Growing Older: That's the impression that I get

I am getting older and more conservative. I'm still left of center, believe that government is a solution and not a problem, and that a country is measured by how it treats its most marginal citizens. However, I would no longer vote for Dennis Kucinich for president nor think that socialism is just misunderstood.

I used to think that my MBA classmates who went to work for investment banks sold their souls. Now, I have a price tag for how much I would sell my soul to a bank. Hey, unless we're a fireman, astronaut, or vampire slayer, we all sold out at one point. None of us grew up wanting to be a consultant, product development manager, or get really good at Excel.

Yesterday, I listened to NPR talk sinisterly about how Goldman Sachs made $3.4 billion in profits last quarter. My reaction was not indignant anti-capitalist rage about how a 75% corporate tax sounded good right now but rather a patronizing, duh, Goldman made money on high lending and transactions spreads and the fact that three of their competitors went up in smoke.

When I think about the argument for legalizing marijuana, I now think about the potential tax revenue and if it would reduce or increase the price of an ounce. I no longer think about how it would be cool if someone could order a bong at a beer garden.

When young bloggers talk about how it is important for corporate America to value their opinion, I comment with a calculation of the Net Present Value of their opinion. And their NPV isn't high enough for corporate America to care yet.

My MBA program didn't change my social leanings at the time. I enjoyed telling my classmates that the pharmaceutical industry should be nationalized and they enjoyed speculating when I would completely join the dark side and try to work at a hedge fund. However, the MBA has accelerated my shift as I read the popular business books for fun and look at the news from a "what's the ROI perspective". Working in health insurance has hardened me. Not because insurance in an evil industry but because everyone likes to say that it's an evil industry. Although if I stayed in social work, I would probably be really cynical.

I also know that it's not just me who's changing while aging. A recent lunch with colleagues my own age included an animated discussion about life insurance options and on-line will creation sites. We no longer rate the attractiveness of our co-workers. Well, just not as much time.

Now, this is not a bad thing. There is some preservation involved, such as not climbing that mountain with a potentially bad hamstring. I've made transitions in the past, such as cutting my shoulder length hair at the beginning of senior year in college. I knew that a post-college transition was coming and it was a way to prepare for it.

I still insist that when I turn 40, I'm going to grow my hair down to my shoulders again or find some other mid-life crisis endeavor. But in the meantime, I am going to follow up with my colleague and get that on-line will website.

Risk and Return of the MBA Social Scene: Cheesy Mustache Parties and other Important Decisions

There is a lot of career development opportunity at MBA programs. MBA's work on business plan, develop the language and skills to switch careers, gain field experience, and there's class. There is also a lot of personal development. That usually comes in what has been described as the second adolescent phase that can be the MBA program. You are back in school and you know now what you wish you knew then. You start to think about being popular again. There's also the combination of a non-structured schedule and alcohol. My classmates who were in the Follies program (a comedy theater production that every MBA program has) started to say that they attend the Wharton School for the Performing Arts. The phrase "hooked up in the bathroom" will pass your lips.

In short, you may not only be changing your career but your social life. A relatively unknown part of the MBA program is wrestling with the risks and returns of bold social moves.

Social scenes are different at each program. I attended an east coast urban finance school (Wharton) which has the fairly non-demure social scene. On the political scale, it's partisan. On the other end of the spectrum are the more suburban general management programs where the social scene is more family friendly. Reaching across the aisle at those programs does not involve slipping dollar bills into g-strings. Therefore, keep the context in mind with my theory below. Equally important, be true to yourself. No one will dramatically change themselves socially. But you would be surprised how far you can stretch your limits.

Most MBA's wisely see their classmates as their future business contacts or current project or study group partners. They figure that that the best approach is to be conservative, stop drinking when they've reached their limit, and wear a full set of clothes to all parties. However, with nothing ventured, nothing will be gained. You are more likely to bond with your classmates and get that life-long connections from streaking then from a simple dinner that ends at 9:30.



Now the tricky part is balancing the risky behavior with the return. Here are some activities to avoid and here are some that you should be pursued with the gusto of Great Odin's Raven!



Avoid:

• Blowing a breathalyzer higher than your college GPA: You are at events with lots of free alcohol, you are within walking distance from your house, and you are celebrating completing exams, a week of class, or an Excel spread sheet. Your tolerance is lower than it used to be. As a result, you drink yourself into a puking mess and suddenly the administration cracks down on free on-campus beer parties. It sounds like an easy thing to avoid and that it's not going to happen to you. However, I threw up at more rugby parties than I care to remember (but as a collary it's okay to boot at all male sports-sponsored drinking fests. In fact, it's downright honorable).


• If you have to ask what being kind means, don't ask: Smoking weed or other assorted soft drugs can be pretty common at some colleges or even some high schools. However, while MBA's will happily drink up any swill beer, they are very discreet with drugs. The reasons should be fairly obvious but even those who smoked enough dope in consulting to open their own brand of baked goods, do not broadcast it at an MBA program. Best not to advertise unless you are very careful. It's not a repuation killer but it's certainly not an enhancer.

Great Odin's Raven: Embrace these Activities with the gusto of Ron Burgundy playing Jethro Tull on a flute:

• Consider an afro wig, 70's shirt, halter top, and body paint to be an essential school supply: 90% of MBA parties will be theme parties. Towards the end of the year people will get so exhausted of themes, that the theme will be a no theme party. It's hard to put together a suitable costume the afternoon of the party even but you should put the effort into it. Going with the theme will make you more friends than fighting it. There is incremental benefit for every additional hour you spent dressing up. You don't get any credit for throwing a set of madi gras beads for the 70's party but you will for having a polyster shirt open to your naval complete with chest hair wig and medallion.


• Bodies are beautful: At the finals of the MBA Rugby Championship of the Free World held every year at Duke in North Carolina, spectators casually look at the Texas ruggers who are streaking in cowboy boot and hat again. At your MBA program, women will flash classmates, guys will streak, you won't wear pants, you'll cross dress, or wear your bra on the outside (both sexes). As long as it's not done during McKinsey's presentation or in a dark stairwell of your classmate's apartment, the enthusiasm will be appreciated. Don't worry about your body but show it off.


• Grow the mustache (men only): When the bulk of interview are over, the guys start growing strange facial hair. This should be encouraged. One of the highlights of my MBA career was winning the first ever Cheesy Mustache contest with an enthusiastic walk off. I still remember standing on a chair, squinting past the glow of the stage lights, to hundreds of cheering classmates. With this moment, I knew how it felt to be Ron Burgundy. Stay classy, MBA's.

Can health care reform be simpler?

Obama has admitted that a health care reform bill probably won't be on his desk by the August recess. Kind of like I admitted that I probably won't be back to my rugby playing weight by the end of the summer. But neither of us are admitting defeat.

Due to the attention and media coverage, it feels like the average citizen is getting very well versed in previously arcane health care terminology. I no longer get blank looks when I mention terms like "bundled payments" or "DSH payments" and receive knowing nods when I mention McAllen, TX (click on the link to see what a former McAllen physician thinks of all this attention). However, the mechanics behind the debate are still complex and require actuaries to understand them. Bills hit 1,000 pages and senators like Chris Dodd give up trying to make concise points with comments like, "I'm just going to start talking and when 10 minutes pass, someone just stop me from talking."

The pursuit of health care reform is missing a clear simple goal. Rather than have a end goal of putting a man on the moon, the end goal is prevent adverse risk selection or cost shifting or something equally wonkish. Does every policy piece require a committee of experts and an actuarial demonstration? And what is an actuarial demonstration? An attractive coworker asked our Office Space-esque actuary that question and was told, "I can show you when I get off work at 5." However, digress.

These ideas below will not solve everything and some are not easy to implement. But they provide direction and are close to meeting 80/20 rule as they accomplish 80% of the goal with 20% of the effort. They give reformers a destination rather than a myriad of direction that include public transport routes, routes that don't use highways, bike routes, old pony express trails, etc.

1. We go back to one of the health insurance industry's earlier ideas.
Simple Explanation: Everyone in the US has to buy insurance and insurance companies will accept everyone. Everyone get the same price based on their age. Insurance is defined as anything that meets the basic state definition so there is no requirement on how comprehensive the policy must be.

Rationale: By accepting all, you remove some insurance administrative costs and share the risk. With no requirements on a certain level of insurance you give everyone the choice on how much insurance they want. Employers can choose to not offer insurance (and perhaps pay employees more) since their employees can get insurance on their own.

While this was initially criticized as a grab for new business by the insurance companies, this can solve more problems than it creates.

The only cost containment levers are likely through individuals having leaner plans (especially for those who choose to purchase catastrophic plans) and using less services. Employers who choose to offer health insurance will likely be larger and have purchasing power or those who feel like they can control costs (like General Mills).

2. Oregon Health Plan for the nation
Simple Explanation: We as a nation (aka a committee of a very prestegiously colored ribbon) decide how much we will spend on health care and rank what we want to cover. When we run out of money, we stop covering services. In Oregon, we call those "below the line services".

Rationale: This is a dramatic overhaul and the committee who decides what is covered will control 20% of the United States economy. However, it controls cost, coverage and can result in a very simple health care system. Medical providers have one entity to convince and they are done with all of their sales and marketing work. Their is one payer, one insurance plan, and one set of benefits.

3. Insurance companies become data centers

Simple Explanation: Insurance companies main function becomes sharing data on how much procedures cost with their set of benefits and provider contracts. That is the vehicle on how people choose their insurance plans.

Rationale: I have been trying to figure out a way to make insurance companies less evil by highlighting their strengths which is a comprehensive set of data. Insurance companies are in the best position to show how much everything costs. With this approach, rather than saying, "No, you can't have it" insurance companies would say, "Sure, you can have it but this is how much it costs."

This information would help both providers and patients understand what a procedure costs. Patients can ask their providers why they charge more than other providers.

4. We make primary care dead sexy
Simple Explanation: We have a lot of specialists, subspecialists, and sub-subspecialists who are expensive and well, specialized. Let's get more primary care physicians and put them in charge of the whole patient rather than just their ascending sigmoid colon.

Rationale: Only 30% of providers are primary care physicians because we have made this specialty unappealing by paying half as much as specialist get paid for half the appointment time. The residency system would be overhauled and primary care physicians would be placed in charge of the health care dollar in the form of capitation. Just like mustaches, capitation would make a comeback and become cool and retro.

While all of these ideas require some substantial institutional change and lifting, they are much simpler to articulate and help a reformer know their goal. For example, reducing geographic cost variation is a great idea but there's nothing in the idea that provides a guide towards an ideal future state. During these hot summer months, health care reform needs ideas that someone can visualize while meditating, not ideas that need a calculator to explain.

$2,000 for that Colonoscopy!?

Congress isn't really debating health care reform right now. That's because the House's latest effort isn't going to change or reform our health care system but rather cause it to reach 20% of GDP sooner by adding taxes to business and wealthy individuals to cover more people. Granted it's easier to address coverage first and costs second but I don't think this is an example of that long-term thinking.

Last summer, Oregon passed a law that is taking a step towards health care reform. It required insurance companies to post the costs of 30 common medical procedures via Treatment Cost Estimators on July 1st. It's a step towards helping consumers understand the real costs of health care services, transparency, and giving information that helps with decisions. The fact that we can research the features of a rotating tie rack twelve ways to Sunday but have no information about who gives the best colonoscopies is a major gap.

One has to be a member of the health plan to see a treatment cost estimator but Regence has started to share their tool as well as provide information to contribute to the debate on the real costs of health care. While the tool's website is riddled by excessive flash graphics, it's the only treatment cost estimator that's available to the public. Click on the "Cost Generator" if you check out the link. I give Regence credit for investing their marketing resources on shaping the discussion of the future of health care rather than only spending money on leads and costs per clicks. While I didn't like their flash graphics, the website is probably geared towards a younger audience. That is probably deliberate as perhaps Regence is trying to reach those who aren't traditionally engaged in the health care debate and not trying to protect their Medicare turf.

Finally, a colonoscopy really does cost $2,000. That's a lot of money for looking around where the sun don't shine. On the flip side, a mammogram only costs $200 and is proven to save lives. This information should cause one to ask questions like, why don't we pay for a mammogram for every woman in this country since it is relatively cheap? We can fund it by paying for less colonoscopies.

Visiting the site of the 90's Health Car Wars

I had previously blogged about how some of the bloodier health care wars in the 90's did not take place in Washington DC. For example, the health care wars in Southern Oregon resulted in a community with medical costs that are 50% higher than most of the state and utilization so high that the amount of cataract surgeries performed exceeds the number of eyes in the counties.

I visited one of the hospitals in Southern Oregon this week. As you can see from the picture on the left, it's still the wild west. They're just as mad about the Indian Wars of the 1850's as they are about the health care wars of the 90's. Actually, I'm kidding. The picture is from a historical mining town called Jacksonville but some are still mad about the Indian Wars.

The day was a tale of two meetings. The hospital that I visited is part of our health system and we have a history of working together. The discussion was very objective as we focused on what were the advantages of bringing our health plan to the region. The hospital CEO noted that patient and provider satisfaction scores were higher in areas where the hospital and health plan were active. This at least demonstrated that the health plan did not distract from satisfaction. We also discussed integration opportunities and how to work together to reduce health care costs and improve quality.

We also discussed opportunities to grow market share. However, an insurance plan that just included the one hospital would not be appealing unless it would be a significantly lower cost plan. Our greatest opportunity was improving health care efficiency not using market forces.

This was a stark contrast with the conversation from the other hospital. I was not there but I was told that they saw no immediate need to lower their reimbursement nor reduce utilization of discretionary procedures. There were still more cataract surgeries to be done. While this hospital acknowledged that change was likely to arrive and their practice was not sustainable, there was no burning platform to reduce health care costs or change practice patterns.

One meeting showed the immense possibilities when the providers and health plans share a common vision. The ability to talk as partners is a foundation for change.

The other meeting showed how far away that change could be and the immense inefficiencies that can are created when a health plan and hospital do not share a common vision. And by inefficiencies, I really mean clusterf#ck but I'm trying to sound scholarly.

Final result of the visit is that I am now just as angry about the 1850's Indian Wars! Southern Oregon is starting to rub off one me. I really enjoyed the town of Jacksonville. This town of 2400 has an amazing music festival with a line-up that includes Blues Traveler, Wilco, orchestras, Ani DiFranco, and some great acts!

Robbing Peter to Reimburse Paul

Leveraging is a very popular word today. It implies that there is still a little bit of wine in the bottle, we can stretch a dollar, or that we should save that roach clip. In health care, Medicaid payments (Medicaid is the state/federal insurance program for low income citizens) have been a big leveraging target. The federal government matches every dollar that the states spend on Medicaid with $1.67. Like the Wire's Prop Joe advocating to buy it for a dollar and sell it for two, the states spend a dollar and make $1.67.

To leverage those dollars, the states started taxing hospitals and health plans a few years ago and using that money to fund their Medicaid programs and thus get more federal dollars. The Bush Administration was not pleased by this, grumbled, and put some caps on these provider taxes (these caps were fairly high at 6% so didn't have an impact). The Obama administration has no such concerns about expanding Medicaid (and may expand it to everyone who wants it).

Oregon recently passed House Bill 2116 that expanded the state's Medicaid program with a higher tax on hospitals (5.5%) and a new 1% tax on health insurance premiums. Note that it's not a tax on health insurance companies but the premiums. I will explain how that's significant.

The hospital tax will ultimately be neutral because hospitals the state will increase Medicaid reimbursement as part of the deal. There will also be less uninsured patients as more will have Medicaid. Generally, the hospital taxes can help the hospitals if done carefully. The additional federal money must be shared proportionately with the hospitals that paid the most taxes. Initial tax proposals were too high and would have wiped one hospital's margin and given it to another.

The tax on the health insurance premiums is where the logic started to break down.

Forgot about Self-Insured Employers: The tax was only for employers and individuals who purchased insurance as it just taxed health insurance premiums. Self-insured employers were not included and health care reform often forgets about self-insured groups. They are exempt from state legislation due to ERISA and often exempt from the reform discussion. For example, I don't know if employer insurance taxes being discussed would apply to self-insured groups nor if any mandates apply to self-insured groups. I don't know if anyone in Congress has thought about it.

Self-insured groups are often the largest employers so they have a fair amount of power. The omission of self-insured groups may be intentional. However, if government continues to focus on taxing insurance plans, employers will move to self-insured plans, and the tax base will shrink.

Why do employers care about a health insurance tax? Because they're paying it. This is the strangest loophole in the tax bill. House Bill 2116 was presented as a tax on the evil insurance companies but the tax is being paid by groups and individuals who purchase insurance. Insurance companies were the able to pass the tax on to customers. The news is just starting to realize this and is properly indignant.

Are the insurance companies being evil? In every industry there are discussions on passing new costs to customers whether it be fuel costs, taxes, or paying off the salary of the former CEO who was caught in compromising positions at the Bovine Artificial Insemination Convention. Insurance companies generally pass on administrative expenses as part of the costs of their insurance. I confess that I am surprised that others are surprised that customers would wind up paying these new taxes since the bill did not prohibit passing on the costs. However, I am too close to the issue to have any objectivity. Are insurance companies being evil or have I grown cold and heartless?

Overall, the true message is that while our health care system is as fragmented as the Balkans, our method of shifting health care costs is as tightly coordinated as a herd of wildebeests thundering across the African plains. If we don't carefully understand where costs will be shifted among the different entities that sign the check for health care, we won't change health care in the way that was intended.

Lake of the Angels Backpack: Olympic Peninsula

Due to weather and assorted injuries, my planned Mt Adams climb was canceled. With the weekend free, I headed to the Olympic Peninsula to backpack up to the Lake of the Angels. I wanted to see Mt Stone and Skokomish and possibly summit Stone. A tweaked hamstring limited me to just backpacking in and scrambling around the basin.
A herd of mountain goats joined me at camp and were quite interested in anything that had any trace of salt on it. Needless to say, they followed me quite closely whenever I went to the bathroom which I thought was fairly undignified.

You can see how close the goats got.






For anyone interested in the details of the backpacking trip, here's my beta:

Driving: Forest Road 25 or Hama Hama is passable all the way to the trail head so you can ignore the "Road Closed Ahead Sign". A slide in 2008 had cut off the last 1.2 miles. It's still not completely cleared but it's possible even in a small sedan if you have a lot of confidence.

Hiking Stats: It's a 3.5 mile hike to Lake of the Angels with 3200 feet of elevation gain (4800 feet at the Lake). It took me 5 hours to hike in which included an hour of resting and 3.5 hours to hike out with a similar hiking:resting ratio. The path is fairly clear but steep. At about 2280 feet of elevation, there are 2 crossing over dry creek beds. At about 2400 feet, the trail briefly joins a logging road for about 30 feet. Right above 4000 feet of elevation, there are 2 class 3 scrambles on the trail which are fun but challenging with a 40 pound pack. At Lake of the False Prophet the trail forks to the right but head left, cross a log bridge directly north of the lake and continue up to the Lake of the Angels.

Camping: There are about 3 campsites near the lake and a few further up on the high ground. A marmot had claimed one of the campsites. We had a spirited conversation about squatters vs hiker rights but to no avail.

The park service has great info on road conditions, trail conditions, and even bear canisters if you were so inclined. Since there are no berries up there, it's unlikely that bears will make an appearance but the canister is good for goat and marmot protection. There are a few numbers of the various agencies so try 360-565-3100, 3131, or 3000.

As you can see, it's a beautiful mountain lake and well worth the hike in:














For anyone interested in the 2 peaks around the Lake, a colleague of mine has some extensive photos of Mt Stone and Mt Skokomish from their climb in early June a few year ago. Notice the difference in the amount of snow between June and July!

The MBA: Not Dead Yet

While perusing Slate and trying to find if there was another Obama Facebook Feed article, I stumbled across RIP MBA by Matthew Stewart. He wrote a 2006 article called The Management Myth which was later turned into a book questioning the values of the business education. A philosophy PhD turned management consultant for 7 or 10 years (depending on which source you read), Stewart started a consulting firm called Mitchell Madison during the economic party that was late 90's that was later rescued by a dot.com company in 1999. Both companies collapsed shortly after the acquisition.

Stewart's article is very similar to other that have stuck the fork in the MBA during the economic hangover of the last 2 years. The exception of Stewart's is that he believes advanced philosophy degrees will replace the MBA. After reading that, I had this image of Socrates, Plato, and Aristotle screaming at each on a Fox news show. Stewart also has a nice piece on the use of the very first assumptions that was used in modeling. The model at hand was, "How many tons of pig iron bars can a worker load onto a rail car in the course of a working day?” The model involved a stop watch, the assumption was that workers are non-productive 40% of the time (for breaks, meals, and the like) and the answer is that 47.5 pig tons can be loaded in a 10 hour work day.

Otherwise I have noticed that a fairly set pattern emerges in these critiques that is consistent that enough that it could be a base line for a blue song.

1. Let's get Wall Street
1/3 of MBA graduates work in finance on Wall Street
Wall Street got the US economy so drunk that it's still dry heaving
Therefore, MBA's broke the economy
This is more or less the logic flow. Some of the more egregious have had MBA's (Enron's Jeff Skilling) and some do not (Bear Stern's Ralph Cioffi) and some had PhD's (Enron's Ken Lay). Some MBA's have fiddled during the burning, some killed the golden goose, some put fingers in the levee. This MBA has run out of metaphors but what I'm trying to say is that I think this proves that MBA's are not immune to business cycles of the financial sector. An MBA is a logical degree to enter finance and the financial sectors has ups and downs. MBA's are really a lagging indicator more than anything as finance gets more popular for graduates during its peak.

2. No, let's get the Consultants!
I don't think there is an easier target than a management consultant. With finance, they at least mastered a discipline, don't need a mouse to use Excel, and understand numbers. The only prerequisite to be a consultant appears to be willingness to travel, calling your power point presentation a deck, and inventing new words. For example, I have started to think that "incent" is really a word (according to Blogger it's not a word). I wonder if there is a prize for the consulting firms who gets the most jargon turned into acceptable words in Scrabble.
Again, consulting or advising is a time honored profession back to the days of Rasputin and other advisers whispering into the ears of rulers. Consultants follow the business cycles.

3. You learn nothing
Can business acumen really be taught or what should you teach? We had the same questions in my social work program. Others question if leadership can truly be taught. I would also query if someone can be taught how to pick up someone at a bar or be a better lover. We all take classes in a discipline and got recognition that we completed those classes in the form of a Masters degree. There's no reason to assume that MBA's learn more or less in a 2 year program than any other non-licensed masters program.

What we all agree upon: Both the writers of the critiques and proponents of MBA programs do agree on some advantages of the MBA which are:

Outsourced recruitment: No one gets fired for hiring someone with a fancy MBA. The degree does get someone in front of the recruiter or on the interview list. There's also the novelty act as I am pretty certain that I have been invited to interview at some places just so they could see what a Wharton MBA looks like. I started to have these suspicions because the interviewer would check my teeth out (I'm just kidding).

The fancier the better: According to the Financial Times, there are now 500,000 MBA's in the world. To put that in perspective, there are 1.5 billion cows in the world. Well, that doesn't help but I haven't mentioned animal husbandry in a while. The point is that there are a lot more MBA graduates so the quality of an MBA program is important to differentiate yourself from the herd.

This I believe (or what I think the MBA truly does for someone):

Career Switching: An MBA is a non-licensed degree so the network administrator for a yak cooperative does not need an MBA to become a process improvement consultant for the organic dairy industry. However, it does make the transition a lot easier. It providers a 2 year window to get an internship in the dairy industry, meet process improvement consultants in grains, and visit other cooperatives that have pioneered new techniques. One could also do those things working full-time but that's a lot of vacation days used, changing into interview clothes in your call, and phone interviews on your cell phone outside of a coffee shop.

Never let class get in the way of your education: Given the questions that some MBA programs have about students dedication to their studies (that has led to questions about Grade Non-Disclosure), I should be more discrete. However, like social work offers field placements, nursing programs offer rotations, MBA programs offer classroom and club led consulting projects that gets the real world experience. Internship programs allow someone to try out a new career for a summer. You learn hands on skills.

The gap between expectations of an MBA program and the reality can either be called frustration or fodder for the critique of MBA programs. Until the philosophy degree emerges as Stewart suggests and togas and tablets replace suits and lap tops, the MBA serve its purpose to help someone transition from a new field or reinforce their credentials.

Physician Perspective on Health Care Reform

Like every good liberal, my primary news station is National Public Radio (I do take breaks to listen to the Dropkick Murphys every now and then). NPR had a series on the state of medical practice with physician interviews of 2 veteran doctors and 2 doctors who recently completed residency. I felt that their opinions on health care reform and what needed to change were so out of touch that it really disappointed me. To be fair, 1 of the physicians, an oncologist, was aware of current issues so this is indicative of the other three.

Now if I ask the average insurance person or pharmaceutical rep about health care reform, I will probably get some pretty stone age answers also that focus on preserving an unsustainable revenue and making their jobs easier. Also, there are strong physician leaders like Atul Gawande and Ezekiel Emanuel. Physicians for a National Health Program is a strong organization. However, we hold doctors to a higher standard and they are very smart so that's one of the reasons that their responses caused me to shake my head and have similar reactions that Robert Gibbs does whenever Joe Biden talks.

When asked about what needed to change about practicing medicine, the responses were:
1. They need to stop holding us to productivity standards and just let us do our jobs.
2. We have to go to many training sessions about the latest new topic.
3. Our patients are different than the norm and we should allow for the art of medicine as much as the science.
4. I wish that I could practice medicine like I did 20 years ago.

I interpreted those responses as being resistant to new practice ideas, being resistant to evidence-based medicine and protocols, being resistant to have any outside review, and a reinforcement of the doctor is always right concept. There is not a reverse Lake Wobegone effect where all of someone's patients are sicker than average. Finally, we all want to be able to do our jobs how we think they should be done and want our ideas to be right.

None of these responses are egregious or incorrect. It's just that these responses are not forward thinking in the slightest, especially #4. There is no acknowledgment of the rising cost of health care, how to improve medicine, or how to coordinate care with other providers. If this is the feeling of most physicians, I can see why the American Medical Association has brought forth no platforms, positions, or their own ideas. At first I thought it was the leadership of that organization but the emphasis on preserving the status quo from 20 years ago may be more widespread.

We all know that physicians are a key part of health care reform and could seize a leadership role. With responses like this, it shows a lack of desire to play a role. If physicians really want to practice like they did 20 years ago, they could propose being paid the same whether a visit is 15 minutes or 1 hour or whether the procedure had complications or not. Don't incur the expense of an office and just make house calls. An average primary care physician still makes $150,000/year after 3 years of practice so they still make a very good living even with medical school loans.

I know that physicians have strong opinions and it frustrates me that none have emerged in health care reform discussions other than they want to be left alone and not have to deal with the complicated business of medicine. As a result, physicians will find themselves working in a system that someone else designed and miss an opportunity to help form it. Where is being the change that you want to see in the world? What will get physicians more engaged in changing health care?