The US spent a record $4.1 trillion on health care in 2020. Health inequities, which cost us $320 billion annually, are on pace to surpass $1 trillion by 2040—an increase that would cost the average person $3,000 a year, up from $1,000 today. Chronic disease, a leading driver of health care costs, afflicts 6 in 10 US adults.
If we are serious about changing the unsustainable trajectory of US health care spending, it is time to stop just managing illness and start finally addressing the root causes of chronic disease and their associated costs.
The good news is that the majority of those chronic diseases—from diabetes to heart disease and many others—are lifestyle related. That means many of them are not only preventable but treatable and even reversible with lifestyle behavior changes.
As the White House prepares for its September 28 Conference on Hunger, Nutrition and Health—the first of its kind in 50 years—it is time to change not only how we talk about chronic disease but how we prepare health care professionals to help patients make sustainable lifestyle behavior changes as well as improve the financial incentives for clinicians to do so successfully.
Prevention Is Not Enough
Most health care strategies to reduce incidence of disease focus on prevention. But, with so many already sick, that’s not good enough—not for those currently suffering or as an effective measure to reduce costs. There is growing evidence that common chronic diseases, including diabetes and heart disease, are 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 treat the underlying cause of noncommunicable chronic disease, without the exorbitant cost of many other interventions.
Consider diabetes, which afflicts 37 million Americans, the vast majority of whom have type 2 diabetes. They incur an average of $16,750 annually in medical expenditures, about 2.3 times higher than those without diabetes, according to the American Diabetes Association. By 2030, type 1 and type 2 diabetes prevalence is forecast to increase by 54 percent and cost more than $622 billion annually. One in five adolescents has prediabetes.
Most treatment plans are prescribed just to manage diabetes. Such an approach is better than leaving a disease untreated but ultimately results in ever-increasing use of medications and procedures. Instead, achieving a clinical outcome of remission of type 2 diabetes should be the goal. Indeed, an expert consensus statement published by the American College of Lifestyle Medicine found agreement that it is possible to achieve remission through diet alone. Hardly an outlier, this statement was 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 for primary care providers to support lifestyle interventions, delivering an annual bonus payment if and when patients maintain remission? According to a 2018 modeling study, this approach could yield substantial future cost savings, potentially reducing costs by thousands of dollars per treated patient every year. Such savings will benefit the overburdened health care system as well as patients, 41 percent of whom report financial hardship from medical bills. Similar potential economic benefits have been identified for other lifestyle medicine interventions aimed at 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 25 hours minimum of nutrition education, but today only 27 percent of medical schools in the US provide that minimum. A good step forward would be to promote the inclusion of substantive nutrition and diet training in health professional training programs such as medical schools and residency. In November 2021, Rep. James McGovern (D-MA) introduced House Resolution 784 calling for exactly that.
Another obstacle is reimbursement.
More than half of physicians practicing lifestyle medicine report receiving no reimbursement for those interventions. Let’s stop punishing physicians 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 higher quantities of procedures and services performed. While some promising new value-based payment models have been implemented in the past decade, many of them rely on care coordination, health screenings, medication adherence, and disease management.
Lifestyle medicine emphasizes disease remission but because quality measures and payment incentives that reward health restoration are often missing from value-based payment models, the true value that can be delivered is limited. We must move away from emphasizing process measures, move toward outcome measures, and financially reward those who achieve better outcomes. Accountable care organizations that incorporate lifestyle medicine may be more likely to deliver better health outcomes and costs savings.
It is also critical that we eliminate coding reimbursement barriers that limit where care can be delivered. Such obstacles currently prevent providers from getting paid if they see patients outside the office in places where people gather, such as churches and community centers. Removing such barriers would allow providers to better reach historically medically underresourced and disproportionately affected communities.
Health Systems Can Lead Change
Thankfully, momentum for change is growing. 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 chronic disease as a threat to war-fighting ability and national security and are incorporating lifestyle medicine concepts into the care they provide.
Real sustainable change will take time. But every day we delay these sensible and essential changes to how we deliver health care is another day our crisis of chronic disease makes its devastating impact and grows more overwhelming.