The problem with Shumlin’s latest brainstorm

On Monday, the Shumlin administration unveiled its proposed all-payer system, which would supposedly remove the perverse incentives driving up health care costs and, as the Governor is fond of saying, “pay our docs and our nurses and our health care providers for keeping us healthy, not for the fee-for-service system that we currently have.”

Sounds like a plan. But is it?

I’ll tell you this. If I was a doctor and the Shummy system goes into effect, I’m going to stop seeing overweight patients. Because contrary to the Governor’s sunny prescription…

“… doctors and hospitals would receive a set of payments for frankly keeping us alive and healthy and feeling good,” he said. “Obviously that puts huge priority on preventive care, on eating right, on exercising, on getting off the smokes, on doing all of the things that we know we should be doing.”

… the truth is, obesity is almost incurable. It doesn’t matter how much prevention and wellness support you provide, the vast majority of overweight people are never going to lose significant amounts of weight.

I speak partly from personal experience, as a chronically overweight guy who constantly struggles with a lifetime’s worth of unhealthy eating habits. And I can tell you, even as I enter my senior years and begin to feel the health consequences, it’s damn hard to lose weight. It’s really damn hard to not overeat. There is always food around.  It never ends. I can win 95% of the battles and still lose the war.

Skinny people, like the Governor, just don’t get that.

Now, if it was simply a matter of my own experience, you could write me off as an undisciplined slob who just needs a bit more self-control to melt away those pounds. But there is a growing consensus in obesity research that says I am absolutely typical.

There’s a disturbing truth that is emerging from the science of obesity. After years of study, it’s becoming apparent that it’s nearly impossible to permanently lose weight.

As incredible as it sounds, that’s what the evidence is showing. For psychologist Traci Mann, who has spent 20 years running an eating lab at the University of Minnesota, the evidence is clear. “It couldn’t be easier to see,” she says. “Long-term weight loss happens to only the smallest minority of people.”

Many people will lose weight for a time; but “only about five percent of people who try to lose weight ultimately succeed.”

This has been tested in randomized controlled trials where people have been separated into groups and given intense exercise and nutrition counseling.

Even in those highly controlled experimental settings, the results show only minor sustained weight loss.

Experts in obesity are now talking about “weight management” instead of “weight loss.” About getting overweight folks to hold the line and add some exercise to their routines — even if they never lose any weight. Why is this so intractable? Obesity researcher Tim Caulfield points to our very nature:

“The fundamental reason,” Caulfield says, “is that we are very efficient biological machines. We evolved not to lose weight. We evolved to keep on as much weight as we possibly can.”

So I ask you. What happens to this grand prevention strategy when 95 percent of obese Vermonters remain obese no matter what their doctors do? How can you expect those doctors to prevent costly medical interventions when the statistics — and our biological nature — are aligned against them?

What happens when reimbursements fail to cover the costs of medical care when prevention fails, as it will in the vast majority of cases?

Just asking. From this fat guy’s perspective, the fee-for-health solution looks like something a skinny guy would come up with. The concept will be swimming against some powerful, ingrained behavioral tides, and the doctors will be held liable for the outcome. So, if I were a doctor, I’d be limiting my exposure to fat people.

By the way: “all-payer” can be instituted without Shumlin’s dream of paying providers to keep patients healthy. Maryland has had an all-payer system since 1971, and it has managed to keep hospital costs lower than elsewhere. It’s not a panacea, but it does help. And it doesn’t depend on finding a magic-bullet cure for obesity.

 

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5 thoughts on “The problem with Shumlin’s latest brainstorm

  1. David Schoales

    Getting the message to people early and for many years can change behaviors and moderate the effects of obesity. Mentioning the Maryland experience in the beginning would provide more valuable service to your readers.

    Reply
    1. John S. Walters Post author

      Also, yes, early intervention can prevent obesity. I am in favor of prevention. But that’ll take decades to have an effect. In the meantime, you’re putting doctors on the hook to solve an unsolvable problem.

      Reply
  2. NanuqFC

    This scheme looks like a discredited proposal discussed some years ago: “capitation.” In that formulation, docs would get paid a fixed amount per patient per month or per year; profit depends on keeping patients out of the hospitals and away from expensive tests. You can perhaps see the incentive for healthcare practices to rely less on tests and to decline potential patients with significant medical histories.

    And, btw, JV, the current language in the fat activist community is “HAES,” Health At Every Size (as in, being fat has nothing to do with having a sinus infection, but it is routine to get a lecture from a healthcare professional about losing weight before getting any actual treatment for the presenting problem).

    Reply

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