The Doctor Will See You After Your Workout

Abstract

Novel approaches to deliver lifestyle medicine that are convenient and accessible to patients are needed. Patients generally seek medical care when they are not well, reinforcing the notion of a “sick” care health system. Conversely, health clubs represent beacons of wellness amid the mire of chronic disease. Many individuals visit health clubs with the goal of becoming or remaining healthy. Expanding health care access to these health club populations creates opportunities to engage those who do not typically seek medical care, and may also attract those who are highly motivated to make lifestyle changes to prevent, treat, and reverse chronic disease. Health club clinics could be expanded with in-person or virtual offerings that go beyond traditional models. Such offerings would stand to improve health and be mutually beneficial for the provider and health club. By decreasing the barrier to access such care and meeting highly motivated patients where they are, providers may be more successful in their efforts to deliver lifestyle medicine to patients who are ready, willing, and able to make lifestyle behaviors changes.

Arguably the best “medicine” available to prevent, treat, and reverse chronic disease is lifestyle medicine.

Six in 10 adults in the United States have at least one chronic disease. ¹ New ways to expand and deliver proactive, preventive, and personalized care are needed. Traditionally, medical care has been reactive and provided by hospitals and outpatient clinics. However, there has been a steady expansion of medical care outside these areas, including pharmacies and retail stores. ² There has also been a dramatic shift toward telemedicine due to the COVID-19 pandemic. ³ It has become increasingly clear that patients value convenience and access to care. ⁴

The COVID-19 pandemic has also highlighted the devastating impact that acute infections can have in patients with chronic comorbidities. ⁵ Arguably the best “medicine” available to prevent, treat, and reverse chronic disease is lifestyle medicine (LM). ⁶ LM is the evidence-based practice of helping individuals and families adopt and sustain healthy behaviors that affect health and quality of life. ⁷ The pandemic created a timely opportunity to deliver this type of care to a receptive audience in novel and unique ways. As society returns to a new normal, efforts must be made to transform how and where care is delivered rather than revert back to traditional delivery methods. A window of opportunity exists to leverage existing facilities that already offer some aspect of LM for more comprehensive medical services. One such example of this type of facility is a health club or gym.

The health club industry has grown every year since 2008 and is worth $96.7 billion globally. ⁸ Of the 210 000 fitness facilities worldwide (not including hotel gyms), 41 370 are located in the United States. ⁸ These facilities attract individuals motivated to improve their health, performance, or overall quality of life.

Contrast this to the US “health” care system, where less than a quarter of in-office visits are for preventive care. ⁹ In 2018, US health care spending totaled $3.6 trillion, which equates to $11 172 per person. ¹⁰ Despite the dramatic 372-fold difference in value between the global health club industry and US health care system, there are fewer outpatient clinics (40 600 clinics, 2800 of which are retail clinics) in the United States than health club facilities. ¹¹ Given the shared goals of improving an individual’s health, unique partnerships between medical clinics and health clubs should be considered to improve health care delivery in the US.

While the number and location of facilities affects patient access, there is variability in the extent of preventive care and LM treatment delivered. Despite 78% of physicians indicating that health promotion is important, less than half reported providing this type of care as a substantial part of their duties in a 2014 survey. ¹² Disconcertingly, it has been estimated to require 7.4 hours per working day for a primary care physician to fully satisfy the US Preventive Services Task Force (USPSTF) recommendations for an average patient panel. ¹³ Clearly, better mechanisms are needed to support health promotion and disease prevention.

One possible solution that could simultaneously expand health care access to motivated patients and encourage the delivery of LM would be for health systems and providers to partner with health clubs to offer these services.

Advantages of Delivering Lifestyle Medicine in a Health Club

An inherent advantage of practicing LM in a health club is the association of health, prevention, and vitality with this type of facility. People typically go to a gym to exercise with the goal of maintaining or improving their health. Outside of traditional primary care office visits for well child, annual preventive, and Medicare Annual Wellness examinations, there remains minimal framework in the US health care system for prevention. Aside from these coded visits, vaccinations, and minimal preventive testing, insurance reimbursement for true preventive services is lacking. Furthermore, there is a sociocultural association with only seeking health care when an individual is ill. These circumstances reinforce the reactive nature of health care as a disease centric model of care, as opposed to a health centric one.

Organizations such as the American College of Sports Medicine (ACSM) have worked to change this dynamic. In 2007, the ACSM launched the Exercise is Medicine (EIM) initiative with the goal of making “physical activity assessment and promotion a standard in clinical care, connecting health care with evidence-based physical activity resources for people everywhere of all abilities.” ¹⁴ Delivering medical care in the health club environment explicitly makes the connection between exercise and medicine for patients and creates a closer relationship between health and exercise professionals.

Two existing examples of exercise-oriented partnerships within the medical system are cardiologists utilizing cardiac rehabilitation services and orthopedists working with physical therapists. Cardiac rehabilitation has shown marked improvements in morbidity, mortality, and quality of life in patients with preexisting cardiovascular disease.^15,16 The increased integration, continuity, and coordination seen in orthopedic practices that have physical therapy in-house are thought to have the potential to deliver superior health outcomes and decrease total cost. ¹⁷

Despite health club clinics targeting a theoretically healthier demographic, offering medical services at health clubs has the potential to increase patient access by connecting with younger populations and those who are “healthy” who seek medical care less often. Only 55% of young adults (aged 18-25) and 65% of adults (aged 26-44) had an office-based health care visit in 2007, compared to 91% of adults 65 years or older. ¹⁸ This represents a huge portion of adults who may miss important preventive care and timely diagnosis when early intervention could treat or reverse the disease. ¹⁸

Economics

Beyond improved access, rapport, and collaboration between fitness professionals and health care providers, merging medical care into health clubs may be mutually beneficial economically. Offering medical care at health clubs could increase membership rates and retention. Providers would gain access to a health-oriented population to deliver LM. Providers could advantageously receive referrals from, or refer patients to personal trainers, dieticians, or health coaches at the gym, creating an ecosystem for patients to receive comprehensive care.

A cost-sharing model between the provider and health club would incentivize success and minimize risk for both parties. Health clubs could contribute the space and cover startup costs in exchange for a percentage of revenue from visits conducted. This could take advantage of underutilized space at health clubs, such as administrative offices, particularly before and after the typical workday. Ironically, those times are also when the most members are using the facility. Using a portion of an unused office or creating a small private space with a camera, monitor, internet access, comfortable seating, and automated vital sign gathering tools (ie, automated blood pressure cuff, bioimpedance scale, pulse oximeter, touchless thermometer) would add relatively little overhead or cost. However, if providers wanted to retain a higher percentage of the revenue, they could rent the space and invest in the startup and maintenance costs.

Scheduling logistics could be determined based on provider and facility preferences. This would include hours of operation, having a physical versus virtual presence, or offering drop-in versus scheduled appointments. Providers might consider being physically present in busier facilities and offering telemedicine services for less popular sites.

To limit overhead and administrative costs, a cash-based model would be logical. If larger practices or health systems partnered with gym franchises, it might be more financially beneficial to accept insurance. Additionally, as care models in the United States shift toward providing value-based care, it is anticipated that reimbursement for prevention and outcomes will increase.

Medical Services Offered

Traditional urgent care, sports medicine, and aspects of primary care could easily be offered at health club clinics; however, this setup would be an ideal environment to practice true LM. Access to motivated patients who are interested in health may improve the likelihood of successful lifestyle behavior change. For gym goers without chronic disease, services could focus on health optimization and longevity. More thorough evaluations that utilize advanced imaging or laboratory testing to identify genetic predispositions, vitamin or mineral insufficiencies, and subclinical pathology could be offered, when appropriate. For individuals who are trying to lose weight or have cardiovascular disease risk factors, implementing the USPSTF Level B recommendations to provide behavioral counseling interventions that focus on healthy diet and physical activity could be delivered effectively.^19,20

Two of the most important drivers of health behavior change are autonomous motivation and self-efficacy, both of which have been shown to be present in patients with cardiovascular disease who are adherent to an exercise program. ²¹ Leveraging these attributes of clients visiting a health club ideally positions providers to facilitate behavior change in other LM domains to combat chronic disease.

Another niche that could be addressed by integrating medicine into the gym is exercise safety. Most gyms, exercise equipment, and exercise-related activities recommend that the individual “consult your doctor before beginning an exercise program.” Whether it is providing reassurance, stratifying a patient’s risk, or ordering additional cardiac screening tests, medical clearance for exercise could be provided on-site to gym members.

Ultimately, the medical services offered must go beyond traditional models of acute and primary care. Simply placing a physician in a corner office within the health club will not be sufficient to engage patients and transform promotion of LM in this space. Clients increasingly look to unique methods to interact with their fitness, including digital exercise sessions, wearable remote monitoring devices, expanded dietary and supplement plans, and virtual health coaching. More than housing a white coat and stethoscope next to a squat rack, true integration into health clubs will occur when the medicine delivered compliments those advanced services provided in an individualized manner to the patient. Likewise, group sessions and health club–wide interventions offer larger population-level health opportunities.

Challenges of Delivering Medical Care in a Health Club

Although there are a few medical clinics within health clubs across the country, it is unknown how receptive health club members would be to receive medical care in this environment. The location may be convenient for consistent gym-goers; however, this is theoretically also a much healthier population with few, if any, chronic diseases. One result is a greater focus on exercise-related issues, health optimization, or longevity, but this could also mean fewer patient visits.

Privacy concerns would need to be addressed so patients feel comfortable discussing personal health issues at a health club. The provider would need a Health Insurance Portability and Accountability Act (HIPAA) compliant electronic medical record, a secure internet connection, and virtual platform to perform visits virtually with patients. Most telehealth visits occur with patients in their homes, so adjusting to seeing a provider at their gym might feel awkward for some, at least initially. The hope would be for it to create additional accountability and positive reinforcement about exercise as medicine, although it has the potential to change the patient-provider dynamic in unintended ways too. Assuming that comprehensive primary care options are not available in these centers, this would require patients to maintain a primary care provider outside of the health club too.

Depending on the reimbursement model used, the cost could be prohibitive to some patients. Cash models may be useful for patients who do not have health insurance or who have the means to pay; however, these may be unaffordable to patients who rely on standard insurance. Traditional medical billing and coding could be utilized, but this would increase administrative costs and shift the focus away from LM toward traditional fee-for-service care. This might still be economically attractive for larger practices and health systems, though individual providers may be less inclined to pursue these types of operations with this patient population.

Conclusion

Novel approaches to deliver LM that are convenient and accessible to patients are needed. Health clubs represent beacons of wellness amid the mire of chronic disease and are frequented by individuals wanting to become or remain healthy. Expanding health care access to this population may not only engage those who do not typically seek medical care but may also identify patients who are highly motivated to make lifestyle changes to prevent, treat, and reverse chronic disease.