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All items for May, 2007


Why The Resistance To A Logical Solution To Repairing The Healthcare System?

Stanley Feld M.D.,FACP,MACE

A key question to ask is how the insurance industry determines the price of the insurance coverage. I will discuss this question in detail in the future. A hint is, price is determined by an archaic, non scientific, administrative cost overloaded system. In my opinion many of the disease cost modeling is bogus. Disease burden could be very straightforward, scientific and logical.

All the discussions by health policy experts are not challenging the escalating health insurance cost directly to solve the key question. In my view the only expert who is challenging the present system in a logical and civil way is John Goodman. Until we face the issue we will make little progress in Repairing the Healthcare System. The insurance industry is going to have to face the facts unless it wants a single party payer system with the government being the payer. If they continue to overload premiums and segregate risk, the insurance industry will be reduced to a 3-6% broker at best. Many healthcare insurance companies will go out of business.

The second important issue deals with the escalating hospital costs. No one is demanding that we understand how a hospital services fees relates to the hospital cost of providing those services. The fact is that many of the prices for hospital services are arbitrary and have built in excesses that cannot be proven to be warranted. One cannot get a direct answer from a hospital administrator. In fact the hospital administrator does not know how they arrived at the price. Why? The pricing is buried is so much opacity and hearsay that most times it is impossible to discover the prices’ origin. Looking at the pricing of neighboring hospitals does not help because one hospital copies the other hospital’s prices. What you can find out is if the hospital is making a profit. If the hospital is making a profit the hospital administrator assumes they are charging the right prices. If the profit is minimal or less then last years’ profit then the hospital administrator has to raise the price. This is not a very effective way to manage a business.

If the hospital buys a new piece of equipment or information system it adds it to the price of hospital services even if the equipment or information technology saves it money and reduces its cost.
In order for the healthcare system to work, price shifting has to stop, inflating costs has to stop, and arriving at true cost per service has to be determined. If we are on a single payer system it will not matter what the hospital costs are. It will received a fixed, deeply discounted payment from the government no matter what the costs are. Finally, the hospital systems will be forced to increase its efficiency or perish.

It seems to me, that rather than reducing costs through efficiency and fees, both the insurance companies and the hospital systems are shooting at the goose that has laid their golden eggs. They had better wake up soon.

No one wants a single party payer run by the government with all the bureaucracy and inefficiency that will follow. We see what has happened in countries that have a single party payer. They are all moving back to an insurance model because a single party payer system does not work for their citizens.
The definition of a universal health care system is not necessarily synonymous with a single party payer system. Universal healthcare could mean a guarantee of health insurance coverage at a fair price for all. I think that is what Governor Schwartzenegger and Governor Romney were trying to construct. However, the manipulation of the political process by secondary facilitator stakeholders has contaminated the policy. The secondary facilitator stakeholders, insurance industry and hospital systems do not want to relinquish any control even though their control is not working. These facilitator stakeholders had better get smart soon or they will have nothing to control.

The role of government should be to enact rules and regulations for the benefit of the people it governs. Then, let private enterprise and private innovation be creative and compete for the business of the people. This is the market driven economy that has made the United States great. Sam Walton did it with Wal-Mart and Sam’s. Sears and J.C. Penny have never recovered. Target and Costco came along and are now giving Wal-Mart a run for their money to the advantage of the consumer.

This can happen in healthcare. We can promote the innovative and competitive spirit of America. We better do it before we get into a bigger mess with a single party payer system that will result in less quality care, less access to care, and escalating cost to all of us.

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Real Price Transparency: What Is The Solution?

Stanley Feld M.D., FACP, MACE

I have explained why the uninsured are billed the retail price by the hospital. The maximum discount the uninsured can negotiate and will receive is 20%, if they could determine the retail price before the service is performed.

Often the uninsured are billed by the hospitals 350% more than Medicare pays the hospitals.

Two thirds of the uninsured are uninsured because they can not obtain a health insurance policy. Many are between 50 and 65 year old and have lost their jobs. They are now self-employed. They are deemed a poor risk by the actuaries at insurance companies and do not qualify, by insurance company criteria, for health insurance. If they could get insurance they would be rated and charged a higher than usual premium. A premium they cannot afford. A concrete example is a premium of $25,000 per year in post tax dollars as opposed to $10,000 with pre-tax dollars for the same coverage in a group plan for the same age person.

The self employed individual pays for health insurance with after tax dollars. The group policy holder health insurance is paid for with pretax dollars. With present tax laws group insurance is discounted in real dollars 30%.

We have also seen that the insurance companies are required to insure all employees in a group health insurance plan no matter the risk or age of the person. The employee in a group plan cannot lose that insurance. A simple solution would be to qualify everyone for group health insurance whether they are in a group or not. In large groups the risk of illness is spread. The premiums can be lowered.

Despite the elimination of high risk patients from the health insurance pool the price of insurance and the price of hospital care is escalating beyond affordability of large corporate employers.

One can see defects in the system at a glance. If the 46.7 million uninsured were in the insurance pool, the risk would be distributed over a greater number of people and there would be more money in the system. The increased money in the system would decrease the pressure to increase prices by the insurance companies. Presently the insurance companies do not care to lower their prices. If the risk was spread and the cost to insure for illness was lowered, the insurance company might not want to pass the saving along to the customer. The customer could then shift to a health insurance company that was interested in passing along the cost savings and lowering their premium price. That company would increase the number of people in their insurance pool and would have a competitive advantage over the former company. This would set up the competitive environment I have been referring to a force companies to keep their premium pricing competitive.

In order to accomplish this, a law would be required to permit the self-employed to buy group insurance at group insurance rates with pre tax dollars. It would also require community rated prices for all and not the present individual rating system. The present system even lets the health insurance industry rate groups individually. The premium price would be level for all. Smaller companies would not be economically challenged by their adverse risk pool and could once again afford insurance for their employees. The simple insurance rule is to spread the risk you can reduce the cost to insure. Once the environment is created prices will fall and be affordable to all. There will be some who cannot truly afford the insurance. The government could not afford not to insure those people. The solution above would be market driven and would not require a new governmental bureaucracy and all the problems it entails.

Next time I will discuss why I think this logical solution has not been adopted and why hospital systems and health insurance companies have resisted this solution.

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Here’s To Good Health!: The Feld Men’s Trip 2007

Stanley Feld M.D., FACP, MACE

Every year my brother Charlie with his two adult son’s Jon and Kenny and I with my two adult son’s Brad and Daniel go on a trip for two days. The purpose of the trip is to simply be with each other and relate to each other without wives or other distractions. The trip is always a wonderful bonding experience as well as intellectually stimulating. I believe we each learn something from each other every year.

In recent years we’ve gone to spring training baseball games. This year we all traveled to Boston for two days of Boston Red Sox baseball at legendary Fenway Park. The Boston Red Sox were playing the Atlanta Braves.

We picked the middle of May because spring time is supposed to be beautiful in Boston. The weather was miserable. It rained every minute we were in Boston. I now remember when I was an endocrine fellow at the Mass General Hospital in 1967-1969, the weather was miserable from October to the beginning of June.
The interleague game between the Boston Red Sox and the Atlanta (PKA Milwaukee, PKA Boston) Braves was rained out on Friday night. We compensated by simply staying at Abe and Moe’s Restaurant for three hours talking about our lives, philosophy and business.

We knew the teams would have to play both games on Saturday even if it continued to rain because the Braves would not be back in Boston the rest of the season.

Needless to say, it rained during both the day and night games on Saturday.
However, all the rain did not deter us from having a great time. We laughed, talked and ate endlessly. I recommend this kind of experience with siblings and your siblings’ children. The togetherness is both inspiring and therapeutic.

Next year’s trip will be to Chicago in May. Chicago Cubs will play the Chicago White Sox in interleague play. I assume it will be another cold and rainy weekend in May because it always seems to be cold and rainy in Chicago in May.

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What Is Real Price Transparency?

Stanley Feld M.D.,FACP,MACE

President Bush has stated that price transparency is essential for healthcare reform. Price opacity has been frustrating to the individual patient. Patients have not been able to find out the price of services they are buying from hospitals before they have the service completed.

This is especially significant for 46.7 million uninsured Americans. Recently, there has been a series of articles exposing the fact that the uninsured are required to pay at least two and one half times the fees that the insured pay.

We have seen Denise’s frustration. She is an uninsured patient. She wrote an appeal for price transparency to Kinky Friedman the Jewish Cowboy Humorist who was running for Governor of Texas.

We have also seen that hospital systems have proudly declared that they have published their prices on the web in the name of Price Transparency. I have been able to find information for hospitals in Wisconsin and Texas. You can find the retail price for an illness’ DRG and the DRG range of prices for hospitals in the area. You can also study the discounts the hospital system gives to Medicare and a basket of insurance companies. Additionally, the hospital systems’ patient mix is published. This is the hospital industry’s definition of price transparency. The uninsured cannot negotiate the price from this published data.

A few weeks ago I was at a lecture given by the CEO of a large hospital system. He was very proud of the fact that his system published this price transparency information. I asked “If I was one of the 46.7 million uninsured, could I successfully negotiate the price his system accepts from Medicare?” The first answer was an answer to a different question. The second answer to the same question was,“No.” I could not negotiate for Medicare’s discount. I could get a certain discount depending on my financial status. I asked, “If I was a self employed consultant earning a good living could I get a discount?” He said, “The maximum discount I could negotiate would be 20% off the retail price.” I then said, “If I am not able to negotiate a price, what good is publishing your prices?”

The California Hospital Association’s defense of their fees charged by hospital systems is lame at best. “They claim the studies quoted are old from 2004.” My guess is from my small sample the results would be even worse in 2007.

If you have health insurance you would not care about this price transparency discussion. You would think your health insurance company is going to take care of your prices and provide adequate coverage. Today I got a note from a nurse practitioner stating that medical insurance coverage is a racket. The California Hospital Association’s reply was;

“There is no relationship between what is charged, the actual cost of care and what hospitals get reimbursed,” a hospital association spokesperson said. “But we are doing our share. It is unfair to expect hospitals to provide care and also fix the system.”

“Why hospitals have full price rates to begin with is the result of a Byzantine pricing system that is as much a result of the country’s broken healthcare system as the hospitals’ billing practices, said Emerson of the California Hospital Assn. Hospitals in large part have borne the brunt of caring for the country’s uninsured population with uncompensated care in their emergency rooms and by writing off what uninsured patients are unable to pay.”.

“If you’re one of the growing numbers of Americans without health insurance, you are billed top dollar for hospital care.”

“Now, for the first time, a study purports to show just how costly that is — although hospital groups immediately took issue with the findings.”

“Uninsured patients on average are billed 2 1/2 times more than what the insured are billed through their health plans, and more than three times what is billed to patients through Medicare, according to the study appearing today in the journal Health Affairs.”

“In effect, the uninsured are billed at full price, while health plans and Medicare receive deep discounts.”

“Hospitals might charge $12,500 for an appendectomy, for example, but collect only $5,000 from a health insurance plan. Members of the plan actually pay a lot less, through nominal co-pays or deductibles.”

I bet Medicare reimbursement for an appendectomy is less than $5,000. The hospital has to accept the payment. Hospitals determine their retail prices by price shifting as a result of the Medicare discount. The brunt of the price shifting is borne by the uninsured.

Health plans can negotiate such discounts because they can direct a large number of patients to certain hospitals by making them part of their provider network.”

“Uninsured patients do not have such leverage and may face full hospital prices.”

Why can’t we set up a system where the uninsured can buy insurance with pretax dollars and receive the same negotiated discounts health insurance plans receive? Why couldn’t we subsidize the uninsured who truly can not afford to buy health insurance? Doing this would level playing field for all.

“As a consequence, uninsured patients who are billed full prices are left with exorbitant hospital bills that are impossible to pay, said Gerard F. Anderson, author of the study and a healthcare researcher at Johns Hopkins University”.

“Hospitals shouldn’t be charging three times” Medicare rates, Anderson said, “especially from poor people who are uninsured.”

This is the crux of the problem. Hospitals have multiple prices. The price varies depending on their need to compete for patients or the patients’ insurance plan. They have to accept Medicare by law. The government sets the price. The 46.7 million uninsured do not have this negotiating power.

Think about it. Why should the hospital want to negotiate price? All over the country aren’t hospitals overbuilding with their new found profits. They are going to need patients to fill their buildings. They will have to become more efficient and provide better prices at better quality, if they want to pay their overhead. This will happen only if the patients control their health care dollars. Remember hospitals are tax exempt. They could lose this status if the government had the guts to pass the appropriate law and enforced hospital non compliance.

“According to the Kaiser Family Foundation, a research institute, about 15% of the nation’s 45 million uninsured earn above 350% of the federal poverty income level, meaning they make too much to qualify for hospital discounts in many cases. But they are also too poor to afford health insurance.”

“The solution is for people to be covered under health insurance,” said Anthony Wright, executive director of Health Access California, a consumer advocacy group.

Anthony Wright’s concept is a simplistic view leading to the simplistic concept of universal healthcare. His views, as well as some of our politicians’ views, is that universal healthcare will fix everything. The universal healthcare concept has been disputed. In my opinion universal healthcare can not work. The patients have to have incentive to be responsible for their healthcare and healthcare costs in order for a system to work. We must empower the people to make the stakeholders compete for their business on price and quality.

A few weeks ago John Goodman proposed a brilliant idea in answer to a question about his Wall Street Journal article. He said “Suppose we passed a law tomorrow prohibiting all insurance companies (including Medicare and Medicaid) from paying any medical bills less than $5,000. What would happen? The medical marketplace would transform almost overnight.”

It would be transformed from a demand side healthcare economy system to a supply side healthcare economy system. Patients would shop for the best quality and the best price just like they shop for cars, TV’s and clothing. Hospitals and Physicians would be force to be more efficient, increase quality and be more price efficient.

“(Just thinking about it makes you wonder why we haven’t done this already?)”

My answer to the question is that the facilitator stakeholders are afraid that they will lose control our healthcare dollar. We, the people, would be in charge of our healthcare dollar. We would force all the waste out of the system, waste that the facilitator stakeholders profit from. The waste that lets the CEO’s of hospital systems justify their million dollar plus salaries and the healthcare plans CEO is their billion dollar compensation package. At the same time the healthcare system is at the verge of bankruptcy.

If the waste was eliminated and a competitive system was instituted, innovative systems would be developed to reduce the price and increase the quality of medical care. The people would be responsible for quality medical care at competitive prices because they would own their healthcare dollar.

Hasn’t Wal-Mart’s innovative $4 a month generic drug price begun to establish such a system? The answer is “Yes.”


Perverse Outcomes: Part 2: Technological Detritus

Stanley Feld M.D.,FACP,MACE

We could look in many areas to see how they result in unintentional perverse outcomes. The outcomes affect the health of the nation and our healthcare costs. One area of unintentional consequences is the creation of toxic waste from obsolete technical hardware.

We are becoming increasingly aware of the dangers of electronic device waste. There are millions of outdated cell phones and computer equipment disposed of each year. Electronic waste or “e-waste” is the fastest growing waste stream in the world, with 3.96 billion pounds of consumer e-waste discarded in the US alone in 2000. To make matters worse, e-waste is also highly toxic. According to US EPA, e-waste is the source of some 70% of heavy metals in US landfills. The volume of computers expected to become obsolete over the coming decade contain at least 1 billion pounds of lead, 1.9 billion pounds of cadmium and 400,000 pounds of mercury. Often dumped in landfills or burned in incinerators, these materials from computers and other electronics can be released to the environment, creating a massive public health hazard. Lead and mercury do not disappear and end up in our rivers and lakes. The mercury and cadmium affect the food chain and ultimately humans.


Chris Jordan’s large-scale color photographs portray the detritus of American consumption. Gaining access to some of the country’s largest industrial waste facilities, Jordan photographs the refuse of consumer culture (e.g., diodes, cell phone chargers, cigarette butts, circuit boards) on an immense scale. Spanning up to ten feet wide, Jordan’s prints are at once abstract and detailed. This is where creative innovation and recycling would be very important to the future health of our children and grandchildren.
An easy thing to do is to require businesses to recycle all the lead, mercury and cadmium. This would decrease the need to produce more lead, mercury and cadmium. It would not only decrease the pollution to the environment it would preserve our natural resources.

We are harming our health while having no idea of the impact to the healthcare system costs. Shouldn’t someone take a leadership position and solve this problem? EPA means Environmental Protection Agency. We need some protection.

If we were able to decrease the complication rate of chronic diseases by 50% we would be saving at least $115 billion dollars in healthcare costs. If we were able to prevent chronic disease the savings would be at least twice that amount. The billions saved would start adding up. However, the industries and subsequent jobs created to service this waste are threatened. They will try to do everything they can to prevent their services from being eliminated. The cost savings would lead to a decrease in the price of insurance. The uninsured could afford to purchase medical insurance.

If we want to do something to increase the health of the nation and decrease the cost of the healthcare system we will have to work very hard as individuals to eradicate these perverse outcomes. There are strong economic reasons that the harmful actions were instituted. There are strong vested interest resistance against any drastic change.

The only way we have seen change occur is by individuals being proactive. We must make our wishes clear to the politicians and policy makers. It can be done. In Texas, we have stopped the ‘dirty coal plants’ for the moment. We are in the process of stopping the governor from giving Texas back to Spain after fighting hard for Texas independence in 1848. The Trans Texas Corridor consists of an 8000 miles by one half a mile wide of toll road. The 8000 mile by one half mile wide land will be confiscated from Texans for a road. Spanish investors will get the contract to make policy. The Spanish investors only have to put 20% down. The remaining funding will come from the Texas retirement funds. The land use including restaurant, hotels, and gas stations will be by Spanish investing. Governor Perry’s policies have frozen out all Texas companies from bidding on the road. Governor Perry has refused to listen to the protests of the Texas farmers losing their land.

The Texas legislature finally had the courage to present bills to stop the governor after the peoples’ protest. Presently, the governor has threatened to veto the legislature’s bills. The people have to remount their protest to overcome Governor Perry’s veto.

Many people in large cities have no idea of what is going on. It took a husband and wife (farmers and working people) to set up a web site and network the people in Texas to protest. Linda and David Stall are a husband and wife team who made it clear to me that in this internet era ordinary people have the power to turn things around in our complex and opaque political society in which deals are made daily that do not represent the interests of the people.

We have to follow the Stall’s example in order to expose these perverse and unwanted outcomes affecting our health to the public. The first step is public awareness of the possible affects and then help the public demand that the problem be solved.

In my last blog I did not link the reference to Newt Gingrich turning green. I apologize.

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Perverse Outcomes: Part 1: Why Do We Have So Many Perverse Outcomes Between Commerce and Our Health?

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.”

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War on Obesity: Part 7: Restaurant Wars

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)

  • Ken

    Interesting debate going on over at Evolving Excellence on portion sizes…

  • Ralph

    It’s great to see a doctor attacking the #1 health issue in America — obesity and its link to restaurants.
    I agree we should stop supporting any restaurant with those inappropriate portions. I’d even go further. Get my government in there to force restaurants to post calorie information right there on the menu. How many people are going to order those chicken wings if they knew it’s 2,000 calories for an appetizer?
    Keep up the good work.

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War on Obesity: Part 6: The Problem With The Farm Bill

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.

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War On Obesity: Part 5 The Economics and Politics Of Food and Its Production?

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.

  • Sloan Hickman

    Well done. This is the most sober, rational and intelligent explanation of this problem that I have read. Only last week I e-miled three senators who opposed the Dorgan Amendment to the FDA Reorganisation bill S1082. This is linked to the politics of food so well explained above and it is the duty of all Americans to write to their senators opposing S1082 – unless, that is, they want to pay vastly inflated costs for drugs and be barred from utilising alternative remedies. The NYT lead story today 9 May is also very relevant.

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