American College of Lifestyle Medicine Expert Panel Discussion: Implementing Intensive Therapeutic Lifestyle Change Programs

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.

Scott Kashman: I wanted to take a couple of minutes to give testimony. I am the Chief Acute Care Officer for Lee Health, formerly known as Lee Memorial Health System. We are one of the major health systems in southwest Florida and hearing these stories is very inspiring. We want great health for our community. Lee Health wanted to make sure we first focused on the health and well-being of our team of employees, physicians, and nurses, so, in turn, they better care of themselves, their colleagues, their patients, and families. The CHIP program was one of several key programs we implemented to focus on the overall wellness of our team. Through the CHIP Program, what we found was that we were able to improve health outcomes and saw a very substantial economic return on the health care costs of the people who had gone through the program.

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.

Christy Gunier: It is an honor to be here in the presence of such great minds. I work for Cummins, which is a manufacturing distributor of diesel engines and components. We have 55 000 employees spread around the world, and our challenge is how do we integrate lifestyle medicine in everything that we do as an employer?

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.

Matt Longjohn: I am the National Health Officer and Vice President for Community Integrated Health at the YMCA of the USA, which is the national resource center for the 2700 YMCAs around the country, such as the incredibly innovative and exciting Y here in Naples, Florida. What is exciting to me is not only what is happening here in Naples but also what is happening in Ys all over the country. The first objective in our Panel’s objectives was to identify what kind of trends are pulling community-based organizations like the Y into the field of lifestyle medicine, preventive services, and so on. I will start there.

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.

Tom Kostohryz: My background is a little bit different from the rest of the panelists. We certainly have heard some inspirational stories from some of the other panel members. Regarding my background, I spent 30 plus years in my career building an employee benefits consulting agency. Included in the agency is a service center that helps frustrated employees get their claims paid. As we all know this can be a real problem. So because of my experiences in this area I have a substantial background in how to properly submit and get claims paid. This is a real benefit for me as we talk about billing for therapeutic lifestyle intervention programs. In 2010, I had the opportunity to sell my business and I transitioned into what I like to say from a “successful” business to a career of “significance.” I started a 501c3 called Live Healthy Appalachia. Our vision is “empowered people making healthy choices.” And we do that by providing programs that promote healthy eating and active living in our community. What we tried to do initially was to find evidence-based programs that could serve as the cornerstone of our nonprofit organization. With Hans Diehl and the CHIP program we found one that we could use as the basis of foundation of our community well-being program.

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.

James Rippe: I am sure the audience has probably gathered as stated in the program for the Expert Panel discussion that this whole panel is devoted to intensive therapeutic lifestyle changes. I view these programs as the tip of the iceberg. It is the part we see. Ninety percent of what’s going on is below the surface. These are very exceptional programs that show how far at this current time you can push the idea of lifestyle medicine programs. They have a very impressive track record of making the kind of changes the panelists are talking about at the end of the day. It is very important that lifestyle medicine be based on strong evidence. That was my initial vision when I edited the first Lifestyle Medicine textbook. If we are going to build a movement, the foundation must be evidence-based. What we are seeing today is a continued evolution of people taking that cornerstone idea and building dynamic programs—programs that work around it. Is it surprising that we can show that these changes occur? I don’t think it is surprising, but we need to show this over and over again and we need to do that in peer-reviewed publications. Many practicing physicians do not know some of the basics of how important changes in lifestyle measures are. For example, I gave a grand round lecture several years ago where I asked the physicians in attendance “how many people here treat hypertension?” One hundred percent of attendees raised their hands. Then I asked, “How many of you use lifestyle measures for the first 6 months in stage 1 hypertension?” Not one person raised their hand. Then I asked, “How many of you know what JNC 7 is? How many of you know that the national recommendation for stage 1 hypertension is lifestyle modalities before starting antihypertensive medications?”

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.