The United States spent a record $4.1 trillion on health care in 2020. Health inequalities, which cost us $320 billion a year, are on track to exceed $1 trillion by by 2040, an increase that would cost the average person $3,000 a year, up from $1,000 today. Chronic diseases, one of the main drivers of health care costs, affect 6 in 10 American adults.
If we are serious about changing the unsustainable trajectory of health care spending in the United States, it’s time to stop just managing disease and finally start tackling the root causes of chronic disease and their associated costs.
The good news is that the majority of these chronic conditions, from diabetes to heart disease and more, are lifestyle-related. This means that many of them are not only preventable, but treatable and even reversible with lifestyle-related behavioral changes.
As the White House prepares for its Sept. 28 conference on hunger, nutrition, and health—the first of its kind 50 years from now – it’s time to change not only the way we talk about chronic disease, but also the way we prepare healthcare professionals to help patients make lasting lifestyle changes and improve financial incentives for that clinicians do it successfully.
Prevention is not enough
Most health care strategies aimed at reducing the incidence of disease focus on prevention. But, with so many people already sick, this is not enough, either for those currently suffering or as an effective measure to cut costs. There is growing evidence that common chronic diseases, including diabetes and heart diseaseare treatable and reversible with sufficiently dosed therapeutic lifestyle medicine interventions. Lifestyle medicine is an evidence-based specialty that leverages behavior change in areas such as nutrition and physical activity to address the underlying cause of chronic non-communicable diseases, without the exorbitant cost many other actions.
Consider diabetes, which affects 37 million Americansthe vast majority of whom have type 2 diabetes. According to the American Diabetes Association, they incur an average of $16,750 per year in medical expenses, about 2.3 times more than people without diabetes. By 2030, the prevalence of type 1 and type 2 diabetes is expected to increase by 54% and cost more than $622 billion per year. One in five teenagers has prediabetes.
Most treatment plans are prescribed only to manage diabetes. Such an approach is better than leaving a disease untreated, but ultimately results in an ever-increasing use of drugs and procedures. Instead, the goal should be to achieve a clinical outcome of type 2 diabetes remission. Indeed, an expert consensus statement published by the American College of Lifestyle Medicine concluded that it is possible to achieve remission through diet alone. Hardly an outlier, this statement has been endorsed by the American Association of Clinical Endocrinology, supported by the Academy of Nutrition and Dietetics, and co-sponsored by the Endocrine Society.
What if our system offered financial incentives to primary care providers to support lifestyle interventions, offering an annual bonus payment if and when patients maintain remission? According to a 2018 modeling study, this approach could generate substantial future cost savings, potentially reducing costs by thousands of dollars per patient treated each year. Such savings will benefit the overburdened healthcare system as well as patients, 41% of whom report financial hardship due to medical bills. Similar potential economic benefits have been identified for other lifestyle medicine interventions targeting conditions such as obesity, high blood pressure, and liver disease.
Obstacles to progress
So why isn’t lifestyle medicine more widely practiced?
One obstacle is training.
In 1985, the National Academy of Sciences recommended a minimum of 25 hours of nutrition education, but today only 27% of medical schools in the United States offer this minimum. A good step forward would be to promote the inclusion of in-depth training in nutrition and dietetics in health professional education programs such as medical schools and residencies. In November 2021, Rep. James McGovern (D-MA) introduced House Resolution 784 calling for exactly that.
Another hurdle is reimbursement.
More than half of physicians practicing lifestyle medicine report receiving no reimbursement for these procedures. Let’s stop punishing doctors who take the time to work with their patients and start rewarding them for prioritizing lifestyle medicine interventions, especially when patients achieve their goals. The dominant fee-for-service model rewards the greatest amounts of procedures and services performed. While some promising new value-based payment models have been implemented over the past decade, many of them rely on care coordination, health screenings, medication adherence, and patient management. diseases.
Lifestyle medicine emphasizes disease remission, but because quality metrics and payment incentives that reward recovery to health are often absent from value-based payment models, true value that can be provided is limited. We need to stop emphasizing process measures, move to outcome measures and financially reward those who perform better. Accountable care organizations that incorporate lifestyle medicine may be more likely to deliver better health outcomes and cost savings.
It is also critical that we remove barriers to coding reimbursement that limit where care can be delivered. These barriers currently prevent providers from getting paid if they see patients outside of the office in places where people congregate, such as churches and community centers. Removing these barriers would allow providers to better reach communities that have historically been medically underresourced and disproportionately affected.
Health systems can drive change
Fortunately, the momentum for change is strengthening. Large health systems are increasingly integrating lifestyle medicine and showing that they value clinicians certified to practice it. The Departments of Defense and Veterans Affairs recognize that chronic diseases pose a threat to combat capability and national security and incorporate lifestyle medicine concepts into the care they provide.
Real, lasting change will take time. But every day that we delay making these sensible and essential changes to the way we deliver health care is another day that our chronic disease crisis takes on a devastating impact and grows more overwhelming.