by Wayne Persky
Founder and President of the Microscopic Colitis Foundation
Or, why your doctor is forced to prescribe medications
Indisputable evidence continues to support the position that making lifestyle behavior changes, when properly done, can be successfully used to prevent, and even reverse common chronic issues such as cardiovascular disease, obesity, and type II diabetes, for example. And the clinical practice guidelines listed for the treatment of such chronic diseases currently suggest lifestyle interventions as the first line of treatment, whenever possible.
But despite the fact that our doctors may recognize the benefits of a healthier lifestyle, they can ill afford to recommend lifestyle changes that don't include the use of prescription medications, when treating their patients. Here's why:
The electronic health record (EHR) system currently contains disincentives.
The EHR contains not only patient records, but the system also determines how doctors are compensated/paid for their performance. According to an online article published last October on the Medscape website, here's an example of how well-intentioned doctors are penalized if they use lifestyle changes to resolve their patients' health issues, rather than writing a prescription for one or more medications (Patel, P. (2023, October 13).i
The use of statins, provides a good example of the dilemma often faced by clinicians who would like to recommend lifestyle changes. A primary care physician had a patient who had been diagnosed with hyperlipidemia (high cholesterol), and who was covered by Medicare Advantage. The patient's total cholesterol level was 226, and their triglyceride level was 132. Instead of prescribing a statin, the physician recommended lifestyle behavior modifications, and within three weeks, the patient's total cholesterol level had gone down to 171, with a triglyceride level of 75. Although that was obviously an outstanding success, and the patient was thrilled, the CMS five star rating system assigned the physician a grade of C, rather than A. Why? As the article points out:
The use of statins, provides a good example of the dilemma often faced by clinicians who would like to recommend lifestyle changes. A primary care physician had a patient who had been diagnosed with hyperlipidemia (high cholesterol), and who was covered by Medicare Advantage. The patient's total cholesterol level was 226, and their triglyceride level was 132. Instead of prescribing a statin, the physician recommended lifestyle behavior modifications, and within three weeks, the patient's total cholesterol level had gone down to 171, with a triglyceride level of 75. Although that was obviously an outstanding success, and the patient was thrilled, the CMS five star rating system assigned the physician a grade of C, rather than A. Why? As the article points out:
Because the system bases its score largely on medication compliance. The physician was penalized despite achieving the optimal health outcome, and at a lower cost than with medication. This misalignment does not incentivize patient-centered care because it disregards patient preference, shared decision-making, and evidence-based practice.
Ironically,
the Centers for Medicare and Medicaid Services (CMS) describes their 2022 National Quality Strategy as an “ambitious long-term initiative that aims to promote the highest quality outcomes and safest care for all individuals."
And as the article points out:
the strategy calls for a multidisciplinary, person-centric approach for individuals throughout the continuum of care, with an emphasis on historically underresourced communities. It is a commendable goal for an overburdened US healthcare system that spends more than other high-income counties yet experiences poorer outcomes. But whole-person, person-centered care cannot be achieved under current misaligned quality measures that fail to measure what we purport to value: the quintuple aim of improved health outcomes, cost savings, patient satisfaction, clinician well-being, and health equity.
So much for CMS claims actually meaning what they say.
The article lists other disincentives
for doctors who recommend lifestyle changes for patients. For example, the goal of lifestyle medicine clinicians is to restore health whenever possible, rather than simply managing disease with increasing amounts of costly medications and expensive procedures. But currently, the Medicare risk adjustment incentives for physicians are set up to promote the management of disease, rather than the elimination of disease.
It appears that big Pharma is allowed to influence certain CMS requirements.
In order to ensure that Medicare health plans are not penalized for the enrollment of sicker patients, they're set up so that the sicker the patient, the more Medicare will pay. But if a physician uses diet changes alone to achieve remission in a patient with type II diabetes, for example, instead of being rewarded for eliminating the need to continue regular medical treatments for the condition, the physician is financially penalized. Here's why that happens:
If a clinician chooses to treat a patient with medications, then laboratory tests can be scheduled on a quarterly basis, and so can follow-up visits and/or medication adjustments. But if the clinician chooses to treat that same patient by means of lifestyle changes, (using no prescribed medications), then allowed laboratory test options, and follow-up visits, are reduced by half, or more. And physician reimbursements by CMS are also decreased by half, or more. Obviously, this is a major disincentive for the physician, since the time required for counseling patients regarding lifestyle changes is significantly greater, and typically requires more follow-up counseling, when compared with simply writing out a prescription for a medication.
If a clinician chooses to treat a patient with medications, then laboratory tests can be scheduled on a quarterly basis, and so can follow-up visits and/or medication adjustments. But if the clinician chooses to treat that same patient by means of lifestyle changes, (using no prescribed medications), then allowed laboratory test options, and follow-up visits, are reduced by half, or more. And physician reimbursements by CMS are also decreased by half, or more. Obviously, this is a major disincentive for the physician, since the time required for counseling patients regarding lifestyle changes is significantly greater, and typically requires more follow-up counseling, when compared with simply writing out a prescription for a medication.
Obviously, this is not what the system claims to be designed to do.
Rather than rewarding a clinician for outstanding service as a result of achieving complete remission of the patient's disease (which is defined by the system as the ideal clinical outcome), the system financially penalizes the physician for their efforts. Such obvious mismanagement of incentives (by the use of disincentives such as this) can only lead to disappointing performance by the healthcare system.
Physicians are frustrated, and disappointed.
And so are patients — many patients realize that they're receiving overpriced, second-rate care. Whether or not patients realize that they're being poorly treated, in the long term, the net result is much unnecessary patient suffering, and a huge amount of money wasted on unnecessary medications. Rather than enjoying remission, patient's are forced to continue to live with a disease that their doctor is not only capable of resolving, but would prefer to resolve, and thereby put an end to the endless need for expensive medications to keep the disease under control.
Apparently there are good reasons why US healthcare is so poorly rated.
How can the individuals who are in charge of administering, and setting up these incentives for physicians, possibly regard this as a satisfactory arrangement? This appears to be a good example of "The Law of Unintended Consequeces". Despite its admirable claims, CMS imposes disincentives in the EMR system that virtually guarantee (because of the financial penalties/disincentives for physicians) that the performance of certain segments of US healthcare will continue to be poor, unless some significant changes are made.
References
1. Patel, P. (2023, October 13). How PCPs Are Penalized for Positive Outcomes From Lifestyle Change. Medscape, Retrieved from https://www.medscape.com/viewarticle/997218?ecd=wnl_infocu10_broad_broad_persoexpansion-algo_20240210_etid6301497&uac=95382HN&impID=6301497