Thursday, January 22, 2009

Safe Eating Discounts

As I drove into work today, I listened to Boston's WROR FM (105.7) and heard an advertisement for 2 Sausage McMuffins with Egg and a cup of Newman's Organic Coffee.

I had just finished a breakfast of Bob's Red Mill Organic Thick Rolled Oats and a cup of green tea. My breakfast was

Nutrient Facts
Calories 190
Calories from Fat 30

Amount Per Serving% Daily
Total Fat3.50g5%
Saturated Fat0.50g3%
Trans Fat0.00g0%
Sodium 0.00mg0%
Total Carbohydrate32.00g11%
Dietary Fiber5.00g20%

The advertised McDonald's special was

Nutrient Facts
Calories 900
Calories from Fat 468

Amount Per Serving% Daily
Total Fat52.0g80%
Saturated Fat 20.0g100%
Total Carbohydrates62g20%
Dietary Fiber4g16%

Essentially the McDonald's meal is diabetes and heart disease in a bag, exceeding the entire daily recommendation for Saturated Fat and Cholesterol. And with the Sodium load, you'll gain a pound or two of water weight.

While driving, it occurred to me that I get a safe driver discount, since I've never had a moving violation or accident claim.

Why not a Safe Eating Discount from my Health Insurer?

If I choose to be a vegan and have a diet that has zero cholesterol by definition, essentially no saturated fat, and almost no sodium, I am extending my life by making a disciplined lifestyle choice.

By keeping a body mass index of 20 via veganism and daily exercise, I am preventing future disease.

I know that Charlie Baker, the CEO of my insurer Harvard Pilgrim Healthcare, is a very smart man and will have a very reasonable analysis. It takes dozens of people like me to support the medical care of the McDonald's eater, so it's really not possible to give a Safe Eating discount. However, if we're really going to have healthcare reform in the US, I would advocate a carrot and stick approach based on personal accountability.

Give folks with low fat, low sodium, low cholesterol diets a Safe Eating discount.

Put a tax on McDonald's meals, just as we do with tobacco products, to cover the cost of medical care incurred by eating more fat and cholesterol in a single meal than the FDA recommends for the entire day.

I realize that this may sound harsh and I will not make friends in the beef and dairy industry. However, at some point we need to be accountable for our own health.

Just as President Obama has encouraged us to take responsibility for reinventing America, we must take personal action to reduce the healthcare costs that reduce the competitiveness of the economy.

Rewarding healthful behaviors and penalizing harmful ones seems like a good idea.

Next time I see Charlie Baker, I'll ask him.


charlie said...

John - No need to wait to see me. And thanks for the comment about my, ah, intelligence. You can have another crack at that one if you like after you read this.
While I couldn't agree more with your larger points about diet - it makes an ENORMOUS DIFFERENCE - you skipped a couple of steps along the way when you transitioned from your safe driver discount to your safe eating discount. The biggest one, of course, is the fact that the state - not the insurer - sets the rules for safe driver discounts. The insurers merely administer them. This is important. The carriers in that industry, like the carriers in my industry, are generally viewed as "self interested" by the public - and would not be granted permission by society to deem one person's eating "safe" and worthy of a discount, and another person's "unsafe" and therefore, subject to a surcharge.
The second issue is the matter of the surcharge. In auto insurance, safe driver discounts are pretty much paid for by unsafe driver surcharges. Moreover, the rules of measurement are pretty clearly defined and registered - speeding tickets, forced accidents, DUI, etc. Figuring out who referees what's reportable and countable and what's not when it comes to food/diet, etc. is a bit more complicated.
Third, safe driver discounts are built up over time. You don't get one for one year of clean driving. You get one for several years of "no incidents" - and you lose it the first time you fall "off the wagon." Does this mean the first time someone who's on a low sodium diet goes nuts with the pretzels loses their discount?
As you may know, our Foundation's sole focus these days is supporting programs that promote good diets and regular exercise for kids. We are totally with you on the importance of eating right. That said, I don't think we have the standing to be the "food police." For the time being, I think you'll simply have to appreciate the benefits you derive from eating right, and accept the fact that you're doing BIDMC a favor by reducing their health care spending as your employer.
On the other hand, there are some employers who have started to adjust their premium contribution policies based on many "lifestyle" criteria - smoking, filling out a Health Risk Assessment, Body Mass Index improvements, adherence to a dietary regime, and the like. This is, needless to say, wildly controversial, but your boss, Paul Levy, seems to like "controversial." Maybe he'd be willing to give you a credit for saving BIDMC some money!

Unknown said...

I read and re-read your "carrot and stick" approach statement as "carrot-stick" approach, and I love the sound of both.

In Canada, with chronic disease becoming such an enormous pressure on the healthcare system every year, the government IS considering pay-for-performance incentives for physicians that can show reduced health incidents and improved results for chronic disease patients. How they will implement this is yet to be confirmed, but many of us are hopeful.

In Ontario, where every health campaign begins with publicly funded advertising we will soon see a reduction in the incredibly successful quitting smoking campaign of the last fifteen years, and a new direction in healthy eating/anti-obesity advertising. I'm looking forward to seeing it in action! (Perhaps a next step should be publicly subsidized rock climbing and yoga memberships, but that is entirely my wild conjecture.)

I felt I should de-lurk for a moment and mention that I began reading your blog in July of last year as part of my work with HITSP. Since then, I have switched from coffee to green tea and further increased my intake of raw fruits and vegetables. These small changes have made such a huge different in my own performance, that I wanted to thank you. My family, friends, and colleagues have all benefited.

readwrite said...

Good timing for this suggestion, as national health 'insurance' comes up for discussion again (picking up on charlie's point re legislation.)

Ben Varone said...

I think Charlie is right that safe eating is complex, and that the "safe eating" discount probably won't work. As he has said though, there is already a precedent for increasing/decreasing premiums based on downstream consequences of unsafe eating or lifestyles.

That said, I think a tax on unhealthy food would be very easy to implement. The FDA already requires labeling of the nutritional facts on most food, and some municipalities are requiring it on restaurant menus as well. Given all of that information, why not set up a system where things we don't like (salt, saturated/trans fat, and caloric content) have associated costs. Like, a 1 cent tax for every 10-20 calories per serving, 1 cent for every 50 mg of sodium, 10 cents for each gram of saturated fat, and so on.

Using that sort of metric, McDonalds value meals would quickly stop being values and start being luxuries, in essence forcing fast food chains to offer healthy offerings or pass on a premium to the consumer, with the result that either way the country benefits.

You've hit the nail on the head though, that the industries which depend on unhealthy American habits will resist any change...which is why we'll still be penalizing the consequences of poor dieting decisions, and not those who enable them. My fear with this is that the average citizen gets caught in a "fat trap', where by the time they start being penalized for poor lifestyle decisions, it's too late, too difficult, or too expensive for the individual to effectively change. :/

Unknown said...

Your liestyle is commendable. Unfortunately it may be too complex for the average citizen.

How about some small changes to start. We don't need special oatmeal...Quaker Oats will work fine. It is much better than a McSomething.

Why can't our fast food providers do away with "Super size"

Everyone needs to walk more.

Display the fat content on the pastries at your local coffee shop and I bet people will think twice about some of the morning choices.

Portion Control: Eat a little less.

Fruit instead of Chips

My point is with relatively minor changes to our lifestyle we can have enourmous changes to our lives and achieve great results.

John Halamka said...

Thanks to everyone for these great comments.

Charlie - your response was insightful, as I knew it would be. I will continue my effort, now in progress for 7 years, to live a healthy lifestyle, minimize my healthcare costs to my employer, and encourage others around me to do the same.

Micah Elliott said...

It does seem our food service system is quite backwards. I eat out maybe once a week. Sometimes it is fast food (junk), but only because it is so much cheaper. In the same way a McCheeseburger should really cost $18, I'd really like to see a healthy sub sandwich at $2. The tax paid by McDonalds could be handed over to the healthy sandwich shop next door. It would be great to make cost inversely commensurate with health value. I don't eat a lot of veggies (maybe because I don't see them much?), but if they were served at a restaurant for nearly nothing, I might eat a bunch of them.

Unknown said...

John, Your choices are admirable. However, to play the devil's advocate; shouldn't you have to pay a little extra for a rock climbing rider?

We have worked hard over the last few decades to protect people from the financial consequences of their choices. Some have suggested the radical idea of just asking people to pay their own bills.

cdombek said...

This would seem to be an extension of lower insurance rate for being a non-smoker. Do you envision a sliding scale based on level of commitment (or success) with a healthy diet? I seem to have success with my diet at breakfast but fail at lunch and even dinner. DO I get 1/3 of the discount?

Good idea I think, just not sure how to implement it.

Bharath Bynagari said...

I really like your suggestion of "Carrot-Stick" approach. At the same it might be very tough to implement the safe eater discounts.

However, the Government can and should ban any single meal that has more fat and cholesterol than the FDA recommends for the entire day.

BTW, I tried to do vegan diet. It is very hard for me, so I just increased 2 more hours of exercise per week! :)

Joseph Sucher, MD FACS said...


I agree with you in principle, but I have a few counter points.

1. While a vegan lifestyle may in fact reduce your risk of disease, it does not prevent it as you state. Take the latest high-profile patient, Mr. Steve Jobs.

2. It is clear that our society engages in social behaviors that increase the healthcare burden (smoking, poor diet, lack of excercise, drug abuse, etc.) But target McDonald's with a tax? Shouldn't you, at the very least, broaden your approach to the fast food industry (I suspect you do, but likely were only using M as an example)?

3. But why stop there? What about the grocery stores? What about beer and alcohol sales (I know there is a tax on these, but not for healthcare)? Why don't we just deny care to the trauma population who's behavior led to their injuries (e.g. the drunk driver who crashed his car and now is in your E.R. with liver, spleen and brain injury)? How about denying prior alcoholics liver transplants, or diabetic hypertensive patients who failed to change their lifestyle and need a kidney/pancreas transplant? These patients will consume more resources than a fat man with a love for McDonald's milkshakes.

Its a slippery slope Johh. I honestly do believe in the principle of your statements. I just do not see how we will change our society in such a way as to have a meaningful impact on healthcare. But mark my words, it will only come through a true change in our culture... and legislating taxes on everything that the government sais is bad is not the answer.


Stephen Buck said...

One underlying issue is how much price discrimination is tolerable and who gets to discriminate (private entities or government imposed). Combine this with the anticipated savings from lifestyle modification and many people may wonder if giving up certain freedoms is worth the benefit of lower cost healthcare. One could argue this could extend to those likely to incur hip/knee replacements based upon excessive wear and tear (running, football, etc).
I guess I'm not convinced that the best way to reduce future utilization of health care is to focus on paying for compliance with good preventative medicine at this detailed of a level. Besides, what if I could argue that based upon my genes I am 5 times less likely than the average citizen to get CAD, so therefore I should be exempt from paying taxes. That's the first argument I might make to challenge laws that sweep everyone into one class. Also, how can you control for the amount and frequency of consumption. The French do a good job of portion control of very high fat foods. Reducing the demand for health care will save money. However, I suspect a lot more "low hanging fruit" on the supply side.

Unknown said...

If only it were that simple. But who will decide on the definition of a "healthy diet"?

I certainly don't think a vegan diet is healthy, and you would likely not consider my high protein diet healthy.

But the beef, pork, chicken, turkey and eggs I consume are all raised on an organic, biodiverse farm using sustainable production methods. I've visited the farm a couple of times and know who is growing much of my food.

When possible (summer and fall) we buy locally grown, organic vegetables.

We've been told for decades that "fat is bad" but the lipid hypothesis remains just that, a hypothesis.

Should those who eat a high carbohydrate diet be penalized? Perhaps, as there is a lot of research to point to this as the culprit in the rise in incidence of metabolic syndrome.

I believe I eat a very healthy diet. Many would agree and many would disagree. Who is going to decide?

I don't want anyone "taxing" me for the way I eat or giving me cash incentives based on my choices.

Much needs to be done in terms of public education, but the ubiquitous phrase, "eat a healthy diet" rings hollow when there is no clear irrefutable proof indicating what that is.

I am not defending McDonalds and other fast food outlets. I don't believe they offer a particularly healthy menu.

But I believe the healthy eating incentive idea you propose is unworkable in our diverse society, where choice is paramount.

DeanSittig said...

I don't think it would be that hard to administer such a program as John suggests. Just as the automobile industry uses "indicators" of safe driving behavior such as no tickets, no accidents, no DUIs...we could do the same in healthcare. What if we measured BMI over the course of your lifetime. Anytime you went above 30, or whatever arbitrary number is identified, you lost your discount. Just as with driving, the fact that I've never had a moving violation, does not mean that I have never gone over the speed limit. Likewise, even though I have a relatively low BMI, I still eat an occasional donut. I agree with John H. on this one (and many other things as well!). Let's make people pay for their gluttonous lifestyles.

Joseph Sucher, MD FACS said...
This comment has been removed by the author.
Joseph Sucher, MD FACS said...

O.K. This is going too far. While I have great respect for Dr. Halamka and Sittig I cannot believe what I am reading. Let's tax it all!

Tax bad eating. Heck while you're at it, tax people sitting around watching T.V. and surfing the Internet. Oops.. I'm getting taxed right now. Tax that guy over there, he's about to put butter on his white bread!

Oh, and since this is all government, we can make it complicated by getting exercise credits. Darn it, I will burn oxygen and produce CO2 if I exercise, so now I will get dinged on my Carbon credits. Dr. Sittig, it is not going to be easy. It will be a disaster.

I disagree with tax everything that is deemed bad. What I am for is education, and leading by example. Despite my disagreement with the both of you I still think you are excellent examples of physician leaders. I admire both of you, but I do so with great disagreement with this line of thought. My bias is to invest more in education and programs that promote healthy living. Give people a good choice, and an optimal pathway for the right thing, and they will follow. It starts with the children, but is led by you and me.

Thank you.

Dr. Jason Corosanite said...

My suggestion would be to give incentives to the patient on the co-pay side for maintaining a healthy lifestyle. I bet you would find a lot more compliance with patients if they knew their co-pay would go from $20 to $50 for gaining an extra 20lbs. It would not change the premium of the plan and in most cases, its the employer paying the premiums anyway.

Dr. Jason Corosanite said...

...or to put it more kindly, your co-pay is $50 under this plan, but it can go down to $20 by doing some lifestyle modifications.

two tuppence said...

Great points John. In my view, this is one more way of charging the end user of healthcare based on their usage. The premise is that an unhealthy eater will shell out additional money in the form of taxes at the food joints, which will eventually go towards paying for their higher usage of the medical resources.

Reading through the comments, Charile and almost everyone else does seem to agree on the premise, but differ on the implementation complexities of a "safe eater doscount".

In my view, the simplest way to implement a "safe eater discount" is through health screening based tiered copay/ deductible structure. This will ensure that we measure outcomes and not actions, and it is easier to implement as well. It does not matter if I live off on McDonalds, but if my BMI, Weight and other health parameters are in the healthy range, I should not be penalized.

Some employers are already moving towards this.

Rob Culbert said...

I am surprised by the quick diismissal of the idea of a safe eating discount. Almost every insurer offers a fitness discount (which I believe is not goverment mandated) for members who prove they stay fit on a regular basis. Is this just a marketing ploy or are there facts that show that members who take advantage of this discount are healthier and reduce healthcare costs? I hope the answer is that they are healthier. No one measures the intensity of their workouts before providing the discount but getting people in the gym significantly increases the chances of them leading a healthier life style.
Offering a healthy eating discount program could be developed in a similar fashion by measuring some simple stats like weight, cholesterol and blood pressure that if fall into an exceptable range could qualify a member for a discount. This would also ensure that more patients have an annual preventive physical exam and all of which leads to healthier members and lower healthcare costs.
Obesity is an epidemic and any effort to encourage more people to avoid obesity has to be worthwhile. Employers are always interested in healthier employees and employees are always interested in lower healthcare costs so why not give it a try? Just please don't ask me to be a vegan to qualify because I so enjoy an occassional steak.

Joseph Sucher, MD FACS said...


It isn't so much a quick dismissal of a "safe eating discount". I think there were two points to be made. But I did them poorly and with too much emotion (surgeon spirit combined with being awake for 40 hours got the better of me). Therefore, I apologize to Dr.'s Halamka and Sittig for being so darn inflamatory. It was poor professional form from me, and I regret it. Please forgive me.

Point one> I don't believe in taxing a business like McDonalds. It is too slippery of a slope. Why don't we then tax Ben & Jerry's, or Krispy Kreme? I feel that this is not an approach that meets with the ideals formed by our great nation.

Point two> I don't think that the implementation would be easy, as Dr. Sittig said. It would be as hard as implementing any government program. That program would probably grow more obese than a lazy person with overactive grehlin production.

However, what about your more direct point? That is, get a discount for being healthy based on parameters measured on yearly physical exams. That has some merit. It gets down to true outcomes and doesn't penalize the capatilism of our corporate world, and it doesn't drive money into the black hole of the government. Does anyone know where all the money goes from tobacco taxation? Additionally, it doesn't get caught up in taking away peoples choices to engage in the occasional beer and hotdog. Its all pretty much OK in moderation, and I for one enjoy a Quarter Pounder with Cheese every once in a while.

Rob, I'm with you. I would like to see a program that measured the outcome of a healthy lifestyle. However, I would like to investigate the merit of getting a discount on my health insurance based on my yearly physical. We would need to know what impact this would have. Imagine... what IF everyone got a yearly physical? What would this cost, and what do we think the savings would be because of it? I really don't know. I can tell you that I had a physical this year, and quite frankly it was very cursory at best. I wouldn't even have called it a physical. It was more of a glancing blow. There would be know way to have picked up anything on this physical. So it would be unclear if subjecting everyone under the age of say, 50, to see the doc to step on a scale and shake hands. You see, this would be an enormous cost of time and money. Somehow we would need to derive what resources should be expended to achieve the best overall return. That type of thinking is where people like Dr. Halamka come into play. He has the background to think this kind of problem through.

Now let's also think about what would happen if everyone with a BMI < 30, good cholesterol levels and normal blood pressure got to pay less for healthcare. Do you think the money going into the healthcare pie would be allowed to shrink? Heck no. That means Mom & Dad and everyone else with chronic diseases will need to pay more, right? What about that problem? Mom & Dad are on a fixed income. People with chronic diseases tend to be in lower socio-economic classes. Should they carry more cost burden?

Heck. This isn't straightforward. In fact, its downright challenging. I honestly do not have an answer. I'm just a simple country surgeon trying to learn more and do his best to take care of the people.

Thank you,


John Stuart Mill said...

Dr. Halamka: A recent issue of JAMA underscores the awkward reality that there is no clear evidence that a high-fat diet is worse than a low-fat diet.

Anyway: here is a quote from the Jan. 14 JAMA, under the headline: Lifestyle Modification and Heart Disease: Researchers Not Deterred by Trials Showing No Benefit

"On the other hand, C. Noel Bairey Merz, MD, medical director of the Preventive and Rehabilitative Cardiac Center at Cedars-Sinai Medical Center in Los Angeles, said that FIT-Heart should be the death knell of the TLC diet, which calls for daily consumption of less than 7% of calories from saturated fat and only 25% to 35% of calories from fat, less than 200 mg of dietary cholesterol, less than 2400 mg of sodium, and just enough calories to achieve or maintain a healthy weight and reduce one's blood cholesterol level.

"TLC is dead in the water—it is not effective in translating into cholesterol lowering or other metabolic parameters that would allow people to avoid heart disease," said Bairey Merz, who was the discussant of Mosca's presentation of FIT-Heart's findings. "We need to test modifications of a Mediterranean diet, which in trials for secondary prevention of heart disease has been shown to be successful."

Clydicus said...

It is disappointing to see that so few people posting comments are remotely concerned about individual freedoms or civil liberties. How much of our lives and our behavior do you people want dictated to you???

Also - people who appreciate rational discourse should insist that whenever this conversation comes up, the self-righteous healthy eater must replace "mcBurger" with "Grandma's Cannoli". I'd like to see if you can make your arguments without having the evil McBurger to kick around...

Unknown said...

I couldn't help but think back to this post after reading this. Ouch!

John Halamka said...

Folks - this blog entry now holds the record for the most comments. A great discourse! I'm certainly a fan of civil liberties and personal choice. I'm also a fan of being responsible for our own actions. I think all agree that incentives to encourage wellness are good thing. It's just the form of those incentives that still needs work.