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As if in follow-up to my previous discussion about the obese healthy care delivery system as well as a follow-up to Escape Fire and the Time Magazine article on health care costs (conventional wisdom says read the article, ignore the conclusions), I was forwarded this link to a story in the Daily Beast about why Cleveland Clinic is the wrong model. In the article, Meg McArdle points out all the good thing that Cleveland Clinic can do, but then points out:

Last spring, I interviewed Charles Bosk, a sociologist who specializes in studying the way that doctors and medical systems handle error. “Atul Gawande answers the wrong question,” he told me. “It’s not whether checklists are effective. Anybody who has made it through third grade, and/or made it through the supermarket with or without a list, knows that checklists work. What you need is to ask is, ‘What would motivate professionals to use checklists?’ ” Checklists invert the normal doctor/nurse hierarchy, giving nurses the authority to, say, step in and stop the procedure of inserting a central line. That’s tough for many doctors to swallow. And hard for nurses to do, unless the culture ensures that they genuinely shouldn’t fear later retaliation.

When I asked Cosgrove [the CEO of the Cleveland Clinic] if other hospitals could really emulate the Cleveland Clinic, he said “yes, other people can do it. One of the things that is beginning to drive this is the patient satisfaction scores that is now becoming part of the pay for hospitals.”

But he also said “both the incentives and the culture matter. They’re inexorably tied. We’ve gone through a very major cultural renaissance if you will to begin to tie everything together.” And he clearly recognizes that on the culture front, the Cleveland Clinic is something special.

In both the Time article and the movie, the Cleveland Clinic is held up as a model. To be successful, the docs at the clinic have suppressed their egos to improve care. Are they really the only health professionals in the US willing to do such? I certainly hope not.



gca0111lThere is a great need to address the social factors that contribute to obesity and to initiate efforts on a broad scale to modify these factors. Much skepticism exists regarding the possibility of achieving success in the treatment of obesity. It is important to note that many of the cardiovascular complications of obesity arise as a result of mild to moderate degrees of overweight. The availability of ancillary personnel, eg, dietitians and exercise therapists, will be required to assist physicians in the treatment of obesity in the clinical setting. Finally, management of associated risk factors (atherogenic dyslipidemia, hypertension, prothrombic state, and insulin resistance) will help prevent the cardiovascular complications of obesity.

Krauss et al, Obesity, impact on cardiovascular disease, American Journal of Cardiology 1998

According to Moss, the first response came from the CEO of General Mills.

“[He] got up and made some very forceful points from his perspective,” Moss tells Fresh Air’sDave Davies, “and his points included this: We at General Mills have been responsible not only to consumers but to shareholders. We offer products that are low-fat, low-sugar, have whole grains in them, to people who are concerned about eating those products. “Bottom line being, though, that we need to ensure that our products taste good, because our accountability is also to our shareholders. And there’s no way we could start down-formulating the usage of salt, sugar, fat if the end result is going to be something that people do not want to eat.”

Report of a meeting about childhood obesity attended by processed food manufacturers in 1999

NPR “How the Food Industry Manipulates Taste Buds with ‘Salt Sugar Fat'”

Americans spent $676 trillion on food in 2012. Of that, 22% was spent on processed food, up from 11% in the 1980s. The percent of the population that is obese was 13% in 1987 and 28% in 2007. The health care expenditure per non-obese person in 1987 (constant dollars) was $2400 in 1987 and $4033 in 2007. The expenditure per OBESE person was $2630 and $5560 in 2007. A cardiologist (the specialty most likely to benefit from the obesity epidemic) makes about $400,000 today. That cardiologist in 1989 made about $200,000 (constant dollars). 

My research

In the world of processed foods, if people choose to drink water from the fountain, Coca Cola doesn’t get paid. The decision point at which the  potential customer decides to put his or her money in a machine and select a product has to happen a whole lot to appease the share holders. The average soda found in a machine costs about $2.00 and (if non-diet) 20 ounces has 227 calories. Why do people want to spend that money and waste those calories? Sugar, Salt, Fat – a new book out by Michael Moss – indicates that we do it because the food in engineered to appeal to all of our senses, leading us to off load some of our hard earned and misleading our bodies into not counting those calories as real. When it became apparent in the 1990s that our food science folks were too good at achieving this “Bliss Point” and childhood obesity was becoming epidemic, industry responded by doubling down on their already proven techniques.

In the fee-for-service world of American medicine, doctors don’t get paid unless people get sick. In the same way that a person walking past a soda machine but drinking from the water fountain is a failure for the vendor, the person who doesn’t have a heart attack is not contributing to the “cardiovascular service line” of their local hospital (they do contribute to the insurance bottom line which is a story for another day). The move Escape Fire (airing on CNN on March 10) “calls out” our current, illness based, system. The movie doesn’t pull any punches regarding patient culpability but makes it clear that our illness system is built on a “Bliss Point” that is unsustainable and does not include confronting the root causes of illness. Our job should be, among other things, counter-programming against the entrenched calorie interests, not benefiting mightily while ignoring 30 years of data regarding the causes and impacts of obesity.

This book and movie, the highly critical article in Time Magazine last week,  the call today of the National Commission on Physician Payment Reform to end the fee-for-service system all point to coming change. I only hope we as physicians end up on the side of health and not fall on our swords trying to protect the status quo.