As I've shared in previous blogs, there are various models for implementing health and well-being services in our health care system. From concierge medicine and Direct Primary Care (DPC) to lifestyle medicine specialists and telehealth, the options are plentiful. However, when the goal is to serve an entire community, a lifestyle medicine center based in a hospital or medical fitness facility stands out as the best choice for universal access and operating efficiency.
Let me take you back to the 1990s when I was the Medical Director of Cardiac Rehabilitation at UPMC’s Montefiore Hospital. During that time, I witnessed firsthand how financial stability is crucial for these programs. Our facility weathered budget cuts, while a sister program at UPMC’s Shadyside Hospital closed its doors. When hospital budgets are tight, cardiac rehab can be viewed as “non-essential”, especially if patient volumes aren’t high because physicians are not sufficiently persuading patients to go and there are not automatic referral mechanisms.[Ritchey]
The irony? Hospital leadership loved to showcase our health promotion programs for PR purposes. I remember former CEO Jeff Romoff visiting our cardiac rehab facility, proudly filming a video with patients exercising behind him. A few years later, when I proposed creating the Cayuga Center for Healthy Living, Cayuga Medical Center’s CFO admitted he’d accept a modest loss just to demonstrate the hospital's commitment to community health. He was pleasantly surprised when my business model showed that we could keep the program in the black.
These experiences taught me that the #1 priority must be to remain “revenue-positive,” even if it feels uncomfortable to prioritize finances over patient outcomes. As Sister Irene Kraus wisely said, “No margin, no mission.”[Szalados] That phrase gets overused and out of the intended context today, as health care systems try to satisfy private equity investors. But when your program has small margins, Sister Kraus’s words are right on - you must protect your staff by designing the program to stay in the black.
For such centers to thrive, they need referrals. Some payers may be concerned about “downward” referrals from specialists to primary care physicians, but demonstrating expertise in lifestyle medicine can alleviate those barriers. Strong hospitals also can persuade payers to include their providers in networks, especially if their self-insured health plan beneficiaries can access these services as covered benefits. It’s a good idea anyway because, as employers, hospitals often pay some of the highest health care costs.[Aetna/Excellus]
I've found that a diagnosis-agnostic approach is very effective because lifestyle interventions focus on unhealthy habits rather than specific ICD-10 diagnoses. This also means it’s easier to form group visits because one needn’t have a minimum number of people with the same diagnosis. In group settings, patients with diverse chronic conditions learn from one another, gaining insights into their health challenges and how lifestyle changes can help.
The clinical objective in such visits is straightforward: address diet, physical activity, stress, tobacco cessation, and sleep, all while fostering social connections.[ACLM Pillars] Some programs even incorporate meal replacements and complementary medical services. Addressing issues like alcohol and drug use often requires specialized care, which I believe works best in settings focused on abstinence.
Being located in a medical fitness facility has its advantages, especially when it includes physical therapy and cardiopulmonary rehab. Many patients feel intimidated by exercise, and having a supportive environment makes all the difference. Medical fitness facilities attract members who relate to one another, creating a more comfortable atmosphere.
Hospital-based centers benefit from a diverse team of allied health professionals —nutritionists, physiologists, health coaches, and more. This collaboration is essential for growth and scalability. While physicians are valuable, their time is costly, so it’s crucial for allied health staff to handle most of the services, reserving physician time for complex cases and group visits.
This team-based care is critically important, because services of lifestyle medicine physicians don’t scale well outside of group visits. Once a hospital has a lifestyle medicine physician on staff, their expertise is rare so they are often pulled into numerous administrative roles: health fairs, diabetes and bariatric programs, workforce wellness programs, tobacco cessation campaigns, discharge planning (to increase referrals) and help with outcomes analysis to name a few.
In my next blog, I’ll explore how to convince hospital leadership to embrace this model. Stay tuned!
Citations
Matthew D, et al. Tracking cardiac rehabilitation participation and completion among medicare beneficiaries to inform the efforts of a national initiative. Circulation: Cardiovasc Quality Outcomes; 2020;13:e005902 https://doi.org/10.1161/CIRCOUTCOMES.119.005902
Szalados, J.E. (2021). Corporate and Partnership Structures Used in Healthcare Entity Formation. In: Szalados, J.E. (eds) The Medical-Legal Aspects of Acute Care Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-68570-6_26
Aetna / Excellus Blue Cross Blue Shield. Personal communications.
ACLM Pillars - https://lifestylemedicine.org/
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