Making dollars and sense of lifestyle medicine

Physicians frustrated with treating patients who are sick instead of helping them stay well are turning toward preventive and lifestyle medicine techniques. However, a new practice philosophy can be risky, possibly costing patients and dollars. Experts say that with the right strategy, practices that invest in lifestyle medicine now are at the forefront of the next big change in healthcare.

In 2007, John Principe, MD, was close to quitting medicine after 20 years of practicing primary care medicine in Palos Heights, Illinois. He was losing his passion for healthcare, but gaining an interest in cooking. He decided to attend the Harvard Healthy Kitchen’s Healthy Lives Program, and realized that lifestyle medicine was the answer to aligning his business with his new interests. The transition has not been an easy one, however.

“Many of (my patients) embraced the change in focus. Others were resistant and did leave the practice as this approach was not the pill for every ill they were accustomed to. They also tended to be patients that were passive about their healthcare,” Principe says. He still practices primary care, but his office now offers massage therapy, acupuncture, nutritional counseling, and classes on stress reduction and physical activity. His office even has a kitchen where he teaches patients healthy cooking.

“It is a difficult process that requires much time and energy,” says Principe, now in his third year with his overhauled practice, WellBeingMD. “It requires you to go against the tide of healthcare reform, but in the end, it can be one of the most rewarding and satisfying professional endeavors that one can undertake.”

Principe is one of a growing number of physicians who are diving into lifestyle and preventive medicine.
“We hear doctors saying, ‘I just want to help people get healthier, and I want to get paid for it.’ The big question they ask is, ‘how do we make money from this?’” says Edward Phillips, MD, assistant professor of physical medicine and rehabilitation at Harvard Medical School. In 2007, Phillips founded the Institute of Lifestyle Medicine (ILM) at Harvard University.

“When I looked at the medical marketplace, there was about $3 trillion spent on sickness and about $500 million spent on wellness. No one was preparing doctors for the new realities that many of the illnesses we were treating were non-communicable diseases. We were not prepped in medical school to talk about exercise, nutrition, and smoking cessation. So we aimed to retrofit doctors to handle the epidemics of physical inactivity and obesity,” Phillips says.

Since its inception, ILM has had more than 6,800 clinicians worldwide take online and in-person classes covering topics such as weight and stress management, prescribing exercise, and nutrition. Phillips says that he is beginning to see interest from Patient-Centered Medical Homes, accountable care organizations (ACOs) and hospital administrators. “We are on the verge of moving beyond the early adopters,” he says.

What Is Lifestyle Medicine?

In July 2010, the Journal of the American Medical Association published results of a 2-year project with the American College of Lifestyle Medicine and the American College of Preventive Medicine, outlining lifestyle medicine standards for primary care physicians. The study included 15 evidence-based standards for smoking cessation, nutrition, exercise, and other behaviors linked to chronic conditions.

The study made a distinction between lifestyle medicine and other alternative and complementary treatments. “Lifestyle medicine allows physicians to stay in an evidence-based place. Integrated medicine isn’t evidence-based. This is the first step in recognizing the current healthcare system is very sick itself,” says Wayne Dysinger, MD, MPH, director of the Lifestyle Medicine Institute, chair of the Department of Preventive Medicine and director of the Lifestyle Medicine Track of the Family and Preventive Medicine Residency at Loma Linda University.

Dysinger has also seen the rise of interest in lifestyle medicine in the past few years. The American College of Lifestyle Medicine started its annual conference in 2011, attracting 50 clinicians. This year, Dysinger expects more than 300 clinicians to attend the October conference. He continues to give presentations and seminars to a growing number of interested physicians.

“Doctors want to practice cost-effective, evidence-based medicine, that is also value-driven healthcare,” Dysinger says. “There is evidence that sending someone through an intensive therapeutic lifestyle change program is cheaper and works just as well if not better than surgical procedures.”

Lifestyle Medicine in Practice

Doctors are already moving toward advising patients about their lifestyle choices. In 2010, more than 30% of adults were advised to begin or continue exercise, a 10% increase from 2000, according to the National Health Interview Survey conducted by Centers for Disease Control and Prevention. Training in lifestyle medicine takes this a step further in helping doctors to lead patients, while empowering them to make health choices.

“We are teaching doctors how to build a relationship with patients. If you feel you are wrestling with a patient, this training will make you feel like you are dancing. Fundamentally, it’s a different way to approach the patient,” Phillips says. “I have to pass the power to the patient through psychological coaching and motivational interviewing.”

Physicians can use continuing medical education (CME) units to take classes to learn more about lifestyle medicine. Some organizations offer additional classes outside of CMEs for specialization, and Loma Linda University in Southern California offers the nation’s only master of public health degree in lifestyle medicine.

Training through classes and conferences might include ways to write prescriptions for exercise, detailed to steps per day, target heart rate and days per week. Clinicians are also taught to discuss behaviors and attitudes that lead to poor lifestyle choices. Phillips recognizes that this type of conversation and relationship-building may not come naturally to busy clinicians.

“You can’t ask people to do something they haven’t been trained to do. We talk about behaviors: how many glasses of water per day, and how many fruits and vegetables per day. In our classes, we do exercises on how you say it, and how you write an exercise prescription,” Phillips says.

The Business of Lifestyle Medicine

There are several different models that primary care physicians (PCPs) and specialists can adopt to incorporate lifestyle medicine in their practices, says Sandy Lawson, co-owner of SD Lawson and Associates and executive director of ILM. “PCPs are well positioned to be successful in lifestyle medicine. With specialists it can take more time and can be more costly,” Lawson says. “We are currently at a stage where doctors are providing preventive services, but they are still being underpaid under the fee-for-service model. They just have to be creative in ways they set up their practices.”

Integrating lifestyle medicine philosophy into every patient interaction through using books and videos are easy, low-cost ways to teach patients about chronic disease prevention. Some PCPs also choose to identify patients who already have problems exacerbated by poor lifestyle choices and offer special services. For example, group appointments that include 10 to 15 patients can offer a series of classes on nutrition and stress management that can be billed to Medicare.

“These are still medical visits around the lifestyle problems that the patients are facing, so it would fall under fee for service,” Lawson says, adding that extra services including fitness and cooking classes are billed separately and paid by the patient.

Specialists often have to be qualified to provide new services by payers and set up separate offices and support services to begin practicing lifestyle medicine. Most specialists also rely on referrals from PCPs or other specialists such as cardiologists, and direct marketing to patients for business.

Lawson also encourages all physicians practicing lifestyle medicine to add ancillary services for additional revenue streams. “I haven’t seen one lifestyle medicine practice that hasn’t been enhanced through other services. Many doctors rent space to yoga teachers and other specialists who charge patients separately, but then the doctor gets paid in rent. Some do extensive training in vitamins and supplements, learning what works and what doesn’t, and have relationships with those companies to sell products a la carte to patients,” he says.

Physicians range between small, incremental changes to add lifestyle medicine into their practices; or drastic changes to their whole practices, where patients pay directly for personalized wellness services. Principe admits that converting his practice to one geared toward lifestyle medicine was costly, but he has no regrets.

“It was a large financial commitment to make these changes as we re-built our physical space to incorporate a teaching kitchen and educational center,” Principe says. “To be truly a physician and health care protector will take courage, dedication and patience.  It truly is the road less travelled.”