Abstract
How do the definitions between health promotion professions differ? Should the shift from using the term wellness to greater use of the well-being term challenge us to explain how our profession improves how people appraise their lives as a whole? After all, achieving well-being is a challenge as relevant to clergy, politicians, artists and entertainers as to health professionals. Successful organizations are keenly attentive to how they differentiate their services so as not to get lost in a sea of like competitors. The American College of Lifestyle Medicine has recently defined lifestyle medicine as a medical specialty delivered by certified clinicians. In contrast, the Society of Behavioral Medicine suggests that virtually any degree holder may be qualified to provide disease management and prevention services. If improved health is one of the surest ways to improve well-being, do we need to more clearly define the health promotion profession’s value proposition? How should definitions about differences between professions influence reimbursement differences between professions?
Keywords
Writers like Ernest Hemingway and F. Scott Fitzgerald and painters like Matisse and Picasso liked to hang out with Gertrude Stein as she “helped shape an artistic movement that demanded a novel form of expression and a conscious break from the past.” 1 Her sentence from her poem “Sacred Emily” that a “Rose is a rose is a rose is a rose” has been debated, derided, and re-hashed by writers interested in literal vs figurative meanings of, and the best uses for, words. Considering the power of words in a different way, Shakespeare’s “a rose by any other name” was Juliet’s way of saying she judged a man by who he was, not what he was called. How important are the definitions, and the words therein, that explain the work of disease prevention and health promotion professionals? How intimately do these definitions inform how a profession thinks, behaves and organizes? And, how much impact should these definitions have on how much a professional is paid?
Are the definitional differences between the various professional organizations dedicated to improving individual and community health significant enough to convey true differentiation with respect to goals and beliefs between the professions? Or are the definitions used by professional groups that are largely aligned offering distinctions that don’t amount to much of a difference? This editorial reviews the definitions for five health promotion professions and argues that definitions matter and that the distinctions between the professions could be better understood if definitions were more explicit about professional credentials needed to perform the work. Alongside greater clarity about credentials should come more rational, outcomes based reimbursement policies. I argue that better differentiation between professions could shift the present focus in healthcare on pay for productivity to more experimentation with reimbursement based on performance.
Professions striving to remain relevant must continue to evolve in accordance to changes in society, scientific discoveries and consumer needs and interests. A profession, compared to an occupation, is characterized by work that requires specialized knowledge and skill. Hence, a health profession that requires a high level of specialized learning, and wants recognition for same via reimbursement, must clearly differentiate itself from the kinds of health services purveyed by those without specialized education. I’d venture that non-professionals in the business of selling wellness to unwitting consumers far outnumber professionals trained to measurably improve wellness in health systems, communities, schools and workplaces.
If healthcare were a product, it is increasingly becoming a Ford, not a Ferrari. When it comes to quality measures and outcomes within and between professionals, healthcare is unusual given the disturbing disconnects between what we’re asked to pay relative to the quality of the deliverables. That is, a surgeon who has done ten thousand procedures is reimbursed that same as one who has done ten. Worse, a surgeon with significantly higher post-surgical survival rates or a physician with significantly lower hospital re-admission rates is reimbursed the same as those with the poorest of such rates. Even worse, pay for productivity has far outpaced pay for performance as health systems experiment with reimbursement reforms suggesting clearly to clinicians that quantity matters more than quality. Physicians I know who retired early did it simply because they wanted off of the treadmill.
In the sections that follow, I provide definitions about professions in the business of improving health and preventing, even reversing, disease. The italicizing in each definition is my own as I try to highlight those aspects of the definitions that infer the need for professional acumen. I underline sections of the definitions that I believe suggest a point of differentiation between one profession and another. As you will see, some words are both italicized and underlined which suggests a requirement for greater professional training and, potentially, could justify the level of reimbursement needed to support the higher level of expertise represented. That is, if and when we reform reimbursement to better incentivize measurable superiority in the attainment of better than usual outcomes.
Health Promotion Definitions
Reflections on Health Promotion Definitions
In previous editorials I have reflected on the health promotion profession’s migration from using the term wellness to a preference for the term well-being. 7 I have also attempted to adjudicate ‘traditional wellness’ and challenge the notion that only a comprehensive approach to health promotion can make a meaningful difference. 8 A strength of each of the above definitions is that they parse between individual and social responsibility for health and indicate that both education and environmental and policy change is important for achieving health and well-being. A weakness of these definitions is that they infer that a herculean professional generalist, equally astute at teaching individual skills while driving public policy change, is needed to achieve health improvement. The credential that seems most closely aligned to these definitions is a Master’s in Public Health (MPH), someone trained at an accredited School of Public Health. Yet, a strength of the health promotion workforce is that it is populated by multi-disciplinary specialists ranging from health educators to psychologists to exercise scientists and nutritionists and many more allied health professions and social science disciplines. These health promotion definitions, in contrast with the “Lifestyle Medicine” and “Preventive Medicine” definitions below, are essentially silent on the expertise needed to be effective at executing the work or what credentials would best qualify who should be, or should not be, reimbursed. Health promotion presents as a big tent with all the foibles that come with the ease with which people can slip under it.
Lifestyle Medicine Definitions
Both of the definitions below come from the American College of Lifestyle Medicine (ACLM) and I offer them in full because, though the wording changes may at first seem minor, there are a handful of word changes that impress me as clear definitional differentiators from other health promotion professionals. What’s more, though the Lifestyle Medicine definitions of yore were regularly iterating, the wording changes were merely refinements on how they characterized the ACLM “pillars.”9-11 The new definition not only distinguishes the work from other professions, it is more explicit about who is qualified to do the work.
Reflections on the Changes in Lifestyle Medicine Definitions
For a time, definitions of Lifestyle Medicine (LM) were silent on who provided LM with most of the definitions relating to the pillars that were “foundational to health and wellness” such as “heathy eating” and “sleep.” More recently, the definitions connoted that LM practitioners worked in health systems with words like “target patient behaviors,” “the practice of” and LM “as a primary therapeutic modality.” Prior to this new revision, the last definition clarified that these pillars were modalities that were delivered by clinicians trained in these modalities.
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The new definition above drives an attention-getting stake in the ground and states that LM is now a “medical specialty” delivered by “certified clinicians.” Where a weakness of health promotion professional definitions relates to the generalist overtones and the sweeping work of changing individuals while also reforming policy and improving society, this LM definition suffers no such generalities. That is, LM clearly aspires to codify the prescription of lifestyle change as a medical practice delivered by certified clinicians. Should a psychologist with a high percent of patients who have successfully sustained weight loss or quit smoking be reimbursed differently than other clinicians with scant outcomes data?
I will be cheering on ACLM as they forge a path to legitimizing their declaration that LM is a medical specialty by taking their case to the hallowed halls of the medical professional associations. You can lobby the Association of American Medical Colleges (AAMC) and the “FREIDA” Specialty Guide of the American Medical Association.15,16 as well as the St George’s University “Ultimate List of Medical Specialties and Subspecialties” if you want to see Lifestyle Medicine included along with other specialties such as Preventive Medicine on their lists. I expect most primary care providers would be motivated to up their skills at providing lifestyle medicine if the extra time needed to do a good job of it was adequately reimbursed. Several “Doctor’s Helping Smokers” studies offer compelling evidence that even brief advice from physicians can be a catalyst for behavior change when coupled with cessation programs. 17
Besides bucking the focus of medical system gatekeepers on, well, medicine, I expect LM has an even greater uphill climb to reach the cloistered deciders of medical reimbursement. Deciphering what constitutes medical necessity is up there with reaching agreement on good food and bad food. It is telling that Medicare coding for counseling on smoking and weight control is apportioned by “greater than 3 min and up to 10 min” besides being tied to a specific diagnosis. 18 A 2019 survey by ACLM found that 74 percent of clinicians offering lifestyle medicine were not reimbursed for such services. 19 Related to who gets paid for what, the new definition for LM is silent on how other health professionals support the work of certified LM clinicians (ie non-LM certified dietitians, health coaches, exercise scientists). I’m confident that the framers of this new definition are fully aware that effective chronic condition management is a team sport with the patient as the most pivotal player. Indeed, one of the reimbursement innovations proposed by ACLM is to remove specific clinical location billing requirements so LM programs can be offered in schools, churches or community centers. 20
ACLM will have a stronger argument for physician reimbursement for LM when they clearly differentiate which “clinicians” are deemed qualified to deliver LM and, ideally, how reimbursement can be tied to outcomes. Specifically, I hope ACLM seeks to define what it is that a physician is uniquely qualified to deliver as compared to what a lower paid clinician or professional such as a health educator, dietitian or psychologist can deliver. Consistent with my call above for more rational reimbursement policy, how might pay for performance bolster LM as a sought after medical specialty? Should a newly minted LM certified physician be paid differently than, say, an LM certified dietitian with 20 years of experience? What’s more, how could reimbursement be tied to outcomes? That is, could a psychologist with a registry of a high percent of patients who have successfully sustained weight loss or quit smoking be reimbursed differently than other clinicians with scant outcomes data?
Preventive Medicine Definition
The American College of Preventive Medicine (ACPM) states that: “Preventive medicine (or preventive care medicine) consists of a wide variety of characteristics, but with preventive disease, disability, and death as core components across all arenas of practice. Preventive medicine specialists work directly with patients to prescribe clinical preventive medicine and lifestyle-based interventions to prevent disease. Preventive medicine physicians’ work with governments, business, health systems, and more to understand the needs of their communities and develop policy and population health practices to prevent disease and improve health at the population-level.” 21
Reflections on the Preventive Medicine Definition
As an established medical specialty ratified by accredited medical schools and societies, it is interesting to observe that the definition of preventive medicine shares more in common with the non-medical definitions of health promotion than it does with the clinically oriented definition of Lifestyle Medicine. Where ACLM articulates six pillars focused on individual lifestyle prescriptions, ACPM physicians work with governments and businesses to assess needs, develop policy and improve population health. I know many M.D./M.P.H. trained physicians. Based on the preventive medicine definition, I’d venture their M.P.H is more related to fulfilling the job requirements than their medical degree. An easy way to refute this observation would be for ACPM to fashion a definition that more clearly describes what a physician can do to improve population health that an M.P.H. is not qualified to do. And, as above, ACPM could exert leadership by rationalizing reimbursement differences between preventive medicine clinicians with a track record of reducing the prevalence of chronic diseases in a population compared to those without performance data.
Behavioral Medicine Definitions
Reflections on Behavioral Medicine Definitions
Like the definitions for health promotion, the SBM rendition of behavioral medicine is quite broad and silent on professional differentiation. In contrast, the Boston Behavioral Medicine definition has a clearer leaning toward mental health and mental health practice. Unlike the ACSM and ACPM, if you read the narrative that follows these definitions on these behavioral medicine web sites, you will see that there is little attempt at exclusivity about who can do the work. Boston Behavioral Medicine notes that:
Population Health Definitions
Reflections on Population Health Definitions
I don’t know of anyone who identifies as a population health professional so including these definitions feels more of a semantic than a practical exercise. Still, Kindig’s definition has been adopted by the American Hospital Association (AHA) and the Institute for Healthcare Improvement (IHI) so someone somewhere may find useful distinctions between population health and other health promoting definitions. I’ve always thought anyone with a goal of improving the health of an entire population is impressively audacious though I vacillate between admiring them and distrusting them. Generally, population health impresses me as a redundant unnecessary term given how little it differs from more commonly accepted professional definitions for the work of public health or preventive medicine.
A Rose is a Rose is a Rose
When people ask me about the differences between being a PhD doctor working in healthcare as compared to an M.D. doctor working in healthcare I usually say: “My work is harder, I don’t get to offer drugs.” Each of the five professional definitions above bespeak the intrepid work of preventing, treating and even reversing disease the hard way; sans pharmacology. That these health promotion related definitions share more in common than not comes as no surprise. Indeed, as with critics of Gertrude Stein, there will no doubt be readers of these definitions who feel that parsing between them serves no useful purpose. Nevertheless, like Stein, I hold that words matter which is why I have written previously about how the well-being term shares most things in common with legacy definitions of health and wellness. 26 If the achievement of well-being has indeed become a focus for some of the above professions, more so than the attainment of physical and mental health, the above definitions from the health promotion professions fall short.
The health promotion expert panel that drafted the latest goals for the nation, “Healthy People 2030,” appears to have adapted a definition for well-being from across the pond à la the New Economics Foundation
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and the Lambeth Happiness Program.
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Healthy People conflates health with well-being and states that: “well-being can be understood as how people think, feel and function, both on a personal and social level, and how they evaluate their lives as a whole.”
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It is a definition that describes a state of well-being with life satisfaction elements that can be measured. To be sure, healthy lifestyle changes and healthful public policy contribute to life satisfaction but if fostering well-being is a prime motivation for health promotion professionals, our job descriptions need to be better aligned with how people feel about their “lives as a whole.” The CDC’s definition of health promotion with its call for peace, economic security, a stable ecosystem, and safe housing seems most closely aligned to a grand goal of well-being for all. Nevertheless, I don’t know of any health promotion professional with a day job that pays them to reign in dictators or solve for redlining. Any of these health promotion professions could truly differentiate themselves from the others with money back guarantees or, at least, warranties.
Paying for Performance, not Credentials
A bromide in the business world is to “under-promise and over-deliver.” Nothing turns off customers more than being led to expect they would get something great only to find a product or service wanting. Are health promotion professionals striking the right balance between having an ambitious vision vs forever coming up short? Perhaps we should leave well-being to the priests and politicians. Improving health is plenty hard enough.
A proven way to comprehend a difficult concept is to offer up the best examples of the concept, and, importantly, to also provide examples of what the concept is not. The Boston Behavioral Medicine definition does this well by noting that experts in this field practice biofeedback, mindfulness meditation and motivational interviewing. The American College of Lifestyle Medicine has been iterating their definition of Lifestyle Medicine such that their former use of healthy eating is now a “whole-food, plant-predominant eating pattern,” sleep is now “restorative sleep” and relationships are now “positive social connections.” On the other hand, where ACLM is explicit about LM being a medical specialty conducted by certified clinicians, the Society for Behavior Medicine and the Health Promotion profession seem to welcome all comers.
Successful organizations are keenly attentive to how they differentiate their services so as not to get lost in a sea of like competitors. While I find these definitional differences interesting, it will be when payers for these services demand quality outcomes that these proclaimed credentialing differences could become true market differentiators. That is, those who claim a different and special ability show payers they produce a higher quality outcome. Once upon a time a national tobacco cessation vendor based their payment model on the percent of smokers who stayed quit. Any of the professions above could truly differentiate themselves from the others with money back guarantees or, at least, warranties. Ultimately, it is the payers who will decide which health promotion professional is the Ford and which is the Ferrari.