No Child Left Behind - A Bariatric Surgery For Every Kid - Doctors Policing Parents

For full disclosure I am in the AMA and take a very active role. I wouldn't condemn the AMA for this really. In fact, the AMA (and state organizations like the OSMA) have been kicking and screaming to stop the Pay for Performance guidelines that coming. However, the AMA has taken a position to help write these P4P guidelines in order to keep the guidelines from being written by government people. I was actually at the Las Vegas AMA meeting in November when Secretary Leavitt told the us point blank that's these things are going to happen whether we (doctors) like it or not. The AMA chose to take a part instead of just having guidelines handed to us. For those that don't know what Pay for Performance is, it's where the government, through Center for Medicare/Medicaid Services (CMS), will cut pay for doctors that don't follow a strict guideline of tests and questions and exams. The problem with it is that many doctors feel it takes away from the "art" of medicine and applies a cookie cutter approach to all patients. I agree. The government needs to keep its hands out of the doctor-patient relationship because it doesn't have a clue what is best for either party.

All that being said, some of the recommendations are actually good. I don't think it should be tied to pay, but they are good nonetheless. Doctors should be talking about weight because it affects health just like drinking, smoking, drugs, and unprotected sex. Doctors should be taking cholesterol levels of at risk teens because we know we can begin treating heart disease then in order to prevent heart attacks in their 30s (yes, they happen that early). FYI, I'm perfectly healthy, have a perfect weight, have exercised my whole life, and eat pretty good, but I still had my cholesterol checked in high school because it's just the smart thing to do. I think it's smart to also test 15 year old kids that are 300 pounds and have never exercised a day in their life.

We need to encourage parents to get their kids to play outside and not in front of the computer. We need to tell them that 5 cans of Coke or Mountain Dew or Kool Aid isn't good for them now or in the future. They need to know that eating a Snickers bar and getting 500 calories isn't the same as getting 500 calories from chicken, potatoes, and green beans. They need to know all this in order to have healthy kids. If kids ate right and got enough excercise I think we'd be amazed at how many medicines become unnecessary in their teen years (depression, ADHD, obesity, etc are all affected in some mannery by lifestyle).

Lastly, these are only recommendations a physician can make. The physician can't make a family put their kids outside to run, and a physician can't force parents to stop feeding their kids chocolate bars instead of veggies. However, it's still good to reinforce that message even if it falls on deaf ears.

RWJF financed smoking bans for profit and are now moving on to new areas of social engineering in the form of diet aids.

I wouldn't exactly call this social engineering. If so, medical organizations of all sorts (heart disease, diabetes, endocrine, etc) have been social engineering for years through recommendations to physicians on how to treat diseases. Are you saying that RWJF shouldn't been speaking out against childhood obesity? Are you denying that obesity causes health risks? There is no legislation here for patients, it's only a matter of education patients about health choices, consequences, and treatment options. Isn't that the whole point behind the medical profession? If doctors didn't do that what do they exist for?

"It was amazing to me how quickly people were willing to give up their freedom when they were told it was for the children." -Excerpt from a letter written by Adolph Hitler after his party gained power

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BRING THE TROOPS HOME-NOW!

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"They keep talking about drafting a constitution for Iraq.Why don't we give them ours? It was written by a lot of really smart guys, and we're not using it any more".

So you quote Hitler and say nobody gets it......hmmmmmm.

Do you think doctors shouldn't mention this to parents? I understand the concern about government essentially mandating that doctors do certain things, but I don't understand your seemingly endless refusal to accept anything that medical science says. Do you deny that fat kids are going to be less healthy, have higher rates of diabetes, and on average die younger? Or do you accept what medical science says and just not care? Or are you not willing to change your lifestyle for health reasons? If you don't care that's fine. I'm just curious where your motivation stems from.

And since we will never agree on anything concerning this subject in a million years('the medical field 'told me that), I'm no longer wasting my time arguing with you on this , or any other,thread. Adios. RWJF is a threat to liberty everywhere.
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BRING THE TROOPS HOME-NOW!

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"They keep talking about drafting a constitution for Iraq.Why don't we give them ours? It was written by a lot of really smart guys, and we're not using it any more".

Who the heck is RWJF?

"All evil and unhappiness in this world comes from the I-concept."

Robert Wood Johnson Foundation

Robert Wood Johnson is a foundation whose goal is to improve health and healthcare delivery in the world. It supports everything from increasing health insurance access to childhood obesity programs. Along with the AMA, federal government, and numerous other organizations its current focus this year is childhood obesity because of the growing data showing childhood obesity spiraling out of control and its inevitable links to certain diseases later in life.

Smokers don't like RWJ because of their campaign against smoking and support of cessation programs.

Darkseid is pointing to the creation of Pay For Performance measures by Center for Medicare/Medicaid Services (CMS) as evidence that RWJF is controlling the world. These are two entirely separate issues. The P4P meaures are a growing movement by CMS and the federal government to link pay for doctors with their "performance." In reality it's not motivated by a desire to improve results, it's motivated by a desire to cut costs by Medicare and Medicaid. Many doctors have come out against these measures because receivig the top level of reimbursement means that you follow a cookie-butter approach to all patients. P4P doesn't just deal with childhood obesity (this is the flaw in this blogger's argument). I believe there will eventually be over 300 such P4P measures ranging from patients with childhood obesity and alcoholics to type I diabetics and hypertensive patients. Currently there are a few dozen such guidelines already written. For each disease state or condition there will be a series of "check-offs" that the doctor complete in order to receive full reimbursement.

The reason the AMA, along with appropriate specialty organizations, is involved in these measures is because doctors want to have a say in what these measures are going to be. The AMA was essentially given the choice of writing these guidelines from the viewpoint of physicians or having them handed to them by government bean counters.

RWJF, to my knowledge, has nothing to do with sitting on these P4P committees. They have issued recomendations for childhood obesity just like other organizations have issued recommendations outlining the treatment options for a myriad of other diseases, but those recommendations (while they can by P4P authors) are completely separate from P4P implementation.

heyhey - I have no problems with doctors educating parents about diet, & offering suggestions about their kids' weight. But THIS goes WAY beyond that. THIS means that doctors will be REQUIRED to police the parenting, and will STEP IN if they don't think the parent is doing a good enough job. And if the doctors do NOT comply, this sounds like they pretty much HAVE to comply or lose payments by medicaid, etc. And WHO stands to benefit financially from all of this? Pharmacutical companies, Johnson & Johnson (who markets diet aids, artifical sweeteners, etc.), and doctors & hospitals & insurance companies for drugs & surgeries. I find it appalling that the final stage is to implement surgery. And what happens if the parent does not WANT the doctor to butt his nose into their parenting? TOUGH LUCK. All parents should be VERY afraid. For those who did not take the time to read the entire article (you really should, it's frightening), THIS is what I find horribly WRONG with this, is as follows (I'm leaping right into Stage 3 here):
Stage 3

To say that obesity is not an inherited trait would just be, well being dishonest. You only need to look at the parent and their adult children to see the similarities in body type, structure and weight.

You cannot police genetics out of the children by indoctrinating health care professionals to police parents to make sure they're doing the impossible.

It's also unacceptable to begin to pre-empt parental rights. We only take over parental rights in this country when the parents are either mentally incapable - either temporarily or permanently or they are abusive toward the child.

This is a very good example on the mindset that if we have a handful of people deciding what everyone else should look like, weigh, do and perform like then we will have the perfect world. This is not a description of a free society - it is a description of totalitarianism.

America doesn't work like that and it won't be accepted. If the government continues to squeeze the people there will be push back and I'll be the loud redhead at the front of the line.

Happens everytime. We get upset when you come for our money - but our kids? Forget about it.

But katie, it has been accepted. Apparently, this new doctors policing your parenting about the weight of your kids - HAPPENED. Even heyhey (who says he's a doctor & a member of the AMA & was at the conference that explained how this will work) said it's an OK thing with him. He said the doctors agreed otherwise their pay would be less, basically? I am dumbfounded this will be happening & I'm glad my kids are grown. I'd hate to be a parent right now. (I know my mouth & how I'd feel with somebody out of family butting into my parenting skills).

And, it squeeked into effect, with nary a sound. Look at how easy it's gotten? Pass the easy ban, for the kids. Then, one at a time, it's the weight of your kids, alcohol, and whatever else they can think of 'for your own good'. I know that a lot of posters here think that darkseid and I just rant for the love of ranting. They assume we just are mad because we want to smoke. But the smoking ban was never about my right to smoke. It was about the rights of private individuals to live their lives as they chose; the rights of private business owners to allow legal activities of their choise on THEIR private property; the rights of private citizens to do legal activities on their own property. And like dark, I'd researched enough before the ban vote to know that a smoking ban would NOT be the end of it. We KNEW they'd next go after overweight kids, and alcohol. NEXT up, will be overweight adults, as far as being fired for their weight to save insurance premium money. Just wait & see. dark & I weren't ranting to rant - we knew the smoking ban would be an omen of the next bans to come. And not because we are smart, or think we know things some other people didn't - but because we had a vested interest in the smoking ban, and we learned through reading up on that, what would be coming next. We ranted our heads off on these boards before the ban vote - and we got a lot of posters bashing us for being addicted whiners, and complaints that they 'don't like how it smells'. We were trying to say "Do NOT pass this ban because it will come back in SPADES".

But the smoking ban was 'for the kids', just like this child obesity policing is 'for the kids'. And 'for the employees' health' - never mind the occupations that come with high risks that shs can't come close to as far as hazardous. Employees in popcorn flavoring factories are getting bizarre types of cancers - do we ban popcorn? Fishermen have one of the most dangerous jobs. Watch "Deadliest Catch" - last episode they showed the crab fishermen sitting in a bar, trading stories & smoking. I can just see the smoking police storming in to tell them they can't smoke because it's bad for their health (at least one fisherman doesn't come back each time out to sea, often enough to creep me out). Do we ban crabs served in restaurants?

katie - I know you have kids, my heart goes out to you. I agree, a lot of weight issues are inherited. But they'd have to drag me kicking & screaming from my kid before I'd allow 'mandated bariatric surgery' & drugs & 'mandatory behavioral modification'.

And I have to assume, if heyhey is a doctor & member of the AMA, then he has a vested financial interest in this mandated weight & parenting control issue.

I'm going to dig and see if I can find the info I had about RWJF-also CSPI and MADD. And I have been fighting smoker bans since the 1980's, because I feel they are an insult to everyone who ever wore a uniform, and totally unamerican. When there is no private property, they have just wiped out freedom, period.

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BRING THE TROOPS HOME-NOW!

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"They keep talking about drafting a constitution for Iraq.Why don't we give them ours? It was written by a lot of really smart guys, and we're not using it any more".

Starling,
I'm a medical student at this point. The AMA has delegations of medical students, residents/fellows, attending physicians, and specialty groups (for urology, pediatrics, OB/Gyn, Family Practice, etc).

Slow down a bit implications of P4P. You're taking this a lot further than P4P is taking this. P4P can only affect what a doctor can do. First off, doctors are ethically bound to treat their patients in the best way even if it results in lower pay and any treatment must be acceptable to that patient. If that's a kid under 18 then legally the parents hold responsibility for all decisions for his or her care. If the parents don't want the kid to have surgery then he won't have surgery.

These are merely recommendations to the physician on how he or she should approach caring for a patient. I believe these fall under something called an E&M code (for evaluation and management) which simply means consultation, education, examination with the patient. Any surgery would have to be done by a surgeon who is paid separately. So the pediatrician's pay isn't going to be affected by the patient's decision to have surgery or not.

Here's how these new requirements will play out:
A 16 year old patient comes in with his mother. He's 5'10" and weighs 275 lbs. Definitely overweight and definitely at and increased risk for heart disease and type 2 diabetes among other diseases. The physician would ask about diet and exercise history (something simply - 3 or 4 minutes probably) in addition to the normal physical exam including things like examining the abdomen, listening to the lungs and heart, sexual history, drunk/tobacco/alcohol use, etc. The pediatrician would then follow the steps outlined in the P4P recommendations as long as the parent goes along with it. So the doctor would give recommendations on exercise and diet and then ask the mom to document the types of foods he eats for the next month or two along with exercise. At a followup visit if the weight isn't getting under control then the doctor may recommend decreasing calories even further and increasing exercies a little more. He or she again asks the mother to keep a journal of meals and exercise. At this point if the mother says she done with all this then there isn't anything the doctor is going to do. That's her decision. Forcing her someway (there is not enforcement mechanism) would go against a central tenet of medical ethics. However, if she complies and even a year later his weight is still inching up (let's say 300 lbs now) then the doctor may recommend more radical approaches to weight loss (medications, inpatient care, surgery, etc). At no time is the patient or his guardians required to follow through with these recommendations. The doctor is providing the best information he or she can and the patient is left to make the decision. For some people surgery is the best alternative. For others it is not.

So in summary P4P is for doctors, not patients, to be concerned with. I doubt once this actually is implemented that any patient will notice any change. Again, these are P4P guidelines for one disease state. There will be three hundred and something guidelines for other diseases as well. Also, P4P is not implemented yet. We're still a few years out from it's implementation. These are simply the published guidelines that will most likely be used at the time P4P is implemented down the road.

Am I okay with all this? In one respect I am. I think it will improve care in most cases because it uses a more "evidence-based" approach to medicine. In another respect I'm not. I don't think the government should have it's hands in the doctor-patient relationship, but I don't think there's any denying that government is going to increasingly have their hands in it as more and more people call for changes in healthcare. That's the price we pay when we have the government funding healthcare through Medicare and Medicaid. But, again, this isn't something that patients should be concerned with interfering with their rights. It's not going to affect your autonomy or the privacy of your healthcare. Those are the things the AMA is a very staunch supporter of and won't relent on - trust me.

I can also say that having been intimately involved in the workings of the AMA that it's members and organization are committed to improving patient care above all else. The more time I spend being involved the more impressed I am with its altruism. It's not the "doctor's union" many people believe it to be, although sometimes I think healthcare would be better for all if doctors would flex their muscle a little more than they do now.

There have been a number of changes in the American diet that have accompanied this rise in obesity.

We're starting to wise up but when you put things in the common diet like trans fats - then the medical community could begin a public education campaign. That is what they have done in the past.

When the majority of the American public drinks large amounts of caffeinated drinks sweetened with fructose - education might play a role here. If people were aware of the damage they are doing by ingesting these substances - they could choose not to do so. I see plenty of Coke and Pepsi commercials - I don't see any brave souls stepping up and offering the truth.

Bariatric surgery for youngsters? See, what a free republic believes is that you educate people with the real facts. Then you step back, shut up and let them make their own choices.

Sometimes they make choices you don't like. But it doesn't negate their right to make them. And it doesn't give you the right to take that right away from them.

This is where people are concerned that the government is overstepping their boundaries. And in many cases this concern is justified.

heyhey, I have to assume you know more about this than I do. So for now, I'll assume that you are right. For now. But the way it seems anymore, as soon as the government, pharmacutical companies, etc. start nosing in for 'our own good', things have a way of sliding down that slope. I read that article twice & it sounded to me, like it was promoting "mandatory" (I believe that was even the word they used) compliance by the parent & doctor.

I also agree that kids are fatter now then they were 30 years ago. For a number of reasons besides pre-sweetened breakfast cereals & cokes. I am a bit over the edge of 50, and they had the SAME pre-sweetened cereals, cokes, fast food places, junk food as they do today (although there are more of them)- parents simply did not buy as much of it, and didn't have as much money to blow on it. A pizza was a rare treat when I was a kid. But McDonalds served greasy fries cooked in beef tallow, and the Hut served greasy hamburgers, and kids still swarmed to those places after school. My parents & grandparents generations grew up eating bacon & eggs every day and cooked with lard. My point is, the fat police cannot blame kid's fat today on the food items that are sold. I am stunned that parents actually sued Kelloggs for selling & promoting products that have been on store shelves for decades. A box of Luckey Charms or Frosted Flakes was as easy to buy then as it is now. One BIG difference that I noticed when my kids were in high school (they are now 24 & 25), was that the guidance office in the school had posters advertising coke & brands of candy. So some of the 'blame' falls onto the schools for taking money any way they could get it. And they installed pop machines in schools. I never thought that was an issue though, because if a kid wants a coke, he'll find a way to get a coke, and many parents consume huge amounts of coke & beer at home anyway, so there's plenty at home. Healthy? Of course not - but the key is moderation & parents that put limits. But that is the parents job, not the government or doctors jobs.

What has changed is our lifestyles. When I was a kid, a typical summer or spring day kids would head outside or to hang out with friends & make their own fun. I remember going out to play & having to be home when the street lights came on - and nobody's parents worried, and no kids had to call and check in every hour. It was a safer world though. Also, more homes had one parent home with the kids then they do now. Factor in that cable tv's, vcr & dvd players, and computers came to be. Instant entertainment, and butt sitting. But on the flip side of that, kids are far more informed about the world due to computers & cable tv (some excellent programs are on). A trade off I guess. People WERE more active decades ago. But the fat fix today is not to force companies to alter their products to appease lazy parents, or to produce a supreme race of people, which is exactly where this is starting to feel like it's going. I realize that I probably sound paranoid & conspiracy theory struck - but the more I read, hear & learn about all these new developments 'for our own good', the more it seems the govt. wants this utopian society, with perfectly engineered people - a supreme race, of the perfect weight, that doesn't drink or smoke, etc. And truth be told, it's creeping me out.

The simple fact is that doctors aren't going to tell the parents or kids any damned thing that they don't already KNOW. You don't think parents & kids don't already know that too much sugar & fat aren't good for you & can make you fat? Or that they need to exercise? They KNOW that, just as our grandparents knew that. The trick is how to MAKE them exercise or eat better. hmmmmmmmm.

And ADD & ADHD seems to be a fairly new label. When my oldest son (now 35) was little, they called it hyperactive & sometimes, put kids on Ritalin - which was a fairly new medical label at the time. Our pediatrician refused to put my active young son on it - to his credit, he said my son was just high energy, and that too many parents wanted to label & medicate kids who were simply being kids. He was right. Back then, a kid on medication or with a label was a rarity, but picking up too fast for my pediatrician's comfort. Nowadays, it seems kids with labels on medications are the norm, more than ever in the history of this country. I have to wonder, where on earth did ADD & ADHD COME FROM? Why NOW? Why are there so many kids with this 'problem' & on medication? It seems there is an epidemic of kids who are diagnosed with these things, but I can't believe the blame is the ease in buying a burger or fries, or pre-sweetened cereal - they've been here for decades. I honestly wonder if it's not just an invented label to lump people into, that otherwise would have just been considered to be 'flighty' or 'flakey' or absent minded, or high energy - I was labeled 'ditzy'. It's just how I am, and I never needed medication for 'ditzy'. I'm sure some people do have attention deficit problems - I know that I do, always have. And perhaps some, like Paris Hilton it's so extreme she cannot cope (??). But in general, people tend to be the same, all over the world, and people now are pretty much the same as they were 50 years ago. Our parents & grandparents had stresses & problems the same as we do, maybe more so, but they handled their stress without the need to attach labels & be medicated. I realize that yes, there have always been people with emotional, mental & physical problems, and there was a time they simply locked whoever they thought was depressed or nuts in the mental ward or attic. But they were rare. I also realize that there have always been bizarre 'fixes' - Mr. Kellogg himself endorsed daily enemas & thought bowel movements to be abnormal (a bit of a conflict?) as a cure all for everything. But by & large, people simply coped, and didn't rush to blame or sue companies or others for their problems or because little Timmy is a bit chubby because it had to have been that dammned lard or ice cream he ate. They sure as hell would not have demanded the ice cream makers to stop advertising or to revise the recipes to suit them. This current generation seems to be a lot of whiners that would more rather blame something or somebody else. And this current goverment seems too intent on fixing us, for 'our own good'.