Abstract
‘And to see the emergence of lifestyle medicine as a social movement is an absolute delight for me.’
The following individuals participated:
Moderator:
James M. Rippe, MD, is the Founder and Director, Rippe Lifestyle Institute. He serves as Editor in Chief, American Journal of Lifestyle Medicine.
Panelists:
Giovanni Campanile, MD, is the Director, Dean Ornish Intensive Cardiac Rehabilitation Program and Director of the Integrative Nutrition and Integrative Cardiology at the Chambers Center for Well Being, Morristown, New Jersey.
Hans Diehl, DrHSc, MPH, FACN, is the Founder of CHIP & Lifestyle Medicine Institute LLC, Loma Linda, California.
Christy Gunier is the Director, Global Health & Wellness, Cummins Inc, Columbus, Indiana.
Tom Kostohryz is the President, Live Healthy Appalachia, Athens, Ohio.
Matt Longjohn, MD, MPH, is the National Health Officer and Vice President for Community Integrated Health at YMCA of the USA, Chicago, Illinois.
Nicole Williams, MBA, is the Director, Clinical Operations, Cummins Inc, Columbus, Indiana.
The second edition of my Lifestyle Medicine textbook came out in 2013, and we are currently working on the third edition. I also edit the only academic peer-reviewed journal in this area, the American Journal of Lifestyle Medicine (AJLM), which, as most of you know, is the official journal of the American College of Lifestyle Medicine (ACLM). For the past 2 years in the September-October issue of AJLM, we devoted the entire issue to the proceedings of the Annual Meeting of the American College of Lifestyle Medicine. It can be viewed on the ACLM website. We intend to do that once again with this year’s conference including the proceedings of this expert panel.
It is now my pleasure to introduce the panel of distinguished individuals who are participating in the Expert Panel today.
Giovanni Campanile is a Harvard-trained cardiologist Director of the Dean Ornish Intensive Cardiac Rehabilitation Program and Director of the Integrative Nutrition and Integrative Cardiology at the Chambers Center for Well Being.
Hans Diehl, DrHSc, MPH, FACN, has been active at ACLM from the start. First on the Board of Directors and now an Advisor and is the Founder of the Lifestyle Medicine Institute LLC in Loma Linda, California.
Tom Kostohryz is the Co-Founder and President of Live Healthy Appalachia, a nonprofit organization in Ohio that promotes health and well-being to all Appalachians.
Matt Longjohn, MD, MPH, is the National Health Officer and VP of Community Integrated Health at the YMCA of USA, and is the first physician executive working at a national level for the YMCA in its 165-year history. Dr Longjohn oversees a team that is charged with developing evidence-based policies programs and practices, and scaling them throughout the Y network.
Christy Gunier is the Director of Global Health & Wellness at Cummins, Inc, and has an extensive background in international benefits policy and helping well-being strategies and program development.
Each panelist will now have 10 minutes to talk about their program. The first speaker will be Giovanni Campanile.
The diagnoses that we use to admit our patients in our program are the same for traditional cardiac rehabilitation. So patients that have had stable angina, that is not well treated with medicines, coronary stents, bypass surgery, heart transplants, or valve replacements are included in our program. All of these conditions are Medicare covered and most private insurances also cover our program.
What the program entails is 4-hour-long sessions, twice per week, for 9 weeks. Thus, it has 72 sessions. In each session the patient has an intense program (4 hours) with a team of people including a nurse, a nutritionist, an exercise physiologist, and a psychologist. The program is divided into 4 parts: One is exercise, another is stress reduction with yoga or another form of stress reduction, and the third is a meal from the Ornish program that is 10% fat as part of a vegetarian diet. Patients are instructed in preparation techniques and given meals to show how to eat and make their own meals and are actually given a meal. The fourth part is a group session where the patient has a safe place to sit and is directed by a psychologist to talk about his or her fears and their feelings.
Each part, we stress to the patients, is equally important as the other parts. The patients and their doctors may focus too much on the nutritional side of this but that is only one part of the 4 components. Once the patients have completed the program, we allow them to come back to the Center indefinitely. They get together and they do group sessions, which allows the establishment of a group that they can talk to and communicate with so the continuity of the program is very important.
The program is designed to reverse heart disease, which has been proven and published in journals such as Lancet, JAMA, and the New England Journal of Medicine.
With regard to my own background, I started my career in cardiology as an interventional cardiologist. I have put in thousands of stents. The amazing thing about the program that we have currently established is that it is based on the strong belief that lifestyle changes are very effective. Nine out of 10 patients tell us that this program is a life-changing program. They start out sometimes with great reluctance because of the misconceptions of the diet, but for the most part, patients thank us for guiding them into this way of thinking and acting. They routinely say there is nothing in their life that has changed it as much as our program.
Over the years, I have learned that one can present hard and even brilliant facts to an audience. But when you ask them the next day what they remember most of it has been forgotten. But, if you tell them a story, they remember. So, let me share 3 short stories with you. They are based on my experience with 75 000 people who have adopted a dietary program that is based on 2 fundamental concepts: it is plant-strong and whole-food oriented. The program also includes an appropriately, gradually increasing exercise program and social support for stress management.
Case Study 1
It features a woman. With a history of multiple sclerosis (MS) of 21 years, she has been brought into the auditorium in her wheel chair. She had heard about our intensive therapeutic lifestyle change program. She came. She attended. She followed the therapeutic lifestyle guidelines. “Foods-as-grown.” Plant based. No junk food. Very little fat, sugar, and salt. But lots of nutrient-dense foods.
And the same lady who had been wheeled into the auditorium only 4 weeks earlier, that evening walked onto the stage and addressed the audience. “I was a well-known singer in Nashville. But because of my MS, I haven’t done much singing. But tonight I want to sing a song for you.” And then she sang, “To God be the glory, great things He hath done.” For a moment, I thought, “Am I at the right place? Has this become a church? A revival meeting?” No! I had to remind myself: “It was the graduation night of the Complete Health Improvement Program, the CHIP program.” With tears streaming down her face and after 21 years of MS, she was walking and singing again! But could a patient with MS respond that quickly? It almost seemed unreal, because it didn’t fit into our rational medical framework.
Case Study 2
It features a 65-year-old gentleman from British Columbia in Canada. He would drive his pick-up to get his daily mail at the mailbox some 200 feet away. He had to drive, because he was basically a cardiac cripple. The disease had progressed to the point that angina became his painful companion. He knew he lived on borrowed time. He “saw” a shadow following him everywhere he would go, a shadow that was 2 feet wide and 7 feet long. And he knew it wasn’t long before he would be going to be in that box. His physician, concerned about his high blood pressure, his Marlboros, and those 60 lbs of excess weight, told him, “Bob, you’ve got to do something about your lifestyle. Why not enroll with your wife in the CHIP program?” They did. They attended. They followed the guidelines. Not just for 4 weeks. They were lifers.
And 2 years later after planning and training and exercising, the very man who could not walk to his mailbox because of his angina pain was cleared by his cardiologist to engage in a 2500-mile trans-Canada journey. After taking off from his home town in British Columbia on the Western side of Canada, he arrived in Canada’s capital Ottawa 60 days later. The media had followed him on his 60-day journey. And they were there on Parliament Hill in Ottawa, just like a choir that sang, “Oh When the Saints Come Cycling In.” You see he had covered those 2500 miles on his 21-gear Titanium bike in 60 days as a champion after having lived for several years like a couch-potato crippled by his declining health.
Case Study 3
This man really did not want to join the CHIP program. He balked. But his wife insisted. Even though a very sick man, he was not interested in any lifestyle changes. He loved the lifestyle he lived! An exotic animal hunter, his freezers were packed with his trophy meats. He enjoyed those meats. He could devour a 2-pound roast in one sitting. It just didn’t dawn on him that his lifestyle may possibly be related to his diabetes, hypertension, obesity, and his multiple medications and angina pain as his constant companion. Even after 2 bypass surgeries and 9 heart attacks, he thought nothing about enjoying his Marlboros and his pipe.
Though reluctantly at first, he began to warm up to the idea of making some lifestyle changes. And gradually he began to settle into his new pattern. And when he came to the 3-month alumni meeting, he gave a glorious report. Most of his medications were gone, hope had returned, and he emerged as a new man.
So, What Is CHIP?
CHIP is one of the flagship programs of the Lifestyle Medicine movement. It is an intensive 30-hour lifestyle intervention program delivered over a 4- to 12-week time frame in a live or online group setting. Through a state-of-the-art educational series of 19 videos, the focus is on helping participants understand the “why” of our most common chronic diseases, and then, through skill acquisition and consistent genuine support, help them discover the “how” to make these changes and turn them through repetition into sustainable changes. We have found that it may take about a year to strengthen these newly acquired behaviors through affirming acknowledgments, genuine caring, and encouragement to establish new habits.
One of the great motivators toward change reside in the pre- and postassessments of risk factors as predictors of disease. This includes biometrics such as blood cholesterol, blood sugar levels, blood pressure, weight, and a thorough explanation and the discussion about goal setting. As a result, knowledge emerges and grows, and participants are learning together. They experience trust, friendship, and mutual support, and they begin to change.
This community-based lifestyle intervention program is delivered through hospital systems, corporations, communities, and churches. Behavioral change is magically facilitated through the idea that the participants are engaged together. They learn to solve problems together. They feel not being treated as patients. Instead they come together as friends on a journey toward hope and health who try to implement what they have learned. As a result, more than 75 000 graduates have made lifestyle changes. Their clinical results have been published in 35 scientific articles in peer-reviewed journals.
With me today is Scott Kashman, who will give us a quick overview of what happened at the Lee Health, a system of hospitals in the Fort Myers area.
We initially ran 25 people through the program. Sixty-five percent of the people remained compliant with it. In our health plan we still experienced a 2:1 dollar return for all the people who entered the program, even including those people who did not complete it. So with all the money invested, we still saw a 2:1 return for the first year. The program helped serve as catalyst for some of our other wellness programs.
It has been an honor to work with Dr Shurney, who has an amazing vision for how we can deliver lifestyle medicine in the workplace. It is a great time to be a part of Cummins because we are rolling out this program, which you will find that many of us are passionate about and it is truly changing lives! We are all very committed to making that happen.
We are just at the beginning of a long journey. We are about to roll out our global health and well-being strategy that has been in development for many years and we need to make sure that we get things right. We refer to it as the Seven Levers of Healthy Lifestyle. Essentially, it is all these things that we have been talking about today in terms of educating people around physical activity, nutrition, stress management, being substance free, getting a proper night’s sleep, getting out in the sunshine each day, making sure that you are properly hydrated, and have access to clean, drinkable water.
We feel that these things are critical for all of our employees globally, and we are committed to assuring that we provide the education and support to everyone in our company—not just to our professionals who can access our programs on their computers. I am personally committed to making sure that we reach every single employee on every single platform where we work and every language just to make sure that we are getting the message across clearly.
We are doing this under the framework of what we call MC2. That involves thinking about motivation and how do we motivate people to achieve sustainable change, which we know is probably the most difficult part of the equation. Everyone is so unique—what drives them, what motivates them can be very different. At any given moment, and over time, these things change. So we are trying to make sure that our strategy is all encompassing because lifestyle change requires employee engagement. If we cannot engage employees we are not going to be successful, and we are determined to do that. So we are taking a real multifaceted approach to get people engaged and get them educated.
We also think about our competencies. So every competency that we are going to be pushing out is going to be linked to one of those 7 levers that I just mentioned. Every single program and offering that we have in any of our sites globally will be required to comply with the set of guidelines and standards that we have set forth. That is what we believe is the best path for our employees to achieve optimal health and, in the long term, be able to sustain that. So we are going to be developing programs to support each and every one of those 7 levers in every single region and every single country for every employee that we have over the next couple of years.
We are also going to make sure that we are creating a culture of health. It starts within the 4 walls of our workplace but it absolutely expands beyond that. We first need to make sure that we ourselves and our leaders are modeling proper behavior for our employees and that we are providing acceptable access to proper nutrition within our workplaces. We also need to push education and support our employees’ families so that they have the same opportunities as our employees themselves to improve their health. We are working with our community providers as well as our grocery stores, our farmers’ markets, and so on, to make sure that we are delivering the types of foods that we are suggesting that our employees consume on a regular basis. All of this is very exciting for us. We have also put some measurements in place in terms of a “lifestyle medicine index” so we can track our progress over time. It is globally relevant and is something that allows us to compare apples to apples—the state of health for our employees around the world.
Another big part of our program is integration and alignment, which means primary care and occupational health. For many employees, the only time they will ever end up seeing a physician is when they are in for an occupational health exam. So we absolutely want to take advantage of that opportunity. We are spending time training all of our physicians, both on the primary care side and the occupational health side, about how to administer lifestyle medicine interventions. Our goal is to make sure that they are incorporating these modalities as part of their practice.
In terms of our plans for going forward, the next year for us will be spent educating our employees around the 7 levers of healthy lifestyle. These are programs that we are developing internally. That is so we can make sure we are meeting the specific needs of our employee population. We will provide a global framework but we also work closely with each of our regions and countries to make sure that we are addressing the issues that are important to them from a health outcome perspective and from a cultural perspective. We recognize that there is no “one size fits all” solution. While some of the concepts may be applied globally, there is a need to change things a little bit to engage employees at the highest level.
One example of this is the CHIP program, which we are working on now to modify for our India participants. We are in the process of taking our India physicians in our health centers, through the lifestyle medicine competency program. It is amazing. When we talk about how this should become a movement here and globally they are very interested.
When I first talked to our physicians in India a year ago about the thought of reversing type 2 diabetes, they thought that I was lying to them! They said, “Absolutely not! That’s not true! You can’t do that!” So it is very interesting as we come alongside them and share Dr Shurney’s vision and really just help them understand that there is another way—that there is hope.
The response that we are getting from our physicians globally and from our employees is very encouraging. Every time that we talk about our strategy we get more and more interest and the momentum is starting to build. So as we get ready to officially announce the strategy here in the next couple of weeks, we are very excited about the opportunities that lie ahead of us.
One of the primary things that we are excited about is the LiveWell Center, which recently opened in Indiana over the summer. The LiveWell Center is designed to provide healthy lifestyle intervention for those on the primary care side as well as the occupational health side. I am so proud to be a part of this initiative. While I really have been on the outskirts, it is pleasing to know that physicians, and health coaches, and the support individuals working in the clinic are so passionate about it. I am absolutely certain that the clinic is going to be successful. We have actually started to see success coming through in our metrics. For example, last week we officially saw our first reported reversal of type 2 diabetes in the clinic. A patient who had previously been on multiple medications is now totally off of them. Now we just have to keep individuals such as this in the program. And that is what we are committed to doing—not only getting people to change but also helping them sustain that change in the long term.
Over the next couple of years, we are going to be continuing with this deployment process. We are going to continue to modify our content. We are going to work with our employees, and we are going to listen to what is working for them, and what is not working for them. For example, many individuals struggle now when we encourage people not to eat meat. But we have a responsibility to do that. When the evidence came out that cigarette smoking was bad, we didn’t encourage people to smoke cigarettes and that was fine. I want to take the same approach here. We have evidence now that we didn’t have years ago. We have a responsibility to share that information with employees. Since we know that information alone does not result in action, we know we have to do more than just inform. We have to come alongside our employees. We have to build a culture around them so that they can be successful and that’s what we intend to do. We hope to be back here next year sharing some more good results and look forward to continuing to work with many of the great partners who are here developing these programs with us.
The story I am going to tell you is actually 165 years long, but I am going to tell it very quickly. The YMCA in the United States was founded in the 1840s; right after the first YMCA in the World was founded in London. YMCAs are now in 122 countries today, and there is a tremendous amount of variation in what a Y looks like, or what it does, and so on. Here in the United States there are actually about 900 nonprofit organizations that comprise our YMCA movement. Those Ys, like the one in Naples, may have a couple branches, or it might be like the YMCA of Greater New York City, or the YMCA of Metropolitan Houston, which each have more than 25 different branches. Because of the nature of programs that we deliver, which are often delivered outside of our buildings (eg, Head Start programs are in schools, diabetes prevention programs in medical facilities, etc), there are actually more than 10 000 Y program sites nationwide. Nearly 80% of US households are located within 10 miles of a Y facility.
I am telling you all this because you couldn’t build this kind of network today. It has been built over time with generous support from philanthropy and business leaders, among others. During the course of our 165-year history, the Y has had to innovate in every generation to serve community needs in a different ways. In the 1840s, the Y was created largely to serve an agrarian, Protestant, young, white male Christian population who were trying to get their feet on the ground in urban centers. Quickly thereafter, as early as 1853, the first all African American Board of Directors at a YMCA was formed in Washington, DC. Since that time, the Y has been a supporter a very progressive civil rights agenda.
In the early 1900s, the Y was focused on immigrants—New American populations. The Y pioneered English as a second language courses; it founded over 100 universities and community colleges, among others.
Fast forward. In the postwar period, after winning a Nobel Prize, and founding the USO, and so on, the Y was set up to serve veterans who were coming back from the war who needed a place to live. The Y created what was essentially, at that point, the largest chain of single-occupant hotel rooms in the world when we created our hostels. Then, in the 1970s, “mom” went back to work and “latch-key kids” needed a place to go afterschool. So, it wasn’t until the 1980s that the Y became what you might recognize it as today—the largest provider of child care and after school programs in the nation.
But our communities have changed again. The epidemics that you’re working with, diabetes, hypertension, arthritis, cancer, and so on, are preventable causes of disease and disability. These are the kinds of concerns that our 22 million members, the staff at those 2700 facilities, and all of our local boards are worrying about every day. So, we are innovating to become one of those community-based organizations that responds to these health demographics and epidemics very quickly. What is happening right now is that health care systems are actually pulling the Y into this work. There are hundreds of YMCAs now that either have rental units or even share complete facilities with health care systems. For example, the front door of an Iowa medical campus in Des Moines is a healthy living center where cardiac rehab, physical therapy, and so on is delivered by the Y in a facility that is co-owned by the Y and the health care system. In addition, there are other health living centers renting space out to pediatricians, travel medicine doctors, and orthopedists who are checking on their hip and knee replacement patients trying to prevent falls.
Thus, the YMCA is becoming an integrated with many health care systems, and it is because we can deliver things with great fidelity and at large scale. We can scale things through our network so that payers and employers can have their remote employees, or their members of insurance plans all get similar products at different YMCAs. We can also support them with things like our own electronic medical records (EMRs). The Robert Wood Johnson Foundation saw this direction in community integrated health and invested in the Y to be able to scale our effort based programs. The Robert Wood Johnson investment allowed us to go to bid for our own EMR, and we ultimately hired AltheaHealth to do our electronic medical records so all the outcomes, the attendance records, the weight loss statistics, the self-reported behaviors of nutrition, physical activity, the range of motion data points, and so on, for all of our chronic disease prevention programs are all in accessible medical records. At the patient’s consent, we can become part of the community integrated care teams, and work on population health alongside of you all.
Using my background in the benefits agency, I wanted to try to see if we could possibly bill for the CHIP program through our 501c3.
Along came the Affordable Care Act and I have a sheet in front of me here that I put on the ACLM app so you can all have access to this if you’re interested in it. There are actually 2 sheets. One is frequently asked questions about the Affordable Care Act. This was published in January of 2014. It is a joint publication by HSS (US Department of Health and Human Services), Department of Labor, and the IRS (Interval Revenue Service), which basically says that effective in 2014 the Affordable Care Act requires non-grandfathered group health plans and individual coverage in the health market to prohibit the imposition of cost sharing requirements for individuals for preventive services. It also states that evidence-based programs or services that have an A or a B rating in the current recommendations of the US Preventive Services Task Force have to be covered by health plans.
Another sheet that I have is the clinical guidelines that were published in 2014 in the Annals of Internal Medicine by the US Preventive Services Task Force. Their recommendations for those that have risk factors for cardiovascular disease, including obesity, hypertension, hyperlipidemia, diabetes, and tobacco, is to use intensive behavioral counselling intervention programs that promote a healthy diet and physical activity. These interventions are considered B rated programs. I think that if you are aware of this and have access to the appropriate information you can feel confident that you would have the ability to bill for intensive lifestyle interventions for those who have cardiovascular risk factors if you do it properly. That’s the good news.
However, can you get reimbursed for these interventions? It is a very frustrating process, but I think that when we talk about the history of anything that is covered though health insurance, the first few years are very difficult to get payers to actually do that especially when the laws are gray and there is some ability to get out of paying for these programs. I don’t think that insurance companies are really in the business of paying claims without everybody going through their specific process. If they can deny it, they will deny it. That is what made my business very successful because I found a way to try to get individual’s services paid.
In billing for these interventions, one thing you have to understand is that not all health plans are alike. That’s a real problem. How would you know the difference between an insured plan and a self-funded plan? Most people do not. Unfortunately, when you see an ID card that you submit to an insurer, if it says “Anthem,” there could be 200 Anthem plans and Anthem could be considered the insurer, or just a third party administrator that could pay the claims for a self-funded health plan.
It gets a little bit confusing there because when a self-funded employer creates a health plan, they have to establish what they call their “plan document.” That plan document is the guiding light for the administrators to pay their claims. What we find sometimes is that plan documents are out of compliance, as shocking as it may seem. So even though in 2014 we had mandates about covering certain wellness and preventive services, we found that a lot of health plans have not updated their plan document to incorporate the newest regulations. These plan document guidelines were previously set up, and as a result of that, we have administrators that will deny these interventions because they are not considered covered benefits in the plan document that they are working off of. One of the things that I did in my earlier years is that I started a third party administration company to pay claims for small self-funded employers, so I know how claims can be covered or not. There was a time when bariatric surgery was very common place and very expensive. So what we would do is eliminate any treatment for obesity in our plan document. Therefore, those claims were not paid. Sometimes we amended the plan to say that unless there were 2 to 3 referrals and there was no other alternative, only then could bariatric surgery be covered. As a result of that, if an old plan document has no coverage for obesity, and you are sending in a claim for intensive lifestyle intervention program with a diagnosis code for obesity, that claim is going to get rejected because the plan document says it doesn’t pay obesity claims! That’s what happens.
So what you have to understand are a few basic principles that you might bump into. Number one is plan document wording, as I previously discussed. Number two is that if you don’t follow proper procedures, you may not get your claims paid. Some of these procedures include you being an “in-network” physician, and the plan can insist that CPT codes and diagnosis codes are all in order. The third thing is you have to understand that there is a lot of incompetency in claims payers. When you talk on the phone to a claims payer you don’t know if that person is a supervisor that’s been there for 25 years or they started a month ago. So you have to understand these are the real problems.
We have been successful in billing for CHIP, a recognized lifestyle intervention, to self-funded plans and several of the major carriers like Aetna, United Health Care, and Anthem. We are getting reimbursements anywhere from $450 to almost $3000 for CHIP.
So my advice to you as a provider would be to be to be persistent. Make sure you document everything properly and understand that you may know more than the claims payer who is resisting in paying for a lifestyle intervention. You are going to have to reach out to a supervisor and constantly follow-up. That’s what my advice is to you and what my experience has been. So in the future when you want to get reimbursed for intensive lifestyle therapeutic programs, it will require attention to all of the issues that I have brought up.
In this first part of our panel discussion, we have seen excellent descriptions of how lifestyle medicine program are spreading. The second part of the discussion will now focus on how these programs work in terms of how we get them paid for. How do they work in diabetes? How do they work with heart disease, and so on?
I also want to introduce a new member of our panel, Nicole Williams from Cummins. She is the Director of Clinical Operations. She has her MBA and has published 2 books.
I am now going to ask a series of questions to specific panelists. If other panelists want to join the discussion they, of course, are welcome to do so it but each of the panelists will get a chance with individual questions.
Question 1: How are intensive therapeutic lifestyle programs being utilized in the corporate setting? What returns on investments are being realized? How can employers be compelled to use ITLCs?
Every person is given the cookbook when they come in to be part of the program. They get the CHIP cookbook as well as a textbook. After each session there is a report that is expected and those things are followed-up on in the next session for questions and answers. But right after that as people are eating their CHIP-approved lunch and asking all these questions, they watch the videos for the next session. Then again there are more questions and answers after that. Another thing to add is that the wellness coaches are really good about sending out email blasts to the group of people who are taking a class each time to give them great new recipes that might not be in the CHIP program, that are CHIP approved, as well as giving different places that they can go in the areas where they live in to get different types of ingredients for meals. So participants get a lot of great feedback and education. We also take them on shopping tours and show them how to effectively shop! Our participants also ask about specific conditions. “Can you go to a local store off the street and can you take me to buy what I need to eat for the rest of the week?” We always answer “Absolutely.” We are grateful for our coaches because they do extra things like that all the time.
We also have alumni meetings for everyone who has been a part of the CHIP program so they can come back and talk about CHIP and any new success stories that they have. We are all about empowering people. We are big on incentivizing our employees to come in. We subsidize a lot of the benefits they get just so we can invest into these types of interventions and not have to invest in so much of the health care costs that can happen that we ultimately would not have to pay for if people paid closer attention to their daily lifestyle habits.
Dee Edington was the director of the University of Michigan Health Management Research Center. He took a consortium of more than 200 000 employees, and had access to their health risk assessments and also their health care claims. He divided everyone into 3 categories: low-, medium-, or high-risk employees. He unequivocally showed the relationship between the number of risk factors that people had and the health care costs that they incurred. What we must do is convince employers that there is an economic benefit to keeping people healthy. If we can do that, I think we can tell a compelling story about the benefits of healthy employees. I believe that is how we will get more intensive therapeutic lifestyle programs into the workplace.
James Rippe: Next Question: Explain to the audience the genesis of the Diabetes Prevention Program, how you are utilizing it and what benefits are being realized
An NIH (National Institutes of Health) trial was then set up based on the concept that if there was such a thing called prediabetes we could recognize it consistently, and we could possibly take advantage of that diagnosis. The study was a 3-arm trial—metformin, a yearlong lifestyle change program, and placebo. A number of years into this 200 million dollar trial, it had to be ended early because of ethical considerations. The reason why it was ended was that the results from the lifestyle change program were so profound and so much better than the best medication for diabetes.
So what was the result? There was a 58% to 71% reduction or delay in new cases of diabetes among people with prediabetes who were in the lifestyle program. Metformin had a 31% reduction in new cases of diabetes. Also significant. But the results were so profound in the lifestyle change program, that they stopped the trial. It got published in the New England Journal of Medicine in 2002. 1
For several years people would fight that study saying, “Look we could do this if we could figure out how to do it.” In 2005, a YMCA in Indianapolis met with some of the original DPP (Diabetes Prevention Program) researchers received their own NIH grant to see if they could replicate the same results by using YMCA staff to deliver the program. The curriculum didn’t change. The same words were on the page. The same copyright was affixed to the intervention, and so on.
The YMCA participated in this study, called the “DEPLOY Study,” and showed not only that they could they produce the exact same result as the original Diabetes Prevention Program Trial, but possibly even better outcomes! Not only that but they could do it at about 10% to 20% of the cost as was seen in clinical delivery systems.
That study has now been replicated 28 times. A meta-analysis and systematic review of church groups of all kinds has shown the value of this type of program to prevent diabetes. The evidence is rock solid. It is evidence-based medicine, but the practice-based evidence comes in when you try to scale something. We had to change our thinking about what we needed to address in terms of science and evidence. We have plenty of evidence that shows that all of these programs work. The question is how do you implement them at scale? We have to have scale, if we are ever going to take these types of programs into the mainstream.
The YMCA of the USA got involved after the DEPLOY Study, and started working through a third party administrator to get the first 30 or so insurers to cover this program. Through cooperative agreement with the CDC (Centers for Disease Control and Prevention) we also began scaling this intervention through our network, trying to get to those programs out among our various program sites. Six years later, we have 252 cities worth of YMCA programs and 1600 sites.
The next step in this story is that in 2012, after the passing of the Affordable Care Act, my team was awarded a Health Care Innovation Award from the Centers of Medicare and Medicaid Services (CMS). In this project, we enrolled 8000 Medicare participants in the intervention in 17 cities, in 8 states. Over time, the actuaries at CMS compared the total cost of care of our program participants to a comparison group over 4 years. We are trying to prevent diabetes, but if they were taking a medication for dyslipidemia or hypertension, or if there were health care claims that resulted from stubbing their toe and an emergency room visit, then the all these costs were included in the total cost of care for these individuals that was compared to a sample group for 4 years.
At the end of the 4-year period, the actuaries at CMS, who are no pushovers, looked at the claims from people who participated in the program and showed that there was approximately a 5:1 return on investment for Medicare. When they invested about $400 or $500 per person in the year-long intervention, there was $2650 annual cost savings to Medicare within the first 15 months after the intervention. This led to Secretary Burwell announcing earlier this year that Medicare would cover the YMCA’s Diabetes Prevention Program, and all other diabetes prevention programs that are certified by the CDC as meeting their quality standards, beginning January 1, 2018.
Go to CDC.gov/diabetes website to find a list of over 1000 organizations like the YMCA that delivered the exact intervention that will be covered with no cost sharing (ie, “first dollar,” with no cost sharing for all Medicare beneficiaries). In recent years, we have also worked with commercial payers, and the reason we have now created a centralized business services unit at YMCA of the USA and hired Athena health to provide an EMR platform for the Y is because now all our YMCAs will have to have their own national provider IDs. They have to be covered entities. They have to have business associate agreements and use data agreements with all of their partners. We contract, out of the National Office for local program services, acting like a third party administrator just for YMCAs. In addition to the YMCA’s DPP, cancer survivorship and blood pressure self-monitoring have been programming that the American Heart Association, the American Medical Association, and the American Cancer Society have been interested in collaborating with us on for years. We are testing right now programs for people with Parkinson’s disease and programs for people with early onset dementia. We are putting this whole portfolio of programs in the national system and trying to innovate our way into models of community integrated health.
Here is my last question to the panelists: What is the best advice you can give to a provider who would like to implement ITLCs into their practice?
Education of colleagues is also very important because many of our colleagues don’t understand the powerful effects of this type of medicine. The Ornish type of program is very consistent with recommendations from the Proceedings of the National Academy of Sciences. Many tumors have also been decreased by the lifestyle change program. It has been shown that participation in the program reduces the risk of prostate cancer and breast cancer that is above and beyond the heart disease prevention, stabilization, and referral outcomes. We have considerable data showing that the disease goes away. As an interventional cardiologist, I was frustrated for many years because what we did in cardiology was to stop a specific measure—for example, we put a stent in or conducted bypass surgery, but the atherosclerosis was the basic problem and it didn’t go away. The programs that I am discussing here actually address those larger, systematic issues in a structured fashion that is not available in traditional medicine.
If you are in a smaller practice, and you have the space and the staffing to become certified into one of these programs, then I think it would make sense to try doing that in your own location. You could also utilize your own patients in the community. On the other side of the coin, if you are in an institution that is not lifestyle medicine friendly and you are in a position where you are mandated to take 15 minutes per patient, in that small time period you are probably not going to be able to really implement the types of programs you have heard about here. So my suggestion would be to go into the community and look for an organization like the YMCA or there are probably one thousand different entities that can offer one or more of these lifestyle intervention programs for your patients. You need to find if this is a good entity, a trustworthy establishment, and maybe recommend that your patients go there.
The reason that this is important is because the real value in a lifestyle intervention program is the group interaction. You’ve got people inspiring one another and empowering one another. We can’t do that one on one. Although health coaching is good a good area for delivering one-on-one counseling it doesn’t compare with what you can do in a group setting. I think most of the panelists would agree to that.
James Rippe: Closing Statements: I will now challenge each of the panelists that in 2 minutes or less please give the 2 or 3 succinct message points that you would like everyone in our audience to take home
My children are in their 20s. They don’t want the traditional type of medicine. We have to keep that in mind as we look at these programs and adherence to these programs. We need to remember that patients will have more open minds to this kind of approach moving forward. They will adhere to it and it will make them feel better, because when it does, things like depression scores go down and satisfaction goes up. The culture of the health care is changing.
We need to start addressing the root causes of problems. If we are not able to really look at ourselves in the mirror and take the time to realize that I myself need to change things about myself so I can be more productive so that I can make life better for the people who depend on me. As providers that brings us back at the hub of where everything starts and then ranges out to make sure that everyone in the health care system has the education for lifestyle medicine and is utilizing it to the top of their ability.
Put the physician back into the point where we can do today’s work today. Thus, physicians will no longer be doing today’s work 3 months from now because all the other things that they with all the other regulations will disappear once we truly are practicing lifestyle medicine. Most important, the future of lifestyle medicine is about a journey. There cannot be an expectation that things will happen overnight. It is about talking to people and finding those little nuggets that can go in on and knowing your population and being able to develop good programs from there and being invested in these programs.
We have to be rowing in the same direction. And I need your help. Local Ys are trying to keep their doors open. Many just don’t think about those kinds of things as necessarily the first thing on their list do to. I did not mention that about 70% of the participants that are going through these programs are not YMCA members. So connecting people to these kinds of program leads into infrastructure. It takes both halves to be able to make the whole!
We are starting to learn more about motivational interviewing today. Maybe that is something that your practices can incorporate to find out what the biggest obstacles are for individuals and how you can help them find the support that the need. Most people have the desire to change and keep their change permanent. We’ve got to build in support in our communities and our workplaces to help them as the obstacles seem to be overwhelming. If we can do that, then we will have much better sustainability of health improvements in the future.
The third thing is that I used the phrase “lifestyle medicine” many years ago when I edited the first textbook in this area because it was going to be the foundation of evidence-based medicine. I was also convinced that a lot of different professionals who are involved in this area need to be involved. It is crystal clear now to me after having the honor of moderating these discussions at the ACLM Annual Meeting over the past few years that the field of improving health in focusing on daily habits and practices is going to coalesce around what we are all calling “lifestyle medicine.” It is not going to be anything else. What you do in your daily life profoundly impacts the short-term and long-term quality of life.
I have been motivated by some of the sweatshirts that I have seen at swim meets when my teenage daughters go to competitions. And one sweatshirt I quoted several years ago stated, “Without a dream there is no reason to work. Without work, there is no reason to dream.” Clearly we’ve got a lot of work to do if we are going to accomplish our dreams. Another favorite of mine comes from Antoine de Saint-Exupéry, who said, “A goal without a plan is a wish.” Both of these slogans reflect issues that we should be thinking about as the field of lifestyle medicine moves forward.
It is wonderful to have these programs that were described today available now to individuals who wish to practice lifestyle medicine. I also want to thank the audience for their passion to keep the lifestyle medicine movement alive. I hope you will leave this conference with specific plans for what you want to do moving forward based on not only this session but also all the other sessions at this outstanding conference.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.