Health for life

With the rising tide of juvenile type 2 diabetes, the debate on school lunches is one which is slowly starting to take the stage. It is, however, one of those subjects in which everyone has an opinion -- but not many have an actual evidence based opinion. Throw in the wrench that every school district is different, and youll find mudslinging from all sides of the opinion spectrum:

Why cant parents just make healthful lunches for students? 

Well, right now, some schools are actually BANNING parents from preparing school lunches for their kids, claiming it is the parents making unhealthful meal choices. Of course, this is often true... No one can deny that. But it also makes many of us with diabetic loved ones CRINGE at the thought of what a school cafeteria lady, or health department, might think is a healthful school lunch. These places often lack in options. Im thinking a main course of carbohydrates slathered in cheese and hot dogs, with a side of carbohydrates slathered in butter or salt, with a dessert full of carbohydrates, and a glass full of carbohydrates (because it has vitamins, so it must be good for your health, unlike that can of soda.) Your main sources of protein come from that powdered, grade A government issued cheese, and that powdered, grade A government issued milk. YAY. To top it off, throw an apple at it, for good measure, because apples make ANYTHING look healthy.

Some will argue, why cant parents just trust the school lunch system? 

I always got healthful meals from the school system, and I turned out JUST fine. I love these people the most. To them, anecdotal evidence is ALL the evidence that anyone will ever need, and it somehow, trumps everything. Its like seeing nothing but yellow parakeets, and assuming there are ONLY yellow parakeets in existence because thats all your local store carries. (Never mind that many of these folks have NO IDEA what a healthy meal even looks like, and tend to think that all a kid needs to do to stay healthy is to avoid candy and soda, and eat lots of fruitsandvegetables.)

Well, heres something that will blow your mind.

Did you know that the original idea of a  food pyramid started  as a way to help  ease food costs by spending money on basic,  cheaper foods, and still get nutrition? The rest  of the foods were meant as complements  to enhance whatever nutrients were missing.  Ever since the USDA started making low fat,  high carb recommendations in the 80s, and  implemented its OWN food pyramid in 1992,  obesity rates have skyrocketed.

The USDA describes their National School Lunch Program as: "a federally assisted meal program operating in public and nonprofit private schools and residential child care institutions. It provides nutritionally balanced, low-cost or free lunches to children each school day. The program was established under the National School Lunch Act, signed by President Harry Truman in 1946."

Right away, when you brush away the chaff... what should jump at you is the low-cost descriptor used in this paragraph. What does this, casually thrown in, adjective have to say about this program? What is hidden between the lines? Well, what they dont tell you is that the National School Lunch Program started as a way to help a poor, starving population, through government subsidies --  the same subsidies programs which are still, to this day, overpowering our agricultural industry, and making it possible to produce mass amounts of low quality, less nutritionally dense foods. (McDonalds anyone?) When you invest in low quality, less nutritionally dense foods, they become LOW-COST, and easy to mass market to a multitude of industries, and other countries. Smaller farms CANNOT compete with the HUGE agribusiness industry that has come to dominate the markets, including... you guessed it -- the school lunch program market. While the school lunch ladies, might VEND food for you, it usually comes pre-packaged, pre-made, or ready to make sources, and local state federal agencies will contract their local school lunch program to a food service management company, to save a few bucks. If your local school district does not contract to one of these, they are the EXCEPTION.

The three companies, right now, that dominate the industry are Aramark, Compass Group, and Sodexo. They mass market less nutritional foods, serve nutritionally imbalanced meals, cut corners to save dollars, and contract with fast food giants to market to kids -- yes, including, soda manufacturers. Not only that, but they have been under investigation in the past, for serving foods SO low in quality, they were rejected by fast food industry safety standards. (Its gotta take a lot of balls to serve a kid something WORSE than fake fast food meat.) They have such a strong arm in the system, many of them have been able to lobby, and block legislation that would improve standards, including legislation that would have banned soda vending machines in some schools, for example. 

So when you throw in less nutritionally dense foods (so, even if you have a small serving of them, theyre still not so great for you,) in an array of unbalanced meals (all carbs, and hardly anything else), no allowances for or enforcing of portion control (and just eat what you want, and how much you want of it), and the attending results of kids who will a.) not feel the stop and go of their hunger signals anymore, and b.) constantly feel hungry because they got no real nutrition, you will get increased likelihood of illness, development of chronic diseases, and a national fat kid tsunami.

Thats right... every time your kid eats at one of these national school lunch programs, its eating food thats probably worse than McDonalds. (And even if it would appear "balanced," the fact is... its still food that is nutritionally inferior. Remember that. Its like comparing a home made creme filled cake, to a Twinkie. They are technically, the same thing, but thats where it ends. One of them still has FIBER, and many, many vitamins and minerals. Ill let you guess which one that is.)

Are you freaked out yet? YOU SHOULD BE.

Still, some people have blind faith in their National School Lunch Programs... And disbelieve or disregard those who try to stand up against it, and call for change. (Including some politicians.) But folks are fighting BACK. 


Folks like Sarah Wu, who "compelled by her own frustration with school meals — both as a mother and a teacher ... known anonymously as "Mrs. Q." committed to eating school lunch every school day in 2010 just like her students. Mrs. Q documented her experience and described the meals by blogging, tweeting and sharing photos on her blog Fed Up With Lunch: The School Lunch Project." Her blog is one of the first blogs to help capture national attention on this very concerning issue. Mrs. Q risked her employment on this... and there were many days I worried shed get caught. Still, I cheered for her. Her voice has been effecting some serious awareness and change... but we need more.

More, nationally, as well as globally... Like little 9 year old, Martha Payne, from Scotland... who writes about her poor lunch school program at NeverSeconds. While youre not going to see her giving you an in-depth analysis on the corruption, and backdraft, of agribusiness subsidies... she will hold up every meal to critique, and scrutiny, so you can see with your own eyes what she and her peers are being served.

America is at a critical point, right now... we are at a point where its starting to matter very little what type of food you eat, because it was all cheaply made, and nutritionally bankrupt. Movies like "King Corn," "Supersize Me," and "Food, Inc.," have created some discussion... but quickly get swept under the rug as passing the buck, and not taking personal responsibility for what we eat. But we are clearly living in a very obesogenic environment where it is getting increasingly difficult to make right and wrong decisions, and increasingly easy to be deceived. Yes, a lot of foods that make false health claims have food labels, and we could be better trained and educated at reading them... but what if we thought we were eating meat, and instead were getting meat with an incredibly high risk of bacteria, and lots of corn filler? What if it was given to us by a school lunch program, with no labels (just trust), and not the you should know better, fast food industry?

Yes, we have freedom of choice, in America... as to what we eat. But to what EXTENT should we let the government and the food industry tamper with our food supplies? Market to us? To children who havent yet developed some of the necessary critical thinking skills, and disciplines, to make good life choices? (Especially, when they dont even have a parent around, to help...) Or to populations with less income, less education, and less access to nutritious alternatives?

The rights and freedoms of those who want to make me less healthy (and not just by consuming more fats and sugars, mind you), start mattering VERY LITTLE to me... when the lives of children, and the future of our nations are involved.

I dont know how ALL chronic illnesses, cancers, and autoimmune conditions come to pass... but sometimes, I have a very good idea what might be contributing to their explosion... And its not just having an extra piece of pie.

...and you can take that to the bank?

It seems no discussion on the Patient Centered Medical Home is complete without a erence to Medicaids Community Care of North Carolina. The states consultants reports on CCNC have been accepted as gospel by the academic community (for example) and have contributed to a widespread consensus that the PCMH saves money. As in billions.

Or does it? For a readable discussion of why CCNC may or may not have saved money, check out this four pager by Joseph Burns appearing in March 2012 issue of Managed Care Magazine. Skeptics point out numerous inconsistencies, including North Carolinas lingering high costs and little change in inpatient utilization. MCM asked analytics impresario Ariel Linden to take a look at CCNC and, after using a time series analysis, he was unable to find evidence of savings.

Nothing new, says the Disease Management Care Blog, which has long been unable to make much sense of the consultants reports either. What is new are the responses of CCNCs Paul Mahoney, founding physician Charles Wilson and advocate Adam Searing. It seems North Carolinas fee schedule is complicated, physician buy-in is high, something must be working because the Medicaid program has avoided making fee schedule cuts and, last but not least, the States legislature never intended the consultants evaluations to meet the exacting standards of the DMCB readership.

The DMCB doubts the controversy will go away.  What we can learn from the CCNC imbroglio is how important it is to think about the analysis early in the planning process. In the meantime, PCMH advocates will probably have to look elsewhere if they want to er to studies that are understandable, transparent and convincing.

Coda: By the way, whatever its imperfections, the CCNC is a good example of a "shared resources" approach to nurse care management. As the DMCB understands it, in CCNC, the primary care sites do not hire their own nurses.  Rather, the costs of the nurses are regionally supported and the nurses are, in effect, loaned out to the clinics. 

The DMCB argues that there is little difference between this and hiring a disease management/population health service provider. To paraphrase Comrade Deng again, the color of the cat may be different, but it still catches mice.

Let the debate begin!

If the Disease Management Care Blog cant personally debate former CMS Administrator Don Berwick on the merits of Medicare-style ACOs, itll just have to have settle for letting others do the heavy lifting.  In this Wall Street Journal article, skeptics Jeff Goldsmith and Thomas Scully ably take on Dr. Berwicks cherished assumptions in a well edited point-counterpoint exchange.

Your ever helpful DMCB provides a short summary of the highlights for its busy readers.   

Donald Berwick:   What the Affordable Care Act seeks is reasonable: high quality, low cost and open access that strikes a balance between unfettered fee for service and onerous managed care.  ACOs take the best features of health maintenance organizations, such as coordinated care and provider incentives to save money, but without the worst, such as restricted networks that hamper patient choice.  Many provider organizations seem to agree.  Thats why interest in participating as ACOs is high. Smart providers will figure out how to do ACOs profitably.  Whats more, private insurers have adopted the model, so there must be some merit to the notion of ACOs.  Last but not least, if ACOs work out, the savings will accumulate into billions in the years to come. Thats when we can think about next steps, such as partially capitated arrangements.

In addition, thanks to the lessons of managed care and the Physician Group Practice Demo, ACOs will be transparent and high quality with closely monitored gain sharing, governance and information systems. Whats more, thanks to its Innovations Center - Medicare will find ways to be flexible over the start-up costs of ACOs with advanced payments.

Hey, this is one experiment among the many innovations of the Affordable Care Act.  The negative murmurings of the malcontents below may be right, but we dont know that and ACOs are still worth a try.

Jeff Goldsmith: Berwicks vision looks good but its an unreal mirage.  Thats because provider organizations a) will have to spend more money than they can possibly recoup in shared savings and b) are fundamentally configured to admit to expensive hospitals and rely on pricey high-end specialists.  While CBO projects mucho savings, its really a lot of inside-the-beltway "budget dust." We know that because in CMSs Physician Group Practice Demo that formed the basis of ACO blueprint, eight out of ten participants lost money. Thats because they were unable to scale the resources necessary to care for their sickest patients.  The two participants that made money probably did so because of creative coding.   Last but not least, remember that Medicare beneficiaries in ACOs - because theyre completely protected from any economic downside - have little incentive to moderate their consumption of health care. 

Thomas Scully:  Nice try Dr. Berwick, but there are credible data that say that ACOs cost as much as $30 million to start up.  The start up price tag is not only putting hospitals in the drivers seat, theres a good chance that theyll turn into market dominant oligopolies. Its that luster of control, not saving money, that has driven provider interest in ACOs  If you want to save money, drop Medicares dysfunctional price fixing, forget about ACOs and give the docs control of all the money in fully capitated arrangements based out of a private insurance system that fosters competition, like TriCare and the Federal Employees Health Plan.