Liana S. Lianov, MD, MPH

Disclosures

August 15, 2011

In This Article

The Business Side of Lifestyle Medicine

The lifestyle medicine competencies and additional training to bolster clinicians' knowledge and skills in these areas offer a solution to 2 of the barriers cited by providers for not prescribing lifestyle medicine: lack of confidence and training. To boost the discipline of lifestyle medicine further, the other barriers must be removed. The barrier most often cited by clinicians for not providing lifestyle medicine services is inadequate payment. Until 2011, Medicare coverage for lifestyle medicine was limited to services such as cardiac rehabilitation following myocardial infarction; cardiac bypass surgery in patients with stable angina; diabetes self management (10 hours of training following the diagnosis); medical nutrition therapy for patients with diabetes or kidney disease (not on dialysis); and smoking cessation in patients diagnosed with a smoking-related disease (8 visits over a 12-month period).[45]

Medicare payment for prevention and lifestyle medicine services has expanded with the recent healthcare reform bill. Beginning in 2011, no coinsurance or deductibles will be charged by Medicare for preventive services that are rated "A" or "B" by the USPSTF or for annual comprehensive wellness visits and personalized prevention plans.[46] Medicare also now covers (with cost sharing) the Dean Ornish and Pritikin lifestyle programs for eligible patients.[47]This coverage may be precedent setting for all insurance companies.

Although reimbursement has been expanded, it is still limited and affects the availability of lifestyle medicine practices. Some healthcare providers who are interested in practicing lifestyle medicine full time are unable to sustain themselves financially. Consequently, they practice primary care and integrate lifestyle medicine whenever possible into their practices, or they set aside regular scheduled time for patients who are seeking only lifestyle medicine services. Innovative models of care include collaborative practices with health psychologists, shared medical appointments, and free-standing senior wellness and prevention centers.

To justify payment, insurance carriers often require intensive lifestyle interventions in primary prevention populations to be backed by evidence. The impact of lifestyle interventions has been difficult to demonstrate as a result of the multifaceted levels of influence -- worksite and school policies, advertising, and social networks, for example -- on health behavior. Further research designed to test clinical counseling and incorporate these other levels of influence would likely not only be expensive, but also impractical. The impact of the clinician is difficult to differentiate from the confounding variables.

Innovative approaches are needed to help us navigate around this barrier. Recent technological advances -- or even older technologies available to low-income populations, such as automated text messages to patients about relevant health behaviors -- offer potential low-cost breakthrough opportunities to support lifestyle-related clinical and clinician counseling services beyond the clinical setting. These new opportunities deserve further intensive study.

In advance of these innovations, several insurers and worksite wellness programs have taken it on faith that their populations will benefit by integrating a role for the clinician and the healthcare team into their programs to offer advanced lifestyle medicine services. Some early-adopter providers have been offering such comprehensive services for decades. Recently a few companies have joined the ranks of these pioneers by paying for comprehensive lifestyle programs in which the clinician is an integral part of the prevention approach for their employees.

The Future: What You Can Do to Promote Lifestyle Medicine

The leaders of the movement behind the lifestyle medicine competencies, including the ACPM and the ACLM, are promoting awareness, developing training, and investigating the business side of the practice to increase healthcare provider motivation, engagement, and self efficacy for implementation of the competencies. We encourage you to join us in this effort. Your contribution may be implementing and testing interventions that are feasible and effective in the primary care setting, inspiring medical colleagues to look for simple ways to emphasize healthy lifestyles in their clinical practices, educating and encouraging young clinicians to develop a comfort level with prescribing lifestyle medicine early in their careers, and advocating for healthcare reform that will support clinical practices to offer intensive health behavior change counseling and assistance services. Using social media is an excellent way to promote this dialogue and advance practical solutions. Our collective efforts can help reverse premature morbidity and mortality from chronic disease.

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