The more I write about health care — it's been close to a couple of decades now — the more convinced I am that any attempt, however incremental, to improve the U.S. system is bound to hit a minefield somewhere along the line. It's a complex enterprise that affects every one of us very personally, and it arouses passions to a degree that maybe no other area of American life does.

I'm reminded of that by the reaction to what I thought was my pretty innocuous blog a few weeks ago looking at how hospitals around the country are working to improve nutrition for their patients and even for staff and visitors. Egged on by a couple of fairly new coalitions — the Hospital Healthy Food Initiative and the Alliance to Advance Patient Nutrition — hospitals have been serving more healthful foods on patient floors and in their cafeterias.

A no-brainer, right? Out with the bad and in with the good. What could be more fundamental to caring for the sick and promoting the health of the community?

Well …

"Around here, people do not want to be told what they can and can't eat," a nurse at a hospital in the Southwest wrote in a LinkedIn post. "We try to teach them what too much sugar and fat is doing to their bodies, and they nod like they get it. But if they want a sausage pizza, they're going to find a way to get a sausage pizza."

Another reader seethed with indignation. "When will Big Brother stop trying to tell me how to live my life! We are not committing a crime! What we eat should be our choice!"

And this from a chief nursing officer in New England: "You would not believe how agitated some patients get when we sit down to explain why french fries are no longer served in our hospital. I've had patients call up the nearest junk food palace and have bags of greasy food delivered."

A hospital CEO in the Midwest wrote to say his system recently revamped patient menus to eliminate choices that were less healthful — a move that touched off "a mass outcry from our patients, resulting in much lower patient satisfaction."

The executive went on to write that he personally does not believe in a nanny state. "Certainly people with heart failure need a strict regimen while hospitalized (and at home, if you can sell it), for example. However, I struggle with forcing otherwise healthy people to eat what we deem they should eat when they or someone is paying $5,000 a day or more to stay in a hospital."

That is certainly food for thought (sorry, I had to say it).

I usually take "nanny state" and "big brother" references with a grain of salt (again, I apologize). Experts — whether policymakers or health care professionals — have a role to play in promoting the health and safety of their communities. An argument could be made that requiring car seats for children or restricting tobacco sales or prohibiting cocaine use interferes with freedom of choice. Some critics even balk at banning sugary drinks in school vending machines or putting calorie counts on restaurant menus. By that line of thinking, are hospitals actually obligated to include food choices that are not healthful on their menus in case someone wants them?

On the other hand, the patient satisfaction angle is interesting and problematic. As people gain more responsibility for how they spend their health care dollars, they're going to shop around for providers they like. And surveys have shown that their opinions are based on the experience — how long they wait, how pleasant the medical staff are, and other factors we might consider "squishy" when compared with how effective the actual medical care is. Food choices may play into that.

It's a fact that HCAHPS scores based on patient experience surveys are playing a bigger role in determining Medicare reimbursements under new payment models. But then again, so are quality of care and outcomes measures.

How do you meet the mandates to (a) make sure patients get and stay well and (b) keep them happy with the whole experience?

I'd like to hear more thoughts about this topic. Email me at
To read the Hospitals & Health Networks' article on nutrition that I based my blog on, click here.