Mixed into the jumbled bouillabaisse of our current healthcare system (from which I decided to elide the scare quotes) is the seemingly beneficent concept of quality improvement. This two-word phrase has lots of different connotations, but for the purposes of this post I’m going to refer only to the way QI insinuates itself into how medical practices are paid. As the fee-for-service horse wheezes its way toward the glue factory, alternative models have emerged. One ascendant approach is to reward practices that meet some benchmark for delivering quality care. For example, if Li’l Stinkers Pediatric Associates reduces the number of emergency room visits for its asthmatic patients by 10%, Leviathan Insurance Co. will pay out a certain amount to the practice. Follow?
The nice thing is that, so far as I can tell, practices are given some say in which benchmarks they’ll try to hit. (This is just what I’ve observed personally, so that may not be a 100% accurate statement.) When the providers in my own practice met to discuss how we might pursue quality-based reimbursement, we had several alternatives from which to choose. We ended up going with something akin to the asthma management goals limned above.
The goal we soundly, unanimously rejected outright? Trying to achieve significant reduction in body mass index for our overweight patients. We are all too familiar with the dismal results consistently shown by medical weight-loss programs to want to pin our practice’s finances on their success. This is not to say that we don’t take seriously the goal of helping our patients reach and maintain a healthy weight, just that we are realistic when it comes to how successful such efforts often are and don’t want to lose money as a result.
It’s easy to get the impression when you read about how hard it is for people to lose weight sustainably that the problem is simply a failure of willpower. That overweight people are that way because of a character flaw, essentially. Or, in the words of an esteemed colleague, the result of a slow, steady gorging process combined with assal horizontology. For people who do not struggle with their weight, an additional assumption is that because it’s easy for them it should be no great matter for overweight people to lose weight if they really wanted. Right?
Tara Parker-Pope’s recent article in the Times about how hard it is to lose weight was eye-opening for me. Try as I might to think otherwise, I find myself making those same assumptions I describe above. I don’t have much of a sweet tooth, and I’ve always enjoyed exercise as recreation. When I’ve had patients who have reported sincere attempts at losing weight without success, part of me remained skeptical. Reading this was very illuminating:
While researchers have known for decades that the body undergoes various metabolic and hormonal changes while it’s losing weight, the Australian team detected something new. A full year after significant weight loss, these men and women remained in what could be described as a biologically altered state. Their still-plump bodies were acting as if they were starving and were working overtime to regain the pounds they lost. For instance, a gastric hormone called ghrelin, often dubbed the “hunger hormone,” was about 20 percent higher than at the start of the study. Another hormone associated with suppressing hunger, peptide YY, was also abnormally low. Levels of leptin, a hormone that suppresses hunger and increases metabolism, also remained lower than expected. A cocktail of other hormones associated with hunger and metabolism all remained significantly changed compared to pre-dieting levels. It was almost as if weight loss had put their bodies into a unique metabolic state, a sort of post-dieting syndrome that set them apart from people who hadn’t tried to lose weight in the first place.
As interesting as it may be to learn the science behind refractory obesity, however, it was the story of two married, formerly obese people who have managed to keep the weight off that really communicated how much effort is truly required. Of the wife, Parker-Pope writes:
She also weighs everything in the kitchen. She knows that lettuce is about 5 calories a cup, while flour is about 400. If she goes out to dinner, she conducts a Web search first to look at the menu and calculate calories to help her decide what to order. She avoids anything with sugar or white flour, which she calls her “gateway drugs” for cravings and overeating. She has also found that drinking copious amounts of water seems to help; she carries a 20-ounce water bottle and fills it five times a day. She writes down everything she eats. At night, she transfers all the information to an electronic record. Adam also keeps track but prefers to keep his record with pencil and paper.
Bridge supports her careful diet with an equally rigorous regimen of physical activity. She exercises from 100 to 120 minutes a day, six or seven days a week, often by riding her bicycle to the gym, where she takes a water-aerobics class. She also works out on an elliptical trainer at home and uses a recumbent bike to “walk” the dog, who loves to run alongside the low, three-wheeled machine. She enjoys gardening as a hobby but allows herself to count it as exercise on only those occasions when she needs to “garden vigorously.” Adam is also a committed exerciser, riding his bike at least two hours a day, five days a week.
Janice Bridge has used years of her exercise and diet data to calculate her own personal fuel efficiency. She knows that her body burns about three calories a minute during gardening, about four calories a minute on the recumbent bike and during water aerobics and about five a minute when she zips around town on her regular bike.
Friends, that woman works much, much harder to stay thin than I do. I’m tentatively planning to run a marathon this year, and she kicks my ass when it comes to how much exercise she gets. I eat a healthy diet, heavy on vegetables and fish, but I don’t pay nearly as much attention to what I eat as she does. I know I put on a few additional pounds over the holidays, but it took one week of my regular routine for it to come off. Reading that, it looks like I’m bragging, but that’s actually the opposite of what I’m trying to communicate. There’s nothing about my ability to stay thin that warrants admiration, certainly not compared to those who really have to strive to obtain the same result.
The entire article is worth a read, lengthy though it may be. It quite effectively clarified just how hard long-term weight loss really is. My only question now is how I might modify my own approach with overweight patients. Even if we don’t make it the basis of a financial incentive, it’s obviously of paramount importance that we continue to address the issue. I’ve typically focused on small, sustainable changes, viewing them as a more realistic recommendation than trying to get patients and their families to sign on to a much more radical change like what the Bridges made for themselves. But even if sustained, it looks like small changes just won’t work, except perhaps if further changes accumulate over time.
The most effective thing would likely be to focus as much as possible on prevention. The Let’s Go program seems to be having some success, with its easy-to-understand guidelines. In any case, whatever modifications I make in my practice will be done by a much less smug provider.
Update: For those interested in the subject, I’d recommend Megan McArdle’s follow-up article. (Hat tip to Will in the comments below.)