President's Desk, March 2013
Liana Lianov, MD, MPH, FACPM

Challenges in Lifestyle Medicine
If you have a passion to pursue a practice that prioritizes lifestyle medicine, you are likely aware of the evidence to support the need for lifestyle medicine interventions. You are also likely familiar with the challenges of implementing them. The crux of lifestyle medicine is the ability to support our patients’ behavior change. Health behavior change can be achieved by effectively negotiating the appropriate lifestyle prescription which the patient is ready to pursue, referring to community and technology resources and assuring the patient obtains intensive support.

However, the US Preventive Services Task Force gives a C grade for counseling for healthful diet and physical activity for prevention of cardiovascular dieases. Studies have not shown efficacy, probably because the providers are unable to offer the intense counseling that is required. Time constraints and lack of training and confidence in counseling present barriers. 

Hence an important lifestyle medicine competency is the ability to work in the context of the multidisciplinary health care team, in which team members offer the intensive counseling and support. The primary provider is then challenged to engage with the patient in shared decision making about an action plan and proactively refer him to the team member. Effective clinical settings are designed to routinely navigate the patient to the appropriate team members for intensive interventions and support and to assure patient follow-up.

A practice dedicated to lifestyle medicine may differ from primary care by allowing the primary provider the necessary time for intensive counseling. Even in those settings, patients may benefit by getting additional support from other health care team members. But integrating multi-disciplinary providers requires special practice flow and reimbursement considerations.

A couple of reimbursement models have been presented at ACLM workshops: 1) working with a health psychologist within the same practice setting who can independently bill for counseling time and 2) group visits or shared medical appointments. Group visits allow the provider the opportunity to efficiently attend to all patients in the group, leaving time for group education and counseling. Unfortunately, the provider can bill for the clinical encounters in the shared medical appointment, but not the education sessions.

Clearly, and rightfully so, the mantra in the lifestyle medicine community has been the urgent need for better reimbursement models. Intensive counseling is costly, but costs less than treating chronic diseases. The Centers for Medicare and Medicaid recognized the need for more intensive counseling by offering reimbursements for the Ornish and Pritikin programs for heart disease patients who meet certain criteria and for counseling obese patients. Since intensive counseling could potentially benefit patients with other conditions, we need to advocate for and pursue research to confirm improved outcomes for other groups. Demonstrating such outcomes is the main path for securing adequate reimbursement.

However, this pursuit faced an additional set back recently. A study published in the December 19th edition of JAMA reported higher diabetes remission rates after bariatric surgery in obese patients.  As a result, providers and patients may look to this “effective” treatment more frequently. But, this procedure is much more costly and has greater morbidity.

Again the lifestyle medicine community needs to respond to these kinds of studies by advocating for high-quality research that investigates the right questions. For example how does bariatric surgery measure up to intensive counseling supported with phone coaching and mobile programs in achieving improved outcomes? How do side effects, cost, and long-term sustainability compare?

These examples highlight the kind of challenges we face as we seek to gain recognition for and emphasis on lifestyle interventions by providers, payers, patients, and the public. I am confident that we are up to the challenge.