The President’s Report from Dexter Shurney

Letter to the Chair of the Senate Committee on Health, Education, Labor, and Pensions (HELP)

By ACLM President Dexter Shurney, MD, MBA, MPH, FACLM

 


The Honorable Lamar Alexander
United States Senate

Dear Senator Alexander:

We are writing on behalf of the American College of Lifestyle Medicine (ACLM) in response to your request as Chair of the Senate Committee on Health, Education, Labor, and Pensions (HELP) to medical and healthcare experts for specific recommendations to help address America’s rising healthcare costs.  The ACLM is the world’s flagship professional medical association for physicians, clinicians, and allied health professionals, devoted to advancing lifestyle medicine.

We agree with your assessment that “…we will never get the cost of health insurance down until we get the cost of health care down.” While it is widely speculated that as much as 30-40% of healthcare spending in America is unnecessary due to waste and inefficiencies in the delivery of care, it is also the case, but less recognized or reimbursed that an unhealthy lifestyle is the root-cause of most common chronic illness. We have a health care system that perpetuates illness vs wellness and compensates for acute care episodes vs lifestyle and preventive care. Moving to value-based care is only part of the solution if we are to reverse the trends of health care costs.

It is widely recognized in the U.S. that approximately 80% of non-communicable disease such as type-2 diabetes, heart disease, stroke, hypertension, cancer, and osteoporosis are preventable primarily through lifestyle.[i] These diseases can also be effectively treated by lifestyle medicine interventions that involve the use of evidence-based lifestyle therapeutic approaches, such as a whole food, predominantly plant-based diet, regular physical activity, adequate sleep, stress management, avoidance of risky substance use. Such  non-drug modalities, used in combination to prevent, treat, and, oftentimes, reverse the lifestyle-related, chronic disease have been shown to be both clinically efficacious and cost-effective.[ii] In line with the tenets of value-based care, a 2012 study published in the Journal of the American Medical Association (JAMA) found that Intensive lifestyle intervention for type-2 diabetic patients were 5.75 times more likely to experience remission compared to those receiving traditional diabetes support and education.[iii][1]

These same, all too prevalent, conditions are also responsible for generating a disproportionate amount of the rising U.S. healthcare cost burden. For example, in the US, the cost of obesity alone to society is enormous: $116 billion/year, 60% of which is attributable to severe obesity.[iv] The average cost of obesity in adults paid for by publicly funded programs (tax dollars) is 41% for adults ≤65 years, and 73% for adults >65 years. iv  Of all healthcare dollars spent, 86% are attributable to chronic conditions[v] and the US spends 18% of its gross national product ($3.35 trillion) on health expenditures.[vi] The Federal Congressional Budget office estimates Medicaid and Medicare alone will account for 20% of the GDP by the year 2050,[vii] placing the US at risk of financial insolvency. Employers also absorb substantial costs for the top five chronic conditions: $11.2 billion (obesity), $10.3 billion (hypertension) $9.1 billion (physical inactivity), $3.6 billion (current smoking), and $2.2 billion (diabetes); or $36.4 billion in total,[viii] and are thus intrinsically motivated to reduce rates of chronic health conditions, particularly for those employers who are self-insured.

Ken Beckman, a healthcare actuary and member of ACLM, summed up the situation nicely in a recent Washington Post Op-ed submission:

“Until the underlying root causes of chronic disease are addressed, more disease will be diagnosed, costs will continue to increase and no amount of preventative screening or care coordination will change that. 

Lifestyle Medicine is the missing link in the ongoing health care reform debate. The research evidence is clear that conditions such as heart disease, Type 2 diabetes, high blood pressure and even arthritis and erectile dysfunction do not have to be permanent or treated with prescription drugs, but in many cases, can be reversed simply by using whole food plant-based nutrition. 

Rather than trying to figure out who is going to pay for the ever-increasing care costs, the focus needs to be on reducing demand for healthcare by reversing chronic disease. A Lifestyle Medicine-first approach to health care will stop the present protocol of managing chronic conditions using prescription drugs and preventative measures that fail to address the underlying cause of disease, which is draining the pocketbooks of Americans.” 

In response to your three questions, as healthcare practitioners and scientists The American College of Lifestyle Medicine proposes the following recommendations:

  1. What specific steps can Congress take to lower health care costs, incentivize care that improves the health and outcomes of patients, and increase the ability for patients to access information about their care to make informed decision?

    Recommendations:

    • Recognize and incentivize the practice of LM as the foundation of health and healthcare
    • Direct the Administration to make education and adoption of LM a priority through leaders such as the Secretary of Health and Human Services (HHS) and the Surgeon General and agencies such as the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), the Agency for Health Research and Quality (AHRQ), the Health Resources and Services Administration (HRSA) and the Centers for Medicare & Medicaid Services (CMS)
    • Authorize new and amend existing federal health care workforce programs to incentive the health practitioners to pursue careers in LM
    • Hold Congressional hearings on the evidence showing improved health status and cost savings resulting from LM
    • Direct CMS to test through the Center for Medicare and Medicaid Innovative new reimbursement models focused less on procedures and centered on LM and their impact on– cost, quality, and overall health status.
    • Direct CMS to incentivize the adoption of LM through the authorization of reimbursement reforms in federal health programs such as Medicare and Medicaid
    • Direct the Medicare Payment Advisory Commission (MedPAC), the Medicaid and CHIP Payment and Access Commission (MACPAC) and the General Accountability Office (GAO) to examine the impact of LM on cost, quality of LM with the populations covered by federal health programs including Medicare and Medicaid

       

  2. What does Congress or the administration need to do to implement those steps? Operationally, how would these recommendations work?

    Recommendations:

    • Commission a Blue-ribbon panel to draft appropriate payment and treatment guideline policies to support the practice of LM
    • Encourage LM training in medical school curricula and along with some minimal CME requirements such as is currently done with opioids
    • Direct CMS and AHRQto examine the impact of LM on cost, quality of LM with the populations including Medicare
    • Promote the adoption of LM in Medicare by creating more flexibility in reimbursement and coverage requirements in both Medicare Advantage and traditional fee-for-service as well as in Medicaid

       

  3. Once implemented, what are the potential shortcomings of those steps, and why are they worthy of consideration despite the shortcomings?

Recommendation:

  • Pressure from various industry interest groups to maintain the status quo – to truly capture savings in our healthcare system, more focus on LM is critical[2]
  • Assure that solutions are both short term and long range

Thank you for your consideration and attention to our recommendations. We also stand ready to meet with you or your committee at any time to answer questions and discuss at a more granular level how our recommendations could work and be implemented.

Sincerely,

Dexter W. Shurney, MD, MBA, MPH, FACLM
President, of the American College of Lifestyle Medicine (ACLM)

Susan Benigas
Executive Director, American College of Lifestyle Medicine (ACLM)

 

[1]


[i] Katz D, Fretes B, et al. Lifestyle as Medicine: The Case for a True Health Initiative. American Journal of Health Promotion 2018; Volume: 32 issue: 6, page(s): 1452-1458

[ii] Shurney D, Hyde S, Hulsey K, Elam R, Cooper A, Groves J. CHIP lifestyle program at Vanderbilt University demonstrates an early ROI for a diabetic cohort in a workplace setting: a case study. Journal of Managed Care Medicine 2012; 15(4): 5-15

[iii]Gregg E, Chen H, et al. Association of an Intensive Lifestyle Intervention with Remission of Type 2  Diabetes.  JAMA 2012 Dec 19: 308(23): 2489-2496

[iv] Wang YC, Pamplin J, Long MW, Ward ZJ, Gortmaker SL, Andreyeva T. Severe Obesity In Adults Cost State Medicaid Programs Nearly $8 Billion In 2013. Health Aff (Millwood). 2015;34(11):1923-1931.

[v] Gerteis J, Izrael D, Deitz D, et al. Multiple chronic conditions chartbook. Rockville (MD): Agency for Healthcare Research and Quality; 2014. In: AHRQ Publications; 2014.

[vii] Orszag PR, Ellis P. The challenge of rising health care costs-a view from the Congressional Budget Office. N Engl J Med. 2007;357(18):1793.

[viii] Asay GRB, Roy K, Lang JE, Payne RL, Howard DH. Peer reviewed: absenteeism and employer costs associated with chronic diseases and health risk factors in the US workforce. Prev Chronic Dis. 2016;13.

Additional References:

1.            O'Neil CE, Keast DR, Fulgoni VL, Nicklas TA. Food sources of energy and nutrients among adults in the US: NHANES 2003-2006. Nutrients. 2012;4(12):2097-2120.

2.            Mattei J, Sotos-Prieto M, Bigornia SJ, Noel SE, Tucker KL. The Mediterranean Diet Score Is More Strongly Associated with Favorable Cardiometabolic Risk Factors over 2 Years Than Other Diet Quality Indexes in Puerto Rican Adults. J Nutr. 2017;147(4):661-669.

3.            Le LT, Sabate J. Beyond meatless, the health effects of vegan diets: findings from the Adventist cohorts. Nutrients. 2014;6(6):2131-2147.

4.            Yokoyama Y, Nishimura K, Barnard ND, et al. Vegetarian diets and blood pressure: a meta-analysis. JAMA Intern Med. 2014;174(4):577-587.

5.            Turner-McGrievy GM, Davidson CR, Wingard EE, Wilcox S, Frongillo EA. Comparative effectiveness of plant-based diets for weight loss: a randomized controlled trial of five different diets. Nutrition. 2015;31(2):350-358.

6.            Barnard ND, Cohen J, Jenkins DJ, et al. A low-fat vegan diet and a conventional diabetes diet in the treatment of type 2 diabetes: a randomized, controlled, 74-wk clinical trial. Am J Clin Nutr. 2009;89(5):1588S-1596S.

7.            Turner-McGrievy GM, Wirth MD, Shivappa N, et al. Randomization to plant-based dietary approaches leads to larger short-term improvements in Dietary Inflammatory Index scores and macronutrient intake compared with diets that contain meat. Nutr Res. 2015;35(2):97-106.

8..          Jenkins DJ, Wong JM, Kendall CW, et al. Effect of a 6-month vegan low-carbohydrate ('Eco-Atkins') diet on cardiovascular risk factors and body weight in hyperlipidaemic adults: a randomised controlled trial. BMJ Open. 2014;4(2):e003505.

10.         Macknin M, Kong T, Weier A, et al. Plant-Based, No-Added-Fat or American Heart Association Diets: Impact on Cardiovascular Risk in Obese Children with Hypercholesterolemia and Their Parents. J Pediatr. 2015;166(4):953-959 e953.

11.         Scientific Report of the 2015 Dietary Guidelines Advisory Committee. 2015.

12.         Health UDo, Services H. 2015–2020 dietary guidelines for Americans. Washington (DC): USDA. 2015.

13.         Van Horn L, Carson JA, Appel LJ, et al. Recommended Dietary Pattern to Achieve Adherence to the American Heart Association/American College of Cardiology (AHA/ACC) Guidelines: A Scientific Statement From the American Heart Association. Circulation. 2016;134(22):e505-e529.

14.         Grosso G, Marventano S, D'Urso M, Mistretta A, Galvano F. The Mediterranean healthy eating, ageing, and lifestyle (MEAL) study: rationale and study design. Int J Food Sci Nutr. 2017;68(5):577-586.

 

15.         Jonsson T, Granfeldt Y, Ahren B, et al. Beneficial effects of a Paleolithic diet on cardiovascular risk factors in type 2 diabetes: a randomized cross-over pilot study. Cardiovasc Diabetol. 2009;8:35.

16.         Micha R, Penalvo JL, Cudhea F, Imamura F, Rehm CD, Mozaffarian D. Association Between Dietary Factors and Mortality From Heart Disease, Stroke, and Type 2 Diabetes in the United States. JAMA. 2017;317(9):912-924.

17.         Esselstyn CB, Jr. Updating a 12-year experience with arrest and reversal therapy for coronary heart disease (an overdue requiem for palliative cardiology). The American journal of cardiology. 1999;84(3):339-341, A338.

18.         Macknin M, Kong T, Weier A, et al. Plant-based, no-added-fat or American Heart Association diets: impact on cardiovascular risk in obese children with hypercholesterolemia and their parents. The Journal of pediatrics. 2015;166(4):953-959.e951-953.

19.         de Souza RJ, Swain JF, Appel LJ, Sacks FM. Alternatives for macronutrient intake and chronic disease: a comparison of the OmniHeart diets with popular diets and with dietary recommendations. Am J Clin Nutr. 2008;88(1):1-11.

20.         Ornish D, Scherwitz LW, Billings JH, et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998;280(23):2001-2007.