A Micropractice/Community Partnership Model for Lifestyle Medicine

Abstract

Lifestyle medicine (LM) has been shown to be effective at preventing and reversing disease, while simultaneously reducing overall medical expenses. However, the current health care system is not designed to reimburse LM clinicians for the value that they provide. The micropractice model is an innovative approach to deliver LM in a financially viable manner. Costs are minimized by automating much of the practice through a website, limiting physical clinic space, and employing only essential staff. Described in this article is a unique micropractice family medicine/lifestyle medicine hybrid office that has partnered with a local health system and a culinary center to offer additional services.

‘The micropractice model minimizes office expenses to enable the clinician to spend extended time with individual patients.’

Lifestyle medicine (LM) has been shown to be effective at preventing and reversing disease, while simultaneously reducing overall medical expenses.¹ However, the current health care system is not designed to reimburse LM clinicians for the value that they provide. Delivering LM within a traditional outpatient setting, in which clinicians are expected to see patients every 10 to 15 minutes, is extremely challenging.

Additionally, one-on-one office visits rarely provide the social support that fosters lifestyle change. Alternatively, group counseling sessions provide an efficient way to deliver education as well as provide support. However, they are typically poorly reimbursed by insurance. While shared medical appointments are a financially viable option for providing education and group support, these types of visits require the availability of multiple staff members, as each patient must also be seen individually in order to bill insurance. Both group counseling sessions and shared medical appointments require meeting space and a reliable pool of patients who are able to attend these sessions. This can be challenging for many medical practices. Furthermore, many patients who want to make dietary changes struggle to do so because they lack cooking skills. Few doctors’ offices are able to provide opportunities for this type of hands-on learning.

Finally, although self-pay models for comprehensive LM programs can be effective, they are cost-prohibitive for many patients who would benefit the most from them. A micropractice model represents an alternative LM practice approach, which addresses some of the aforementioned challenges. Described in this article is a unique micropractice family medicine/lifestyle medicine hybrid office that has partnered with a local health system and a culinary center to offer additional services. This approach has enabled this author to have a financially viable practice that provides affordable LM education and group support.

The Micropractice Model

The micropractice model minimizes office expenses to enable the clinician to spend extended time with individual patients. A micropractice attempts to automate as much of the practice as possible, maximize efficiency, and limit the need for additional staff. Most micropractices have 1 clinician (who also does nursing duties) and 1 administrative person. It generally utilizes a small clinical space or shares staff and space with another practice. By keeping costs low, an office can remain profitable while still offering 30- to 60-minute patient visits.

Evolution of Lake Country Family Medicine, Professional Corporation (PC)/Lifestyle Medicine Consultation Service

Prior to opening Lake Country Family Medicine, P.C. (LCFM) in 2006, I worked for 9 years at a hospital-owned family medicine practice 15 miles west of Canandaigua, New York. I started LCFM in Canandaigua, New York, as a family medicine micropractice when I needed work-life flexibility while raising young children. Start-up costs for the practice were less than $10 000 and it went from concept to seeing patients within 3 months. It was financially viable immediately, as I retained many of the patients from my previous office. Initial and physical examination visits were 60 minutes and follow-up visits were 30 minutes, allowing time for psychosocial elements to be addressed more fully.

Initially, the practice space was subleased from a podiatrist who was willing to share his secretarial staff with me. Two years later, appropriately sized office space became available nearby. The office was moved to this independent site and I hired a full-time administrative assistant. The new space was approximately 500 square feet and consisted of a waiting room, an administrative office, a physician office, one examination room, and a handicapped accessible bathroom.

After I adopted a whole food plant-based (WFPB) diet in 2013 and was able to completely reverse prediabetes, hypothyroidism, esophageal reflux, constipation, depression, and the extra 25 pounds I was carrying, I started incorporating LM concepts into the care of my family medicine patients. In 2016, a LM consultation service was added to meet demand for LM services in the community.

Practice Demographics

LCFM is located in Canandaigua, New York, which is home to roughly 10 000 people. However, the practice draws from all of Ontario County (population ~110 000). While the county has some of the most expensive lakefront property in the United States, it is primarily farmland and is financially heterogeneous. Patients in the practice reflect this diversity of income. Ethnically, it is 95% Caucasian.²

Practice Website/Automation

One of the primary contributors to the success of our micropractice is automation. The robust website (www.kerrygraffmd.com) provides answers to most questions regarding our office philosophy, policies, and general information about becoming a patient. The website also contains many resources for those interested in WFPB diets and LM in general. It also includes a link to our patient scheduling system, AppointmentQuest,³ which allows established patients to schedule appointments online. Approximately 60% of all appointments are made directly by patients rather than through office staff. AppointmentQuest also sends out email reminders of appointments automatically. Our practice website contains a link to Updox,⁴ which is used for HIPAA (Health Insurance Portability and Accountability Act)–compliant patient communication. Approximately 95% of all medical reports arrive at our office electronically through Updox, which further minimizes staff time required to scan documents into charts. Announcements regarding the practice, upcoming classes, and events of interest are sent to patients through this system as well.

Medical Issues Addressed

The family medicine practice offers a full range of outpatient primary care services, while emphasizing a healthy lifestyle for prevention and treatment of illness. Our LM consultation service focuses on chronic lifestyle-related diseases, including prediabetes/diabetes, hyperlipidemia, cardiovascular disease, rheumatoid arthritis, Crohn’s disease, ulcerative colitis, lupus, dementia, and various types of cancer. While we address the need for physical activity, stress management, adequate sleep, and social connection, most of our work involves helping patients adopt healthier diets. We use the 4Leaf survey^5,6 to assess the healthfulness of a patient’s diet and track their 4Leaf score as a vital sign. A detailed medical and lifestyle history is obtained, and the consultation and follow-up visits are tailored to a patient’s concerns and areas where he or she is willing to make changes. Our LM consultation service helps patients

1. recognize that patients have the ability to modify disease by changing lifestyle

2. learn what constitutes a healthy diet

3. get as close to a WFPB diet as they are willing and able

4. reduce or stop medications (in coordination with their primary care physician) to prevent overmedicating as health improves

5. figure out why they are struggling and work together to circumvent barriers.

Currently, I split my time equally between comprehensive family medicine, with a strong LM emphasis, and providing LM consultations and related activities.

Billing and Insurance

The office accepts most insurance, including Medicare and Medicaid. LM visits are billed by time using standard CPT (Current Procedural Terminology) codes (ie, 99214, 99215, etc) as long as greater than 50% of the visit is in counseling. In order to be able to receive insurance reimbursement when I am not a patient’s primary care physician, I bill using my National Provider Identification (NPI) registration in preventive medicine, instead of family medicine. (The preventive medicine registration will be switched to LM once that designation becomes available.) While we have not had denials of payment for consultative LM services when billing this way, whether a patient is expected to pay a primary care versus a specialist copay has occasionally been an issue.

After-Hours Coverage

I am on call for roughly 800 patients on a 24/7 basis and contract with another provider for coverage on an as-needed basis. After-hours calls by patients average 3 per week.

Community Collaboration

LCFM partners locally with UR Medicine Thompson Health (a small hospital system associated with the University of Rochester Medical Center) to offer LM/WFPB classes and with the NY Wine and Culinary Center (NYWCC) to provide WFPB cooking classes. These partnerships extend LCFM’s outreach into the community, provide LM services in a cost-effective way, and add credibility to a specialty that is little recognized by physicians or patients at this time.

Four times a year, LCFM and UR Medicine Thompson Health jointly offer a free class to the community about the effect of lifestyle on health, with specific emphasis on the health benefits of adopting a WFPB diet. For anyone who would like assistance adopting a WFPB diet, a 4-week class is offered for $125. The class, run jointly by LCFM and a UR Medicine Thompson Health dietician, utilizes the 4Leaf Guide to Vibrant Health⁷ and The Forks Over Knives Plan⁸ books. A hospital conference room is used and most of the advertising for the class is done by UR Medicine Thompson Health. Scholarships are offered to patients on a needs basis. Additionally, there is a free monthly conjointly run WFPB support group at the hospital. The monthly meeting is a potluck supper where people can taste various WFPB foods, exchange recipes, and share successes and challenges that they have experienced. It also includes a short educational component.

The NYWCC is a nonprofit entity that contains a hands-on teaching kitchen where WFPB cooking classes are offered at least once a month. The classes focus on teaching new skills and improving efficiency in the kitchen. As a nonprofit entity, the NYWCC has the ability to secure grant funding to make the classes more affordable for patients.

Recruiting Lifestyle Medicine Patients

Many of our LM consultation patients are referred by current patients or come to us after taking one of the classes at UR Medicine Thompson Health or the NYWCC. In addition, several local specialists and primary care clinicians refer patients for LM consultations. Generally, we do not accept new primary care patients. This fosters good relationships with referring primary care physicians and allows them to see firsthand the tremendous health improvements their patients have when heathier lifestyles are adopted. Without needing to provide routine and sick care to our LM patients, we are able to accommodate more patients.

Benefits of the Micropractice/Community Collaboration Model

1. There is a low initial financial investment and a micropractice is relatively easy to implement.

2. Partnering with a health system and a culinary center to provide resources allows us to minimize our costs. These affiliations also add legitimacy and enhanced visibility for our practice in the community.

3. Using nonprofit partners provides opportunity to seek grant funding for services not typically covered by insurance. This helps keep patients’ costs low and increases access.

4. Having a low overhead office allows for significant flexibility. Patient visits can be longer to better address LM issues. Taking off time for parenting or personal needs is relatively easy as well.

5. The practice model enables a clinician to blend LM consultation services with primary care (or a subspecialty) practice. Maintaining a part-time primary care practice provides additional financial stability to the practice while a part-time LM consultation service expands access to the entire community.

Disadvantages of the Micropractice/Community Collaboration Model

1. Requires partners willing to host/advertise for group lifestyle medicine activities.

2. Likely less lucrative than self-pay models, at least on a per patient basis.

3. Requires the clinician (or office personnel) to do practice management and be relatively proficient in using technology.

4. Works less efficiently with patients who are not tech-savvy.

5. Office staffing difficulties when single administrative person is off.

6. Potential difficulty getting on-call coverage.

7. Sharing space and staff with another practice increases the risk of conflict and limits the ability to expand the practice, if needed.

Conclusion

LM represents a powerful approach to help prevent and treat the majority of chronic illnesses that exist today. However, there has been difficulty in translating these medical services into a financially viable practice model. By partnering a micropractice medical office with a local health system and a culinary center, we have created a financially viable approach that allows us to successfully deliver LM services to our community.