Increasing US health plan coverage for exercise programming in community mental health settings for people with serious mental illness: a position statement from the Society of Behavior Medicine and the American College of Sports Medicine

Abstract

Adults with serious mental illness die more than 10 years earlier than the average American. Premature mortality is due to the high prevalence of preventable diseases including cardiovascular disease and diabetes. Poor lifestyle behaviors including lack of exercise and physical inactivity contribute to the epidemic levels of obesity, diabetes, and cardiovascular disease observed among adults with serious mental illness. Not surprisingly, people with serious mental illness are among the most costly consumers of health services due to increased visits for poorly managed mental and physical health. Recent studies have demonstrated that exercise interventions based on community mental health settings can significantly improve physical and mental health in people with serious mental illness. However, current funding regulations limit the ability of community mental health settings to offer exercise programming services to people with serious mental illness. Policy efforts are needed to improve the dissemination and sustainability of exercise programs for people with serious mental illness.

INTRODUCTION

The Society of Behavioral Medicine and the American College of Sports Medicine encourages legislation and policies that require Medicare, Medicaid, and private insurers to reimburse exercise programming for people with serious mental illness treated in community mental health settings.

Exercise improves both mental and physical health while reducing health care costs [1]. Even the most sedentary individuals in the highest obesity classes benefit from both exercise as well as dietary restriction [2]. However, these benefits often do not reach adult consumers of community mental health programs who need them most. Specifically, consumers with serious mental illness have lower fitness and physical activity levels than the general US population [3, 4]. Reduction in health risks are the greatest for those who move from a sedentary to modestly active lifestyle [5]. Thus, policy changes are needed to support wellness services offered in community mental health to include exercise programs for people with serious mental illness.

THE HEALTH INEQUITIES OF SERIOUS MENTAL ILLNESS IN THE USA

Serious mental illnesses like bipolar disorder and schizophrenia affect one in twenty Americans [6]. Broader definitions of serious mental illness also include major depressive, anxiety, and personality disorders. Notably, people with serious mental illness die at least 10 years earlier than the average American [7, 8]. This disparity in premature death is largely due to the disproportionately high prevalence of preventable diseases such as cardiovascular disease and diabetes [7]. Furthermore, psychiatric medications prescribed for serious mental illness contribute to epidemic levels of obesity which occurs in more than 50 % of adults with these disorders [7, 9]. Despite these physical risk factors, many people with chronic and debilitating serious mental illnesses receive most of their care in community mental health settings where preventive and medical care services are lacking.

A complex interaction of factors contributes to poor physical health in this vulnerable population including side effects from pharmacologic therapies, poor health behaviors, and low socioeconomic status. People with serious mental illness often struggle with persistent psychiatric symptoms as well as impairments in memory, executive functioning, and motor coordination that make it difficult to adopt and sustain positive health behaviors without professional support [10]. Fewer than 20 % of adults with serious mental illness engage in regular physical activity that is sufficient to provide health benefits [11].

EXERCISE IN COMMUNITY MENTAL HEALTH PROGRAMS TO IMPROVE HEALTH

Studies conducted in community mental health settings show that supported exercise programming can significantly reduce health risks in people with serious mental illness [11–14] by helping people achieve a healthy weight and better manage chronic disease risk factors [10, 15–17]. Regular exercise also increases cardiovascular fitness and helps prevent costly, disease-related disability [11, 12, 14]. Furthermore, exercise reduces psychiatric symptoms, supports brain health, and provides a healthy lifestyle alternative for people with co-occurring nicotine and substance use disorders [13, 18]. Finally, exercise can enhance social reintegration as part of a psychosocial rehabilitation program [10, 11].

EXERCISE CAN REDUCE THE PUBLIC HEALTH BURDEN OF SERIOUS MENTAL ILLNESS ON SOCIETY

Exercise is a key preventive strategy to reduce the public health burden of medical conditions of individuals who are treated primarily in community mental health settings. People with serious mental illness are among the most costly consumers of health services in the USA across health settings [19]. Exercise helps manage psychiatric symptoms that contribute to unhealthy behaviors and reduce compliance with mental health and medical treatments [20]. Inadequate preventive and medical care for people with serious mental illness, results in higher healthcare costs [21, 22].

CURRENT BARRIERS TO OFFERING EXERCISE SERVICES

Despite the availability of evidence-based programs to improve physical health and wellness behaviors among people with serious mental illness [11, 12], there are multiple policies and funding barriers that make it difficult for community mental health programs to offer these programs to consumers [21, 23]. Health care policies typically “carve out” mental health funds from physical health funds, denying community mental health programs the financial ability to offer exercise programming [21, 23]. Few funds are set aside for community mental health programs to train staff to deliver preventive health services like exercise programs [21, 22]. Finally, billing rules set by the Centers for Medicare and Medicaid Services (CMS) and private insurers prohibit most allied health professionals from receiving reimbursement for providing exercise programming [23–26] in mental health settings.

Although funding for preventive services in general, including exercise programming, lags behind reimbursement for disease care [27], this is particularly true for people with serious mental illness. Increasingly, private insurance companies, recognizing the cost savings to be accrued from increased engagement in regular exercise [28–30], offer their members a variety of incentives to engage in exercise, such as reimbursement for gym memberships, cash rebates for selecting healthy food at the grocery store, and reduced premiums for people who engage in regular exercise [31, 32]. The top 10 health insurance companies as ranked by US News and World Report all offer their members incentives for engagement in exercise [33]. Large corporations also offer incentives for engagement in exercise, such as on-site fitness equipment [31].

Lack of funding is often the greatest challenge to broad dissemination of services for people with serious mental illness, even practices that have been widely researched and have an extensive evidence base. Supported employment is one of the best examples of this. In spite of an impressive volume of research supporting its effectiveness, supported employment is only available to 1.7 % of adults receiving services in public mental health settings in the USA [34] due to the limited reimbursement options for financing this intervention [35, 36]. Evidence-based exercise programs designed for people with serious mental illness are similarly challenged by lack of funding mechanisms.

POLICY RECOMMENDATIONS

The Society of Behavioral Medicine and the American College of Sports Medicine offer the following policy recommendations to support the use of exercise programming in conjunction with community mental health services as a first-line medical treatment to improve health outcomes and reduce healthcare costs.

1. Promote evidenced-based exercise programming for people with serious mental illness by

   • including evidence-based lifestyle programs designed for people with serious mental illness that are eligible for reimbursement by regional and national health care providers in the Substance Abuse and Mental Health Services Administration’s National Registry of Evidence-based Programs and Practices (NREPP) and
   • ensuring that treatment settings maximize effectiveness by providing programs that are of sufficient duration (>4 months) with adequate frequency of face-to-face contact and support from fitness professionals.

2. Expand health care services for people with serious mental illness to specify exercise programming as a reimbursable service through mechanisms in the Affordable Care Act for health promotion including the Medicaid 1915i State Plan and Community Based Services Program and adaptations of the Specialty Health Home Program.

3. Clearly specify standards of professional accreditation or competency to deliver exercise programming to people with serious mental illness by

   • establishing minimum training competencies for the health professionals who deliver exercise programming for people with serious mental illness and
   • allocating funding to support training health professionals to deliver exercise programming in community mental health settings.

4. Increase the range of disciplines of licensed/certified allied and mental health professionals who are eligible for reimbursement to deliver exercise programming in mental health settings.

Compliance with ethical standards

Conflict of interest

Mark Stoutenberg is a consultant to Exercise is Medicine®, a program of the American College of Sports Medicine, which receives funding from The Coca-Cola Company and Technogym. The remaining authors declare that they have no conflict of interest.