Last month, CMS announced several proposed changes to the physician fee schedule for 2024. As ever, some are Good and some are Bad.
To end on a positive, let’s start with the Bad. The worst thing is a 3.34% pay cut. In a private practice, the physician’s billings pays not only their own salary, but also for all of the staff. So a time when inflation is up and everyone is hoping for a raise, CMS wants to cut the pay of health care workers. What a nice way to say, “Gee, thanks for all you did during COVID”.
On a more upbeat note, there are some Good things in the CMS announcements. First, CMS proposes to pay for addressing Social Determinants of Health (SDOH) - both for assessing SDOH and for helping patients address deficiencies in these areas. That’s a really big deal because chronic disease is skewed toward the urban and rural middle class and poor, many of whom don’t have the internal or external resources to overcome their barriers to better health. Public health officials have spent a couple of decades preaching about SDOH, but so far nobody was being paid to do anything about it. Somewhat of a “build it and they will come” public health / Hollywood mantra. In America, the main rule is pay for it and they will come. Investing in helping people with SDOH needs is the right thing to do. Hopefully CMS will pay enough to cover the costs of the assessments and interventions (plus, they’ll almost surely want reporting)!
The second really big deal is that CMS is proposing to temporarily cover health and well-being coaching services via telehealth. Imagine, actually helping people improve their health status! What a novel idea! Ultimately, CMS needs to go beyond telehealth and cover face-to-face health coaching too, but, hey, telehealth is a start.
Covering SDOH and health coaching is really big in two ways: 1) it’s acknowledging that our disease-care system does not actually produce health (“health care” is a complete misnomer), and 2) it’s recognition that few health care workers are trained in how to help people improve their own health and well-being. Health coaching is very, very different than what mainstream medicine does, which is to preach medical mainstream biases and call it “education”.
After 35 years of doing research, clinical care and administration of what is now called “lifestyle medicine”, I have learned that the honest truth about lifestyle interventions is that very little is about nutrition or steps per day or target heart rates or whatever. Yes, lifestyle interventions require the clinician to know the evidence on diet and exercise, stress coping and sleep hygiene, as well as social support and substance use (including tobacco). But the overwhelming majority of barriers to change are things like not knowing how to shop for produce, not knowing how to season and cook vegetables to make them appetizing, or not having access or adequate transportation to find fresh produce or get to a safe place to be physically active. Most of all, Americans feel like they do not have the time to make these investments in themselves.
In our society, time is money. When people are confronted with carving out time for self (spending money) or ignoring self to save time (to make more money), people reliably choose money over time. Desire to spend less time on food is why we have so much use of convenience foods and so many (in the words of Michael Pollan) “edible food-like substances”. In my opinion, the #1 problem leading to poor health and well-being is priority-setting around how we spend our time. Unhealthy diets, lack of exercise, lack of sleep and poor stress coping (including with substances) are not the root causes of bad health, but are symptoms of how we prioritize spending time.
These are not highly technical matters. They are emotionally challenging. Such discussions don’t align well with, and are probably not the most economical use of, a mind that cost a million or so dollars to train in how to do complex diagnostics involving molecular biology, history-taking, physical exams, imaging, interpreting blood and tissue tests, calculating the trade-offs of polypharmacy, estimating the risk/benefit relationships of therapeutic choices, and then distilling all of that knowledge to help a patient make a well-informed decision.
We need to help more people resist the pull of the doctor’s medical technology, and to decide to invest in leading a healthier life. If CMS wants to spend America’s health care dollars wisely, we need more health coaches who are trained in how to help people, especially those who have SDOH challenges, make behavior choices that promote health and well-being. That would give CMS real value for our tax dollars.
So while there are some very dark and serious health care storm clouds over our heads, this year CMS is showing a bit of silver lining.