The Centers for Medicare & Medicaid Services 2022 National Quality Strategy is described as an “ambitious long-term initiative that aims to promote the highest quality outcomes and safest care for all individuals.” It is a commendable goal for an overburdened U.S. health care system that spends more than other high-income counties yet experiences poorer outcomes. But whole-person, person-centered care cannot be achieved under current misaligned quality measures that fail to measure what we purport to value: the quintuple aim of improved health outcomes, cost savings, patient satisfaction, clinician well-being, and health equity.
Lifestyle first
Clinical practice guidelines for many chronic diseases recommend lifestyle intervention as the first and optimal treatment. A growing body of evidence supports lifestyle behavior interventions to treat and, when used intensively, even reverse common chronic conditions such as cardiovascular disease, obesity, and type 2 diabetes, while also providing effective prevention for those conditions. However, no current quality measures consider lifestyle interventions. In fact, some quality measures unintentionally penalize physicians for successfully treating or reversing disease through lifestyle behavior interventions while rewarding clinicians for meeting process measures – usually adherence to medication – regardless of whether health outcomes improved.
Rewarding medication adherence for the treatment of diseases in which lifestyle is a primary therapy (such as hypertension), combined with other health care constraints (lack of lifestyle education, time to spend with patients, and infrastructure support) incentivizes physicians to skip the conversation about lifestyle changes and go straight to medication prescription. Meanwhile, the clinician who takes the extra time to guide a patient toward lifestyle interventions that could treat their current disease and prevent future diseases – without side effects – is penalized.
Misaligned quality measures like these can stifle clinical judgment and risk reducing the practice of medicine to mindless box-checking. In many cases, patients are not even informed that lifestyle behavior change may be a treatment option (much less the first recommended option) for their conditions. This delivery of care is not person-centered and, in fact, may raise questions about the adequacy of informed treatment consent.
Reimbursement barriers
Lifestyle medicine is a growing medical specialty that uses therapeutic lifestyle interventions as a primary modality to treat chronic conditions. Since certification began in 2017, almost 2500 US physicians and 1000 nonphysician health professionals have earned certification. Health systems, including the U.S. military, are increasingly integrating lifestyle medicine. There have been advancements since one survey found that more than half of lifestyle medicine clinicians reported receiving no reimbursement for lifestyle behavior interventions. However, barriers, especially in fee-for-service systems, still inhibit many patients from receiving insurance coverage for comprehensive, interdisciplinary, and whole-person treatments called intensive therapeutic lifestyle change (ITLC) programs.
Existing comprehensive lifestyle programs that patients are eligible for (ie, the Diabetes Prevention Program and intensive behavioral therapy) are often so poorly reimbursed that clinicians and health systems decline to offer them. An example of a well-reimbursed ITLC program is intensive cardiac rehabilitation (ICR), which remains underutilized and limited to a narrow segment of patients, despite ICR›s proven benefits for managing comorbid risk factors such as hemoglobin A1c and weight. Even when lifestyle intervention programs are available and patients are eligible to participate (often through shared medical appointments), patient copays for the frequent visits required to achieve and sustain behavior change – or the lack of reimbursement for interdisciplinary team members – discourage engagement.