It is well known that unhealthy behaviors, such as tobacco use, poor nutrition, and lack of physical activity, contribute to chronic illness and premature death in the United States. About half of all adults have at least one chronic health condition such as heart disease, type 2 diabetes, and obesity. The financial cost is enormous. According to the Centers for Disease Control and Prevention, 86% of all health care spending in 2010 went toward people with one or more chronic conditions.
Dozens of medical professional treatment guidelines start with helping the patient make healthier lifestyle choices around regular exercise, healthy eating, stress reduction, not smoking, and limited alcohol use. Tools like prescriptions for exercise and fresh produce are emerging across the country. With the academic medical community endorsing this kind of approach, why isn’t lifestyle medicine being put into standard practice in the health care system? Why aren’t healthy habits considered essential to the value equation in health care?
More than 6 years have passed since Michael Porter’s seminal article “What Is Value in Health Care?” was published in the New England Journal of Medicine. “Value” — which is defined as clinical outcomes (health) achieved relative to resources spent (cost) — has become part of the general vernacular in health management circles and even physician training. Movements such as the Choosing Wisely initiative and the development of professional associations like the High Value Practice Academic Alliance have taken root to reduce unnecessary tests, treatments, and procedures that burden patients financially without improving their medical care. There is reason for optimism that the health care community is becoming a more responsible steward of our health care resources.
However, the majority of the value work is still based on the premise of a sick care system centered on treating illness over prevention. What is needed is a paradigm shift in how we achieve optimum value in health care. When our health care delivery systems are redesigned to take full advantage of healthy choices and lifestyle as medicine, we will begin to see exponential progress in preventing and managing chronic disease while lowering medical expenditures. What could provide more value than supporting our patients in eating healthfully, exercising, not smoking, and lowering stress?
The effectiveness of comprehensive programs that encourage healthier lifestyle choices has passed the threshold for insurance coverage. The Centers for Medicare and Medicaid Services (CMS), Aetna, United, Anthem BCBS, and a variety of regional health insurers reimburse for programs such as Intensive Cardiac Rehabilitation (ICR) and the national Diabetes Prevention Program (DPP). These evidence-based approaches provide education and skill building around nutrition, exercise, relaxation, and social support. They are delivered in group settings, several hours per week, over a period of months. The results are impressive, including an intensive lifestyle support group that was 34% less likely to progress from prediabetes to diabetes over a 10-year period than the usual care group. Patients receiving ICR can expect significant improvements in body mass index, triglycerides, low-density lipoprotein cholesterol, blood pressure, and other biometrics — as well as levels of depression.
Cost reduction is another potential outcome of lifestyle interventions. The Complete Health Improvement Program (CHIP) is an initiative promoting daily exercise, a plant-based whole-foods diet, stress reduction, and increased support systems. When offered in the workplace, it lowered health care costs by decreasing medication needs among participating employees and reducing outpatient medical visits between 11 and 25% over a year.
Conversely, the alternative to better lifestyle habits is more medicine and more procedures, but does that lead to better outcomes? Not necessarily. As an example, intensifying pharmacologic control of sugar levels in patients with type 2 diabetes actually worsened outcomes in a randomized study. Procedures aren’t always the answer either, as evidenced by worse outcomes from percutaneous coronary interventions in high-risk patients with persistent coronary artery occlusion after myocardial infarction.
The changing payment landscape offers a unique opportunity to fortify efforts around healthier lifestyle choices. It’s possible that a fee-for-service model could support practitioners who want to deliver high-quality counseling and skill building on lifestyle. However, the challenges are many, including the time needed to effectively help patients change. For primary care physicians and many allied health care professionals, the traditional fee-for-service system translates into a frenetic care schedule that physicians and patients often find unsatisfying. Group visits allow more time for lifestyle education and can be effective and economically viable. CMS has led the charge, in many ways, on fee-for-service reimbursement for lifestyle approaches, but there are shortcomings. Using Intensive Cardiac Rehabilitation as an example, only three programs have been approved for CMS coverage. Most practices face a large financial barrier to achieving the threshold for approval: 2 years of data and positive outcomes published in a peer-reviewed journal.
Health systems that take a financial risk on populations are most likely to benefit from integrating lifestyle into care delivery. Accountable care organizations, bundled payment systems, and self-insured employers are all working under the same premise — that costs go down when a defined population stays healthy. The state of Maryland now makes it attractive for hospitals to invest in lifestyle as medicine and avoid unnecessary care. In exchange for a Medicare waiver that allows all payers to pay the same hospital rates, Maryland hospitals have committed to reducing 30-day hospital readmissions and limiting per capita hospital inpatient and outpatient growth.
A Way Forward
Setting up a system to extract value out of healthy choices won’t happen overnight. To make lifestyle medicine a productive reality:
- Practitioners need to align themselves in teams, similar to optimizing delivery of other health care services such as surgery, to provide a variety of lifestyle services (e.g., mindfulness training, nutrition counseling) for enhancing health.
- Systems will have to be built to ensure that best practices in lifestyle medicine are being followed and not delivered haphazardly or by unqualified practitioners.
- Providers will need to bundle lifestyle services to address different disease states, such as diabetes and heart disease, and payers will need to reimburse for these programs.
- Providers must consider delivering lifestyle services as part of the treatment plan for many conditions, as well as pre-operative and discharge planning, instead of isolating lifestyle medicine as a separate unit.
- Health care teams will have to take some financial risk. It’s likely to be an easier match within an integrated delivery network, where the payer has a large influence on the health care services delivered to the member.
Lifestyle interventions must be convenient for patients if they are going to be effective, given the level of commitment — several hours a week for more than a month — required by the participant. Thus, providing these services within an outpatient setting, as opposed to a hospital, is more likely to sustain regular involvement. Other options include offering lifestyle programming in houses of worship, within the workplace, or at a medical fitness facility.
Wellness goals are also easier to reach when a patient’s environment is conducive to supporting health. Communities with walking and biking paths, access to fresh fruits and vegetables, and social services for those in need make it easier for participants to pursue a healthy path and reduce their risk factors for chronic illness.
Lifestyle-as-medicine programs will not solve every challenge because they address only some of the many determinants of health. But they are foundational to transforming our sick care system into a sustainable model. For those who don’t think people change, there are almost 50 million former smokers in our country, and 50% of Americans make at least one attempt to quit each year. The real cynics will focus on the 50% who don’t try to stop. Let’s remind these doubters that medication compliance for such conditions as hypercholesterolemia and diabetes is also in the range of 50%. Smoking and childhood obesity rates are both down, so there is reason to be optimistic.
As hospitals and health systems grapple with new payment models, including lifestyle-as-medicine programs will be an important part of their value strategy.