Stanley Feld M.D., FACP, MACE

We are a very innovative people. As technology increases there are increases in goods and services created. Many of these new goods and services have been discovered to have unintentional negative consequences to our health. This is discovered after the product or processing of the product has been well established. It is difficult to reverse the exposure to these consequences without having grave economic and political consequences. Powerful vested interests exert political influence on policy to protect their profit domain at the expense of our general well being. This results in perverse outcomes.

We all know the healthcare system is broken. We are experiencing uncontrolled and unaffordable costs as our population becomes more obese and subsequently sicker. I have pointed out that the patients as the primary stakeholders are the most important members of the healthcare team. Physicians are also primary stakeholders. Their job is to teach patients to be professors of their disease in order to effectively prevent complications of chronic disease from occurring. The facilitator stakeholders are the government, the employers, the insurance companies and the hospitals. Facilitator stakeholders waste at least $150 billion dollars of healthcare costs a year through administrative waste.

Malpractice insurance and the threat of law suits because of weak government legislation, a topic I have not discussed yet, drives physicians to practice defensive medicine in order to avoid law suits. The cost of defensive medicine is beyond estimate. I would bet it is more than $150 billion dollars per year.

We also know that the complications’ of chronic disease consume 90% of the direct medical care costs of the health care dollar. If we can eliminate 50% of the complications, we could cut the healthcare bill theoretically in half. If this could be accomplished we could make health insurance affordable to everyone.

Obesity precipitates type 2 diabetes mellitus. The cost to the healthcare system is $160 billion dollars per year. The farm bill costs 25 billion per year in subsidies in order to help us become obese. This perverse outcome is the result of supporting the vested interests of the mega farmer and not the small farmer. Recently the cost of a bushel of corn has doubled because we do not have enough corn for food, animal feed and biodegradable fuel production. A complaint is there are too many ethanol refineries being built to make fuel from corn. The goal of the production of increasing amounts of ethanol for fuel is to free us from our dependence on foreign oil as well as create a renewable source of energy. However, this will result in a shortage for the food industry.

A simple solution is for congress to enact a law requiring all automobile manufacturers to produce ethanol friendly engines immediately. In addition, immediately enact a law that would permit the mega farmers to produce genetically engineered big corn. This corn would eliminate the shortage of raw material for ethanol, and lower the price of corn. The third immediately enacted law should be to eliminate corn subsidies. Finally we should eliminate corn and its many byproducts from the food supply. We would be on the way to eliminate manufactured food with excess calories which leads to obesity and diabetes. We could potentially save the healthcare system 160 billion dollars as well as eliminate our dependence on foreign oil.

This could be also being accomplished without government regulation by people buying only ethanol friendly cars and eliminating the purchase of junk food. It will probably be a combination of both.

We could do the same with soy bean production. These two sources of energy would be renewable forever. Tomorrow’s world will not look anything like todays if we had the leadership and courage to act.

If we built “clean” coal plants we would have a one time cost to build these 11 plants in Texas of $4.8 billion dollars. “Dirty” coal plants cause diseases that cost the healthcare system at least $34 billion dollars per year. The $34 billion dollars does not include the cost of care for autism. The autism and attention deficit syndrome cost has been estimated to be $100 billion dollars per year. How can we be so silly as to let this perverse outcome occur? We can announce that the people of Texas have stopped the building of dirty coal plants for the time being.

Osteoporosis complications cost 18 billion dollars per year. The cost savings of discouraging bone densitometry to prevent the complications of osteoporosis is insignificant compared to the cost of the complications of a disease that could be slowed or prevented. Why do we do this? We do this because some bureaucrat thought it was a good idea. It is a terrible idea.

The people must be proactive. We can turn most anything around. After many years people have pleaded for environmental responsibility because it is bad for our health and can have devastating consequences for our cities and ecological environment. All of a sudden are the last couple of months “Green” is in. We do not have Red States or Blue States because it is a bipartisan problem. We should have 50 Green States. We have to do everything we can to preserve our nations health, natural resources, and ecology.

Maybe the tipping point was Al Gore film “Inconvenient Truth”. Maybe the tipping point was Thomas Friedman’s series of articles on the importance of the environment. Even Newt Gingrich has stepped up to the plate and pleaded to not let the Democratic Party take over this important initiative because it is a problem all of us need to address. Mostly, I believe the tipping point was the education of the people. The popular sentiment of the people realized the common sense thing to do is to protect the environment for the good of the nation. The people, through public opinion, have pressured the congress and the various state legislatures to act. Now, policy is beginning to change. I believe policy can change and we will avoid perverse outcomes. We have the power to make it change. Instant communication through the internet will provide the education to force change.

I have pointed out several perverse outcomes that are harmful to the cost to the healthcare system. I will point out others from time to time in the series entitled “Perverse Outcomes.”

Stanley Feld M.D.,FACP,MACE

As a nation we started to “eat out” more in restaurants in the last 30 years. Fast food restaurants have proliferated. We have invented “Power Breakfasts”, “Power Lunches” and “Power Dinners”. We meet friends for lunch. There is not a day that goes by that I do not have the opportunity to ingest 1500 calories for lunch, whether it is at hospital rounds, or a lunch meeting.

Restaurants have become meeting as well social gathering places for people. In the past we might meet on the baseball field, basketball court or gym. We might even go to a foodless educational meeting or social dance halls. Sunday bikers meet for a latte and a muffin at Starbucks before their bike ride.

As the number of restaurants have proliferated, restaurants somehow had to increase demand. Price and volume became the attraction for the fast food restaurants. Volume of food at the mid level restaurants enabled them to increase the price and the perceived “value”.

We find ourselves in the midst of Restaurant Wars. The war is about serving more food for less money. This concept is supposed to give one restaurant a competitive advantage over the next restaurant.

“Americans are eating about 12 percent more calories a day than they did in the mid-1980s, according to government statistics. The percentage of Americans who are overweight, meanwhile, increased to 66 percent in 2004 from 47 percent in the late 1970s. Hardly anyone believes it is a coincidence that Americans became fatter at the same time they began eating out more than ever and restaurants super sized their portions.”

In McDonald’s advertising “Campaign 55” in 1997 the price of a Big Mac was decreased to 55 cents. According to classic economic theory, the steep price cut will draw more customers, who will buy more Big Macs, which will fatten the company’s bottom line.

“But what of the fattening of American waistlines? What of the thickening of American arteries?”
Ray Kroc, the patron saint of franchisers, opened his first McDonald’s in 1955 with a 55 cent hamburger. In 1997 as business slowed, Campaign 55 was successful in increasing store traffic. The Big Mac is good only when a Big Mac (530 calories and 28 grams of fat) is purchased with french fries (450 calories and 22 grams of fat for a large order) and a soda (310 calories for 32 ounces). The total meal is three-quarters of the government’s recommended daily allowance of 66 grams of fat. “

The total calories are 1290. Our government’s theoretical 1500 calorie intake is the number of calories necessary to stay even with our caloric output. We would be allowed only 210 more calories to go to reach 1500 calories the rest of the day.

Morgan Spurlock in his 2004 documentary ”Super Size Me,” ate only the super sized McDonald meals for breakfast lunch and diner for one month. He had a physical and laboratory examination by a physician before the diet and at the end of the month. His weight increased 20 lbs. His blood pressure increased, as did his cholesterol and triglycerides. He also felt lousy. He was on his way to the complications of metabolic syndrome. The metabolic syndrome leads to type 2 diabetes mellitus. Morgan Spurlock documentary movie is brilliant. It makes obesity’s danger vivid. I think the movie should be shown to every child in every school in the country. I believe its showing would be a great public service. If we are serious about public health and preventative medicine we should do some serious things to prevent chronic diseases.

In the last 30 years restaurant portions have increased in size as prices have decreased or stayed the same. The bottom line dictates the policy of the CEOs of restaurant chains. You simply make more money with bigger portions. The increase in price for the larger meals far outstrips the cost of the food. The big costs are labor, rents, interior build out and appliances. They are the fixed costs that are present whether the portions are large or small.

The real problem is we, as a nation, have been programmed to believe that we get better value from bigger portions than smaller portions.

Let us suppose we could reprogrammed ourselves to understand that we get better value from smaller portions than larger portions. The expectation would be that we would not become obese and we would prevent debilitating diseases. We need a public service advertising campaign sponsored by the government to make this happen.

In our “short term instant gratification society”, the concept of decreasing food intake is a very hard sell. However, if a few restaurants exercised some social responsibility, the media publicized the value of small portions, and the government had a national campaign to fight obesity, it might work. The CEO of Carlson Restaurants Worldwide has chopped portion sizes at TGI Friday’s. Carlson’s chain is famous for calorie-rich items like deep-fried potato skins stuffed with cheddar cheese, bacon and sour cream.

Many restaurant chains that have tried to reduce portion sizes have had catastrophic results. The reduced portion sizes have failed because:

• People want volume
• Wall Street wants to see bigger profits
• Dilemma: How do you sell the idea of giving people less food? More important, how do you make money at it?
• Consumers say they want smaller portions or healthier choices.
• However, when confronted with a choice they order the larger portions

I suggest that each person reading this go to TGI Friday’s this week and eat one of their small portion meals and support the concept.* A point might be made. We should not patronize restaurants providing bigger portions, portions that help us become obese and unhealthy. We could also share a large portion with your companion and have more than enough food for half the price.

People Power can be extremely powerful. However we have to exercise our power for it to work.

* (Note: I do not own Carlson Restaurant stock)

Stanley Feld M.D.,FACP,MACE

Farm bill legislation is reenacted every five years. This is the year the 2007 farm bill comes up for passage. Most politicians do not pay much attention to the farm bill. The provisions of the bill are difficult to understand. Politician trade their farm bill vote for a vote on their agenda. Michael Pollan points out ”The fact that the bill is deeply encrusted with incomprehensible jargon and prehensile programs dating back to the 1930s makes it almost impossible for the average legislator to understand the bill should he or she try to, much less the average citizen. It’s doubtful this is an accident.”

The farm bill subsidies generate overproduction of food. “The farm bill helps determine what sort of food your children will have for lunch in school tomorrow. The school-lunch program began at a time when the public-health problem of America’s children was undernourishment, so feeding surplus agricultural commodities to kids seemed like a win-win strategy. Today the problem is over nutrition. but a school lunch lady trying to prepare healthful fresh food is apt to get dinged by U.S.D.A. inspectors for failing to serve enough calories. The farm bill essentially treats our children as a human disposal for all the unhealthful calories that the farm bill has encouraged American farmers to overproduce.”

This is one reason for the increased incidence of type 2 diabetes in children. The care of type 2 diabetes mellitus increases the costs of healthcare. As complications of type 2 diabetes mellitus occur they will increase the cost of healthcare even further.

The farm bill also has an important impact on the environment and in turn our health. “The smorgasbord of incentives and disincentives built into the farm bill helps decide what happens on nearly half of the private land in America. The health of the American soil, the purity of its water, the biodiversity and the very look of its landscape owe in no small part to impenetrable titles, programs and formulae buried deep in the farm bill.”

The medical community is now recognizing that you cannot solve the obesity problem or the type 2 diabetes problem without addressing the farm bill. Michael Pollan suggests the new bill be called the food bill. The environmental community recognizes that as long as the farm bill promotes chemical and a feedlot mentality we cannot master the fight for clean water. A grass roots social movement is developing around the quality and volume of food produced. Parents are protesting vending machines in the schools and quality of school lunches. As more and more people are getting information from the web as well as other sources, there is more and more agitation about our food supply. If we could reprogram ourselves, we could vote with our forks and change the thrust of the farm bill away from junk food. However, junk food is cheap. We have also learned to like it a lot. We must protest our agricultural policies and demand that society educate itself toward healthy eating. The process has begun.

Pollan says “there are many more who recognize the real cost of artificially cheap food — to their health, to the land, to the animals, to the public purse. At a minimum, these eaters want a bill that aligns agricultural policy with our public-health and environmental values, one with incentives to produce food cleanly, sustain ably and humanely. Eaters want a bill that makes the most healthful calories in the supermarket competitive with the least healthful ones. Eaters want a bill that feeds schoolchildren fresh food from local farms rather than processed surplus commodities from far away. “

Fixing the food supply chain will not be that easy. It is not simply eliminating subsidies. Somehow, the incentive to overproduce food for the food processing industry has to be replaced by incentives for producing fresh food in local markets. The emphasis has to be on vegetables of all kinds. Rather than having tomato factories all over South America which efficiently produce tasteless tomatoes and ship them thousands of miles prior to ripening, we must encourage local farmers to produce fresh, nutritious, and tasty tomatoes. The incentives should be aimed away from overproduction of raw materials for manufactured food toward changing the eating habits of our people. It has to be incentive driven for the local farmer and not for the benefit of the large farm conglomerates that produces oversized cows and overproduced corn, soy beans, rice and wheat. Corn production might not be a problem if we accelerate its use in gasoline and helps free us from foreign oil dependency. The same could be done for soy beans. Our policy makers have to be creative, innovative and tough minded for the good of the nation without destroying the small farmer.

Once we realize the dangers of the farm bill, we can demand that our food policy become aligned with our health so our food will be of a quality that can protect us from becoming obese and subsequently from the chronic diseases obesity precipitates. It will take awareness by the people and a demand for farm policy change. This is the year.

Stanley Feld M.D.,FACP,MACE

I said our population should not have to bear the exclusive blame for becoming more and more overweight by overeating. However, we have a choice and should bear the burden of blame for not saying “we are tired of this and are not going to take it anymore.” We must be responsible for our choice to overeat even though we realize we are being programmed to overeat daily.

The question is, why and how are we being programmed to overeat? Michael Pollan has written an excellent book “The Omnivore’s Dilemma”. The book describes the problem of obesity clearly. He is also a contributing writer to the New York Times and has written several articles in the past year outlining the causes of the obesity problem. His last article nails it.

He pointed out the research of an obesity researcher at the University of Washington Adam Drewnowski. Drewnowiski went to the supermarket to solve the mystery . “He wanted to figure out why it is that the most reliable predictor of obesity in America today is a person’s wealth. For most of history, after all, the poor have typically suffered from a shortage of calories, not a surfeit. So how is it that today the people with the least amount of money to spend on food are the ones most likely to be overweight?”

This is a powerful observation. However, the socioeconomic factor is fading rapidly as all socioeconomic groups are becoming obese today. He wanted to see how many calories a dollar could buy. “He discovered that he could buy the most calories per dollar in the middle aisles of the supermarket, among the towering canyons of processed food and soft drink. (In the typical American supermarket, the fresh foods — dairy, meat, fish and produce — line the perimeter walls, while the imperishable packaged goods dominate the center.)” He also found that “a dollar could buy 1,200 calories of cookies or potato chips but only 250 calories of carrots. Looking for something to wash down those chips, he discovered that his dollar bought 875 calories of soda but only 170 calories of orange juice.”

The supermarkets prime square footage and shelf space is devoted to processed foods that are considered junk food. What is junk food? Junk food typically contains high levels of fat, salt or sugar and numerous food additives such as monosodium glutamate and tartrazine; at the same time, it is lacking in proteins, vitamins and fiber, among others. It is popular with suppliers because it is relatively cheap to manufacture, has a long shelf life and may not require refrigeration. It is popular with consumers because it is easy to purchase, requires little or no preparation, is convenient to consume and has lots of flavor. Consumption of junk food is associated with obesity, heart disease, Type 2 diabetes and dental cavities. There is also concern about the targeting of marketing at children.

Pollan the states that “Drewnowski concluded that the rules of the food game in America are organized in such a way that if you are eating on a budget, the most rational economic strategy is to eat badly — and get fat”.

Pollan observes that “This perverse state of affairs is not, as you might think, the inevitable result of the free market. Compared with a bunch of carrots, a package of Twinkies, to take one iconic processed foodlike substance as an example, is a highly complicated, high-tech piece of manufacture, involving no fewer than 39 ingredients, many themselves elaborately manufactured, as well as the packaging and a hefty marketing budget.”

The Twinke is commonly regarded as the quintessential junk food. Each Twinkie contains about 145 Calories (607 kilojoules).A package of three Twinkies is one third of an average persons daily caloric intake. Five hundred million packages of Twinkies are produced each year.
Twinkie the Kid is the advertising mascot for Twinkies and can be found on packaging and related merchandise.

Are we being programmed and conditioned by the media? You bet we are.

“

So how can the supermarket possibly sell two or three of these synthetic cream-filled pseudocakes for less than a bunch of roots?” Michael Pollan points out the answer. It is in the farm bill. The farm bill subsidizes the Twinkie and not the carrot. “Like most processed foods, the Twinkie is basically a clever arrangement of carbohydrates and fats teased out of corn, soybeans and wheat — three of the five commodity crops that the farm bill supports, to the tune of some $25 billion a year. (Rice and cotton are the others.) For the last several decades — indeed, for about as long as the American waistline has been ballooning — U.S. agricultural policy has been designed in such a way as to promote the overproduction of these five commodities, especially corn and soy.”

The creative manufacture of increasing amounts of junk food has increased with each increasing farm subsidy.

The farm bill does nothing to support the farmers that grow fresh produce. Pollan points out that the real price of fruit and vegetables increased by 40% between 1985 and 2000 while soft drink (aka liquid corn) declined by 23 percent. The reason junk food is the cheapest food is the farm bill subsidizes these foods.

Shouldn’t we wonder why when faced with increasing obesity and the complications of chronic diseases precipitated by obesity leading to 90% of our healthcare costs, would our policy makers subsidizes businesses that promote obesity? Shouldn’t the government subsidize busnissess that promote wellness?

There are many perverse outcomes in our nation’s complex economic and political systems. The government permits energy companies to build “dirty coal plants” to generate electricity to solve our fossil fuel problem because we have an abundance of coal in America. The thinking is logical. However, the pollution from the particulate matter released by coal causes asthma, chronic obstructive lung disease and heart disease. Aside from the resulting morbidity to people affected by these diseases from the pollution, it costs the healthcare system $34 billion per year in avoidable recurring costs if the dirty coal plant pollution did not exist. It does not make sense when we are trying to solve healthcare costs if less harmful alternatives exist.

Another perverse example is osteoporosis. The complications of osteoporosis cost the healthcare system 20 billion dollars annually. You can decrease the fracture rate by at least 50% with current treatment. However, you have to discover this silent disease by measuring a patient’s bone mineral density. In order to save money Medicare is reducing reimbursement of bone density measurements by 70% in the next two years. The reimbursement will be below the cost of the test for most clinics. This is certainly not a way to promote early detection and treatment to prevent complications of this chronic disease. Faulty, perverse policy decisions occur frequently. I believe it is a result of an obsolete policy making process. We assume our elected representatives represent our interests but they seem to represent the vested interest of other powerful stakeholders. The result often is an expression of a lack of common sense.

The only way to stop it is if we the people express our opinions to our politicians and force our political system to respond and represent our needs and not the needs of other vested interests. Our well being is the only need they should be considering. With the internet, blogs, and instant communication we are capable of making our needs known. We must exercise our people power.

Stanley Feld M.D.,FACP,MACE

Obesity is an important contributor to our nation’s declining health and increasing healthcare costs. Obesity precipitates the onset of chronic diseases such as Type 2 diabetes mellitus. Five percent of our population has Type 2 diabetes mellitus. That 5% of the population with Type 2 diabetes mellitus consume 15% of our healthcare dollar.

Why are we as a nation becoming more obese annually? The answer is complex and has multiple interrelated reasons. These multiple factors must be understood and dealt with in order to solve the problem of obesity and decrease our healthcare costs. Solving the problem of obesity would be a major step in repairing the healthcare system.

As physicians we are quick to blame the patient for eating more than they are burning. Simply put this is the reason people gain weight. Why are we eating more than we are burning in 2007 rather than 50 years ago?

In order to answer this important question we must understand the relationship of calories to weight gain. We must also appreciate the ease of accumulating calories and the difficulty in losing calories. We as a nation have become obsessed with dieting and dieting schemes. The success of diets has been minimal. There is no quick fix to obesity. We must under go a lifestyle change. Effective durable lifestyle changes will only occur if there is a cultural change in our food preparation in America

The arithmetic of weight loss is discouraging. In order to lose 2.2 lbs we must lose kilogram (1000 grams) of fat. Fat is very dense in calories. Each gram of fat is 9 calories as opposed to each gram of carbohydrate or protein which is 4 calories. 2.2 lbs (1000 grams) equal 9000 calories. In order to lose 22 lbs you would have to burn 90,000 calories more than you eat or eat 90,000 calories less than you burn.

Let’s assume we burn 1500 to 2000 calories per day due to our basal metabolic rate (BMR) and normal daily activity. The BMR and the expenditure of calories with activity of daily living varies depending on age, height, and weight.

Let’s say you burn 2000 calories per day and eat 1500 calories per day. You would lose 500 calories that day. As soon as you go into negative caloric balance most people lose some body tissue water. The water weight loss is a meaningless measure of weight loss. In two days at 500 calories a day you would lose 1000 calories and in 18 days you would loss 2.2 lbs or 9000 calories. It would take 180 days to lose 22 lbs on a diet of 1500 calories a day if you burn 2000 calories a day. Most people burn fewer than 2000 calories a day. It is very difficult to stay on a diet for one half year and only lose 22 pounds when you might need to lose 40 pounds.

This is the reason that the approach to weight loss has to be a lifestyle change. A lifestyle change must be permanent. It should result in eating less and exercising (burning) more than you eat.

If we were predisposed to Type 2 diabetes mellitus and lost the weight we would avoid the ravages of the disease and decrease the cost to the healthcare system.

It is not our fault that the nation overeats. Overeating or eating calorie dense food has much to do with the economics, and politics of food production. The food industry’s economics and politics have resulted in social conditioning and mind manipulations that have resulted in overeating. We have to say this has got to change if we are serious about our health and controlling our healthcare costs.

Stanley Feld M.D.,FACP,MACE

The nation must declared War on Obesity to save its people from themselves. If you think, about it the problem is we get in our own way. It is time that we recognize that obesity is a disease and we must do everything we can to eliminate it.

I like to think of obesity as a disease with a genetic predisposition precipitated by environmental stimuli leading us to become a nation of overeaters. We as a nation must say we are tired of being manipulated. This will take national leadership and compromise by vested interests that are profiting from the obesity epidemic. The epidemic is decreasing the health of our nation. It will have a devastating effect on the costs of healthcare if not corrected now.

The benefited vested interest is the food industry. They have conditioned us so that as a nation we eat more and more and get fatter and fatter. Presently, our children are also being affected. Childhood Type 2 Diabetes Mellitus is becoming more and more prevalent because of the abuse by the large agribusinesses, the restaurant industry, the snack food industry and the supermarket industry. The abuse is driven by profit margins.

People power along with strong leadership has the ability to turn this around. We have started to create the hype for healthy eating. However, the food industries have countered the positive direction we were going in by engaging the advertising industry to undermine the effort. They have also gone on the offensive with subliminal advertising that encourage us to feel good eating junk food.

There was a recent article in the New York Times magazine section “You Are What You Eat: 2006 and the Politics of Food”. It is important that we spend some time on this article. It is up the nation to say enough is enough.

“The headlines about food this year read like a remarkable replay of Woody Allen’s “Sleeper,” in which the things Americans think they should eat more of — lettuce and spinach — were suddenly the ones that could make them sick, or even kill them.”

I do not think anyone has gotten killed by a potato chip or soda pop in the short term. I know there is excellent evidence that it will kill you slowly.

Marion Nestle a professor in the department of nutrition at NYU said. “This is the year everyone discovered that food is about politics and people can do something about it,” she said. “In a world in which people feel more and more distant from global forces that control their lives, they can do something by, as the British put it, ‘voting with your trolley,’ their word for shopping cart.”

We can certainly avoid unhealthy food if we were educated to recognize unhealthy food. We would then be able to mount a national protest, but only with the governments help. Eric Schlosser, author of “Fast Food Nation,” is equally upbeat about the spinach disaster. “Those negative events brought attention to the problems,” he said of the past year. “Even the growers think the system is broken and has to be fixed.”

I have observed some positive movement. There is a growing bipartisan consensus that obesity is bad. Soft drinks and junk food vending machines are being removed from schools by individual school districts as the expense of losing an income producing profit center for the school district. Governors nation wide are making nutrition a priority in schools. Some states have even reinstituted physical education.
Whole Foods has become a major food marketer in the United States. They have forced main stream food marketers to advertise “healthy food”. The organic food movement even becomes main stream with Wal-Mart and Target food markets. However, as more and more “organic food” has been demanded the food has become less “organic”.

“As Mr. Pollan wrote in The New York Times in 2001, about the dairy farms operated by the organic milk producer Horizon, “thousands of cows that never encounter a blade of grass spend their days confined to a fenced dry lot, eating (certified organic) grain and tethered to milking machines three times a day.”

The Department of Agriculture is now considering allowing salmon farmers to call their fish organic even if the fish are fed nonorganic fishmeal. The increasingly loose meaning of the word has led some consumers, who once bought anything labeled organic, to rely on new signifiers, like grass-fed, sustainable or local.”

“It is not only individual shoppers who are choosing to vote with their food dollars. Tired of waiting for the federal government to act, local governments have stepped in. New York City banned trans fats in restaurants and told restaurants with standardized recipes that they must provide easy access to calorie information. Other municipal and state governments are requiring public institutions to buy more nutritious, locally produced food.”

My question is “where is the evidence that “organic” is better for your health than non organic food?” The key questions in my view are food quality and food safety. As food has become a huge business whose profits making potential can be leveraged, we need to worry about the safety of growing the foodstuff, its processing and delivery. Organic assumes that chemical fertilizers are bad and pesticides are toxic to humans in the doses used. Therefore organic fertilizers are imperative and pesticides should be forbidden. I do not think there is any evidence for this assertion. I can visual abuse of pesticides but have not seen evidence. It could be that organic fertilizer could threaten food safety more than chemical fertilizers. The organic food movement is making us aware that something is wrong with the food industry.

I think the real issues are the safety, quality and quantity of the food we eat. The quality and quantity of the food we eat has a direct impact on the obesity epidemic.

I will discuss the quality and quantity of food we are exposed to next time.

Stanley Feld M.D.,FACP,MACE

I hit a nerve with my criticism of P4P. The reaction came from healthcare professionals who have worked hard to help organizations generate guidelines to improve the quality of care. They recognize that the healthcare system is in trouble. They all are sincere in wanting to help fix the dysfunctional system. You may recall I said everyone is to blame for the dysfunctional healthcare system. Government, insurance companies, hospitals, patients, and pharmaceutical companies as well as physicians are at fault. The healthcare system has to be repaired before it implodes.

In 1984, the government was certain that the DRG system for hospital reimbursement would control the escalating hospital costs. The defects in the DRG system made DRGs ineffective in controlling hospital costs. The result was escalating hospital costs rather than decreasing costs.

Intuitively, P4P is system that sounds like it should work. However, P4P does not include the entire meaning of the evaluation of quality of care. It is a good idea to develop criteria to judge effective treatment. However, who is the judge of effective treatment? Does anyone have the power to judge the judge? Both the physicians and the patients are responsible for the effective treatment outcomes. Patients must understand their responsibility in the outcomes of treatment. If they do not comply, the treatment will be ineffective. If the physicians are not reimbursed for developing education centers and a team approach to the treatment of chronic disease in order to help the patients become the professor of their disease, they are unlikely to develop that resource necessary for the treatment of chronic disease. The approach to treatment for chronic diseases must be a team approach with the patient at the center of the team. Physicians can not afford to set up the educational facility if they are not reimbursed for the service. Hospitals have opened and subsequently closed chronic disease education centers. They can not afford to keep them open. Who is at fault? Is it the physician, the patient, the government, the hospital or the insurance company? Who should bear the burden of proof of performance be on?

It is generally accepted that most of the money spent in the healthcare system is on treating the complications of chronic disease. Physicians are great at fixing things that are broken. We have not done very well at preventing disease or treating chronic diseases according to the Institute of Medicine. Why is there no compensation for this important skill set?

We know obesity is a risk factor for many chronic diseases such as heart disease and diabetes. Yet we continue to gain weight and increase the chances for the complications of these diseases. Who is responsible for this obesity epidemic? Is it the patients, the physicians, the government or our farm subsidies?

Patients are frustrated by the difficulty in negotiating with the healthcare system stakeholders. It is claimed that it is nearing impossible to speak to a physician on the telephone. There are stories of long waits for appointments to see physicians. Once the appointment is made there are long waiting room waits. It is difficult to coordinate tests in a timely manner. The work up is often attenuated when diagnosis should be made promptly and treatment should start quickly. The problem coordinating schedules with the various medical services is becoming more difficult. The segmentation of diagnostic workup and delays in getting workups completed have created increased distrust for physicians and eroded their therapeutic effectiveness. The physician patient relationship, an important aspect of therapeutic effectiveness is undermined. Whose fault is that and how does it get fixed? The answer is all the stakeholders are at fault as costs continue to escalate.

Physicians have to see more patients in a shorter time without complete workup in order to meet productivity quotas imposed by hospital systems that employ the physicians. If the physicians are in private practice, they have to see more patients in a short time in order to meet their overhead as reimbursement diminishes. They cannot afford not technologies that might improve their efficiency and lower the cost. Also, they might not have the skill set to make their practice more efficient. Electronic medical records have been an expensive false hope to many physician practices.

All the key stakeholders are frustrated. Hospital administrators claim they work hard for their million dollar plus salaries, and insurance executive claim things are tough as they go home with their two million plus salaries.

There are many things wrong with the healthcare system. P4P is not going to fix it. It is time to be honest and get serious about fixing all the defects in the healthcare system. I have outlined many of the steps necessary in my recent summaries.

Stanley Feld M.D.,FACP,MACE

Various non-physician organizations (NCQA and NDRP) have developed quality measurements that should be used as educational tools for the primary stakeholders. Instead, these quality measurements are code for secondary stakeholders to penalize physicians in the form of P4P. This is the problem in a healthcare system that has generated so much stakeholder mistrust. As long as the insurance industry, the government and the hospitals control the healthcare dollar, I do not believe these initiatives will work. The system must be driven by the patients. The patients must reward the physicians who utilize some of the resources that are being developed. The resources should not be forced on the physicians by the third parties.

The measurements used in evaluating quality lack an understanding of the complexity of the various disease processes or the responsibility of both the physicians and the patients in the patient-physician relationship. Physicians and patients have previously experienced negative information technology with pre-certification requirements for referral and procedures. Unfortunately, information technology does not work all the time. It can not substitute for physician judgment. The pre-certification system was modified so that the physician had to justify his thinking to a computer or review of a newly hired medical director that might not have expertise in that area of medicine. The result was is time comsuming process. The process threatens the physicians’ intellectual and moral integrity while increasing the intensity of mistrust and mutual disrespect.

The organizations developing these quality measures are very sincere and want to fix the healthcare system. It is my belief that it can not be done measuring only one criterion in the definition of medical quality care improvement. I also believe that if you are going to judge physicians it must be done by a peer group in a very discrete manner. Imagine in our litigious society the opportunity the P4P system offers to lawyers in the absence or real tort reform. A new profit center for lawyers will be developed.

The clinical endocrinologist knows it is possible to achieve an excellent HbA1c of 6%. However, it is very difficult. Very compliant diabetic patients can achieve a perfect HbA1c but they fully appreciate the difficulty. Neither the patient nor the physician should be punished for not achieving the goal they are seeking.

The physician-patient teaching relationship has been the tradition in medical care without 3rd party interference. This relationship needs to be promoted. If the punitive measures of reducing reimbursement inherent in P4P drive the Family Practitioners and Internists out of business, who will take care of the 20 million diabetics in the country? I know the 2000 practicing full time clinical endocrinologists can not take care of 20 million diabetics. If the process of quality care measurements were started after the onset of complications, achieving a HbA1c 8.1% would not halt the progression of the impending costly complications.

Each diabetic patient is at a different stage of his disease. Therefore each patient is at different stage of risk for complications. Patients have to be “risk weighted” to guess at the prognosis. Risk weighting is not a science at present. Patients further along the disease complication curve might not be able to have the progression of complications their complications stopped. They may be able to have the progression of complications slowed. However, the cost of treatment at each stage of diabetes mellitus and treatments will be different. The quality care measurement of how many times a HbA1c is done each year and the average level of HbA1c will not measure the skill of the physician or patient in decreasing the cost of the complications of the disease. This is a matter of physician judgment and patient adherence. Information technology can not make those judgments.

A faulty payment system (P4P) that cannot judge physician performance should not be instituted. It will only create a more dysfunctional healthcare system. Patients alone need to determine the quality of their care as previously described. Consumer driven healthcare will drive physicians to increased quality medical care. It can only happen if the healthcare dollar is in the hands of the patient, not the insurance industry or the government. The insurance industry’s and government’s job should be to help physicians develop systems of care and to educate the patient on the principles of good quality care and compliance. Patients must be taught their responsibility to their healthcare and how to use their healthcare dollar wisely. We have the information technology available to teach and reward both patients and physicians (the primary stakeholder). The result would be a competitive improvement is the quality of medical care. Remember the Lasik example.

We as physicians should create the systems of care for our fellow physicians. Many physicians do create systems of care and provide excellent care. However, preventive medicine services and educational services are not compensated or poorly compensated. Only when an environment is created for the success of focused factories for chronic diseases and patients control their health care dollar will we have true quality care. P4P is not the answer!

Stanley Feld M.D.,FACP,MACE

Unfortunately, the devil is in the details. P4P has devils in its details because of potential misuse of information technology. I will present of the many examples in endocrinology alone. The example of an application of P4P will make the concept of P4P seem ridiculous.

The insurance industry and the government have been trying for many years to define quality in order to measure quality care. They have asked healthcare organizations and healthcare administration organizations to develop the standards.

The American Diabetes Association volunteered for the Diabetes Mellitus Quality Improvement Project (DQIP) initiated in 1997. There were no physician organizations represented in this project initially. Unfortunately, this is not uncommon when one wants to develop standards or set reimbursement principles for the practicing physician.

If physician organizations wanted to have a seat at the table they could join. Physician organizations that joined were practicing clinical endocrinologists as well as others. Clinical Endocrinologists are most effective in treating diabetes because of their training and their clinical experience. Academic endocrinologists have much research experience. These academic endocrinologists know little about the challenges of clinical practice.

The steering committee, composed of representatives from four organizations (American Diabetes Association (ADA), the Foundation for Accountability (FACCT), the Health Care Financing Administration (HCFA), and the National Committee for Quality Assurance (NCQA) met, with the overall goal of establishing a set of diabetes-specific performance and outcome measures. The goal was to allow for fair comparisons of health care plans, stimulate quality improvement, be based on scientific evidence, and yet be user-friendly to payers and consumers. DIQP is funded by the HCFA portion of the Balanced Budget Act of 1997. The design of the Project was well intended but the outcome of the measures used by the insurance industry is punitive to physicians and patients rather than educational.

Few of the participants understood that compliance with these outcome measures was predicated on the patients making lifestyle changes as well as the patients adhering to medication prescribed and faithfully doing home blood glucose monitoring so they could effectively self-manage their disease. There is a 40-60% non adherence rate. In additional, even if the physicians give the recommended medications there might be subtle barriers in the clinical disease that renders the recommended medication ineffective in controlling the blood sugar. These patient barriers to diabetes care might include occupational stress or situational depression.

DQIP was formed to develop minimal guidelines for measurable outcomes of diabetes mellitus. I believe DQIP was very sincere in the quest to improve the outcomes of diabetes, namely decrease the chronic complications rates of diabetes. The complications of diabetes mellitus are heart disease, eye disease, kidney disease and neurological disease. It is true that controlling ones blood sugar will prevent or slow down the onset of complications of the disease.

The HbA1c test measures the integrated three month average blood sugar. It could be the average blood sugar was a combination of blood sugars that were high and low with very few normal blood sugars. A normal HbA1c level is 5.5% or lower. With the development of national laboratories and their national data basis we can now determine the national average of HbA1c, by zip code, or by physician. The national average is 9.2%. This is a terrible HbA1c and is a good predictor of complications of diabetes mellitus. DQIP stated the standard average HbA1c should be 8.1%. The total burden quality of care (achieving HbA1c) is on the physician. The American Association of Clinical Endocrinologist (AACE) goal is 6.5% The DQIP goal was to be a wake up call to the physician to try harder. A HbA1c of 8.1% is high value. The onset of complications of diabetes mellitus will be significant at 8.1%. Therefore the standards published are for educational purposes in my view. These standards are inadequate and will not decrease the complication rate or the cost of care.

Physicians’ agenda was to decrease the complications of diabetes by increasing awareness of the need for intensive self-management. Others in DQIP had other agendas. Some wanted to increase their funding from whoever would fund a project. Some just wanted to get the benefit of the consensus of intellectual property after compromises were made. Others wanted to sell more drugs or medical devices.

The agenda of all the stakeholders should have been to create a system that could create a competitive environment for excellent care among physicians without punitive consequences. The punitive consequences should come from the consumer driven market place. The only punitive consequence should come from the demand by their patients to help them get their HbA1c down to normal. If their physician could not help them they should be empowered to know the physician that could.

This did not happen. Instead a system of minimal quality care measurements was created. If they were not met by the physician then his P4P would be decreased by the government and the insurance industry. The quality measurements that DQIP created to help improve the quality of care delivered turned out to be a stick to beat physicians. The responsibility of the patient to improved quality of care is not taken into account. Only the physician and his healthcare team with the patient being the most important member of the team will increase the quality of medical care delivered and not the faulty incentive of P4P.