Lifestyle Medicine Reimbursement: A Proposal for Policy Priorities Informed by a Cross-Sectional Survey of Lifestyle Medicine Practitioners

Abstract

Lifestyle medicine (LM) is a rapidly emerging clinical discipline that focuses on intensive therapeutic lifestyle changes to treat chronic disease, often producing dramatic health benefits. In spite of these well-documented benefits of LM approaches to provide evidence-based care that follows current clinical guidelines, LM practitioners have found reimbursement challenging. The objectives of this paper are to present the results of a cross-sectional survey of LM practitioners regarding lifestyle medicine reimbursement and to propose policy priorities related to the ability of practitioners to implement and achieve reimbursement for these necessary services. Results from a closed, online survey in 2019 were analyzed, with a total of n = 857 included in this analysis. Results were descriptively analyzed. This manuscript articulates policy proposals informed by the survey results. The study sample was 58% female, with median age of 51. A minority of the sample (17%) reported that all their practice was LM, while 56% reported that some of their practice was LM. A total of 55% of practitioners reported not being able to receive reimbursement for LM practice. Of those survey respondents who provided an answer to the question of what would make the practice of LM easier (n = 471), the following suggestions were offered: reimbursement overall (18%), reimbursement for more time spent with patients (17%), more support from leadership (16%), policy measures to incentivize health (13%), education in LM for practitioners (11%), LM-specific billing codes and billing knowledge along with better electronic medical record (EMR) capabilities and streamlined reporting/paperwork (11%), and reimbursement for the extended care team (10%). Proposed policy changes focus on three areas of focus: (1) support for the care process using a LM approach, (2) reimbursement emphasizing outcomes of health, patient experience, and delivering person-centered care, and (3) incentivizing treatment that produces disease remission/reversal. Rectifying reimbursement barriers to lifestyle medicine practice will require a sustained effort from health systems and policy makers. The urgency of this transition towards lifestyle medicine interventions to effectively address the epidemic of chronic diseases in a way that can significantly improve outcomes is being hindered by current reimbursement policies and models.

Lifestyle Medicine Practitioners Implementing a Greater Proportion of Lifestyle Medicine Experience Less Burnout

“…10,13,14,24,49,50 Specific to this sample, our previous analysis of this same survey data indicates that 55% of LM practitioners reported frustration at not being able to receive reimbursement for utilizing LM in their practice, as well a lack of support for LM practice from colleagues and administrators. 51 The results of this analysis suggest that the team approach of LM, incorporating dietitians, coaches, exercise physiologists, health educators and others, 52-55 may address feelings of isolation within an ineffective system that respondents in this survey describe as rewarding volume over value. 12,46…”

“…Additionally, a previous analysis of the survey data presented here found that LM treatment is poorly aligned with current reimbursement pathways. 25 Thus, while some LM practitioners exclusively practice LM, others incorporate LM into their practice to varying degrees. Those able to integrate a greater degree of LM bring more health behavior education and behavior change into their patient encounters, which may occur in the form of one-on-one counseling during an appointment, referral to a dietitian or health coach, or deployment of shared medical appointments (SMAs) for health education.…”

American College of Lifestyle Medicine Expert Consensus Statement: Lifestyle Medicine for Optimal Outcomes in Primary Care

“…This survey identified reimbursement challenges, including those related to spending more time with patients and payment for the extended care team, as primary obstacles to providing LM services. 91…”

“…This assessment aligns with survey results of LM practitioners demonstrating that 59% of respondents reported difficulty achieving sufficient reimbursement from SMAs due to the unpredictability of adequately filling the group visit during normal operating hours of operation and the challenge of obtaining compensation for services provided in non-healthcare community settings, which despite being more convenient for patients lack an NPI number for reimbursement. 91 Some clinicians successfully provide LM services in the FFS model using standard evaluation and management billing codes (99202-99215), chronic care management (CCM) and remote patient monitoring (RPM) codes and a multidisciplinary care team utilizing several billable provider types (physician, NP, PA, RDN, PT/OT, licensed behavioral counselor), including SMAs. 90,92 However, alternative payment models that adequately reimburse the time-intensive, comprehensive approach to supporting health behavior change that is necessary to achieve an optimal therapeutic dose leading to improve clinical outcomes are desperately needed to accelerate the integration of LM into primary care.…”

“…This survey identified reimbursement challenges, including those related to spending more time with patients and payment for the extended care team, as primary obstacles to providing LM services. 91 Our expert panel members agreed that reimbursement issues pertaining to LM services are one of the principal challenges impeding the implementation of this approach. There was strong consensus supporting the need for reimbursement models that incentivize effective collaboration with patients to implement evidence-based lifestyle change as a necessary step for successfully integrating LM into primary care.…”