Can lifestyle interventions bend the cost curve in healthcare?

Almost every physician has a few patients they call their “Champions.” These are the rare, motivated individuals that jump head first into a new lifestyle after a chronic disease wake up call. They start eating salads, drinking smoothies, going to the gym, and doing whatever else it takes to get healthy. They soon lose tens of pounds, get off their insulin, cut their blood pressure meds, and reverse the progression of their chronic disease. They have saved the health care system tens or even hundreds of thousands of dollars by adopting a healthier lifestyle.

Unfortunately, these patients make up a tiny fraction of a physician’s typical patient population. With determined innovation and effort, would it be possible to raise that number enough to impact the alarming growth in healthcare costs in America and the world?

Chronic disease drives the bulk of healthcare spending

Here are some statistics that put the problem of cost and chronic disease in perspective. In 2015, health care spending in the US reached $3.2 trillion, or 17.8% of GDP and will continue to grow at 5.8% per year.(1,2) In 2012, Americans spent 86% of healthcare dollars to treat individuals with chronic disease.(3) In 2016, an estimated 190mm Americans (59% of the adult population) had one or more chronic disease, which will cost the healthcare system $42 trillion between 2016–2030.(4) The most common chronic diseases are heart disease, cancer, diabetes, stroke, obesity and arthritis.(5)

A healthy lifestyle can prevent and slow the progression of the major chronic disease

The good news is that a healthier lifestyle can prevent, slow down, and even reverse many chronic conditions. Lifestyle changes encompass diet, exercise, alcohol, smoking, and stress management. Countless studies have demonstrated that modest changes can dramatically reduce the risk of developing a chronic disease and more intensive therapy, like adopting a strict plant-based diet, can reverse advanced heart disease.(6,7)

So, can lifestyle interventions bend the cost curve in health care? On paper, it seems like the answer to our question is yes! Programs to help Americans lead healthier lifestyles on a large enough scale could make a giant dent in healthcare spending. But, the reality is much more complicated and fraught with obstacles.

Changing behavior is really hard…

As anyone who has ever dieted or resolved to exercise in the New Year will attest, behavior change is hard. Our society is set up to encourage eating too much unhealthy food and to discourage physical activity. To have a healthy lifestyle in America, you have to behave quite differently from most of the people around you, which can create tension in interpersonal relationships and demand considerable willpower. Even discussing diet and lifestyle can be difficult because many individuals feel “judged”, are confused by conflicting dietary advice, and/or feel a sense of dread at the prospect of giving up cherished foods and engaging in new behaviors.

Furthermore, most physicians receive little to no training in nutrition and lifestyle interventions in medical school. Even if they did, the 5–20 minute physician visit provides hardly enough time for the in-depth engagement and counseling that is often required to stimulate behavior change. Many healthcare providers, not unreasonably, believe that “people won’t change” or that lifestyle changes will not make that much of a difference anyway. Others do believe that lifestyle interventions can impact their patients, but they do not have the time or resources to implement behavior change programs or measure their success.

Doctors aren’t paid to do this stuff

Finally, the right financial incentives are not in place to promote the use of lifestyle interventions. In the traditional fee-for-service healthcare payment model, providers are paid for consultations and procedures and not outcomes. There are only a small handful of billing codes that reimburse lifestyle related services like obesity counseling or working with a diabetes educator. Physicians and nurses are generally not reimbursed for or measured on their ability to get their patients to eat healthier or exercise. Lifestyle counseling plays a very small role in the traditional fee-for-service healthcare payment model.

Value based payments could change that

There is a major shift underway in the healthcare industry that could change everything: value-based payments for healthcare services and population health management. In a value-based payment model, providers are paid for improving outcomes, improving the patient experience, and lowering the cost of care. Improving the health outcomes of a population of patients through targeted interventions is known as population health management.

To date, most of the efforts around value based care focus on reducing the utilization of very expensive services such hospital readmissions and Emergency Room (ER) visit and reducing unnecessary diagnostic tests. Providers also track metrics on their patient panel such as the percent of patients with high blood pressure that have their blood pressure under control or the percent of diabetics with their blood sugar under control.(9) Providers with quality metrics that are above a baseline and improve over time, and are also showing a reduction in the average cost of care receive pay-outs that can substantially improve their bottom line.

Although there are currently no widely used metrics that explicitly reward healthcare providers for promoting lifestyle behavior change, the potential to get paid for successfully using lifestyle to improve the health of a patient population is there.

Technology is creating new possibilities

Furthermore, traditional lifestyle behavior change techniques can now benefit from modern tech. Wearables, detailed data tracking, and predictive analytics all open the door for lifestyle behavior change initiatives to be more personalized, more effective, and less expensive. Healthcare organizations are investing in population health management tools that analyze data and segment their patient population. These investments open up the market for ancillary tools to facilitate care coordination, patient engagement, and lifestyle interventions. The potential to use technology to deliver lifestyle interventions at scale is there.

Answering the big questions

But, the big question is: how can this potential be realized?

• What are the best ideas for preventing, managing, and reversing chronic disease?
• Can lifestyle interventions be delivered effectively on a large scale?
• What types of programs and technologies already exist and what more innovation is needed in this space?
• How do lifestyle interventions fit into the larger framework of a population health management strategy?
• What would a value based model that explicitly rewards lifestyle change look like?
• Is this an idea whose time has come or are the barriers to do this at scale still insurmountable?

I don’t have the answers, but I am on a mission to find some. I can envision a future where programs to help patients lead a healthier lifestyle are not on the fringes, but central to their treatment. Doctors might write out exercise and vegetable prescriptions. People that want to change are given the support they need, but do not feel judged. Those that are reluctant are respected for their personal decisions and given small steps to help them through their own process of change. I could envision a future where people routinely get off their insulin and blood pressure meds and don’t need to see their doctor that often, let alone the ER.

Is this pie in the sky (healthy pie!)? Could we make this happen on a large scale? Tell me what YOU think. Let’s start the conversation.

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Sources

1. Centers for Medicare and Medicaid Services. “National Health Expenditures 2015 Highlights.” https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/downloads/highlights.pdf
2. Centers for Medicare and Medicaid Services. “National Health Expenditure Projections 2015–2025.” https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/Proj2015.pdf
3. Gerteis J, Izrael D, Deitz D, LeRoy L, Ricciardi R, Miller T, Basu J. Multiple Chronic Conditions Chartbook.[PDF — 10.62 MB] AHRQ Publications No, Q14–0038. Rockville, MD: Agency for Healthcare Research and Quality; 2014. Accessed January 27th, 2016.
4. The Partnership to Fight Chronic Disease. “What is the impact of chronic disease on America?” http://www.fightchronicdisease.org/sites/default/files/pfcd_blocks/PFCD_US.FactSheet_FINAL1%20%282%29.pdf
5. American College of Lifestyle Medicine. “What is Lifestyle Medicine?” https://lifestylemedicine.org/What-is-Lifestyle-Medicine
6. The Diabetes Prevention Program Research Group: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346:393–403, 2002.
7. Ornish D, Scherwitz LW, Billings JH, Gould KL, Merritt TA, Sparler S, Armstrong WT, Ports TA, Kirkeeide RL, Hogeboom C, Brand RJ. Intensive Lifestyle Changes for Reversal of Coronary Heart Disease. JAMA. 1998;280(23):2001–2007. doi:10.1001/jama.280.23.2001
8. Quality Payment Program. https://qpp.cms.gov/measures/quality