Framing the issue:
• The movement to accountable care and population health management is prompting hospitals to look beyond the “sick care” model.
• When wellness and prevention first entered the health field’s vocabulary, many hospitals bought existing fitness centers and rebranded them.
• So-called medical fitness facilities go beyond that idea, bringing together fitness and medical services.
• Proponents say the concept can protect and even increase a hospital’s market share.
• Research is underway to determine the true value of the medical fitness concept.
In 2013, after enduring months of rehabilitation to recover from a car accident caused by a drunk driver, Vicki Lynn Younkin, then 53, decided to get physically fit for the first time. “It was something I had always wanted to do, but I guess it took a near-death experience to make it happen,” says the resident of Coventry Township, just south of Akron, Ohio.
The fitness center she chose was near her home and was familiar — it was the same place where she received her rehab care. A physical therapist introduced Younkin to an exercise physiologist to get her started on a workout plan.
“When I first got on the treadmill, I was so weak I couldn’t walk a mile,” she says. “The exercise guys are always right there with me, and the other day I rode a bike machine more than 15 miles. I also love to swim, and I have lost about 17 pounds in a year. I wanted to get healthy for myself, my husband and kids, but I really want to be around for my grandkids.”
The center, one of three run by Akron General Health System, is called Health & Wellness Center–Green. Far from a traditional health club, the sprawling 98,000-square-foot facility brings together outpatient services, a stand-alone emergency department, radiology, sports medicine, physical therapy, orthopedics and cardiac rehab, and aqua therapy. Former rehab patients pay to become members of LifeStyles, a fitness program. Next door, a 40,000-square-foot medical office building houses Akron General physicians.
The center, built through a partnership with national developer Rendina Healthcare Real Estate, has hundreds of pieces of cardiovascular and weight-lifting equipment, an indoor lap pool and warm water pool, a gymnasium, indoor and outdoor running tracks, a youth fitness area, exercise studios and an indoor rock climbing wall. Board-certified sports medicine doctors, licensed physical therapists, certified athletic trainers, exercise physiologists and strength and conditioning specialists work with thousands of patients and LifeStyles members.
“There is a lot of back and forth among our professionals,” says Troy Clevenger, the Green facility’s LifeStyles director. “A therapist working with a patient will talk to him or her about continuing as a LifeStyles member when the course of therapy is over. An exercise physiologist may walk a LifeStyles member over to see a physical therapist with a concern. If it is serious, the therapist may recommend a visit with a sports medicine physician, all of whom work in this facility.”
An older concept renewed
Medical fitness — the term used to differentiate facilities like Green from what goes on in commercial health clubs — dates to the 1980s, when “wellness” and “prevention” first came into vogue. There was a burst of construction and new affiliations from the late 1990s to the economic crash of 2008, but some of it consisted of rebranding existing health clubs, not true medical fitness facilities, says Bob Boone, CEO and president of the Medical Fitness Association, Richmond, Va.
“A lot of hospitals and health systems simply bought commercial facilities and slapped their logos on them,” he says. “Many of those went by the wayside because they were not well-run.”
The advent of accountable care organizations and other efforts to improve population health have compelled many health systems to seek solutions outside the traditional “sick care” model. With new penalties for excessive readmissions, hospitals have both a financial and clinical need to solve chronic illness, and exercise may be a magic pill — if done right.
“I knew all the way back 20 years ago before we started our first center that if we in this industry didn’t pay attention to the prevention side of the health care equation, we would likely run out of money and we would likely run out of providers,” says Thomas L. Stover, M.D., president and CEO of Akron General. “It turns out we have done both.”
According to the Centers for Disease Control and Prevention, as of 2012, about half of all U.S. adults — 117 million people — had one or more chronic health conditions. Treatment of chronic disease accounts for 75 percent of health care spending, the Centers for Medicare & Medicaid Services reports.
Data from the Medical Fitness Association indicate that profound change is underway to help solve that problem. Its surveys and information from other sources show that the number of centers has grown from 79 in 1985 to 1,284 in 2014 and, this year, membership in such centers is projected to top 4 million.
The average age of members is around 50, far older than the usual health club member, and half have never been a member of an exercise facility. Fully half of the members are managing at least one chronic condition.
Clinical integration is key
Valley Health System in Ridgewood, N.J., plans to vastly expand its presence in medical fitness. Fourteen years ago, it built a stand-alone, 3,000-square-foot facility a mile from the hospital, mainly to serve cardiac rehab maintenance patients and people graduating from physical therapy.
“We’re now looking to a large, hospital-based wellness facility,” says Don Tomaszewski, director of Valley’s Sports Institute. “We want that clinical collaboration with an enterprise staffed by people from the hospital departments, all under one roof instead of miles apart.”
Several factors are driving Valley’s renewed interest in health and wellness. The system is part of an ACO with nearby Atlantic Health System, so getting people with congestive heart failure or diabetes to exercise and ease their symptoms is key to achieving shared savings with payers.
A new wellness center is also a means of “strategically placing a flag in outpatient services,” Tomaszewski says. Valley has acquired a number of physician practices and wants to drive business to them and from them, so the location of the new center is critical.
The medical fitness part of wellness centers is usually paid out-of-pocket, so they are cash businesses. A facility easily can drive $2 million to a system’s bottom line, says Doug Ribley, senior vice president of health and wellness services for Akron General. “That’s not a huge amount, but it’s attractive to many health care organizations that are looking for new sources of revenue.”
A more compelling financial motive is that the centers are being used strategically to either protect existing or create new market share. “These centers become a community hub, with lots of different clinical services and retail-oriented wellness services,” Ribley says. “This is a branding strategy; people become very familiar with the sponsoring organization.”
Akron General surveys its 16,000 LifeStyles members twice a year, asking the question: Since you have been a member, have you used an Akron General physician or other clinical services for the first time? “Every time we ask the question, we get a positive response rate of 30–35 percent, so we know medical fitness is driving volume,” Ribley says.
A new business
Ribley and Stover have become proselytizers for the medical fitness movement. Almost any given week, leaders of health systems from around the country descend on the city to walk through the three wellness centers and learn from Akron’s experiences, with the goal of returning home to bake those lessons into their own new facilities.
Often, Akron officials go with them. The system has turned its intellectual property into a consulting, design and operations business called Akron General Health & Wellness Innovations. It works with clients first to produce a feasibility study of market needs, competition from health clubs and other providers, geographic barriers and demographics. “The goal is to rightsize the facility to the market,” says Matt Edwards, director of business development for the Innovations subsidiary. “Then, we lay out the services — the diagnostics and urgent care, for example, and work to rightsize those as well.”
Akron General also partners with real estate developers to help finance and build the projects for clients interested in that help. With access to capital scarce, it can be a particularly valuable service.
Akron itself benefited from a developer’s help in building the Green project. After using cash reserves for its first center in 1996, it turned to tax-exempt bonds for the second a decade later. “In 2011 and 2012, we were in a very different environment and, in order to make the project work, we felt we needed a developer solution, so we turned to Rendina to finance and build,” Ribley says. “There was concern about our being a lessee; when you do a developer deal, it’s a capital lease, so this is immediately debt and it doesn’t amortize. But the developer understands the industry and, in the end, we came out with a project that is world-class.”
Other lessons Akron learned along the way included efficiency in utilization and space allocation — Green is less than half the size of the first center. Also, leaders fully realized the value of colocating clinical services and medical fitness. “At the West facility [the first center], we literally had to tear down the walls between physical therapy and the LifeStyles area,” Stover says. “It was my idea from the very beginning that well people should be working out with not-so-well people. I wanted each to get synergies from the other. The physical therapists thought we were crazy, but once we tore down that wall, within three months physical therapy tripled its business.”
Innovations is in discussions with about 20 different systems as a consultant, designer and perhaps even an operator of wellness facilities, including a major provider that is planning to build seven wellness centers throughout a multistate service area, Ribley says.
Clearly, a movement is afoot. Given the lofty nature of the goals of health and wellness centers, the question must be asked: Do these facilities really move the needle on population health?
Today, there aren’t the data to say “yes” in any definitive way, though that may now be changing.
Exercise is Medicine, a nonprofit initiative launched in 2007 by the American College of Sports Medicine and the American Medical Association, states that a wide range of studies have found that exercise is crucial to the prevention, management and treatment of numerous chronic conditions, such as Type 2 diabetes, heart disease, obesity, high blood pressure and other medical problems.
A 2013 study published in the British medical journal BMJ found that exercise can be as effective as many frequently prescribed drugs in treating some of the leading causes of death. For example, people who once had suffered a stroke had significantly less risk of dying from that condition if they exercised than if they used medications.
Having direct data tying outcomes to membership in a medical fitness program would be more valuable, however. This is why Akron General has joined forces with Kent State University’s Health and Wellness Research Collaborative to study that very issue. As part of the effort, teams of wellness investigators will work on pilot projects to develop new models of prevention and new technologies that support wellness and the management of chronic disease.
In addition, the Medical Fitness Association recently kicked off an outcomes initiative to study the cost-effectiveness and clinical efficacy of exercise in the treatment of chronic disease. “We will be looking at three particular measures — hypertension, diabetes and obesity,” Boone says. “We will not only be looking at improvements and physiological measures, we will also be looking at things like medication changes, admissions and readmissions to the hospital, and frequency and total number of physician office visits.”
The study probably will take about 18–24 months to complete, he says.
Such evidence would bolster the case for much greater investment in prevention, Stover says.
“Eighty percent of our health care spending is on 20 percent of the population, those with these chronic diseases," he says. "Are we assuming that the 20 percent is always going to be there? That’s nuts; we can’t just accept that. What we need to be doing is knocking that down to 18 percent and 15 percent and then 12 percent. Only then will you have a real effect on health care spending.”
Last August, the Cleveland Clinic agreed to invest $100 million in Akron General Health System as a minority owner. The deal will allow the clinic to buy Akron General after Sept. 1. Stover says that with Cleveland Clinic on board, his system is going to be able to advance the mission of health and wellness in a more thorough and much shorter time frame.
“We believe that every health system in the country is going to have this type of facility within the next 10–15 years,” he says. “With costs rising and reimbursement falling, we have no choice. The ‘sick care’ model is broken.”
— Todd Sloane is a freelance writer in Highland Park, Ill.
Certification requirements from the Medical Fitness Association and advice from Akron General Health & Wellness Innovations specify a number of factors that must be present for a facility to be certified by the association as well as meet the goals of wellness and prevention. They include:
• Active and regular medical oversight. Every decision, including individual exercise plans, must be signed off on by a qualified physician. A medical advisory board approves changes to programs and policies.
• Certified and licensed staff with the qualifications to address the health-related concerns of the membership. For example, a minimum qualification of a four-year degree in exercise physiology.
• Clinical integration so that physicians, physical therapists and exercise physiologists share common space.
• Disease management and prevention programs.
• Health-risk reduction and therapeutic-lifestyle programs.