Medicare managed care members who elected to participate in a community-based physical activity benefit (EF) had similar predicted total healthcare costs in the first year after visiting the program and significantly lower total costs (~$1,200 lower; P=.005) in the second year than age- and sex-matched health plan members who did not participate. These differences were largely attributable to significantly lower inpatient costs for EF users that were not simply explained by differences in high-cost outliers.
Evidence was also found of a program “dose” effect. After adjustment, lower EF users had more primary and specialty care visits than nonusers and similar total costs during the 2 years after their first EF visit. Conversely, more-frequent users of EF had fewer hospitalizations and lower total healthcare costs than nonusers during the first 12 months after beginning EF and persistent differences in total healthcare costs during the second year after beginning the program. In the absence of strong randomized trials demonstrating improvements in health after initiation of a community-based physical activity health benefit, these findings may be the most compelling evidence available that health plan coverage and use of a preventive health benefit by seniors can help to improve health and return short-term cost savings.
This study had some notable limitations. First, information was available only about the number of EF visits for each user and not about other sources of physical activity participation. As such, the current analysis cannot disentangle the benefits of EF visits from changes in physical activity occurring outside of the program, nor can it differentiate differences between higher use for short periods (e.g., visits twice per week for 6 months) from more consistent use at lower frequencies (e.g., visits once per week for 12 months). However, because EF program sessions meet approximately once weekly, it is likely that changes in lifestyle behaviors that occur outside of formal program visits may mediate potential health benefits resulting from EF program use. Changes in physical activity and other lifestyle behaviors have been observed in prior research of lifestyle interventions that do not include supervised physical activity and may result from the development of behavioral skills and social support in association with regular program visits.30
Regardless of the exact mechanism for how EF use might improve the health of participants, exposure to this program appears to be a strong independent predictor of lower future healthcare expenditures in older adults. Second, information was not available about all variables that might confound associations between EF use and healthcare consumption (e.g., tobacco use, diet, other sources of physical activity). To reduce confounding and selection bias, covariate adjustment with several indicators of comorbidity, health status, and past use of elective preventive services was used. Sensitivity analyses were also performed using PS quintiles with adjustment, and similar results were obtained.31,32
Although these data offer robust information about overall health and the prevention-seeking profile of each member, it is always possible that these methods were incomplete in adjustment for selection bias. Third, reverse causality is possible when exposure (the frequency of EF visits) is determined over the same period as the outcome (healthcare costs and utilization). To avoid reverse causality, healthcare cost and utilization outcomes were compared during Year 2 for groups with different EF “dosage” levels during Year 1 (i.e., before the measurement of outcomes). In adjusted models, members using EF at least once during Year 1 had total costs during Year 2 that were $1,186 (P
=.005) lower than those of nonusers; those who used EF at least once per week during Year 1 had total costs during Year 2 that were $1,784 (P
<.001) lower than those of non-users.
Given the ability of this analysis to incorporate longitudinal cost data and to use more-robust health plan data to adjust for differences in overall health-seeking behaviors of members, the results of this study provide the strongest evidence available to date that health plan efforts to offer coverage for an elective, group-based physical activity benefit for older adult members has the potential to offer return on investment in the short term. The potential for cost recovery will depend highly on the per-member costs of offering the program and the proportion of participating members who use the benefit regularly. Although greater program use will generate higher charges from EF program sites, these analyses suggest that savings may be possible only with regular program use. Thus, one unanswered question arising from this study is whether efforts to increase program participation by non-use and low-use members will result in similarly lower total healthcare costs as those observed in elective high users. Because efforts to promote higher program use are likely to generate additional costs for a health plan, it will also be worthwhile to consider the extent to which reduced future healthcare costs will offset additional programmatic costs (i.e., to promote adoption and maintenance). Answering these questions in the context of a large, group-randomized trial would require numerous health plans and considerable evaluation resources and is, thus, not likely to be forthcoming. To address these issues in a more-practical context, it will be important for health plans to collect information about the costs invested in efforts to increase use of community-based lifestyle benefits, as well as all cost inputs required to offer such a program for its members. Until then, this study provides valuable information for policy makers who may be considering whether to provide coverage for a community-based, group physical activity benefit for older adults.