ACLM Lifestyle Medicine Newsletter

The Sweet Spot for Lifestyle Medicine in Health Reform

 By Dexter Shurney, MD, MBA, MPH, FACLM, DipABLM

This is an article to help inform the various conversations occurring among the stakeholders in Lifestyle Medicine. Of all the stakeholders in health care, it is employers and consumers who have the greatest motivation for reforming the current system. Few feel the pain of rising costs and sub-optimal outcomes than they do, as little has changed recently in our fee-for-service world of chronic disease management using ever more drugs and procedures which for the most part fail to address the root-causes of our increasingly dire health care predicament.

Only employers have enough influence "buying power" to facilitate change. Arguably, the government programs of Medicaid, Medicare, the VA and Tricare also do, but are hamstrung by being slow, bureaucratic behemoths.

Even with buying power, in my opinion few in those ranks know what to do to make a real difference. And while motivated, consumers find themselves alone, at the mercy of insurance companies and health care-related politics du jour.

Despite the lip-service given to lowering costs, most every health care-related entity stands to profit from the expansion of caring for the ill. In other words, more sick people mean more revenue. To no fault of theirs, THAT is the current health care business model. Is there any wonder that over the course of decades we have experienced such lack of success in controlling health care costs when there is really little incentive to change the system or to reverse/prevent disease?  

Have you ever heard a health system make the following kind of statement: “We performed 50 percent fewer procedures and our admission rates were equally reduced…what a wonderful year!”?  In fact, chose any health care industry organization and ask the fundamental question of business model. And while there are some notable exceptions the following is generally what you find:
  • For pharmaceutical companies and pharmacy benefits managers, more prescription medication prescribing means more profits.  
  • For hospitals, more admissions mean more profits (think of hotels-- empty beds in either scenario is undesirable and unprofitable).
  • For health Insurance companies, most generate the majority of their revenues from administrative service contracts with self-insured employers that equal a percentage of claims costs. Therefore, higher health care costs translate directly into more topline revenue for the plan.  The other side of the plan business is what people typically think of as “insurance” or underwritten business, where they charge the customer a premium for coverage. Fortunately, or unfortunately, when they experience a rate funding loss, they merely go to the state insurance commissioner and ask permission to raise premiums. This is seldom denied. (Negotiating goes like this...ask for a 40 percent increase and you get 18-20 percent. Not bad!).  Then there’s the Medical Loss Ratio (MLR) provision that also acts to incentivize higher costs, not less. Under this provision, plans must spend 80-85 percent of their premium dollars on the cost of care leaving 15-20 percent for administrative costs and fees. Sounds good, but a reduction on the cost of care also means less available to the plan in administrative dollars to fund overhead and staff.
  • For physicians, having more sick patients means more visits and more procedures for which to bill, and for the sicker patients you get to bill even more. Think about some of the incentives for High Cost Claimants (HCCs).

Unfortunately, employers all too often go these health care entities that for the most part are financially misaligned with what the employer is really trying to do around controlling costs to help advise them! But this is for another article.

The bottom line is healthy people don't need pills, procedures or hospitals, but the existence of too many healthy people is not good for the so-called "health care” industry…or should we say the "sick care” industry.

Employers, on the other hand, want value for their health care dollars, especially as they have more employees with high-cost illnesses like Type 2 diabetes, heart disease and cancer. We typically have defined “value” as quality divided by cost. However, this definition of value is not sufficient in today’s health care world. Purchasers expect to have good quality and service and access as well. And, yet for all the time and effort spent on improving quality metrics, we have not seen anything in the way of a corresponding payoff in reduced costs or, do I dare say, in the overall health status in the United States -- think U.S. obesity rates, diabetes prevalence, cancer rates, etc. Now, no one is suggesting that we abandon the efforts to continue to improve the quality of care. Rather, only that we add Lifestyle Medicine to the mix and include metrics that also incentivize lifestyle approaches to care that are able to address the root-causes of our ails.

Employers stand to gain when their work force is healthy. Overall, however, when they look for improved value, they are looking in all the wrong places. What if they focused on addressing the root cause of most chronic disease by implementing Lifestyle Medicine programs?

A lot is being said about value-based care.  That said, the number of downside risk contracts on a national level are in the single digits. We should argue that Lifestyle Medicine is the ultimate in value-based care   since it addresses the root cause that none of the other strategies can address. Lifestyle Medicine is the most powerful form of medicine since it has been shown to be effective in the prevention of disease (thus addressing the issue of a growing chronic disease prevalence), the treatment of disease, and even the reversal of disease for many common chronic conditions.  This approach to care results in better outcomes and lower costs, the very definition of value-based care.

Of the 12 current micro-trends in health care I have identified in the slide below, Lifestyle Medicine is number eight, and actually has a place in each with the exception of #11- Medical Marijuana.

Lifestyle Medicine is the answer for both employers and consumers to lower costs and improve outcomes—to create real health care reform. One newly announced resource from ACLM, Making the Case for Lifestyle Medicine in the Workplace, may be of interest in incorporating LM into the corporate world. Members can obtain this in the members’ only section of our website: