A Hybrid Value-Based Lifestyle Medicine Practice Model

Abstract

A lifestyle medicine approach to primary care that is value based can provide positive triple aim outcomes and demonstrate market equivalent reimbursement for the practitioner.

. . . study after study has supported the value of nutrition, physical activity, stress management, and other core lifestyle medicine pillars in the prevention and treatment of disease.

The field of lifestyle medicine has grown rapidly over the last 15 years. At its conception lifestyle medicine occupied the high ground as far as morally being the right thing to do. Treating the root cause of disease, and doing it in natural, low-cost ways not only makes sense but is ethically sound as well. From the beginning, and increasingly stronger each year, lifestyle medicine has also occupied the high ground from the perspective of being the right thing to do scientifically. Lifestyle medicine has always emphasized its evidence base, and study after study has supported the value of nutrition, physical activity, stress management, and other core lifestyle medicine pillars in the prevention and treatment of disease. Until now, however, the field of lifestyle medicine has lacked the ability to clearly claim the economic high ground. The ability for a lifestyle medicine approach to save money while improving clinical outcomes has not been well documented. But this is starting to change.

Lifestyle Medical is a 2-clinic primary care practice in the Inland Empire region of Southern California whose goal is to provide innovative primary care using a lifestyle medicine foundation. The clinic concept was started in 2015 when Charles Martin, a health care business innovator, approached Wayne Dysinger, a lifestyle medicine pioneer, about starting a new model clinic. Over the next 3 years, Mr Martin provided the economic foundation for Dr Dysinger to create clinical systems that infused lifestyle medicine throughout a full service primary care clinic. ¹ In 2018, Arwin Soetanto joined the operation as chief operating and financial officer, and Lifestyle Medical was formed. The clinical innovations were merged with solid financial accountability and consistency to create an economically strong operation that has the potential to be replicated across the United States.

From its inception, Lifestyle Medical has been committed to value-based care. It is difficult if not impossible to fully apply lifestyle medicine principals in a fee-for-service environment where the emphasis is on seeing a patient quickly and efficiently. But if a practice is reimbursed in a capitated manner and measured using the triple aim—decreased overall cost, improved clinical outcomes, and greater patient satisfaction—the lifestyle medicine philosophy and the practice economics align well. Following this path is not easy, but is increasingly not only doable but also encouraged as population- and value-based care continues to gain a foothold in the American health care system. ²

Reimbursement at Lifestyle Medical focuses on 4 core categories: (1) Medicare Advantage, (2) Original Medicare, (3) Commercial low-entry membership, and (4) direct primary care. By providing innovative, value-based approaches, Lifestyle Medical has been able to achieve solid profitability in each of these categories. Although the value-based component varies in each category, all of them have significant capitated reimbursement components, which allow the primary care Lifestyle Medical practitioner to keep the same mindset no matter which type of patient they are serving and supporting.

Medicare Advantage

Medicare Advantage (MA), also called Medicare C or HMO Medicare, has been available since 1997, but has only recently really started gaining a foothold from the perspective of seniors who choose it, and physicians who accept it. The difference between Medicare Advantage and Original Medicare is that MA uses a fully value-based reimbursement approach. ³ The Center for Medicare and Medicaid Services (CMS) provides around $11,000 per senior per year to contracted insurance companies. Those insurance companies then contract with hospitals and physicians to try to achieve the triple aim. If resources are used efficiently, any leftover dollars are kept by the insurance companies. The MA insurance companies will frequently contract with primary care physicians in a capitated way as well. More progressive companies will even provide risk sharing contracts with primary care physicians.

Lifestyle Medical currently has 4 separate Medicare Advantage contracts. Two of those are risk sharing contracts. This has been by far the most economically profitable sector for Lifestyle Medical. In the shared risk contracts, Lifestyle Medical receives a share of the profits for hitting the triple aim with our patients. This means when we keep patients out of the hospital, utilize less specialty care, and decrease imaging and medication costs, we get to keep a portion of this. There are multiple ways to capture this, but the overall income from each shared risk patient is around $200 per member per month. Our 2 non–shared risk Medicare Advantage contracts reimburse closer to $80 per member per month.

Original Medicare

Original Medicare, or from a physician reimbursement perspective, Medicare B, has been a core reimbursement model for over 5 decades. In recent years, however, Medicare B has added value-based components to its reimbursement strategies. Lifestyle Medical takes advantage of 2 of those tools: (1) chronic care management (CCM) and (2) remote patient monitoring (RPM). Lifestyle Medical contracts with a vendor (Carium) to assist in meeting the technical requirements of both CCM and RPM. When fully implemented, practices can achieve as much as $130 per member per month from CCM and/or RPM reimbursement mechanisms. An investment is required to get this started, but when in place it works financially, and it helps original Medicare to feel more like a value based reimbursement approach as well.

Commercial Low-Entry Membership

Because Lifestyle Medical is dedicated to both a lifestyle medicine approach to primary care and applying value-based care in all aspects of what we do, Lifestyle Medical has also implemented a low-entry membership fee for all of our commercial patients—whether HMO (health maintenance organization) or PPO (preferred provider organization). This means that non-Medicare patients who have an insurance that reimburses Lifestyle Medical will pay an additional $18/month or $199/year to become a member in our practice. This is a cost that most patients can pay, and many are willing to pay in exchange for the various lifestyle medicine resources available in our practice. This includes classes, groups, individual counseling and coaching, longer visits, email visits, and multiple other unique approaches. The additional monthly income allows Lifestyle Medical to apply full scope lifestyle medicine primary care to all of our patients.

Direct Primary Care

For patients who either do not have an insurance that Lifestyle Medical accepts, or who may have a very high deductible insurance policy, Lifestyle Medical also offers a $78/month or $899/year contract that provides all our lifestyle medicine and primary care services at no additional cost. Initially, before the practice evolved into Lifestyle Medical, this was the only reimbursement model available. We found, however, at least in our area of the country, that this narrowed our potential patients too much. This reimbursement model now is about 10% of our overall practice. We do think it will grow though, especially as employers begin to do more direct contracting with value-based care health care organizations.

Lifestyle Medical has found that by being innovative and flexible, and working with current reimbursement strategies, we can achieve strong economic results coupled with excellent clinical outcomes and incredibly high patient satisfaction. We believe this model is doable for many practices around the country, thereby allowing more and more patients to experience the beauty of health care based on the principles of lifestyle medicine.