Firmly Establishing Lifestyle Medicine Within the Value Framework

Abstract

The rapid growth of Lifestyle Medicine (LM) and Value-Based Care (VBC) are occurring simultaneously yet are not fully aligned in the minds of key stakeholders. Both focus on bending the healthcare cost curve by improving patient outcomes, providing greater access to chronic disease risk reduction services and in the case of LM, driving toward chronic disease remission and reversal. Both require strong physician engagement to be effective and will greatly benefit from thoughtful use of digital health technologies. In this review, key focus areas will be highlighted as foundational aspects in which LM is synonymous with high-value care. Continued efforts in these key areas will ensure that LM becomes the foundation for VBC.

“The early success of the LM clinic at Corwell Health has generated interest from both primary care and specialty service lines to embed aspects of LM within their own clinic locations.”

Make no mistake, it is not mere coincidence that Lifestyle Medicine (LM) and Value-Based Care (VBC) are accelerating at similar rates. With over 4 trillion dollars spent each year on the treatment and management of lifestyle-sensitive chronic conditions, new therapeutic approaches and payment models are necessary to bend the financial curve. Among practicing clinicians, record numbers have become certified in the growing of field of LM with well over 2000 physicians certified since 2017. Many clinicians cite LM as an antidote to the moral injury experienced by practicing medicine within the current model which is focused on volume rather than patient outcomes and provider satisfaction. In fact, growth of LM may provide a roadmap for health systems to achieve the Quintuple Aim, ¹ a topic of great interest at the American College of Lifestyle Medicine (ACLM) annual conference in October 2022.

However, for LM certified providers to deliver LM focused services, health systems must be willing to adopt longitudinal, patient-centered models that align with tenets of value-based care such as financial and clinical outcomes accountability, consumerism and patient engagement, and health equity. The transactional, fee-for-service model of episodic sick care is demoralizing for clinicians, excessively profit-driven, and has no place in the future of American medicine. The creation of the ACLM Health Systems Council (HSC) has provided a forum for interested health systems to collaborate and learn best practices in delivering high-value lifestyle focused care. Since the founding of the HSC in 2021, it has grown year over year and now includes over 80 health systems. Those participating in the HSC might be described as “learning health systems” defined by the Institute of Medicine as one “in which science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience,” ² key features for health systems undergoing value transformation and seeking to make LM a foundation for high-value care.

The growth of LM has occurred alongside of rapidly changing payment models focused on value, broadly defined as promoting better outcomes at a lower cost. ³ These value-based payment models occur over a spectrum of financial risk including upside, downside, and full-risk globally capitated models of care with many payers, health systems and accountable care organizations. The federal government is the leading force in value-based payment innovation with CMS setting the goal of having all traditional Medicare fee-for-service beneficiaries in an accountable care relationship by 2030. ⁴ Correspondingly, there has been significant momentum in investment in VBC models of care with an estimated growth projection of $1trillion in enterprise value upon full market maturation, according to a 2022 McKinsey & Company report. ⁵ The confluence of federal policy promulgation and private sector investment in value-based care has created opportunities for further scalability and impact of evidence-based lifestyle therapeutic interventions to improve patient outcomes.

With integration of lifestyle medicine across the continuum of care producing demonstrably better results than traditional healthcare programs, it is readily apparent that LM and VBC are inextricably linked in their pursuit of improved clinical and financial outcomes. However, a larger question looms within the minds of LM providers and leaders in terms of industry acceptance. Specifically, how do we bridge growth efforts to ensure that LM is well positioned to become a foundational aspect of VBC, such that LM becomes synonymous with high-value care and payment models are aligned to support these efforts? Here, we propose three areas that will build alignment and establish a productive framework for LM to meaningfully contribute to value creation within healthcare: (1) Growth of LM practice model “bright spots”; (2) Prioritization of technology-enabled person-centered care; (3) Expansion of provider workforce training in LM to enhance joy in practice and provider wellbeing.

Growth of LM practice model “bright spots.” LM shared medical appointments (LMSMAs) have developed as an entry point for delivering high value care by offering an effective and efficient team-based approach that can be delivered in-person or via telehealth. LMSMAs have demonstrated improved patient self-efficacy for behavior change through group support, improved access to care and are reimbursed via traditional fee-for-service billing codes. ⁶ Many health systems and individual practices have implemented LMSMAs, including successful practice models at ACLM HSC member sites such as Corewell Health, Kaiser Permanente, and Massachusetts General Hospital.

At Corewell Health, LMSMAs were embedded at the foundation of the LM medical specialty practice situated within a large integrated health system where full-risk contracts contribute to a growing percentage of revenue. Patients referred to LM from either primary care or a variety of medical specialties such as gastroenterology, stroke neurology, women’s health, rheumatology, and orthopedics, typically enter LMSMAs for part or all their lifestyle-focused care over a 3–12-month period. As an example, culinary medicine SMAs have been successfully delivered for the past 2 years and involve a team comprised of a physician, registered dietitian, chef, and medical assistant who guide groups of patients through a food as medicine approach to reducing a variety of metabolic diseases including obesity, type 2 diabetes, hyperlipidemia, and non-alcoholic fatty liver disease. Initial outcomes have demonstrated reductions in weight, HbA1c, total cholesterol and improvement in overall diet quality. Typical reimbursement occurs through use of Evaluation & Management and Group Medical Nutrition Therapy coding and billing for qualifying conditions. Clinical outcomes metrics from these programs align with system level VBC goals of reducing total cost of care by reducing emergency department visits, hospital admissions, and pharmacy spending.

A second “bright spot” has been demonstrated by LM clinicians delivering Intensive Cardiac Rehabilitation (ICR) to patients who meet eligibility criteria for purposes of secondary prevention of cardiovascular disease. At Midland Health, ICR has been offered through the LM practice and has delivered meaningful outcomes for secondary prevention while providing sustainable reimbursement of up over $8k for 72 contact hours per patient. Surprisingly, ICR is a widely underutilized LM program with proven benefits to patients and VBC payment models by preventing recurrent symptomatic cardiac disease. Challenges with ICR include restrictive eligibility criteria for patients and uncertainty of ongoing coverage for virtual delivery, currently covered via temporary telehealth waivers effective through 12-31-2023. ⁷

While these “bright spots” have accelerated the adoption of LM within health systems, financial sustainability and scalability remain notable challenges which must be overcome for LM to lie at the foundation of VBC.

Prioritization of technology-enabled person-centered care. Increasingly, digital health is being implemented as a next phase of LM care delivery for purposes of real-time monitoring, longitudinal support, and scalability. During the Covid-19 pandemic, rapid implementation and maturity of digital health technologies occurred to minimize interruptions in care allowing for greater adoption and integration of new technologies ⁸ suitable for LM focused chronic disease risk mitigation. While the digital health landscape has undergone a recent “cooling” and decline in funding, ⁹ there remains significant opportunity for LM to be a leader in healthcare digital transformation efforts. Mauriello et al termed this Digital Lifestyle Medicine (DLM) ¹⁰ and recommended LM clinicians become leaders in digital transformation to overcome resistance from executive leadership through development of patient-centric, cost-effective, scalable solutions responsive to VBC needs within health systems.

At Corewell Health, care provided to patients in LM has been delivered with a virtual and digital-first approach from the inception of this practice. Over 60% of patient visits are performed using telehealth including nearly 50% of LMSMAs being offered virtually. Patients scheduled for a new patient visit in LM receive intake assessments delivered asynchronously from the EMR for collection and review by the LM physician during the initial patient visit. An app prescribing formulary is embedded within the EMR to prescribe relevant downloadable apps to be used as part of the patient’s care plan. Data collection on health behaviors, anthropometric values, and relevant lab biomarkers filter into flowsheets within the EMR built to trend this data longitudinally as patients engage in LM focused care.

The next phase of LM at Corewell Health will prioritize expansion and scaling of services for risk-contracted patients with defined health conditions, while continuing services for all patients referred to LM with extension to local community-based organizations when appropriate. New services will be offered including remote physiological monitoring for patients with overweight, obesity, and/or hypertension. Longitudinal touchpoints with patients will be enhanced by implementing behavioral health collaborative care services delivered by a team of LM-trained healthcare professionals including registered dietitians, physical therapists, social workers, and health coaches with oversight collaboration with an LM-certified psychiatrist. Clinical outcomes will be continuously measured with an initial treat to target goal within 12-16 weeks using a variety of assessment tools including validated patient reported outcomes metrics, health behavior surveys, and relevant clinical biomarkers.

The prioritization of patient-centric digital solutions within LM will be required for continued growth within health systems and support of LM services by payers. Ideally, new digital health technologies become “invisible” to the patient, seamless for the care team, and an anchor for exceptional patient experience. These are aspirational goals to strive for and will be a critical component to firmly place LM at the foundation of VBC.

Expansion of provider workforce training in LM to enhance joy in practice and provider wellbeing. Of all the current challenges in healthcare, contraction of the physician workforce may be the top concern for executive leadership. According to a 2019 published report by the Association of American Medical Colleges, there will be a shortage of up to 122 000 physicians by the year 2032. ¹¹ This report didn’t take into account the impact of the COVID-19 pandemic but is now being realized as specialties such as Emergency Medicine are experiencing a reduction in medical trainees in their residency programs. ¹² Multiple factors have contributed to these concerning trends, including (1) corporatization of medicine; (2) declining reimbursement; (3) increasing clinical demands; (4) increasing administrative burden; (5) experience of moral injury and finally leadership failure in preventing and mitigating these issues, among others.

Once again, LM may offer a solution to the progressive decline in physician engagement, a pressing dilemma to rectify for success within VBC. Core to longevity in a career in medicine is maintaining the spirit of altruism which inspires many to pursue the profession in the first place. Within the fee-for-service model, reward is placed on volume and prohibits the affirming, bidirectional impact of relationship-based care central to the process of healing and ultimately disease reversal. Volume-based targets also do not incent team-based care thereby reducing top of licensure practice and patient experience. In contrast, the practice of LM elevates both relationship- and team-based care, both of which are critical to empowering patients to make and sustain beneficial lifestyle changes.

Within Corewell Health, LM care is delivered in a team-based model with ongoing touchpoints with health coaches, registered dietitians, chefs, and social workers in between visits with LM-certified physicians. After a patient’s initial visit with LM physician, a “warm hand-off” occurs to the certified health and wellness coach for goal setting, resource procurement and follow-up planning. All LM patients are invited to attend bimonthly “LM coach meet ups” provided in a virtual group format allowing for group support, accountability, and guidance from certified coaches. These are a low burden and resource-light approach for longitudinal care which improves patient and provider experience and supports improvement in clinical outcomes.

The early success of the LM clinic at Corewell Health has generated interest from both primary care and specialty service lines to embed aspects of LM within their own clinic locations. Providers are eager to access LM education, apply this knowledge to their own lives and then share it with their patients. They recognize the opportunity to treat chronic disease at the root cause as an effective method to stem rising healthcare costs and prevent poor patient outcomes. They are energized to practice medicine in a way that is in alignment with their core values thereby mitigating moral injury and the poorly named syndrome of burnout. Training in and applying LM within clinical care has even been described as an antidote to burnout.

In summary, alignment of LM treatment and services may be the next iteration of high-value care and is characterized by energized and engaged clinical teams delivering root-cause treatments, supported by the thoughtful use of technology, while witnessing populations of patients empowered to heal. There is a present opportunity to firmly align LM with VBC to ensure sustainability and growth for the benefit of greater health within populations, reduction in health care expenditures and maintenance of a highly engaged provider community. We are optimistic this alignment will catalyze health care transformation from the inside out to create a uniquely American system of high-value care.

ORCID iD

Kristi Artz https://orcid.org/0000-0002-7919-2564