A Systematic Review: Effects of Health Plan-Sponsored Fitness Center Benefits on Physical Activity, Health Outcomes, and Healthcare Costs and Utilization

Regular physical activity has many positive health benefits, while lack of physical activity is associated with higher healthcare costs and utilization. However, many Americans do not get the recommended levels of physical activity, and Veterans who use the VA healthcare system are less likely to meet physical activity recommendations and more likely to be physically inactive compared with Veterans who do not use VA healthcare. Multiple personal, social, and environmental factors influence participation in physical activity. Providing memberships to fitness centers may increase physical activity and the positive health outcomes associated with such activity. Therefore, health plan promotion of and coverage for fitness center memberships has the potential to address multiple barriers to physical activity (e.g., cost, access).

Investigators with the VA Evidence-based Synthesis Program (ESP) Center in Durham, NC conducted a review of the published literature from database inception through May 2012, in addition to searching www.ClinicalTrials.gov for completed but unpublished studies in July 2012. After reviewing more than 3,500 citations, investigators identified four articles -- one main paper and three associated papers -- representing one unique study. This retrospective, observational cohort study, rated fair quality, assessed a health plan-sponsored fitness center membership benefit (known as the Silver Sneakers program) among adults 65 years of age and older who were enrolled in a Medicare Advantage plan. These articles were used to address the following questions:

Question #1
What are the effects of policy/benefits packages that include vouchers, rebates, premium reductions, or other economic incentives to encourage physical activity through fitness center memberships on:

• Physical activity participation rates among plan members?
• Health outcomes demonstrated to be improved by physical activity (i.e., weight, pain, glucose, blood pressure, health-related quality of life)?
• Overall healthcare costs and healthcare utilization?

Physical Activity Participation
The only metric of physical activity was the frequency of fitness center visits by participants in the Silver Sneakers program. In year one of the main study, Silver Sneakers participants averaged 75 visits. In year two, the average number of visits declined to 55. While participation dropped in the second year, 61% of participants continued to visit fitness centers. A separate analysis using a subset of members with diabetes reported similar number of average visits per year (72 visits in year 1; 49 visits in year 2).

Two companion articles provided information on other factors associated with fitness center membership uptake and frequency of use. As expected, enrollment was less likely among people living farther from gyms. Additionally, greater distance from fitness centers and history of depression reduced frequency of use for those who enrolled in fitness centers.

Physical Health Outcomes
No identified studies addressed this question.

Health Care Costs and Healthcare Utilization The main study and one companion article reported the effects of health plan-sponsored fitness center memberships on healthcare costs and utilization. Total healthcare costs were not different between Silver Sneakers participants and non-participants by the end of the first year. By the end of year two, participants incurred significantly lower total healthcare costs (-$500), likely due to fewer inpatient admissions and lower inpatient care costs compared with controls. There also was evidence of a dose-response by average number of health club visits. Compared with participants who attended fitness centers less than one time per week, participants had lower healthcare costs if they averaged 2 to < 3 visits per week (-$1,252) or = 3 visits per week over two years (-$1309).

In another paper, Silver Sneakers participants with diabetes had lower total healthcare costs (-$1,633) compared with matched non-participants with diabetes after one year of enrollment in the fitness center program. This cost savings was likely due to fewer hospitalizations and lower inpatient costs. In year two, participants accumulated lower total healthcare costs, but these savings were not statistically significantly different from non-participants with diabetes.

Question #2
What are the effects of policy/benefits packages that include vouchers, rebates, premium reductions, or other economic incentives to encourage physical activity through fitness center memberships on satisfaction with the health plan and retention of members in the health plan?

No identified studies addressed this question.

Question #3
Do the effects of policy/benefits packages to encourage physical activity vary by specific characteristics of the package (premium vs. lump sum) or age, sex, and physical illness of participants?

No identified studies addressed this question.

Conclusions/Future Research
Health plan-sponsored fitness center memberships have the potential to increase levels of physical activity and, subsequently, improve health and economic outcomes for Veterans. However, few studies have assessed the impact of health plan-sponsored fitness membership benefits. The evidence base for these claims remains weak due to study design limitations and the paucity of literature. The evidence from a single Medicare managed care plan provides limited support for reductions in healthcare costs and utilization, when comparing health plan members who choose to participate in health plan-sponsored gym memberships with those who do not. These results may be influenced by selection bias (i.e. the fact that patients who voluntarily joined a fitness center had fewer chronic illnesses than those who didn't), and they may not be generalizable to Veterans because this evidence is based on a sample of elderly enrollees from a single Medicare managed care plan in the Northwest U.S. The existing literature provides little insight into other outcomes such as physical health outcomes or health plan member satisfaction or retention. Thus, further evidence is needed on which to base policy recommendations on the merits of providing health plan-sponsored fitness center memberships.

This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers -- and to disseminate these reports throughout VA.

Reference
King HA, Gierisch JM, Williams JW Jr, Maciejewski ML. Effects of Health Plan-Sponsored Fitness Center Benefits on Physical Activity, Health Outcomes, and Health Care Costs and Utilization: A Systematic Review. VA-ESP Project #09-010; 2012.

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This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers - and to disseminate these reports throughout VA.

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