How PCPs Are Penalized for Positive Outcomes From Lifestyle Change

Commentary

Padmaja Patel, MD, President-Elect, American College of Lifestyle Medicine

The Centers for Medicare & Medicaid Services (CMS) 2022 National Quality Strategy is described as an «ambitious long-term initiative that aims to promote the highest quality outcomes and safest care for all individuals.» The strategy calls for a multidisciplinary, person-centric approach for individuals throughout the continuum of care, with an emphasis on historically underresourced communities. It is a commendable goal for an overburdened US healthcare system that spends more than other high-income counties yet experiences poorer outcomes. But whole-person, person-centered care cannot be achieved under current misaligned quality measures that fail to measure what we purport to value: the quintuple aim of improved health outcomes, cost savings, patient satisfaction, clinician well-being, and health equity.

Lifestyle First

Clinical practice guidelines for many chronic diseases recommend lifestyle intervention as the first and optimal treatment. A growing body of evidence supports lifestyle behavior interventions to treat and, when used intensively, even reverse common chronic conditions such as cardiovascular disease, obesity, and type 2 diabetes, while also providing effective prevention for those conditions. However, no current quality measures consider lifestyle interventions. In fact, some quality measures unintentionally penalize physicians for successfully treating or reversing disease through lifestyle behavior interventions while rewarding clinicians for meeting process measures — usually adherence to medication — regardless of whether health outcomes improved.

Rewarding medication adherence for the treatment of diseases in which lifestyle is a primary therapy (such as hypertension), combined with other healthcare constraints (lack of lifestyle education, time to spend with patients, and infrastructure support) incentivizes physicians to skip the conversation about lifestyle changes and go straight to medication prescription. Meanwhile, the clinician who takes the extra time to guide a patient toward lifestyle interventions that could treat their current disease and prevent future diseases — without side effects — is penalized.

Misaligned quality measures like these can stifle clinical judgement and risk reducing the practice of medicine to mindless box-checking. In many cases, patients are not even informed that lifestyle behavior change may be a treatment option (much less the first recommended option) for their conditions. This delivery of care is not person-centered and, in fact, may raise questions about the adequacy of informed treatment consent.

Reimbursement Barriers

Lifestyle medicine is a growing medical specialty that uses therapeutic lifestyle interventions as a primary modality to treat chronic conditions. Since certification began in 2017, almost 2500 US physicians and 1000 nonphysician health professionals have earned certification. Health systems, including the US military, are increasingly integrating lifestyle medicine. There have been advancements since one survey found that more than half of lifestyle medicine clinicians reported receiving no reimbursement for lifestyle behavior interventions. However, barriers, especially in fee-for-service systems, still inhibit many patients from receiving insurance coverage for comprehensive, interdisciplinary, and whole-person treatments called intensive therapeutic lifestyle change (ITLC) programs.

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