Padmaja Patel, Maryland
Next president of the American Academy of Lifestyle Medicine
The Centers for Medicare and Medicaid Services’ (CMS) 2022 National Quality Strategy is an “ambitious, long-term initiative aimed at promoting the highest quality outcomes and the safest care for all individuals.” explained. The strategy calls for a multidisciplinary, person-centered approach to individuals across the continuum of care, with an emphasis on historically under-resourced communities. That’s a laudable goal for America’s overburdened health care system, which spends more than other high-income counties and yet performs worse. But holistic, person-centered care fails to measure the five objectives we claim to value: improved health outcomes, cost reduction, patient satisfaction, clinician well-being, and health equity. This cannot be achieved under current inconsistent quality measures.
lifestyle first
Clinical practice guidelines for many chronic diseases recommend lifestyle interventions as the first and best treatment. Evidence that lifestyle behavioral interventions can treat common chronic diseases such as cardiovascular disease, obesity, and type 2 diabetes, and when used intensively, can not only improve but also effectively prevent these diseases. Evidence is mounting. However, none of the current quality measures consider lifestyle interventions. In fact, some quality measures unintentionally penalize physicians who successfully treat or reverse disease through lifestyle behavioral interventions, while process measures Rewards clinicians who achieve (usually compliance).
Rewarding medication adherence in the treatment of diseases for which lifestyle is the main treatment (e.g. hypertension) and other medical constraints (lack of lifestyle education, time spent with patients, lack of infrastructure support) Combined, they encourage physicians to omit conversations about lifestyle. Change it and immediately proceed to prescribing the drug. On the other hand, clinicians are penalized for taking extra time to guide patients toward lifestyle interventions that can treat current illnesses and prevent future illnesses, without side effects.
When these quality standards slip, clinical judgment is compromised and medical practice risks being subject to ill-advised checks. Often, patients are not even informed that lifestyle behavior changes may be a treatment option (let alone a recommended option in the first place) for their condition. Because the provision of such care is not person-centered, questions may arise as to whether informed consent to treatment is, in fact, appropriate.
wall of redemption
Lifestyle medicine is a growing medical specialty that uses therapeutic lifestyle interventions as a primary means of treating chronic diseases. Approximately 2,500 U.S. physicians and his 1,000 non-physician health care professionals have achieved certification since certification began in 2017. Healthcare systems, including the U.S. military, are increasingly integrating lifestyle medicine. Progress has been made since one survey found that more than half of lifestyle medicine clinicians report receiving no reimbursement for lifestyle behavioral interventions. However, barriers, particularly in the fee-for-service system, continue to prevent many patients from obtaining insurance coverage for comprehensive, multidisciplinary, whole-person treatments called intensive therapeutic lifestyle change (ITLC) programs.
Existing comprehensive lifestyle programs to which patients are entitled (i.e., diabetes prevention programs and intensive behavioral therapy) are often so poorly reimbursed that clinicians and health systems are reluctant to provide them. I’m refusing. An example of a fully compensated ITLC program is Intensive Cardiac Rehabilitation (ICR). Despite its demonstrated benefits in the management of comorbid risk factors such as A1c and body weight, ICR remains underutilized and limited to a subset of patients. Even when lifestyle intervention programs are available and patients are eligible to participate (often through common medical appointments), the cost of the frequent office visits required to achieve and maintain behavior change is beyond the patient’s expense. Participation is discouraged by the lack of out-of-pocket costs or reimbursement for interdisciplinary team members.
Penalize successful results
Despite the fact that lifestyle behaviors make a significant contribution to health and, conversely, contribute to up to 80% of chronic diseases, there is a lack of quality research focused on screening for lifestyle factors and treating diseases through lifestyle interventions. There are very few high-level measures. Examples of existing quality measures include screening for or treating the use of hazardous substances.
Specific quality measures that penalize lifestyle medicine approaches include medications for type 2 diabetes, dyslipidemia, osteoporosis, and gout, as well as approaches for rheumatoid arthritis.
Statins provide an instructive example of the challenges faced by clinicians wishing to provide lifestyle interventions. A lifestyle medicine primary care physician was caring for a patient eligible for Medicare Her Advantage who was diagnosed with hyperlipidemia. The patient’s total cholesterol level was 226 and triglyceride level was 132. Instead of prescribing routine statins, doctors prescribed lifestyle behavioral modifications. Within three weeks, the patient’s total cholesterol improved to 171 and triglycerides to 75. This was a great success for the patient. However, CMS’s five-star rating system assigns primary care physicians a grade of C instead of A, putting the doctor’s five-star rating at risk. why? This is because the system determines the score primarily based on medication compliance. This doctor was punished even though he achieved optimal health outcomes at a lower cost than medication. Such discrepancies do not encourage patient-centered care because they ignore patient preferences, shared decision-making, and evidence-based practice.
risk adjustment
Lifestyle medicine clinicians first pursue the goal of restoring health when needed, rather than automatically managing disease through an ever-increasing array of expensive drugs and procedures. But Medicare’s risk adjustment gives doctors an incentive to manage disease rather than cure it. The amount Medicare pays for health insurance depends in part on how sick the patient is. The sicker the patient is, the higher the patient’s costs are expected to be and therefore the more Medicare will pay. This ensures that health plans are not penalized for enrolling sicker patients. However, physicians who use diet alone to achieve remission in patients with type 2 diabetes are financially penalized. This is because once the risk is adjusted, diabetes is no longer included in the patient’s symptoms. Therefore, Medicare pays doctors less. This misalignment motivates clinicians to try to manage type 2 diabetes symptoms rather than achieve remission, even though remission is the ideal clinical outcome.
Recalibration of quality measures
Quality measures have been developed to quantify healthcare processes and outcomes and ensure safe care for all patients. But over time, his number of quality standards ballooned to 2,500, creating a confusing, time-consuming, and even soul-crushing responsibility for physicians.
Rather than relying heavily on process measurements, we need to encourage outcome measurements that respect patient autonomy and allow clinicians to offer lifestyle interventions as the first line of treatment. Risk score calculations should be adjusted to stop encouraging disease management or penalizing disease recovery.
The development of a “universal basis” for quality measures, as proposed by CMS, is an opportunity to begin a realignment of quality measures and values. The foundation aims to reduce clinician burnout and promote health equity by establishing more consistent and meaningful measures and streamlining reporting processes. Lifestyle behavioral interventions such as optimal nutrition, physical activity, restorative sleep, social connections, stress management, and avoidance of toxins are essential for the success of this change. Become The basis of universal quality measures. This will ensure that all clinicians are motivated to discuss lifestyle behaviors with their patients and pursue the clinical first steps recommended in most chronic disease practice guidelines. Only then can we truly deliver high-value, holistic, person-centered care and achieve our five goals.
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