Anita J. Hobson-Powell and Jeff S. Coombes, Australia

Throughout the world, Exercise is Medicine® (EIM) has been designed to invigorate healthcare professionals to consider exercise as part of standard medical treatment. In most countries, EIM has invested in the education and training of doctors to undertake a physical activity as a ‘vital sign’ primary assessment and to prioritise the provision of an exercise prescription for patients. This educational investment has seen thousands of doctors undergo training courses to up-skill them to provide advice to increase physical activity levels and motivate their patients to be active.

For EIM to work optimally at a local level, it has been important that this global initiative has allowed countries to adapt the programme to fit local healthcare systems and governance. EIM Australia is managed by the peak professional body for exercise and sports science; Exercise & Sports Science Australia (ESSA), who provide funding for a project officer to work on various initiatives. The key for EIM to be a success in Australia was to ensure initiatives were designed to consider the Australian healthcare system and the recognition of the differences in exercise professionals. Indeed, one of the main drivers for the development of the EIM Australia approach is the different levels of education and training of exercise professionals and the fact that not all have access to financial rebates when working with patients.

In Australia, there are basically three levels of exercise professionals:

1. Non-university-trained personal trainers/fitness instructors.
2. University-trained exercise scientists.
3. University-trained accredited exercise physiologists.

Exercise scientists have knowledge in pathophysiology and exercise disease interactions and their scope of practice allows them to deliver prescribed exercise to patients with chronic diseases and/or complex medical conditions. Accredited Exercise Physiologists (AEPs) are exercise scientists with additional knowledge, training and clinical exercise practicum experience. They are recognised as an allied health professional in the national health system and have access to numerous financial rebates for prescribing clinical exercise services. It is the status of AEPs in the healthcare system that has led to many of the EIM Australia initiatives that aim to strengthen the partnerships between doctors and AEPs. It should also be mentioned that in Australia, physiotherapists are regarded to have a similar level of exercise professional status as AEPs.

ACCREDITED EXERCISE PHYSIOLOGISTS

AEPs undertake either a 4-year Bachelor's degree or a postgraduate Master's programme by coursework that provides them with the specialist knowledge, skills and competencies to design, deliver and evaluate safe and effective exercise interventions for people who have acute, sub-acute or chronic medical conditions, injuries and disabilities¹. These interventions include health and physical activity education, advice and support, and lifestyle modification with a strong focus on achieving behavioural change. During their university studies, AEPs are required to undertake 500 hours of clinical practicum across areas such as cardiovascular, metabolic, musculoskeletal, cancer, renal, mental and neurological health. ESSA provides a self-regulating quality training and professional development framework to accredit university programmes to train AEPs in Australia. Unlike other countries, such as the USA, EIM Australia has chosen not to attempt to up-skill other exercise professionals (e.g. non-university trained individuals) with short courses. Given the quality of the AEP training, there is a concern that it would devalue AEPs and confuse the public when lesser trained exercise professionals are involved in prescribing exercise for patients with chronic disease.

REBATABLE EXERCISE SERVICES

Not only is the Australian healthcare system progressive in its recognition of AEPs as an allied health profession, it also provides dedicated funding streams to health consumers to assist with the costs associated with receiving specialist exercise treatment provided by AEPs or physiotherapists. Funding pathways are available through Medicare, the Department of Veterans’ Affairs, worker compensation agencies and private health insurance, via one general practitioner (family care physician in the USA) as detailed in Table 1. For example, a general practitioner can refer their patients with chronic and complex medical conditions to AEPs as part of a Chronic Disease Management Plan. The plan allows for a patient to have up to five rebatable consultations with an AEP, with the government providing approximately $50 per consult to the AEP to provide the services. In addition, people with diabetes can have an additional eight consults and war veterans can receive unlimited clinically necessary exercise services. In Australia, patients have been able to claim for their AEP services since 2006 and this has led to an increase in the number of AEPs from 350 at the start of 2006, to more than 4000 at the end of 2016. In Australia, we now have a critical mass of AEPs and that has made it easier for doctors to efficiently refer their patients to highly qualified exercise professionals.

Another unique aspect of Australia’s health system is that the primary healthcare system also allows for nurses and aboriginal healthcare workers to have a greater role in assisting doctors with the management of their patients. As a result, EIM Australia actively engages with representatives from these professions on our National Advisory Council, along with members from Sports Medicine Australia, the Australasian College of Sport and Exercise Physicians, the Australian Primary Health Care Nurses Association, the Australian Physiotherapy Association and the Federal Department of Health.

EXERCISE IS MEDICINE® AUSTRALIA STRATEGIC PLAN

EIM Australia has developed a strategic plan that is centred around the status of AEPs in the health system. Figure 1 shows the five Focus Areas. Across these areas there are three guiding principles:

1. Physical activity and exercise are important to health and the prevention and treatment of many chronic diseases.
2. More should be done to address physical activity and exercise in primary healthcare settings.
3. Support the referral of patients to appropriately-trained allied health professionals to deliver exercise services for the prevention and treatment of chronic disease.

EIM Australia has the following objectives:

1. Create broad awareness that physical activity/exercise is indeed medicine.
2. Make ‘level of physical activity and exercise’ a standard vital sign question in each patient visit (when appropriate).
3. Empower doctors, nurses, aboriginal health workers and other primary healthcare providers to become consistently effective in counselling and referring patients as to their physical activity and exercise needs.

REFERRING TO ACCREDITED EXERCISE PHYSIOLOGISTS

In Australia, doctors at the frontline consistently indicate they have limited time to discuss physical activity with their patients. This has led EIM Australia to focus on providing educational opportunities for general practitioners to include a discussion around physical activity and exercise in the most time efficient manner. This includes improving knowledge about assessing the physical activity levels of a patient and, where indicated, providing advice and motivation to increase activity levels. In addition, and probably the most important aspect, is regarding the previously-mentioned referral and rebatable opportunities for exercise professionals that exist in the Australian Health System. EIM Australia is providing tools (e.g. established referral pathways) to make it easier and more time-effective to incorporate a discussion of a patient’s physical activity levels as part of every consultation. These skills and resources also allow doctors to efficiently refer patients to an AEP for targeted, personalised exercise prescription.

Although Australia is progressive compared to other countries regarding the recognition of AEPs and having a funding scheme to support access to their services, the rate of referrals to AEPs from general practitioners remains relatively low. Medicare data shows that 85% of Australians visit a general practitioner each year. Of these, more than a third have more than 6 visits a year². Furthermore, approximately 70% of these presentations are the results of a chronic condition³. Despite the levels of contact Australians are having with a general practitioner, less than 1% of patients who were overweight or obese, or who had type 2 diabetes were referred to an AEP². Aboriginal and Torres Strait Islander populations were referred at a staggeringly low rate of 0.08%. Clearly there is a need to improve the utilisation of the referral pathways to manage these chronic diseases with specialised and personalised exercise prescriptions.

EXERCISE IS MEDICINE® AUSTRALIA INITIATIVES

The low referral rates of patients from general practitioners to AEPs led EIM Australia to develop a number of initiatives. One of the most popular was called ‘31 days, 31 patients’. It asked doctors to change their clinical consultation behaviour and undertake a physical activity as a ‘vital sign’ assessment and, when necessary, refer their patients to an AEP. The initiative challenged doctors to achieve these outcomes with just one patient per day for 31 days. EIM Australia provided resources to better enable doctors to achieve these goals. Before the initiative commenced, doctors underwent a 90-minute workshop, including skills on assisting with behaviour change through motivational interviewing. EIM Australia provided doctors with a professional kit including promotional posters for the waiting room, patient educational material, a referral pad and a magnet for each patient promoting the EIM Australia website. These practice resources assisted general practitioners and medical practices to prioritise exercise as medicine and the role of incorporating a discussion on physical activity as a vital sign to be documented in the clinical consultation and treatment plan.

Key outcomes from the evaluation of this medical practice based initiative included³:

• A 15% increase in doctors discussing physical activity/exercise with their patients.
• A 70% increase in doctors assessing physical activity.
• A 76% increase in clinicians utilising the EIM resourses and distributing to their patients.
• 58% of doctors reporting the need for more support and resources to assist them and their patients increasing physical activity levels³.

After the initiative, there was a significant increase in requests to EIM Australia for additional resources to provide support and quality exercise advice for patients. This led to the development of an extensive library of resources for clinicians to use with their patients who have a chronic condition and would benefit from the value of exercise. At the centre of these resources are online one- and two-page factsheets. Currently EIM Australia has developed more than 30 of these fact sheets, including those catering to populations such as Aboriginal and Torres Strait Islander patients. They are available to download at http://exerciseismedicine.com.au/health-care-providers/factsheets-2/ and have been rated as the second most valuable exercise/physical activity resource for healthcare professionals in Australia, behind the National Physical Activity Guidelines. Figure 2 provides some examples of these resources.

After 2 years of implementing ‘31 days, 31 patients’, it became evident that general practitioners needed further resources, education and practice support to refer patients to the appropriate exercise professionals, based on patient healthcare needs. In 2016, EIM Australia undertook a new programme; ‘EIM in Practice’. This pilot programme built on from the previous initiatives and engaged with six general practice clinics across Australia where they were assigned an AEP who delivered an EIM workshop and supported the practice with resources and assistance required for patient referrals. Table 2 provides data from an evaluation of the programme.

COST EFFECTIVENESS OF ACCREDITED EXERCISE PHYSIOLOGISTS

In 2015, an independent cost-effectiveness evaluation of AEP services was conducted by Deloitte Access Economics. They reported total annual financial gains for patients through the use of an exercise intervention with an AEP. For patients with type 2 diabetes, it is $7967 per person per year, $6115 for a pre-diabetic and $2239 for a person with depression⁴. In addition, the benefit-cost ratio for AEP services was 6.0:1 for pre-diabetes, 8.8:1 for type 2 diabetes and 2.7:1 for depression. While medical management remains fundamental in the treatment of these chronic diseases, the partnership with an AEP can significantly reduce the burden of the disease on the patient and on healthcare resources the system encounters.

SUMMARY

The initiatives of EIM Australia are based on our unique healthcare system that provides for rebates when doctors refer their patients to AEPs. Strategically, EIM Australia has focused on supporting this referral pathway with initiatives such as 31 patients, 31 days and EIM in Practice. Supporting health practitioners to treat patients effectively and collaborate with AEPs has been shown to be financially beneficial for the health system. EIM Australia will continue to strengthen the partnerships between primary care physicians and exercise professionals. This will reduce the burden of chronic diseases on the Australian health system, leading to a healthier quality of life for patients and Australian society.

Anita J. Hobson-Powell M.Bus., M.Sc., B.Sc.App (HMS), G.A.I.C.D.

Chief Executive Officer

Exercise & Sports Science Australia

Hamilton, Australia

Jeff S. Coombes Ph.D., M.Ed.

EIM Australia National Director

Professor

Centre for Research in Exercise, Physical Activity and Health, School of Human Movement and Nutrition Sciences

University of Queensland

Brisbane, Australia

Contact: anita.hobson-powell@essa.org.au

References

1. Exercise & Sports Science Australia. How can an accredited exercise physiologist help? Brisbane: Exercise & Sports Science Australia 2016. Available from: www.essa.org.au/essa-me/about-us/ourmembers/how-can-an-accredited-exercise-physiologist-help/ [Accessed February 2017].
2. Cheema BS, Robergs RA, Askew CD. Exercise physiologists emerge as allied healthcare professionals in the era of non-communicable disease pandemics: a report from Australia 2006–2012. Sports Medicine 2014; 44:869-877.
3. Exercise is Medicine Australia & Dutton S. Report of the Evaluation of the EIM 31 Days 31 Patients Australia Initiative – 2013 Technical Report. EIM, ESSA 2014. p. 35.
4. Deloitte Access Economics. The Value of accredited exercise physiologist to consumers in Australia; Brisbane: Exercise & Sports Science Australia 2015. Available from: https://www.essa.org.au/wp-content/uploads/2016/04/Deloitte-Value-of-AEP-to-Consumers.pdf [Accessed February 2017].

Image by Brad Scruse