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

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

The following are additional solutions necessary for the Repair of the Healthcare System

• Develop Centers of Excellence and Focused Factories in both hospital based clinics and physician outpatient clinics to treat chronic diseases by a team of multi disciplinary experts using systems of care based on evidenced based medicine. Disease management systems can be developed in primary care physicians’ offices because there are not enough specialists to take care of all the patients with chronic disease. Treating chronic diseases this way should lower the complication rate for chronic diseases. The result should be a reduction in the cost of healthcare by at least 45%.

• Emphasis should be place on teaching the patient how to be the “professor of his disease”. Payment should be available to the Center of Excellence for this education.

• Promotion of and payment for early evaluation and recognition of chronic disease. It is essential to detect and prevent these chronic diseases early to prevent costly complications of these diseases.

• A sophisticated information system connecting medical care with financial outcomes. An ideal EHR should be made available to physicians on a per use basis so that the investment cost is not a burden to the physician. The information technology should be used as a learning tool for the physician to continually improve the quality of care and not as a weapon to penalize the physician. .

• Quality of care should be defined as whom to evaluate, how to evaluate, whom to treat, how to treat, how long to treat, how often the patient should be seen, how often the patient should be retested, and the measurement of adherence to medication. Measurement of quality should be all of the above. However, the key measurement of quality is the medical outcome as it relates to the financial outcome. If you prevent a $50,000 complication utilizing $1,000 of treatment you have a leveraged financial outcome as well as an excellent medical outcome. The main question is, “was the complication of the chronic disease avoided?” We are misguided when we start believing that measuring the percentage of our patients we measure cholesterol on, or the percentage of patients on whom we do colonoscopies or bone densities is a measure of quality of care. It is simply one element of quality medical care and it should not be rewarded as the Pay 4 Performance advocates are suggesting. This thinking makes us vulnerable to another false hope of reducing complications of chronic diseases.

• Increasing obesity in our population is a huge health risk. The government should declare war on obesity. It should strive to eliminate the many stimuli we are exposed to. It should institute a gigantic public media campaign to explain the health risks and the stimuli to overeat.

The most important need is to put the patient in charge of his disease management. The patient must be responsible for his care and in control of his health care dollar. We do not need more schemes destined to fail such as the California and Massachusetts mandates. We do not need the Pay 4 Performance scheme that will distort the healthcare system even further. We need some common sense infused into the development of a system that is driven by the patients and not the facilitator stakeholder for the purpose of the facilitator stakeholders’ bottom line.

If patients do not want to take care of themselves they will suffer medically and financially.
These are some of the solutions I have proposed. We need the political will and leadership to institute and execute these solutions. Responsibility for follow up care and compliance must be the patient. The physicians are the teachers educating patients to be experts in their disease self- management. In the present system the penalty to the patient is bad health. The new system should have a clear message of good health and financial reward. It is much cheaper for all the stakeholders in the long run.

The patient has to;
• Be responsible for the purchase of care.
• Have ready access to care.
• Be responsible for the appropriate adherence to care and medication regime given by the physicians.
• Be rewarded for excellent lifestyle changes and avoidance of complications of disease.

If this is accomplished, and it can be with appropriate leadership and the demand by the consumer, we can repair the healthcare system.