The Centers for Medicare and Medicaid Services (CMS) 2022 National Quality Strategy is described as an "ambitious long-term initiative that aims to promote the highest quality outcomes and safest care for all individuals." This sounds great, and it would be if there were any possible way for this initiative to fulfill its promise. But, as with many programs operated by the government, high-quality outcomes are not likely to occur..
Most doctors and most patients know that diet, exercise, hydration, sleep, and other lifestyle factors are important determinants of health. Clinical practice guidelines for many conditions include recommendations that diet and lifestyle intervention should be the first and is the best treatment. Many studies have shown that type-2 diabetes can be reversed with a whole food plant-based diet (WFPB).[1] [2] Long-term adherence to a WFPB diet has been shown to result in atherosclerotic regression, reduction in angina and reduced risk of cardiac events, even in people who have been diagnosed with severe coronary artery disease.[3] [4]
So why aren’t more doctors spending more time during office visits to discuss these types of health improvement strategies with their patients? The answer might surprise you. Quality measures used to evaluate the performance of doctors and reimbursement schedules do not take into consideration issues such as improved health outcomes and reduced costs of care. For example, adherence to medication is rewarded, even if the patient does not experience any health improvement at all. Diet and lifestyle education requires more time than most medical institutions allocate for patient visits, which further incentivizes prescribing instead of engaging in meaningful discussions about health.
Thus, in most cases, patients are not informed about diet and lifestyle change as an option or an alternative to medication. A commonly held misconception is that most Americans would rather just take a pill than change their diet and increase their exercise. But the reality is that this choice, along with the risks and benefits of both options, is not presented to most patients most of the time.
Lifestyle medicine is now a medical specialty, and since certification began in 2017, 2500 physicians have become board-certified. In addition to the limitations already mentioned, a survey found that over half of lifestyle medicine clinicians receive no reimbursement for offering such services. And some programs that are eligible for reimbursement offer so little money that clinicians cannot afford to spend time on them.[5]
One program that is reimbursed adequately is intensive cardiac rehabilitation. It’s underutilized and one of the reasons may be that patients are required to co-pay for visits. For the program to work, visits need to be scheduled frequently, increasing the expense to patients, and creating yet another barrier to real health improvement.
One of the best illustrations of just how dysfunctional the current system has become is what happened to a lifestyle medicine family practice physician who prescribed lifestyle change instead of a statin drug to a patient with hyperlipidemia. Within just three weeks, total cholesterol dropped from 226 mg/dl to 171 mg/dl and triglycerides dropped from 132 mg/dl to 75 mg/dl. This was obviously a great outcome for the patient. But the CMS 5-Star Rating System assigned the physician a Grade C, which placed the doctor’s previous 5-star rating at risk. The reason was that scores are largely based on medication compliance. The physician was penalized even though the outcome was much better than would be expected from treatment with a statin.[6]
There are other ways the system can punish doctors for curing people. The sicker the patient, the higher the reimbursement rate from Medicare, because it is assumed that care will cost more. The physician who reverses type 2 diabetes with diet is penalized because diabetes is no longer listed as a condition the patient has, so Medicare pays the doctor less money. In other words, Medicare pays doctors to manage, not reverse disease.[7]
There are now over 2500 quality measures for doctors to pay attention to, and curing people is not one of them. This sad state of affairs reinforces our advice that consumers must take responsibility for their health and should not outsource decisions about treatment to their doctors.
[1] Anderson JW. "Dietary fiber in nutrition management of diabetes." In: G. Vahouny, V and D Kritchevsky (eds), Dietary Fiber: Basic and Clinical Aspects." Pp.343-360. New York: Plenum Press,1986.
[2] De Natale C, Annuzzi G, Bozzetto L et al. "Effects of a Plant-Based High-Carbohydrate/High-Fiber Diet Versus High–Monounsaturated Fat/Low-Carbohydrate Diet on Postprandial Lipids in Type 2 Diabetic Patients." Diabetes Care 2009 Dec;32(12):2168-2173
[3] Ornish D, Scherwitz LW, Billings JH et al. "Intensive lifestyle changes for reversal of coronary heart disease." JAMA 1998 Dec;280(23):2001-2007
[4] Esselstyn CB, Ellis SG, Mendendorp SV, Crowe TD. "A strategy to arrest and reverse coronary artery disease: a 5-year longitudinal study of a single physicians’ practice." J Fam Practice 1995 Dec;41(6):560-568
[5] Padmaja Patel MD. How PCPs Are Penalized for Positive Outcomes From Lifestyle Change. Medscape October 13 2023
[6] IBID
[7] IBID
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