by: George E. Guthrie, MD, MPH, FAAFP, FACLM, CDE
In 1957, Rhode Island Democratic congressman Aime Forand1
introduced a new proposal to cover hospital costs for Americans over the age of 65 on social security. Although plans supported by Franklin D. Roosevelt and Harry Truman over the previous 40-50 years had failed, a grassroots effort of the elderly overcame the arguments and political pressures of the American Medical Association and others. The necessary political compromises of private concessions to the doctors (reimbursements of their customary, reasonable, and prevailing fees), to the hospitals (cost plus reimbursement), and to the Republican minority at the time led to the three-part plan we have today -- comprehensive health insurance (“Part A”), a government subsidized voluntary physician insurance (“Part B”), and Medicaid. In 1965, President Johnson signed it into law as part of his Great Society Legislation. We now work in this system developed through over 30 years of legislative and political wrangling.2
Even before the institution of the Medicare payment system the financial incentives of health care were a significant motivator in the business of medicine. The “old family physicians” traditional motivation of the desire to serve has become overshadowed by the business of healthcare—as insurance companies, treatment modalities, and complex delivery systems have grown. Health care workers of many disciplines often come into their chosen profession with a sincere desire to help people, but it seems the educational debt, demands of life, and the system inevitably distort their initial passion. While the marketing messages of insurance, pharmaceutical, and device companies focus on benefits to the patient population, the real motivator is making money for the investor. Conflicts of interest, whether personal or corporate, have distorted the mission, finance, and politics of the health care system and the cost keeps going up.
The expense of health care has been driven up by these forces to the point that the Centers for Medicare and Medicaid Services (CMS) estimates3
that between 2015-25, health spending is projected to grow at an average rate of 5.8 percent per year (4.8 percent on a per capita basis). Health spending is projected to grow 1.3 percent faster than Gross Domestic Product (GDP) per year over this period; as a result, the health share of GDP is expected to rise from 17.5 percent in 2014 to 20.1 percent by 2025. Other experts, such as Paul Zane Pilzer, have estimated that health care will make up 50% of GDP by 2050 unless the trajectory of the disease burden changes.4
During the Obama administration, the Federal government took aggressive steps toward outcomes-based payment systems that would reward those who do the best at preventing disease and avoiding potential complications of treatments. (i.e. reducing costs). Health Care systems that successfully implement lifestyle medicine preventive services-- primary, secondary and tertiary – will be positioned to be the most successful in reducing costs and bringing meaningful health change.
It is instructive to note that an outcomes-based payment system will allow actionable evidence of treatment success and a measure of relative effectiveness that does not require the randomized control trial (RCT) for implementation. In the world of business, and that includes medical business, the Plan-Do-Study-Act cycle5
(or other similar improvement cycles) suffices if it shows cost savings. As RCT’s are not likely to be funded to directly compare drug and lifestyle treatments, this is likely the most effective method to introduce the principles of lifestyle medicine into our health care culture. Money has been talking through pharmaceutical, device, and insurance companies, but pay-for-performance billing will level the field and create a powerful advocacy for lifestyle medicine practices. By speaking directly to the pocket book, pay-for-performance bypasses much of the political posturing and the practical delay usually seen between acceptance of a truth and its implementation.
The American College of Lifestyle Medicine (ACLM) is a group of physicians, medical professionals, and allied health professionals trying to spread awareness of the power of lifestyle treatment of chronic disease among the allopathic medical community. It is a place where clinicians and trainees can learn about evidence-based lifestyle medicine treatments and learn how to successfully incorporate lifestyle medicine principles into their practices. Additionally, the ACLM works with the American College of Preventive Medicine (ACPM), which focuses more on population health and public health policy
The ACLM wants to help providers and patients prevent, treat, and potentially reverse chronic disease with intensive lifestyle interventions.6,7,8
With a Lifestyle Medicine board certification now available, the ACLM hopes that every community will have Lifestyle medicine specialists. Physicians will be able to refer their challenging patients to these clinicians who will utilize a team approach to provide evidence-based, intensive lifestyle medicine treatments to restore health.
The influence of the relatively small, but rapidly growing, ACLM will be made more effective by working in parallel to larger pressing societal trends, rather than by aggressively opposing the health-destructive forces of the United States. There is good reason for the ACLM to applaud and engage in efforts to implement an outcomes-based payment system, while continuing to apply lifestyle medicine principles in personal practices. It is much better to be “discovered” by society as a great way to save money than as a direct threat to specific industries. Change will come slowly, but the end result will be worth it.
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Tracing the History of CMS Programs: From President Theodore Roosevelt to President George W. Bush https://www.cms.gov/about-cms/agency-information/history/downloads/presidentcmsmilestones.pdf. Accessed December 16, 2016.
 Palmer KS, A Brief History: Universal Health Care Efforts in the US
http://www.pnhp.org/facts/a-brief-history-universal-health-care-efforts-in-the-us. Published Spring, 1999. Accessed December 12, 2016.
 CMS, National Health Expenditure Projections 2015-2025 https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/Proj2015.pdf Published 2015, Accessed 12/13/2016
 Paul Zane Pilzer The Wellness Revolution. San Francisco, CA. Wiley Press, 2002.
Institute for Health Care Improvement (IHCI). How to Improve. http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx. Accessed December 13, 2016.
 Ornish D, Scherwitz LW, Billings JH,
et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998;280:2001-2007. doi:10.1001/ jama.280.23.2001.
 Esselstyn CB Jr, Gendy G, Doyle J, Golubic M, Roizen MF. A way to reverse CAD? J Fam Pract. 2014;63:356-364.
 Taylor R. Banting Memorial Lecture 2012: reversing the twin cycles of type 2 diabetes. Diabet Med. 2013;30:267-275. doi:10.1111/dme.12039.