26 February 2020

Exercise needs to be embraced and funded as a medical treatment

Non Drug Interventions

One of the traditional mantras of the medical student is “only 50% of what we do in medicine actually benefits the patient, but we don’t know which 50%, so we have to keep doing all of it”.

It is a reasonable attitude, although as more research gets published, we are getting much better at recognising the proportion of healthcare which is wasteful.

We are perhaps also appreciating that the estimate of 50% of healthcare services being beneficial may be optimistic. The “true” percentage of beneficial health care depends on whether treatments that only offer a placebo effect are deemed “helpful” or “ineffective”.  Even, more subtly, how does one classify a treatment if it is effective because of a placebo effect but can have harmful side effects.

A mature analysis is that invasive treatment which offers no advantage over placebo is ineffective and wasteful if less invasive treatments are available. Healthcare systems are not getting better at curbing this waste.

We also assume that all important healthcare in Australia is funded by the public system, but this is not necessarily true.

For example, while the vast majority of healthcare in Australia is GST exempt, a notable exception are the services of exercise physiologists (EP). EPs are not fully funded by Medicare, and, furthermore, consultations with EPs attract GST, unlike other healthcare providers.

We also assume that all “medical specialists” in Australia are fully funded by the public system. However, specialist sport and exercise medicine physicians are not generally available in public system and not adequately funded by Medicare, including being unable to participate in the MBS chronic care system. In fact, Sport and exercise medicine physicians are the only specialists in Australia that have ever had a Medicare consultation rebate cut.

It is probably not a coincidence that the peak medical specialty group based on exercise and the peak allied health group based on exercise both have a lesser status in the Australian health system than others. That is, there is a fundamental discrimination in the Australian health system against practitioners who prescribe exercise.

There is a strong argument based on medical evidence that exercise-based practitioners, including EPs, sports physicians and GPs prescribing exercise management plans should be better funded, as exercise is now an evidence-based treatment for osteoarthritis, back pain, cancer, cardiovascular disease, depression, diabetes and osteoporosis.

Moderate or higher levels of exercise strongly predict reduced all-cause mortality.

And exercise prescription is not nearly as simple as one might think. For the proportion of the population not exercising enough, there are massive barriers to increasing their activity level, including fear of pain and injury which often requires professional advice. At the other end of the scale, for those who are overloading (high-level athletes, manual workers, exercise addicts) it is also very hard to implement sensible reductions in exercise load. It is difficult management, but worth it, as the health benefits of moderate exercise are pronounced.

Exercise as a medical treatment sadly must battle some strong prevailing myths.

One of these is that exercise is free, so exercise as a medical treatment does not deserve or need to be funded. There are growing calls by doctors for more exercise promotion, but often without reference to the health professionals that are the experts in prescribing exercise.

If one follows the logic, “exercise is free so it is all up to the individual, not doctors”, psychologists and psychiatrists should not need to be funded either because “happiness/good mental health is free”. This would be an absurd proposition, just as it is an absurd proposition that those not exercising at a healthy dose do not require medica or healthcare when it is proven to be so beneficial for so many conditions.

Perhaps an even stronger myth is that exercise is a “soft” treatment and could never be as effective as drugs and surgery, which must be better because they are so much more expensive. This assumption is just an outright falsehood, as there are dozens if not hundreds of  instances where exercise has been shown to be a potentially helpful/effective alternative to more invasive treatments.

Some examples include spinal fusion surgery for chronic back pain, knee arthroscopy for osteoarthritis, angioplasty / stents for stable angina, opioid pain relief for musculoskeletal pain, acromioplasty for shoulder pain, antidepressants and benzodiazepines for mild depression.

The myth of exercise being a “soft” treatment means that the actual evidence of efficacy is being ignored.

In addition to exercise being a cheaper and often more effective treatment strategy, there is a further argument emerging for often preferring exercise over drugs and surgery. The healthcare sector in Australia is responsible for up to 7% of carbon emissions. This is an area where healthcare does not deserve  a special leave pass. Carbon emissions affect climate change whether they arise from the healthcare sector or any other sector, and therefore the healthcare sector has just as much responsibility to reduce carbon emissions.

Transition from carbon-intensive ineffective procedures to more effective carbon-neutral exercise provides an even stronger argument for better funding of exercise as a medical treatment.

Exercise physiology visits have always attracted GST ever since 2000 when the tax was introduced. And sport and exercise medicine physician consultation rebates were cut in 2010. Healthcare systems can and must remove these funding inequities which currently discriminate against health professionals who prescribe exercise as a medical treatment.

In Australia, this means removing the GST on services provided by exercise physiologists and allowing sport and exercise medicine physicians the same Medicare rebates as other specialist physicians.

If health authorities want to get serious about supporting evidence-based medicine, they need to get serious about making these changes. They need to get moving on supporting the practitioners that get patients moving.

John W Orchard is adjunct professor, School of Public Health, University of Sydney and a sports and exercise medicine physician with a combination career in professional sports team care, sports administration, clinical sports medicine practice and research.

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