Geoffrey E. Moore, MD FACSM
In this series of blogs, I will share essential insights from over three decades of experience in lifestyle medicine. I spent almost 15 years mainly as a researcher and, by the late 1990s, had become convinced of the ample evidence supporting lifestyle interventions, particularly for diet and exercise, in the management of chronic conditions. Outside of research settings, however, lifestyle medicine services were limited to health spas and providers of expensive executive physicals.
I concluded that there was not a viable business model for these services. Thus, 20 years ago, I embarked on a mission that pioneered three key components: 1) establishing a business model for lifestyle medicine services, 2) optimizing clinic operations for the benefit of both patients and providers, and 3) developing web-based technologies to make these services scalable. With a shortage of clinicians to meet the demand for such services, it was essential to find effective ways to extend human resources.
In 3 blogs, I will provide guidance on incorporating a health and well-being service line into your medical practice. Part I will explore billing procedures and staffing suggestions, Part II will delve into maximizing productivity and effectiveness, and Part III will focus on optimizing technology and persuading your CFO that a health and well-being services can be a profitable venture.
Part I: Paving the Way for Health and Well-being
While it's common knowledge that diet and exercise promote health and well-being, many are surprised to discover that lifestyle changes can reverse and lead to remission of chronic conditions like diabetes. [Lean; Lean; Taylor] This myopia is largely a result of our health care system's emphasis on billing health insurers for disease care, making it a challenge to provide health-promoting services within such a framework.
There are some existing solutions such as concierge medicine, direct primary care, specialized clinics like the Cooper Clinic in Dallas, Texas, as well as wellness resorts like Canyon Ranch, but these options are financially out of reach for most Americans. What our health care system truly needs is a scalable solution for delivering health and well-being services through mainstream medical practices.
In 2003, I became acutely aware of the looming threat of the obesity epidemic, foreseeing a future where 15-20% of the population could suffer from diabetes. My research with kidney failure patients had persuaded me that America couldn't bear the cost of severe diabetes-related complications such as visual impairment, peripheral neuropathy, kidney failure, coronary artery disease, and cerebrovascular disease. This realization prompted me to establish a practice centered on exercise, diet, stress management and tobacco cessation. My goal was to create an adaptable and sustainable business model catering to all socioeconomic classes in clinics across America.
Fast-forward 20 years and the obesity epidemic persists. Although there are new medications capable of inducing substantial weight loss and reversing diabetes, their prohibitive cost makes them unaffordable for many. The need for effective and affordable health and well-being services as a covered benefit remains unmet.
Seeking Payer Support
I started out solo, providing exercise and lifestyle medicine consulting to local practices. My colleagues who knew of other doctors who had attempted a similar path but failed and abandoned the idea. One reason it was difficult is that the conventional practices assign almost all billable duties to physicians and mid-level providers. In order to pay for staff and overhead, providers must have packed schedules that leaves insufficient time for effective behavior change counseling.
Recognizing this, I reached out to health insurers that had recently added me to their company panels. They advised me to use regular physician evaluation and management (E&M) codes, rather than the prevention, obesity counseling, or cardiovascular disease intervention codes. For patients with an appropriate diagnosis, payers held that lifestyle interventions were a covered benefit under "counseling and coordination of care". Indeed, they saw lifestyle interventions as the preferred treatment of choice. This was excellent news because 1) it meant I could treat the majority of the adult population and never receive payment denials, and 2) E&M codes paid better than the prevention codes. I guess it wasn’t surprising that payers saw my work as disease care!
Maximizing Efficiency and Effectiveness
As a consultant, my focus was primarily on treating existing diagnoses rather than addressing new problems. Initial visits included a brief history and a pre-participation physical examination focused on issues hindering physical activity. Musculoskeletal pain is common in individuals with obesity, so I frequently referred patients to physical therapy and performed joint injections. Follow-up visits primarily involved time-based billing for counseling.
Time-based billing was inadequately compensated by payers (and still is), underscoring the importance of being efficient and effective. I wanted to provide proven programs, but at that time there were few off-the-shelf lifestyle programs that aligned with my goals. I favored Dr. Kelly Brownell's LEARN Manual, but its research-oriented design involved six months of weekly visits, considerably more than my patients would do. [Brownell] Unlike research subjects who participate in studies for altruistic reasons, my patients were motivated purely by personal reasons. Mini-courses of 4-6 sessions were what patients were willing to do.
I decided to create my program materials from scratch, which had the benefit of reinforcing my words in clinic. When you create your own materials, you and your staff are deeply invested in the program. But creating my own materials did take time. Today, it might be pragmatic to initially subscribe to a vendor's materials to expedite the process, then gradually incorporate your own content over time.
So that was the beginning of my journey. In Part II, I’ll discuss the secrets to optimizing revenue and growing your health and well-being services.
R Taylor, A Ramachandran, WS Yancy, Jr, NG Forouhi. Nutritional basis of type 2 diabetes remission. BMJ 2021;373:n1449. http://dx.doi.org/10.1136/bmj.n1449
MEJ Lean, WS Leslie, AC Barnes, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet 2018;391:541–51. http://dx.doi.org/10.1016/S0140-6736(17)33102-1
MEJ Lean, WS Leslie, AC Barnes, et al. Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial. Lancet Diabetes Endocrinol 2019;7:344–55. http://dx.doi.org/10.1016/S2213-8587(19)30068-3
KD Brownell. The LEARN Program for Weight Control, 7th Edition. 1997. American Health Publishing Company, Dallas, TX.