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Wednesday, April 29, 2009

Pushing Bounderies: Checking work email while on vacation

I checked my work email during my vacation last week. As a confession or something that might shock, that ranks up there with, "I pick my nose while driving" or "I like singing along to Cher". However, on principle I had never checked work email during vacation because there are boundaries. Work and vacation cannot exist at the same time. If you're doing work than you are not on vacation. There must be a physics equation that includes variables like time, temperature, alcohol, and work to express it.

For those whose jobs require checking email at all times, these principles don't apply and I should get as much sympathy as Octomom would for getting her lips sunburned. Anyone in that situation can stop reading in disgust or rip me a new one in comments about how I am whining.

Speaking of whining, my vacation wasn't really a vacation. I returned to the Midwest with my family to visit more family. Flying just feels like a harrowing experience now and I would feel safer on a wagon train that was under attack by Native Americans than on a plane. Also, more comfortable. I didn't sleep well, got sick, and I spent too much time in the suburbs at family events. Checking work email was entertainment compared to the vacation.

In a typical world, my vacation involves going into the wilderness where you can't even pick up an FM radio channel let alone an internet connection. Therefore, checking email is never an issue. I consider that distinction to be important in today's world where it's too easy to let the latest communication tools control us. Ultimately, this is about a control issue for me. I control my vacation time and will fight off anyone attempts to control it.

The typical reasons that I hear for why people check work email sound like loss of control to me. There is the worry that there will be so much email to read the first day back that it will be overwhelming. There is fear that there will be something really important that won't get done because only you know the answer. The self-employed just can't stop working. All sound like loss of control of me. If anything really important happened while I was away, I would deal with it first when I got back. Everything else that wasn't really important can wait. It's nothing that prioritization can't solve.

In this regards, email is often a misused tool. When I read about companies that have No Email Fridays, I think that is a company that has very serious communication issues. Eliminating a tool should not be cause for a holiday. It's like having No Power Point Wednesdays (which actually would be a really good idea). If a company misuses email to such an extent that they have to ban it for a day to get out from under it, there is a much larger issue.

I consider not checking work email while on vacation to be a larger issue than just cleaning out the inbox or keeping an eye at what's going on in the office. It's about boundaries, control, and how to properly use a tool.

Tuesday, April 21, 2009

At Wharton, Leadership training involves getting High

High Altitude that is. Mountain Climbing. Glaciers and snow. About 5 years ago, Wharton began to incorporate field trips or ventures into its curriculum that would emphasize leadership. These field trips were often mountain climbing on snow or glaciers which lead to some joking among the student body that leadership involves ordinary team dynamics that are just placed on a mountain. A learning team argument about how to divide up the work load for a team building paper at sea level is just typical group interaction. However, when placed at least 15,000 feet on a glacier, than it's a leadership opportunity!

This characterization is more of typical MBA self-deprecating humor as Professor Mike Useem, who is an excellent professor, and a friend of mine lead the program and I think they do a good job. The leadership ventures are very popular and provide unique field experience not found at many graduate schools.

However, given my previous post about leadership training at MBA programs, I am obviously skeptical of the whole concept of leadership training in a business school and this is no exception. A recent Wharton Journal article entitled "Leadership in the Death Zone: K2" was one reason that I thought about Wharton's mountain climbing leadership ventures. The article is very objective, provides good background, and concludes with metaphors of the same tools that we use in climbing real mountains are used for goals that seem like mountains. I have no complaints about the article as it is well-written.

The main reason that I decided to post about leadership training through mountain climbing is that I started climbing shortly after moving out to Oregon 6 years ago. I climbed about 4-6 peaks per season, take climbing classes, and have been an assistant leader on a few climbs. In short, I am that guy in your class who worked at the company that was the topic of the case study. Just like that guy in your class, I now consider myself to be the true expert on the topic and that even professors or professional mountain climbers are going to hang on my every word. In case this isn't clear, this is another example of that self-deprecating MBA humor.

There are some elements of climbing in a team that make it very conducive to leadership development. Decisions on setting anchors, rope teams, or routes need to be made quickly with the available information and the team has to move as one. Everyone has to be aware of the conditions of each team member as the entire team makes it to the summit or the entire team does not.

However, there are some elements of mountain climbing that are not really conducive to leadership training. A climber can have communication skills that suggest autism and think that team building is an type of construction project. However, if they have excellent climb skills, they will be a good leader. A solid anchor will comfort a nervous climber as much as a kind word. Navigation skills are more important than being a skilled communicator. Whenever I lead a group, I focused on the route as getting lost was the surest way to lose faith in my leadership ability. Or I delegate navigation to the entire group and told them that it was just as much their fault if we got lost.

Overall, my biggest objection to mountain climbing as a leadership development tool is that it strips climbing of its passion. For me, mountain climbing is about being in the wilderness, being with fellow climbers, making it to the summit, and celebrating when we get down safely. My thoughts are not about leadership opportunities but more enjoying the moment of seeing the sun come up when you're break the treeline. Or thinking about the utter misery when it's dark, cold, and you question why you selected this hobby. A successful summit feels like winning a championship and make you forgot those midnight alpine starts. I do try to improve my climbing skills and learn in that regards but this feels more like a personal quest than a team exercise.

There are many lessons that a team could learn and deconstruct after a climb. However, I would rather just enjoy getting high. High on the altitude that is.

Monday, April 20, 2009

My latest knitting project; a Helmet

At the beginning, I had advertised that this blog would be about health care, MBA admissions consulting, and even knitting! The "Even Knitting" posts have been few and far between mainly because my latest project turned out to take a lot more time than I had imagined. However, it's done. Pictured on the left is my helmet or basically a ski mask without a face. It was completed last night just in time for the climbing season.

I should have predicted that this was not a quick hat project when it called for casting on 160 stitches on size 4 needles (which are small needles). However, it was a great pattern and perfect to work on during our marathon NCIS TV watching sessions. The pattern came from Kristin Spurkland's Knitting (Man)ual (get it Man-ual or knitting for guys). This pattern is what initially attracted me to this knitting book as well as the fact that the author had a website with an FAQ section that entertained any query that a knitter could come up with. This was a welcome contrast to Sirdar's approach to knitting questions which was pretty much a "Don't get mad at us if you're too dumb to figure out the pattern" philosophy.

My wife was less than thrilled with the hat only because she thinks that I look like an incredible dork in the hat. Wearing it around the house with my pajamas before bedtime didn't help my cause.

My next pattern will be a fruit hat for my cousin's 6 month old baby.

Wednesday, April 15, 2009

My Lost Networking Opportunity: How I could end the Obama Administration's Public Plan

If I was a really, really good net worker, I might be doing health care policy work with the Obama administration. Most of you are probably thinking, would you really want to be tackling health care reform where stakeholders attack you with actual stakes? The answer is probably not, especially since I would have to leave the Pacific Northwest and climbing season is starting.

I would have networked my way to the White House if I had kept in touch with one of my Wharton professors, Nancy-Anne Deparle who is now the White House health care czar. She taught our health policy class, which was an evening class filledwith the few of my classmates who were interested in working at hospitals or health plans plus the odd nursing student and very odd physician. Nancy-Anne had great stories from working at the predecessor to CMS, called HCFA (Health Care Financing Administration). She did not come across as a beltway powerhouse, even with her southern accent. She was very friendly, very measured, and unassuming. She was offered a CEO positions at the Tenet hospital chain's Group Purchasing Organization (GPO) and asked my advice about the position since I had completed a summer internship at another GPO. In hindsight that was highly flattering that she asked me for career advice. Therefore, if I had followed up with her, kept in touch, I could have been reading the questions of the Simple Son at the White House Passover Sedar.

I hadn't seen Nancy-Anne in the newspaper a great deal until she was quoted last week about the Obama administration's Public plan. The administration had been pushing for a government-run Public Plan much like Medicare or Medicaid as part of it's health care reform efforts. This Public Plan (dubbed Medicare Part E as in Medicare for Everyone in some circles) would provide an option for individuals and small businesses, be cheaper than private plans, and keep private health plans "honest" through competition. Private health plans are very concerned about this potentially new powerful government competitor.

The Lewin Group, a health care and policy consulting firm located in Washington DC did a paper on the impact of this Public Plan that has provided the best analysis to date of what would happen. Here are the main points and my comments below:
  • One Sweet Plan: The Lewin group assumed that the Public Plan would be the same as the health insurance that federal employees currently receive. This includes $15 copays for doctor office visits, a mere $250 deductible, and the most someone ever have to pay for health care services that they used (or an out of pocket maximum) is $4000. All this and dental benefits, too! To put it in perspective, with traditional Medicare, you pay 20% of everything, no dental, and no out of pocket maximum or cap on what you have to pay. This is fantastic insurance and really too good for the governement to be able to afford. With any assumptions about a Public Plan, we have to be realistic about the level of benefits. It's more likely to be closer to traditional Medicare where you pay 20% than what the federal employees receive.
  • Not so sweet for doctors: The Lewin group looked at the costs and figured for the Public Plan to be affordable, it would pay doctors and hospitals 20%-30% less than they currently get paid. This is where everyone started to realize the tough choices in health care reform as this would be a big pay cut for the providers. Nancy-Anne weighed in at this point by noting that there were ways to make this plan affordable without rolling back provider payments to the 1970's. However, I don't see a way and this will be a big stumbling back. Cutting back provider payments will be a tough sell and doesn't do anything to change that fact that we don't pay for good outcomes but rather how much stuff a doctor performs. It's also very possible that doctors will refuse to accept this insurance just like they refuse to accept Medicaid or traditional Medicare.
  • Administrative Costs: How much it costs to keep track of how providers get paid, what they should get paid, answer phones, send letters to subscribers, ID cards, keeping track of enrollment information, and all of that administrative stuff that insurance companies do is a popular topic. The Lewin Group believes that 32% of the health care dollar goes towards administration for groups of 50 people or less or individuals. For the overall membership, administrative costs are more like 15% but this Public Plan is intended for small groups and individuals. The Lewin Group believes by removing the profit margin and broker commissions (who sell insurance) that the government can reduce administrative expenses to 12%. This is my main point of disagreement as the math doesn't support it. Broker commissions are likely to be only 5% of the administrative costs and profit margins won't exceed 3% in this era. That's another 12% of savings that will have to be found and that assumes the government will be as efficient as the insurance companies with the administration. That will be a big stretch given that that the government has typically outsourced all health insurance functions. Any drug purchasing is outsourced to private companies. When traditional Medicare was created, the Blue Cross plans did the claims administration.
There has been a lot of concern with a government Public Plan. My main concern is that the numbers don't support the savings and it will do nothing to improve health care. It won't make health care delivery more coordinated or reward more efficient care. It won't help make hard choices about rationing health care. It won't change the fact that there are too little primary care physicians (and will pay existing physicians a lot less). It would be another version of traditional Medicare which has had no successful disease management pilots, pays providers too little so many won't accept it as payment, and bills so inefficiently that studies have shown that it only pays 45 cents of every dollar billed.

The Public Plan is a great way to threaten the insurance industry. I am putting my faith in Nancy-Anne that it's part of the political posturing and that the Obama administration would look at the numbers and think of the implications before trying to launch an idea. Maybe, I should try to see if being a former student of Nancy Anne's would get me an audience with her to present my idea? If a big part of MBA programs is supposed to be networking, this should work right?

Monday, April 13, 2009

Public Displays of Job Searching

I heard a story on Fox News while I was on the elliptical machine about a couple's job search. In North Carolina, a wife placed her husband's resume under car wind shield wipers at an office building parking lot with permission from the building. While her husband was reluctant for obvious reasons, it seemed like given the current state of his job search, he was in no position to say no. I couldn't find a link to the story but for argument's sake, let's assume it's factual. The husband had worked in Sales for 12 years and looked very much like a Web 1.0 kind of guy. No blogs, twitter, flutter, or anything fancy other than a lot of copying and some leg work. He got 3 calls for interviews so his family had some success. They looked happier and I am happy for them.

I had previously blogged about using social media to get attention for the job search. Looks like it's possible to get national attention without social media, too but still use paper rather than electronic to spread the word. While the unique marketing tactics drove the success, I think that the guy's resume is what closed the deal. From the TV screen, I could tell the following:
  • Quality paper and professional looking resume
  • One page. He fit 12 years of experience on to 1 page
  • I could see the headers, showing that the information is probably well organized
If the job searcher didn't have a quality resume, he would haven't had any success with his campaign. One thing that this shows is despite all the mediums and vehicles for getting your resume to the top, we still need to succinctly show our experience in a clear format.

On the bigger picture, I wonder if using stunts or unconventional tactics is going to become the norm for advertising one's job search? Will we see resumes on bill boards, on the Net Flix envelopes, Google ads, or more dedicated websites? Some of these tactics are really examples of portfolios as it would make sense for a Public Relation professional to use these tactics as an example of their skills. However, I don't see these as an example of new marketing but more of a demonstration of a new psychology of the job search. Carpet bombing your resume looks desperate and desperation doesn't sell.

I think that candidates have been driven to this state because in this era of on-line job applications, it feels like no one is paying attention to them. The complete lack of response can cause candidates to question to feel ignored, feel like they do not exist, and they are being passed by. A very public display of their job search at least affirms that someone noticed them and thought about them. Its affirming one's existence as opposed to a job search strategy.

Rather than an evolution in the job search process, I think that these public displays of job search are a psychological response the alienation of today's job search.

Thursday, April 9, 2009

Come to my Rave! Rant and Rave that is

I've written 24 fairly wonky health care posts, 8 posts about the MBA admissions process that are fairly enjoyable reading and I actually might share some useful information, and 13 posts about articles related to MBA's. The most popular post was about the not very sweet and surprisingly inept story of the love lives of MBA students. I've been fairly disciplined with very few posts about the mundanities of my daily life around traffic, lines at the company cafeteria, or corporate decision-making process. I definitely could be accused of having too many analogies with colons and yak herding but that's not going to change. What is going to change is I am going to indulge myself with some good old fashioned complaining. Welcome to my Rant (and Rave).

It's not the economy, you're just being stupid: In general, we read a lot of more about business and finance these days. This could be driven by the fact that we are now mostly responsible for managing our retirement accounts. One result is more people, especially bloggers, try to build an economic rationale for their social or political opinion when it really isn't there. For example, if taxes were an economic issue, than economists would have figured out the ideal tax structure and every country would use it. Taxes are a political and social issue and a values question. High taxes to fund services for the all or the low income, low taxes with no services and you eat what you kill, or a very progressive tax structure that has the rich pay for the low income are all societal or political issues. It's about fitting an economic structure into a set of values and not the other way around.

I've seen some posts that try to discuss unions or cigarette taxes as purely economic decisions. The economic results are mixed and cases could be made for either. Value are picked first.

Vblogging: I attended an Edward Tufte presentation where he described how we can read twice as fast as someone can talk. Therefore, why are bloggers videotaping their posts? There is no interesting video being done, the blogger just talks. Thus, a reader has to spend twice as much time on that post. Videos on blogs are being misused like power point as they mainly slow down the delivery of information.

My favorite part of the Edward Tufte presentation is when I approached him with an example of a data display were were working on. We were trying to show patient visits in a combination of our hospital, health plan, and physicians and came up with a peacock. Before, I could even open my mouth to describe, Tufte said, "No. Set it up like a distance table between cities like they have on maps." I nodded and walked away without saying a word.

Obama, Medicare Advantage is not the health plan that doesn't work: It has been amazing to watch what competent or even good politicians can do. Obama already has done more for health care than any president in a long time with the COBRA subsidies, expanding SCHIP, and framing health care as an economic issue (and really an economic issue as opposed to a values issue). However, his statements that Medicare Advantage "doesn't work" because they cost the government 12% more than original Medicare does not look at why they cost more. Rather than private plan profits, the extra 12% comes from more benefits for beneficiary and paying providers enough that they will actually accept the insurance. Original Medicare does not do anything to promote good health care usage other than paying below market rates. It's like complaining that a car with 4 wheels is more expensive than a car with 3 wheels.

The health plan that really does not work is the individual insurance market for those who aren't 65 yet. Health plans have steadily gotten stricter and stricter about who they will accept to the point where it's really difficult to get individual insurance if you actually need it. Prices typically increase 10% year making it one of the faster rising products in health care. Rather than tinker with a segment of the population that has many insurance options, the Obama administration should focus on the most dysfunctional insurance market.

Tuesday, April 7, 2009

Go ahead and shoot the messenger: Defending the US health insurance industry

The health insurance industry is not solely responsible and the source of all that is wrong with the US health care system. Posts like this are usually as welcome as unsedated colonoscopy but I am ready to post it. Even if all of the health insurance companies were merged into one gigantic non-profit organization, it would not solve fundamental issues in the health care system and probably not improve the situation.

I first became interested in working in the insurance industry while working in a psychiatric crisis center in Philadelphia. I would triage patients, work with the clinical team to develop the treatment plan and would submit this treatment plan to the insurance companies for authorization. They would decide the patients' fate. As a result, I decided that my career in health care should follow the money and that at one point, I would work for an insurance company. While this story make insurance companies look like the equivalent of Roman emperors deciding who lives or dies at the coliseum, the point is more to show that I came to work in health insurance through being a clinician and a clinician who worked with some very sick and desperate individuals. Readers can know there is at least one person in the insurance industry who had a heart at one point in their lives.

Best Data in the industry: When it comes to health care data, most think of academic medical centers and the research. However, their data comes from only their patients in their geographic area and only from their providers. Additionally, hospitals and physicians also do not have very good data systems beyond their billing systems. A provider also has to be very large for it to be economical to purchase a really robust data system attached to an Electronic Medical Record. Insurance companies have data from multiple geographies and multiple providers in claims systems that can search by diagnosis code, providers, geographies, etc. There can be comparisons between different hospitals, providers, age cohorts across a broad section. My best example of the data is that during the Anthrax scares in 2001, the government asked the large national insurance companies to review their databases for anyone who sought treatment for Anthrax.

This data is important because truly effective reform needs to be based on data-driven decisions and ultimately tracked. For example, this data can be used for development of evidence-based treatments or tracking patients with chronic diseases.

Only ones that say No: In every health care system there is some kind of rationing. We typically hear of long waits for certain elective surgeries in Canada or Great Britain which is a type of rationing. In the US we ration by not always providing health care for those without the ability to pay for it. Insurance companies ration by requiring people to pay more for the brand drug than the generic or limiting the number of days that someone can stay in a nursing facility. Insurance companies use their data to ration based on acceptable levels of care. Bad outcomes are always more expensive so insurance companies do have the financial incentive to ration based on effective medical care.

We all want to receive as much care as possible. However, there is not enough health care in the country for everyone. Doctors and hospitals do not typically refuse to provide health care services especially since they get paid to provide it and might get sued if they do not. Therefore, insurance companies are the only part of the health care industry to tell someone that the $10 generic is just as good as the $150 brand even though it didn't advertise on TV last night.

Here is one example where insurance companies rationing or saying no helped end a very invasive and effective jaw surgery. People who had jaw pain (or temporal mandibular joint disorder or TMJ) would get these extensive surgeries that would remove pain for a few years because the surgery killed all the nerves. When the nerves grew back, the pain returned. It was an ineffective, expensive surgery and is now excluded by most insurance companies.

The hard choice that will be made in health care reform is how to say no to giving someone the health care that they want. Health care is a limited resource and if we want to spread it across an entire population as equitably as possible, we need to learn to say no. Oregon's Medicaid reform in the early 90's was an example where services were ranked from top to bottom. Those on the top of the list were covered and when the money ran out, the rest were not covered.

Administration: Someone has to collect enrollment information, pay providers, pay providers the right amount when they should, and not pay when they should not. This information gets updated and revised daily. It's simple data storage and a commodity so it should be done by the cheapest vendor who can do it accurately. The insurance companies have the data systems and experience doing this. Would it make sense for anyone else to take over this function? When Medicare was created in the 60's, the federal government had Blue Cross Blue Shield handle all of these functions so the government has never done this. There is no other candidate than the insurance companies.

This is not an exciting part of health care reform. However, someone needs to pay the bills correctly. Traditional Medicare is so inefficient with paying bills that providers receive only 45 cents of every dollar billed. If providers get paid this ineffectively under a new system, it will undo the reform.

While I was working at the psychiatric facility, we were fairly good at knowing when someone really did not need an inpatient hospitalization. They weren't unable to cope at the time with their situation but rather they just didn't want to. However, when someone was hospitalized or needed treatment, we would want to keep them in treatment for much longer than they probably really needed. Kind of like you always want one more slice of pizza. That was my weakness when I worked on the clinical side and now I see that is an insurance company's strength.

Saturday, April 4, 2009

Purchasing Value in Health Care: So Many Roads

I have primarily talked about Medicare and Individual health insurance purchases because that's my area of responsibility. My counterpart handles all of the employer group insurance and I'm substituting for him on a conference call on value-based health plan purchasing. This gave me an opportunity to think about how your employer might buy health insurance and the purchasing process.

On a side note, I used to work at a health plan that called their employer clients, "Purchasers". Websites made references to "Purchasers" as did some literature. When groups realized that they were viewed as buyers, they did not appreciate the term. They thought of themselves as clients if not partners, not a just a buyer of health insurance akin to an import-export agent at an open air market who is haggling and trying to snap up bargains.

Back to the topic, there has been a movement in the last 5 years where employers and coalitions require that health plans to explain the outcomes or "value" of their plan. For example, their network of providers provides the cleanest colonoscopies in town as opposed to scoping every asshole they see and getting paid on volume. At first, there was little data to support the clean colonoscopy (which is kind of like clean coal, sounds nice but doesn't exist yet). However, the employers and coalitions stuck to their values, insisted on outcomes, and carriers began providing data around preventive care, disease management outcomes, proper technology use, and demonstrating that they had steps to promote evidence-based practice. Evalu8 is the Oregon Coalition of Health Care Purchaser's efforts and they have successfully caused most local carriers to focus on outcomes in order to score high on the survey.

Putting together the survey and compelling health plan's to fill it out was no small task. However, the harder task for employers is to trust that selecting a plan that scores well on the survey is the best choice for their employee's health plan. Usually, the price and number of doctors and hospitals on the plan drives the decision and are things that the employee readily sees and is of greater interest. Remaining with a plan that an employer believes will provide the best outcomes and thus lower medical costs requires a longer horizon and a relationship that is not transactional. Employers that self-fund their own plans have more of a financial incentive for this longer term relationship. Regardless an employer needs an interest in their health plan and a belief that it can turn into a competitive advantage over time. This is a difficult vision to maintain especially since it's possible to save just as much medical costs by switching plans every year and picking the plan that underbids everyone else.

The next phase to create value is through the benefit designs. Some health plans are coming up with benefit designs that give away services for free if they help someone with chronic disease manage their illness (like drugs or doctor's appointments for blood sugar tests) or preventive services like prostate checks. The cost of even a $10 drug copay can add up over time or these are procedures that people don't want to do (like prostate checks). Therefore, there is little concerns about abuse of these free services and it makes sense for the employee to pay very little. Since these type of benefit designs encourage more utilization of these preventive services, they will initially cost more. Hopefully over time, always taking their drugs for chronic diseases or getting prostates checked will result in healthier employees and lower costs for the employer groups.

These benefit designs have been called value-based designs or have value in the name. One interesting issue is that health plans currently use the name "value" for their cheaper plans. This new design has to overcome the connotation that the word value in name means cheap plans that cover less as opposed to encouraging effective or highly valued health care services. There has also been some thoughts around requiring employees to pay more for services that are deemed to be low value like certain high tech imaging that is not always appropriate. For example, someone does not always need a 3-D image of their heart for every problem. However from focus groups, we learned that there is a reluctance to inject this type of consumerism into group health plans. Employers do not want their employees to face higher costs for services even if they are not deemed to be high value of evidence-based. The employers were protective of their employees even though it is more expensive and less effective.

In summary, there are 2 roads for value-based purchasing of health insurance. The road that has been traveled is that a certain segment of employers have decided that they will pay more for a health plan that has a track record with producing better outcomes. The road less traveled is that a health plans will set up financial rewards or disincentives for using certain health care services. From the same focus group, there is a real question of whether or not health plans should be the ones dictating which services are effective and which are not. While this does seem to be the domain of the health care provider, health plans do have decades of treatment data from a cross-section of providers.

Will the road less traveled make all the difference? Or based on some interpretations of the Frost poem, it is just idle musing about a journey and either road will reach the destination? Given that employers may no longer be making health care decisions in the future that may also be the case.

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