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Tuesday, December 20, 2011

What is your ideal Job and other Terrible Questions that Interviewers Ask

I am letting this blog continue its descent into exploring the job interview process. That's probably better than a descent into animal husbandry, colonoscopies, Molly Ivins quotes, and other places this blog has descended to.

I have learned that there are some interview questions that are intended to be traps. They yield little to no useful information and are really intended to trap applicants into revealing information that will eliminate them. The question of "What is your ideal job?" almost trapped me in a recent interview. Therefore, I started using it on people that my department interviewed to see how others responded. Here are the results.

My ideal job is one where I can considered a subject matter expert and coworkers look to me for my expertise. Sounds like a good harmless answer to a bad question. However, the job was for a project manager who would work on such a range of projects that they would never become an expert in any area. In fact, the job called for someone who was comfortable not being a subject matter expert.

I want to be a in a position that uses my skills and provides opportunities to grow. That became my favorite answer to this question. It reveals nothing to trap someone but answers the question. It even adds just a hint of "Ask a stupid question and get a stupid answer," to get the interviewer to back off future bad questions.

I want to continue to work and grow in Field XYZ that I am interviewing for. That was my answer. My biggest problem was my delivery where I made it appear that I had just come to this revelation during the interview. Otherwise, it's not a bad answer.

For both readers, what's your favorite terrible interview questions and how do you respond? My other favorite was How do you like to be praised? My answer was with with a parade complete with clowns and a marching band.

Friday, November 18, 2011

Advice from an Interviewee

After my scintillating series about how employers have no clue how to hire people, this post is from the other side of the desk. I believe in interviewing every 6 months whether you need to or not to keep skills and contacts fresh. This also helps me check out if my suit still fits.

The other reason for this Always Be Interviewing Approach is that the line between the employed and long-term chronically unemployed who are getting discriminated against by recruiters is as thin as the Kardashian's credibility. That is why I will march with and donate to Occupy Wall Street even if they are a little dirty, their message is a little muddled, or their positions are not that crisp. There is no longer a lot of difference in the backgrounds of someone who logs into a corporate version of Microsoft Outlook every morning compared to someone who is soaking their bandana with apple cider vinegar to protect themselves from pepper spray.

I interviewed for a provider strategy position at a large insurance company. I don't know if I got the job or not but wanted to write the post before I was tainted one way or the other when judgement is rendered. In this post, I will describe the three things I learned which were 1) the importance of answering why you want the position, 2) how career switchers can position themselves, and 3) uh, it's um, uh, Oops (bet none of you saw that one coming.)

Why do you want this position? Of course, I came up with 3 reasons for the job. My formula is a basic one of 1) this position will allow me to participate in market trend Y, 2) this position will support my career goal of doing Z, and 3) I really admire the company for reasons ABC. What I didn't do is reinforce the message constantly during the interview. An interviewee needs to hammer that message like a presidential candidate. The interviewer is always concerned that someone won't stay in the position and this is the best way to address that concern is talk about how perfect the position is for you.

With my interview, since this position represented a new functional area, I really needed to do more than come up with 3 reasons. I need to show excitement, industry knowledge, the opportunity, why I couldn't do it from my current position, and crank it up to 11. I don't think that I threaded it into enough answers to satisfy a skeptical interviewer. I used too much terminology from my current job and not enough of the new position's lingo.

What career switchers can do? I wasn't a career switcher but within health care this was definitely a switch. Employers are increasingly reluctant to hire anyone who doesn't done a job before. Training is not considered part of the onboarding process anymore which prevents employers from filling a lot of positions. I do fault the employers for not taking the time to determine what skills can be taught, what skills cannot, and how to assess how different experiences meet the skills that cannot be taught. That's half the story behind the belief that there aren't enough skilled workers for certain positions. However, we can't hate the player, just the game.

To address the lack of direct skills that I had, I drew clear parallels from other experiences. I hadn't negotiated with providers but I had negotiated with vendors. I hadn't done statistical analysis on bundled payments but I had done other statistical analysis. I pointed out that I learned indigenous South American languages in 3 months so I could learn skills. What I should have done is been more clear about career switching that I had done in the past and how I had been successful with projects where nothing in my resume indicated that I had the direct skills.

Fancy Graduate Degrees still matter. During the interview, my fancy MBA was referenced three times indirectly. One asked if I knew her former coworker who graduated from my program, one noted my major, one asked me if I had taken classes in a specific area. As in the past, my fancy degree got me the interview since the employer probably just wanted to see what fancy MBA's look like, just like folks from Appalachia want to see if Jews have horns. Of course, it won't get me the job but you also can't get a job if the employer doesn't have a reason to interview you.

For all those who criticize graduate degrees and promote alternatives like blogging or starting websites that one claims are a business, the evidence isn't there. This blog certainly wouldn't have gotten me an interview. It's more likely to get me on a federal no fly list than it is to get an interview scheduled.

The benefits that blogging provides are a way for me to require myself to take some time and think about the interview in a way that does not involve telling myself that the smell coming out of my butt is a rose. It forces me to explain the experience to a vaguely interested third party (my faithful readers) in a way that's relevant. Most importantly, I now have a better understanding of what I need to do better the next time that I interview. The third and final thing that I learned is uh, um, uh, oops (now I really bet that you didn't seen that one coming. Hey, if Nancy Pelosi can beat this horse to death why can't I give it a few kicks!).

Monday, November 14, 2011

Understanding what to Haul off the MBA admissions process

Alex Fleming wrote a post about how "Business School Admissions needs an Overhaul" My joy increased as I read it since it gave me great material for a post of my own. There are various genre of blogger posts such as the List (i.e. Top 5 ways to give yourself a Colonoscopy), the Repost (look at this funny baby and animal video where someone makes them talk about colonoscopies), and this genre of the Disagree. With the Disagree, I simply disagree with Alex's post.

Alex's premise is that the MBA admissions process needs some innovative techniques to help schools better assess candidates and render MBA admissions consultants obsolete. He attacks the essays as being prone to ghost writing and whispering by admissions consultants His suggestions for new innovation are:

1) Group interviewing which the Wharton school is piloting
2) Stealth interviewing where everyone from the Security guard to the fellow who just clogged a toilet in the men's room is a potential interviewer
3) Personality evaluation

Personally, I think that the best approach is to combine all three and have stealth group interviewers evaluate personalities. To be able to assess Alex's approach, we need to break down the MBA evaluation process into its parts

Talent Level: This is the GMAT score, work experience, and grades. Admissions simply wants to gauge academic and professional capability. This has largely already been predetermined and there is little a candidate can do to change anything in this category other than taking a quantitative class to address a major in Comparative Scandinavian Skiing and no classes that involve numbers. The best thing that a candidate can do is use this determine their safety, sweet spot, and stretch school

Community Involvement: Extracurriculars are as much a part of the MBA experience as classes and the job search. A history of extracurricular involvement is a strong predictor of future extracurricular involvement. Blinding Case of the Obvious is the group that sponsored this research. It also is likely to indicate an engaged alumni. The insightful cultural comments that I get on the rugby team alumni list serve also give me fond memories. A candidate can't change a past history of extracurriculars that includes "It's Always Sunny in Philadelphia" TV marathons but it truly is never too late to start. This will separate an applicant from the candidate who never does start.

Is the Candidate Clueless: This is addressed by the variety of Why do you want an MBA and what will you do with it essays. No admission consultant can make up a reason to apply for an MBA if the candidate has no idea. I have worked with candidates who tried to pick noble MBA goals but we could never get their work experience and career choices to ever tie together. The candidate who develops a sudden passion for public health can't explain why they are not applying for a Masters in Public Health. The candidate who wants to start a non-profit can't explain how the passion started with only large corporate experience and a post MBA goal of investment banking. The candidate who can't decide if they want to work in consulting or investment banking but who really wants to work in private equity can't even meet the essay word limit in a coherent way.

Schools are moving away from this question because there are only about 6 different answers that they ever see. However, a candidate who can't come up with one of those 6 will eliminate themselves from consideration.

Does the candidate have a personality: This is where the essays and interview come in and where ghost writing is also less useful. From reading the essays, does the admissions committee want to risk running to them on campus? Will they be interesting learning teammates? Are their essays littered with passions, interests, or funny stories about their past or more mundane tales about leveraging project management resources to ensure that IT met its deliverables?

What part of the MBA application process do Alex's interventions target and what do they reveal?

Group Interviews: Some think this will produce the same environment as TV's Apprentice. However, that doesn't give a lot of credit to MBA candidates who will figure out that group interviews are intended to see if candidate can play nicely with each other in the sand box. Assholes will be easy to spot but wouldn't a 1:1 interview pick up the same trait? My main criticism is that it will reduce applicants contributions to sound bites. With less air time, there isn't time for thoughtful anecdotes about one's past, hopes, and dreams. It's speed dating rather than a candle lit dinner. How will creating an artificial social atmosphere provide new information to an admissions committee and help them figure out if they have a clue or personality?

Stealth Interviews: If someone has been promoted once in their lifetime, haven't they already figured out to be nice to everyone's administrative assistant? Unless the stealth interview involves tackling the applicant, this is about as innovative as emailing a thank you note to someone as a way to differentiate yourself. I don't see how this will answer the clue or personality question either.

Personality Test: Alex's theory is that admissions should look for the same personality traits that great leaders have in MBA candidates. My first reaction was to Google search "CEO psychopath personality test" which has 91,900 hits and links like this. This solution also addresses the Talent Level category of which there is ample information. Assessing the candidate's personality in terms of how well they get along with their classmates seems like a larger opportunity. Finally, this suggests that admissions have the data capabilities and bandwidth for social engineering which I have addressed previously in this post. In summary, this addresses a need where this is already plenty of information, there are unintended consequences, and there isn't even the infrastructure in place.

Alex's post seems to be guided on a notion that admissions consultants need to be removed from the system. However, admissions and consultants seem to be developing closer relationships. As an admissions consultant, I have a vested interest in the status quo but I also don't see a need for an internal ethical reflection. Most successful applicants use some kind of external review process since they think their own poop smells like roses. That external review can be a co-worker with an MBA, a former teacher (which is what I used), or an admissions consultant. Admissions consultants fill the same niche as mail order brides. Those who can't get the quality of service they want for free, have to pay for it.

Tuesday, November 8, 2011

Objecting to the Objective Statement

Long-time readers might remember that this is the time of the year where I review the latest Wharton MBA Health Care Management class's objective statements on their resume book. Readers who do remember these posts are highly encouraged to get a life- er I mean commended for their loyalty but still highly encouraged to get a life.

By review objective statements, I mean make fun of them like a snarky hipster makes fun of anything that is not ironic. Now some readers might start thinking that my get-a-life comment was a little bit of a defense mechanism so here is the usual disclaimer:
  • I don't know the difference between a disclaimer or a disclosure.
  • I don't even really know what ironic means either.
  • The students who I am about to make fun of are a lot smarter and more talented me. By a lot, I kind of mean like trillion used to sound like a lot.
  • I made fun of my own classmates objective statements at our annual banquet so I would do this to the class of 2012 face-to-face. The main reason that I do not is because the class of 2012 has no interest in meeting me and playing Angry Birds is a better use of their free time.
  • Given that the students are ridiculously good-looking in their resume book photos in addition to being smarter and talented than me, no one's feeling should be hurt. While I am a cinnamon roll away from obesity on the BMI, most of these students look like they have chiseled abs in their head shots.
What did this year's objective statements bring us?

Leveraging is still the hottest activity on campus but others are catching up: Everyone is still leveraging their "business knowledge and their clinical experience", their "real estate banking and pharmaceutical experience" (which sounds like snorting cocaine off the granite counter tops of expensive condos to me), or peanut butter and jelly. However some have gone a different path and used words that actually still have their original meaning like "combining my experience." One was bold enough to announce that his experiences were already not only leveraged but "integrated". Well played, sir.

Hedging is back in fashion: The toughest thing about objective statements is narrowing it down to the one industry where you want to work. Therefore, objective statements sound like an elaborate list of qualities that guys look for in girlfriends where they are trying to not rule out anyone who might actually have sex with them. Last year some students got bold and placed a stake in the ground. This year, not so much. One student announced an interest in both "international and domestic public equities" and another was looking for opportunities in "new markets in the US or abroad". This meant they only eliminated Mars and 20,000 Leagues Under the Sea from their future plans. One announced they were seeking an opportunity in "commercial management in health care". Either that's really broad or they are being very specific about wanting to work in advertising with Don Draper.

Raising the stakes: This year's class was bold and I would expect nothing less than from these millennials who don't have to spend their time watching their hair line with the same level of scrutiny typically reserved for the Pakistan-Afghan border. Besides just wanting a job in either "venture capital, business development, or innovative start-ups", they talked about transforming the health care system. Soon to be graduates had plans to "improve efficiency and effectiveness", "access and quality", "identify and drive long-term value," and "improve health care quality and delivery." They weren't just looking for a job but they were going to make big changes. To these efforts, I will salute the class of 2012 as soon as they pass me my cinnamon roll.

Monday, October 24, 2011

The MBA Oath is just making me Swear

The MBA Oath was started in May 2009 by Harvard Business School students. The Oath was intended to serve as a Hippocratic Oath for MBA's, encourage students to start local Oath or Oathian clubs on their campus, and promote the emphasis on greater societal good. I blogged twice about my assessment of the Oath's progress and this post represents the eagerly anticipated third installment of the series. This is probably similar to how the public eagerly waited the second Chronicles of Riddick since they had no idea that a first version was released.

How is the Oath doing? It might even be similar to the Chronicles of Riddick
  • Since 2009, 6,303 students have signed the oat and the MBA Oath states that it has been embraced by about 300 schools and institutions. 37 schools were highlighted as working on significant events which I guess is kind of like getting past first base. 17 schools were highlighted as significant contributors which I guess is second base. Either the MBA Oath doesn't put out or it's not getting any action. Given that hundreds of programs graduate 150,000 MBA's per year, this is looking like less than 5% market share. From a volume perspective, it's not looking like it's impactful, making impacts, having an impact, leveraging, optimizing, or transforming. Value is not being created but at least no value was harmed in this process.
  • In my first post, I praised it's slick website which is the equivalent of a corporate business card in this day and age (not saying that I consider corporations to be people since Occupy Wall Street clearly disagrees). That's good when your website is in good shape. When your website's blog and media page haven't been updated since the last World Series, that's a pretty clear out of business sign. To be fair, it looks like they moved their activity to their Facebook page which I guess is either really a savvy move or lazy move. Since moving to Facebook, most of the MBA Oath's activity has been from one very critical poster who is riding them harder then then headless horseman rode Ichabod Crane. Based on that, I don't think that it's working out too well.
  • The MBA Oath's best opportunity was to position itself as a requisite for MBA's as part of a hopeful movement to provide some form of license or ways to guarantee that all MBA's come with some minimal standards. If they chose to position themselves as a resource and driver for socially minded MBA students, they would compete with Net Impact. Net Impact has a long track record of providing resources and opportunities to this segment. They seem to be trying to compete with Net Impact which is duplication of services at best but really an example of a lack of clear goals.
The last bullet point is what made this post timely for me since Occupy Wall Street is being charged with a lack of focus and having no clear goals. I have no shortage of snarky posts about wellness, ACO's, resumes, and job interviewing so it's not like I needed to make fun of the Oath for material. The parallels between Occupy Wall Street and the MBA Oath became fairly clear to me as I got more interested in the Occupy movement.
  • Both are good examples of excellent marketing campaigns that captured a key movement of their times. They both are good shorthand for these movements with Occupy representing angry leftists trying to salvage the American middle class and the Oath representing socially minded MBA's trying to salvage the reputation of their schools.
  • Both had clear goals but no clear way to get there. Occupy is about the end of corporate personhood (note the foreshadowing), boycotting national banks in favor of local credit unions, and a "Robin Hood" tax on investment transactions. They are trying to get there with human microphones, face paint, and funny hand gestures. The Oath is about doing financially well while doing good, responsible corporate behavior, and encouraging their classmates to take an oath to do these things. They are trying to get there with a petition. I would recommend adding face paint.
  • Both face a backlash from those who should be their most ardent supporters for appearing to be a marketing campaign with no clear goals that is capitalizing on popular sentiment
From my visit to the Occupy Portland camp, I have to say the main difference between the two movements right now is their personal hygiene of their participants. However, I am rooting for Occupy Wall Street's legislative agenda and hoping that the rate of voting in the 18-29 segment rises above 50% in the next election.

Tuesday, October 18, 2011

The Wellness Industrial Complex

My place of employment (no not this blog, luckily I have a real job), required us employees to do a biometric screening this year. They drew blood to measure our cholesterol and lipids, took our blood pressure, and weighed us. Opinions varied. I listened to one coworker ask what our insurance company was going to do when they got her results. She was assured that her results were just for her to better understand her health. Another coworker commented on how this screening was a great idea and she was really interested in seeing if behavior changed.

The coworker who was nervous about the insurance company probably got results that indicated she wasn't so healthy. The coworker who thought this was a great idea probably was perfectly healthy, knew it, and was acting smug about it. The coworker who was nervous about the insurance company was told a half truth. This first year, the results would be just for us to see if we improve our health on our own. However, in future years, our employer and insurance company will slowly but surely get more active. The first year is voluntary and a free service to show they care. Next year, a nurse will probably call us about our high BMI. The following year, it will be outcomes focused and there will be rewards for improving health. The next year, the carrot will be replaced by a stick and we will be beaten with it until we lose that weight.

I know that some of my coworkers who work for insurance companies refuse the reward to take biometric screenings for fear that their insurance company will no longer cover them if they have poor results. That's not true. The insurance company will just give them lesser coverage until they show improvement and have nurses harass them.

I am being a little apocalyptic since the scenarios above are probably unlikely. However, they are unlikely because of employers and insurance companies ability to make these hard decisions about when to start the more punative measures for poor employee decisions about their health. Employers don't really want to be in the health insurance business let alone run weight loss centers. These more draconian measures of hiring companies to make employees give them their candy in exchange for fruit (a company really does this) will result in hard conversations and distraction. Most employers don't want to deal this. However, their desperation to reduce medical costs have resulted in the Wellness Industrial Complex.

We have an endless choice of Health Risk Assessments from all kinds of company that ask about our health based on the theory that we will take these tests and suddenly discover that we have unhealthy behaviors and stop them. For example, "Oh I thought it was 5 servings of bacon a day not 5 servings of vegetables!" or "I will certainly stop snorting cocaine off my Iphone while driving in traffic and go back to snorting it off stripper's chests. That is much less risky." Thanks Health Risk Assessment for showing me the light.

The Health Risk Assessments are followed up by Health Coaches which are often non-clinical, non-licensed staff who talk with you on the phone about your bacon consumption. These Health Coaches are coupled with Incentive management programs who are solely dedicated to mailing gift cards or horse's heads for those who do well or do poorly on their health scores. This is all complemented with Wellness in a Box campaigns that include some lovely marketing material such as vegetable of the month of how to start a walking club at your work.

That sucking noise that you hear is the cost of the Health Risk Assessments, Health Coaches, Incentive programs, and material to celebrate National Pedometer Day. What's the ROI on that readers are probably all shouting like the Timbers Army at a Portland MISL soccer game.

The ROI in terms of medical costs saved is as elusive as a moderate Republican. It isn't really there and hard to find even it is. That's because the whole implementation of the Wellness Industrial Complex was foisted on health insurance companies. For insurance companies, the ROI is based on medical cost savings. Their business model does not reward them for improving wellness, productivity, or making employees happy. For an insurance company, the ideal customer is the one who dies in their sleep of a massive undetected heart attack after using no medical services for the year and not the client who manages their diabetes with monthly doctor visits and 3 prescription medications.

Provider groups or even unions are more logical candidates for hosting Wellness programs because they have different interests and are looking for different results. Both get rewarded for keeping workers happy and productive. That's where there is potential for ROI as opposed to the very indirect connection with medical costs.

Employers, in their insatiable desire for vendor consolidation, assigned Wellness programs to their health insurance companies because they thought incentives would be aligned and because they could. Insurance companies saw a market differentiation and revenue opportunity and grabbed it. However, the marriage of insurance companies and Wellness is proving to be as awkward as Bristol Palin on Dancing with the Stars. It's proving to be an added expense for insurance companies and the medical cost savings aren't there.

Since I like to offer solutions on this blog, I am pleased to say that I have one that should help all parties. Since employers are interested in vendor consolidation, they should have their Waste Management vendors run their Wellness programs. Given that most Waste Management companies can tell what employees are eating at work by going through their trash, they have the information. No need for a Health Risk Assessment. More importantly, since most Waste Management companies are mob run, they should be very successful in this endeavor. Their loan sharking and enforcement arms can easily handle the health coaching and incentive programs. The medical costs may rise in the first year due to some broken knee caps but I am confident, they would show a better ROI then health insurance companies.

Thursday, October 13, 2011

Corporate Jargon, dead yet?

The MBA admissions season is starting to tail off. As usual, I spent at least 25% of my time pulling corporate jargon out of client's essays. Words like "value extraction" or "create value" are replaced with what the person actually did. "Leverage" and "optimize" are replaced with real verbs rather than name of a TV show and a Transformer. "Tool kit" is replaced with an actual description of skills unless the person is describing a carpentry project. "Impactful" or "Impacts" is changed to the humble original word of impact. I also pull out the word unique, profound, and deeply because they are just another way of saying "very" and suggest that they use real adjectives instead.

Given that MBA admissions cracks down on corporate jargon, I wonder if this effort will eradicate impactful value streams from future MBA's vocabulary like the invasive species that it is? I had further hopes during a conference call with a vendor that was trying to cross sell us their products. Since we were on mute, we spent the call laughing at phrases like:
  • To be honest with you
  • As the risk of sound sales-y
  • I don't want to get into the weeds
  • In order to wrap your arms around this
We spent the time trying to use as many of those phrases in one sentence. The winner announced "At the risk of being honest with you, I really want to wrap my arms around this project while I am down in the weeds." These corporate jargon phrases caused the person's stock to plummet as fast as the actual stock market in August.

After these observations, I was feeling hopeful that standard English was making a come back at the expense of corporate jargon. Real words and adjectives were the new black. Or is it the new pink? My hopes were dashed after receiving this email from a current MBA student. I had expressed an interest in writing for their newsletter and this was the response that I got:

Thanks. Will be in touch. We are refining a plan based on the responses we have been getting so we can optimally leverage the talents and enthusiasm of all those interested in a high level of engagement. We would like to "share the wealth" such that the time commitment for any single individual is manageable and to have a full queue of content throughout the year to maintain momentum as each edition rolls out.
For readers who don't speak corporate jargon, the response was "We are trying to get a lot more writers so we have enough material to produce at least a few issues." FML. MBA student's writing ability is a lost cause just like Rick Santorum's hope of ever solving his Google problem.

Friday, September 16, 2011

Medicare Advantage took the next dance from ACO's

Accountable Care Organizations (ACO's) were one of the more eagerly anticipated part of health reform. Well, they were eagerly anticipated by policy wonks and larger provider groups but the general community probably the ACO was a ligament in your knee.

ACO's were going to reward provider groups based on outcomes not volume of care. Provider groups would organize into ACO's, be assigned patients by the Center for Medicare (CMS), and receive additional payment if they managed costs well or penalities if they manged costs poorly. Providers responded since new revenue opportunities in a post-reform world are about as rare as moderate Republicans. They organized different provider structures, explored risk management software, and different techniques for population health management.

When the ACO rules were released by CMS, someone switched the dance music to the polka. Nothing's wrong with a good polka especially with my new lederhosen but it was the wrong dance beat. Providers were disappointed at the requirements and low likelihood of receiving additional revenue. What followed was like a hangover as providers were irritable and nauseous.

However, providers had already organized into structures that could manage population health and a global budget. They were also becoming successful at managing costs as Medicare increases were cut in half in 2010. Now they were looking for a payer partner to be compensated for their success. Although Molly Ivins says that you've got to dance with them that brung you, providers had a new dance partner. The much maligned, overpaid Medicare Advantage (MA) plans filled out that dance card.

Medicare Advantage plans typically pay providers more than Medicare or if they pay the same or less, they offer captive volume through networks that don't cover health care from providers that don't contract with them. MA plans are also accustomed to offering the same type of reimbursement methodology as ACO's without the additional requirements. As a result, large provider groups are starting to look for MA partners who can offer this type of reimbursement and starting to close their offices to patients with original Medicare and the ACO. Providers can negotiate with Medicare Advantage plans but not with CMS.

These relationship also reflect what is happening in the merger and acquisition world. MA plans are purchasing provider groups to build this arrangement. I guess that's an example of dance partners getting married. I hope the babies are cute. For provider groups who have a higher criteria for dance partners, may only want to dance with MA plans that receive a 4 or 5 star rating from CMS. Those plans get a 5% to 10% higher reimbursement from CMS and that bonus comes out of the pockets of 2 or 3 star MA plans. That's more revenue to share with providers. Since the star ratings are mainly driven by the better health outcomes for a plan's membership, this alignment makes a lot of sense.

This was the intended result of the ACO. Provider groups would be rewarded for moving from being paid on volume to being paid based on better outcomes. The surprise was that it's Medicare Advantage plans that are achieving this result while ACO's are still looking for dance partners.

Friday, September 2, 2011

The TV Show that Best Mirrors the MBA Admissions Process

Some would guess the Apprentice or Survior are more reflective of the MBA admissions process given their cutthroat nature, latent sexual tension, and winner take all mentality. For those who are curious about that list, yes, despite a 2:1 male/female ratio, one can generally cut the sexual tension in an MBA classroom with a food processor. However, that's a common mistake MBA applicants make. For a guide to how to approach the MBA admissions process, there is no better show than the Glee Project.

The Glee Project is a singing, acting, and dancing competition where the cast member wins a spot on the TV show Glee. It is generally assumed that the winner will play a socially awkward, downtrodden character who is an underdog who dares to dream and fight for the dreams. While most MBA applicants would like to identify with the cooler kids in school, in truth they have a lot more in common with the members of the Glee club. Thus, it makes sense that the selection process for both is a parallel as opposed to a paradigm shift (One always gets a bonus in MBA school for using buzz words like paradigm shift). Here is an episode by episode example:

  • Vulnerability: In this episode, characters are expected to exhibit their vulnerability in one word. It requires introspection and brevity which are two things that are difficult for the average MBA applicant. The vulnerability is important because it shows the real side of the candidate (for both Glee and MBA programs) and allows both admissions committees a chance to understand more about them as a person. Everyone is vulnerable and has issues. The candidate who presents themselve as having never failed and expects the evaluation to be a victory lap is an incomplete candidate. The introspection that comes with identifying vulnerabilities also shows an ability to indentify true career passions and goals. This is an MBA candidate that will not have a herd mentality and truly take advantage of the program.

  • Pairability: In this episode, the Glee Project cast pair up to perform and in some cases, kiss. MBA programs involve teams or pairs to manage work and projects. This is not exactly a stretch nor should be a surprise. The message for MBA candidates is that better essays should demonstrate team work and ability to work in teams rather than a desire to work independently and be a lone wolf.

  • Believability: Characters were critiqued for trying to put on appearances and not being themselves and inviting the audience in. For the TV show, this was about connecting with the audience, creating believable characters, and not being one-dimensional. Diva-esqe characters were encouraged to show other sides, the scrappy underdog was encouraged to show that he can be a leading man, the cool, dread-locked cast member was encouraged to try using a different facial expression. The cast member who tried to be perfect was told that no one believed that she was perfect. That is an especially important message for MBA candidates as admissions will never believe that a candidate is perfect so no one should position themselves accordingly. Successful MBA candidates will show multiple sides of their personalities in their essays.

  • Damian: Damian is not an episode but a cast member from Ireland with a great Irish accent and incredibly mobile eye brows. When he was really nervous, his eye brows looked like they were going to jump off his face. He was clearly identifed as not the most talented and had to scrap to not be eliminated in the final song in almost every episode. Yet he was one of the two winners in the Lake Wobegone-esque season finale. His personality was very clear and enthralled everyone despite not having the same level of talents as others. This a key lesson for MBA applicants which is the importance of showing your personality in essays. A talented personable candidate will trump a more talented candidate who comes across as too perfect.

All the cast members of the Glee Project were very talented with resumes that included long histories of acting, singing, and dancing competitively. Some were also ridiculously good-looking. Some had really bright blue eyes that were kind of innerving. In summary, they mirrored the MBA admissions pool for top schools (except for the bright blue eyes).

Monday, August 8, 2011

Advice from a Hiring Manager: We still have no clue how to hire people

The actual title should be "Advice from the some guy whose Boss got him involved in the hiring process because he looked like he has too much free time on his hands and the Boss wanted him to think that he could actually be trusted with a crumb of responsibility." However, readers should know that I try to avoid long titles. It could be shortened to "Advice from a Putz" but that wouldn't rank as high on Google searches.

Not surprisingly, I have digressed before writing the sequel to my previous post intended to assure job seekers that it is not you, it's us. The people that are interviewing you have the decision-making capabilities of a stoned teenager in a grocery story with the munchies and sense of reality is about the same. Here are the bullet points:
  • When we are looking for a right handed business analyst with 3 years experience with SQL servers in our industry, that is exactly what we want. We have no ability to gauge if a previous programming language is the same or if experience in another industry is relevant. Left handedness is an immediate disqualification. Some higher power needs to help career switchers because interviewer cannot.
  • Interviewers are also looking for someone who can help them with the project that they are working on that day. Doesn't matter if the position doesn't pay enough to attract anyone with experience in that project or if that's the responsibility of another position.
  • While you must meet all these qualifications, you also cannot be overqualified. That's because someone who is overqualified will leave for a better position as soon as they can. One candidate had the thought (in a private conversation) that it would be a good idea to hire overqualified individuals during a recession because one could stockpile talent. However, that talent won't be loyal. Anyone who's been laid off in a recession loses all sense of loyalty. I know that I did and I think it's a smart survival tactic in today's economy.
  • In summary, interviewers are Goldilocks only not as cute. Interviewees are probably like the bears who wanted to rip Goldilocks head off for messing with their house. However, job interviews like nursery rhymes don't allow physical violence.
  • Interviewers are also very anxious and look at every negative features about candidates. Limiting the interviewer anxiety levels is probably the most important thing to do.
  • It doesn't matter if you are unemployed right now. Most of the candidates that we interviewed were unemployed and the best way to address the question was with a quick and simple answer. The longer and interviewee talks about the unemployment, the more the interviewers start to realize that their own odds of future unemployment are pretty high too. That makes interviewers anxious which gets into the bullet point above. A recent New York Times article had the opposite point of view, that want ads were specifying that they only wanted currently employed candidates. That sounds like a human resource department who was looking for an easy way to screen resumes. In this day and age, it is highly likely that your interviewer had a bout of unemployment or knows how close they are.

Saturday, July 23, 2011

June Mount Adams Climb in Winter Conditions

At the end of this June, I led three friends up a south side route of Mt Adams. Only one of them had climbed a glaciated peak before and towards the end of our first day approach, I was worried that this climb might kill them and I would lose a few friends. Luckily, everyone adjusted on the 2nd day and we all made it to the false summit at 11,600 feet. Two of us summited. Their difficulties were probably driven by the fact that this was the first time they had backpacked up elevation in the snow. I think that our bodies have an initial defense mechanism to prevent us from doing that by creating extreme muscle fatigue.

Despite the end of June date, we had to do the winter route of the south side of Adams since there was that much snow on the ground. That included hiking an additional 3 miles to the parking lot which contributed to the excessive first day for all. It wasn't even a leisurely 3 additional miles as it involved some trail finding, setting compass points, and snow whacking.

Prior to leaving, we also had a lively discussion about whether to bring snow shoes or not due to soft snow in the late afternoon. We did and were very happy since we were on the soft snow in the late afternoon. If a group can make good time and get to their destinations while the snow is still firm, then snow shoes would not be necessary.

In the summer, the south side route typically is west of Crescent Glacier. However, from the photo below on the left, one can see how the enormous cornice (aka overhanging shelf of snow) made that route too dangerous. Therefore, we took the route from the photo on the right which was east of Crescent Glacier up the unfortunately named Suksorf Ridge.

The route up Suksdorf ridge was fairly straight forward and one can see the boot tracks in the photo. It ends at the Lunch Counter (9,000 feet elevation) just like the typical south side route. However, we camped at around 8,100 feet of elevation at a wonderful spot that had a flat area for 2 tents and 1 kitchen area. There were numerous quiet campsites on the way to the Lunch Counter which provided a rest from the additional 3 miles on the snow covered forest road.

The next day, we left camp at 6 am and headed up the south route. We were extremely fortunate that the snow conditions preserved a pristine set of steps all the way from the Lunch Counter to the False Summit. We made it to the False Summit by 10:30 and it then took two of us an hour to make it to the last 600 feet to the top (pictured below):

That's Mount Rainier in the background.

Wednesday, July 20, 2011

Building Customer Feedback Loops and Surveying Medicare members in a Non-Resource Intensive Way

My longest blog title ever describes my presentation at the Medicare Market Innovations Conference. Although the title could have been "Speaking about Building Customer Feedback Loops and Surveying Medicare members in a Non-Resource Intensive Way while eating at In-N-Out Burger and getting Sunburned at the Beach." I get some points for brevity. It was a very enjoyable 2 days in Newport Beach, California and a great conference by Strategic Solutions Group. Now I see why Orange County, CA was the location of The OC as opposed to Oregon City, OR.

Below is a link to a presentation about how someone can create customer surveys and get good information without needing to do third party, double blind research with every Chi square dotted and every t test crossed. I also share the dramatic moments that this created in product development. Most readers are probably thinking, "Dramatic moments in product developments? Harry Potter fighting Voldemert creates dramatic moments. The only dramatic moments in product development are wondering if the finance folks are going to fall asleep during your meetings."

Here are the highlights from the rest of the conference:
  • Best quote: "According to John Hopkins, here is what people are thinking about during presentations like this. 10% of you are paying attention to what I say. 20% of you are surfing the web on your phone. 70% of you are thinking about sexual fantasies. That means, no matter what I say, 70% of you are going to have a great time during my talk."
  • Second best quote from the marketing director of a plan that serves Medicare and Medicaid: "According to state statistics, our company's customers represent 5 of the 10 poorest, unhealthiest, fattest, laziest, and least educated, people in America. But it's home."
  • If anyone in insurance is looking for a group to test the strategy of doing absolutely nothing to respond to external market changes, the Medicare Supplement or Medigap insurance business provides an excellent example. The speaker for Medicare Supplement shared all the times that industry analysts thought the Medicare Supplement business was over due to external changes. The business didn't change tactics and luckily, neither did its customers. When I asked how the speaker would respond to an external threat that I identified in the northwest (providers no longer accepting original Medicare), his response was, "Oh yeah? We'll see."
  • The average conference attendee composition is 66% vendors who are trying to sell services to 33% of the other attendees. As I learned previously, 70% of each groups are spending most of their time thinking about sexual fantasies.

Friday, June 24, 2011

Paradise Lost and Found and Lost Again: the Mission of Playgrounds

As a parent of a young boy, I spend a lot of time on playgrounds. I like the rock climbing walls and appreciate a good fast slide. I also really like swings that have really long chains since you feel like you are flying.

My young boy likes the animals or cars that rock on large springs, a large sand box, and the dome jungle gyms. There are a lot of other features which are hit and miss. In general, if my little one can play on most of the equipment without getting frustrated, we're happy. It's a bonus, if I can spend some times swinging on monkey bars and refraining from looking too triumphant if I successfully swing across.

I thought that the societal role and social mission of playgrounds was fairly straight forward and transactional relationship. Until I went to New York City where I learned about the Rockwell Foundation and other architect's mission to transform society and create a future paradise through playgrounds.

Some of the quotes from the linked article (which require a subscription to see the full text) include the 1959 United Nations declaration about playgrounds as "as a place where children, by playing, learn to become non-playing adults." Alternative perspectives include playground development as a substitute for war training. On the other hand, playgrounds that introduce too many repetitive tasks like the 3 S's of swings, slides, and see saws are considered to tools of oppressors to stifle creativity in children.

Architects like Rockwell, Gehry, and others that we have never heard fought these pedestrian playground design and developed "Playgrounds in a Box" and "Loose parts." Children were entrusted with more control over pieces of the playgrounds to encourage the discovery and creativity process. Whacking each other with foam noodles is one example of this process.

Overally, their goals were best summed up with the following quote from the article:
Over the past century, the thinking about playgrounds has evolved from figuring out how play can instill youngsters with discipline to figuring out how play can build brains by fostering creativity and independent thinking. The hope of Rockwell's playground project is that children who have experimented with fitting together oversized blocks and cogs-and who have learned to navigate a place where the social challenges of sharing and collaboration are built into the experience-will be better equipped to handle the complexities of twenty-first-century life.

How did our experience with playgrounds changes through these carefully designed New York City playgrounds. Were my youngster and I transformed in anyway? I am going to answer in repetitive bullet points so you can clearly see that I am a lost cause for these playground architects:

  • We watched slightly older kids take over water sources or fountains and spray other kids who got too close. As the designers intended, kids learn at an early age that sharing is for the weak and they should dominate key resources.

  • A group of kids were digging an elaborate canal system in the sand. Two of them yelled at all the other kids to dig more and dig faster. It was inspiring to see their imagination settling on building their own sweat shops.

  • One two year old was very vigilant about tearing down any block or "Loose Parts" construction that any child built and left alone for more than 15 seconds. Clad in baggy back shorts, a medallion around his neck, and a pot belly, he looked like a little mob enforcer. Actually, he might have been.
It looks like the playgrounds do mimic the work environment quite well. This is New York City.

Wednesday, June 8, 2011

Be the Change that you can Abdicate to Others

Not quite the snappiest title like "Be the change that you see in the world" which is both a popular bumper sticker and looks good on the back of graduation T-shirts from social work programs. However, I like the word "abdicate" as much as I like the word "colonoscopy" and it's easier to spell.

The fact that I completely digressed before I even started writing the post is completely impressive, too. I can't even use "But I digress" as a transition. My point is that local governments are running away from making any difficult decisions in designing health care systems. Their lack of boldness is making Wisconsin governor Scott Walker's decision to declare war on organized labor look good because at least he made a decision and stuck to it.

The state of Oregon has provided some very fine recent examples of such abdication with their Medicaid program. Rather than make difficult, thoughtful decisions to guide the program, they throw half baked ideas to health plans and providers. They are:

1. Charge copays for services. The state gave the option to charge a $1 to $3 copay to non-Native American adults for prescription drugs and primary care. This was intended to reduce the amount of money that the state paid for services by passing on the costs to the Medicaid beneficiaries. However, trips to the emergency room were still no cost to the Medicaid beneficiary. In an effort to save money, the state made an incredibly poor benefit design decision and and as a bonus, set up in a way that was difficult to administer. Providers would have to figure out who they could collect $1 to $3 from and what to do if that individual did not have any money (like send them to the Emergency Room rather than give them their $4 generic prescription drugs).

Almost all the carriers decided not to implement this copay scheme and just take less money from the state. This is an example of a bad idea to save money that the state floated to health plans and providers. It went over like a lead zeppelin. This was an opportunity to have a serious discuss about benefit designs and what Medicaid beneficiaries should pay for and what they should not pay for. Incentives could have been developed to guide positive behavior and punish negative behavior. Instead, an administratively unwieldy option was offered to punish positive behavior. The end result was a waste of time.

2. Ask health plans what the reduction in Medicaid costs should be: Oregon is facing a budget shortfall and has stated that it plans to reduce Medicaid spending by 19%. Another option is increase the provider tax in order to get more federal matching funds and face a 10% to 12% reduction. Oregon also has a rule that its Medicaid spending must be actuarial sound. That means if they want to cut costs by 10%, or 12%, or 19%, then the health care services used should also be projected to reduced by that same amount. This also provides yet another example of how actuaries are guaranteed employment forever.

Oregon has proposed some good ideas to redesign their Medicaid system to achieve those savings. However, they don't think that they can achieve the savings this year. They are squandering a perfectly good crisis and asking health plans to come up with their own actuarial sound analysis of the lowest cost to provide health care services for Medicaid beneficiaries. In other words, they are asking health plans what the cut in spending should be. This is a crucial decision in Oregon's Medicaid program and they asking health plans to do their homework for them.

A budget cut is just a loss of services but a budget cut and a health care system redesign is an opportunity. Under health reform, states have more options available to transform their health care system with Xxchanges that will allow them more control over the health insurance market. There are "pay or play" options where carriers must participate in Medicaid or providing guaranteed issue to children or face a financial penalty. This is the opportunity for bold and difficult decisions for states to make that will change the lives of their most vulnerable citizens.

This is not the time to buy a vowel.

Saturday, June 4, 2011

Death's Door Bandit; A Sad Tale about the US Health Care System

An elderly gentleman walked into a bank and indicated to the teller that he had a weapon. The teller was convinced enough about the danger or nauseated enough by his ear hair that they considered the threat to be serious. Before anyone handed him the money, the gentleman collapsed into a chair and had a heart attack.

This turned out to be an actual lucky turn of events for our ear haired protagonist because he had robbed the bank to get money to pay for health care. Due to a 1976 US Supreme Court decision, it is considered cruel and unusual punishment for a prison not to provide health care. Since the elderly gentleman was now in the prison system, he got the medical care that he needed.

However, there is a plot twist for the Death's Door bandit (This is a better term than the Ear Haired Bandit. I don't know if he had ear hair or not but if he is over 65, it's safe to assume that he did. The Bleeding Heart bandit is also an option). Readers may be wondering if the Death's Door bandit (DDB) was old enough to qualify for Medicare, the health insurance scheme for senior citizens. Not only was he eligible for Medicare but also Medicaid, the health insurance scheme for the low income! In case anyone is wondering, why I am calling Medicare and Medicaid a scheme, it is because I am imitating the Economist who uses that terminology. If you read it with a British accent, it sounds much more regal.

DDB is getting his health care paid for by the prison system but could also get his health care paid for by Medicare and Medicaid. He will no longer need to rob banks for health care so this story appears to have a happy ending. But wait, this scheme has a plot twist!

Heart attacks and medical care for senior citizens whose physical and mental status has decompensated to the point that they don't even realize that they qualify for basic government programs is not cheap. It's costly enough that administrators for the prison health system and Medicare and Medicaid started to pay attention. Both administrators took the high road and began to maneuver to try and stick the other one with DDB's medical bill. Medicare and Medicaid administrators want DDB to stay in jail so the prison will pay for his health care while the prison administrators wants to release DDB so Medicare and Medicaid will pay for his health care. The justice system is caught in the middle.

Only in America. Our health system must rank number one in something for this scenario.

Full disclosure: This is a true story. Names and details would have been changed to protect the innocent, except there are no innocent in this story.
Full disclaimer: I don't know the difference between disclosure or disclaimer.

Monday, May 16, 2011

So you want to be a Product Manager?

No, you still want to be a rock star? Me, too but I'm tone deaf. Let's face it, if we didn't become astronauts, fire fighters, princesses, or vampire slayers, we all sold out our 8 year old selves. That's okay as long as you felt that you got a fair value for your soul. One relatively new career that provides fair value is product manager.

Product Manager has become a popular short-term career goal for MBA graduates to write about in their essays. I have recommended it to a few folks who are struggling with their career goals and they all seemed to like it. However, when you are struggling with the MBA career goal essays, if someone suggests being Colonel Mustard in the library with a candle stick, you consider it.

Digressions aside, product manager is a more savvy way of saying that you want to work in general management. Another option to the general management career track (which does not involve actually managing generals or even colonels) is management consulting. However, unless something in your background indicates that you can tolerate the rigor and demands of the lifestyle associated with a consulting career, it's not likely to make your essay look believable. In this example, managing even private first classes would be a rigorous enough background.

In the last five to ten years, product management departments have been created at companies, like health insurance, that did not previous have this functional area. Tech companies have used product managements since the industry was first created way back in 1991. Geek MBA 360 covers product management at tech companies very well while my knowledge is product management in health insurance. The product management position has become popular since it provides a clear accountable person or "one throat to choke" for a line of business. The fact that it's becoming a more common post-MBA destination shows how widespread it's become and how it may have peaked.

I hope that it won't go the direction of project management which is often confused with product management not only because the names sound very similar especially if you say them quickly. The demise of project management is the endless certificate options like PMP or PgMP. These certificates or license have proven to be very good predictors of tolerance for standardized tests and adult education classes and a very poor predictor of the level of quality of a project manager. They are also very good at creating an easy way for recruiters to screen out applications for positions that could attract a lot of candidates with every diverse backgrounds and many applicable skills. This type of certificate program is a significant risk for the demise of the product management position.

My tirade against project management served as an opportunity for me to both vent and juxtapose it with product management. At some companies, a product manager is very similar to a project manager as they tend to focus on implementation. These implementation product managers are more internally focused and implement new strategies, products, or decisions that someone else, usually the Sales department, made. In the case, they don't usually conduct market analysis except to validate specific decisions or build business cases since that work was already done.

What an implementation product manager will do is:
  • Use bullet points because product managers know that their implementation teams won't read anything they write unless they use bullet points
  • Work closely with IT or IS or Computer people Product Managers to define requirements and get sign off from business owners
  • Develop and maintain documentation on decisions
  • Resolve interpretations of different decisions or different documentations that may vary across departments or systems
  • Product training
  • Ensure that any annual processes are completed
  • Work closely with internal departments on new process development
  • Lots of project management
The work is very tangible, specific, and it's a great way to learn about how an industry works. This is a good way to enter a new industry or get training to become a strategy product manager.

A strategy product manager is definitely sexier. However, to put that in perspective, that's like saying one member of the Hell's Angels has better flossing habits than another one. The strategy product manager can generally get project managers to do the implementation work and is the one involved in the decisions for new products, geographies, or other strategies. The work includes:
  • Still has to use bullet points but communications are shorter and more like "We decided to do launch a new product that will appear to niche X. The project manager will actually implement it and I will pretend that I am the project manager's boss."
  • More external facing with lots of market assessment, developing market segments, forecasting market growth, and talking with customers
  • Presenting to customers. The Sales folks will generally trust you in front of clients to not talk about the difficulties that the latest request will create with the billing department's invoice batch process
  • Develop 3 year product plans called road maps
  • Assess new business opportunities.
  • Be the product expert and know how it should work but you will get to buy a vowel or use a lifeline with another functional area that knows the actual answer. The strategy product manager just has to know who to ask
  • Develop very good judgment on what projects really require the strategy product manager to manage in order to be successful but won't absolutely suck away too much time
Since the grass is always greener, strategy product managers strive to be budget product managers or work at a company where the product manages their budget and is responsible for profit. That is typically called "P and L" responsibilities which stands for Profit and Loss. However, I don't know why anyone would want to be responsible for the loss. Try to find someone else to take that on so I would describe it as being responsible for just the profit.

The main difference with strategy product managers is that budget product managers don't have to beg other functional areas to free up FTE time or hours to support their products. They already have an allocated FTE time that they can spend how they choose. In the corporate world, control of budget trumps all. Whenever someone tries to assign me a new responsibility, I demand the budget and resources to cover it. No one has called my bluff and given me both which shows how much people value their budget. Therefore, I am still a strategy product manager.

Monday, April 25, 2011

We need a Single Payer System like a Fish needs an XBox

I used to wear T-shirt that I got from a thrift store that said "It's time for Peace, Jerry Brown '92" while I drank from a water bottle with a Dennis Kucinich sticker. Yet, I don't see how a single payer system can be viable.

Here are the reasons that I hear from proponents of a single payer system:

1. It will provide health insurance for everyone and cover all services.
2. Insurance companies will no longer make huge profits and the money saved will cover health insurance for everyone, the national debt, and an Xbox for every fish.
3. It will make the health care system simpler and more efficient and the money saved will provide Guitar Hero III for every non-vertebrae.
4. It's easy to do, just expand Medicare to cover everyone.

Here are the problems:
1. Health Reform has been working towards preventing the denial of health insurance which is necessary to have a humane society. However, access to health insurance won't solve health care costs that exceed inflation. It won't create more primary care physicians or more care providers. It also won't address the approximstely 33% of the uninsured who make more than $50,000/year and refuse to buy auto insurance, wear motorcycle helmets, and still probably try to smoke on airplanes.

2. With a little extrapolation from this data of the large publicly traded health insurance companies, I see about $12-$15 billion in profits that can be seized. That would cover about 50,000 hip replacements which will probably be needed by the 50 million Baby Boomers or 12,500 very premature babies. In today's health care dollars, that's actually not a lot of money. Health insurance plans have an average profit margin of 3%. Some might argue that we should include money spent on marketing and CEO salaries. However, a single payer system will have to market to explain its system and have expenses developing a large enough system to cover the whole US. If I was feeling really snarky, I would counter that the likely rich benefit packages from unionized government workers would be about the same as large CEO salaries. If I was feeling less snarky, I would point out that $10 million in salaries is 1% of a billion dollar in revenue company so that savings opportunities is closer to 40 more hip replacements.

While ending the existance of evil health plans creates the same delight that one gets when their favorite team beats the New England Patriots, the money would cover the cost increases for the next few years at the most.

3. One claims system, one billing system, one benefit package, and one coverage system is very appealing. I have heard that it would eliminate provider administrative costs by 30%. Oregon had made movements towards consolidating its Medicaid carriers into one carrier per geographic region with this same argument. However, they pulled away because there were not necessarily carriers that could serve all the Medicaid beneficiaries in that region. Some carriers and provider groups that did service a particular county would be eliminated. That approach would award a monopoly to one group. That's the danger of the Highlander (In the end, there can only be one) approach. If one company controls an entire market with no competitors, how do we expect them to behave?

Health care is also very local and segmented both geographically and demographically. The east coast features large academic medical centers while the west coast features the integrated delivery systems while the south has entrants as new as most of its latest round of carpet baggers. In Oregon, you have to cover naturopathic medicine to be competitive while in Boston, you have to include the Partners Health Group.

Some individuals want alternative care covered, some can't afford their diabetic medications unless there is no cost share, and some want the cheapest plan possible and would rather pay 50% when they have to use services. It's not possible to create one universal benefit plan that would meet the needs of everyone and be affordable. Segmentation is a hallmark of successful business ventures. Trying to be all things to all people is a recipe for failure. The banking system and telephone lines lends itself towards a national model. Most other services lend themselves to a state wide model at best.

Creating this simplicity would entail a lot of sacrifice of personal choice. We're not good at sacrificing choice in cell phone plans, let alone health care coverage. Part of growing up as a health care system is figuring out what we really want to be. One universal model is not something that appeals to any characteristic of our nation.

4. The biggest problem is that the only group that is really equipped to offer a universal health plan is Unitedhealth Group. They are the only ones who have the size and scale.

The Medicare program has no experience with any level of sophisticated claims processing, network management, or negotiating for medical services. Network management and even a rudimentery claims processing is necessary for any type of system that pays providers for offering the right level of services and not just lots of services. Their price negotiations involves setting a price and telling people to take it or leave it. The idea that they can negotiate with prescription drug companies on pricing will be undermined by the fact that they have no department that can do it. Currently, they rely on the same companies that private insuracne companies use for prescription drug negotiation. Medicare can barely prevent fraud and abuse let alone managing costs. It has driven disease management programs into bankruptcy.

Someone who provides universal coverage would also need to staff up on customer service and basic communications which are not Medicare's area of expertise. I would offer the image of the DMV running your health plan except that I don't like to drag in the poor DMV. They get picked on enough.

Since Medicare doesn't have the basic expertise, the other option is to contract with private health plans to offer universal coverage. This is called the Medicare Advantage program which has its critics, including President Obama.

The solution: Since I haven't come up with a colonoscopy joke, by my new rule, I have to come up with a solution. Personally, I like Germany's approach. A basic level of services is covered by the government and people can buy private insurance for more coverage. This is basically like our eduction system.

Thursday, April 21, 2011

Are ACO's DOA?

A lot of people have been staking the future of health care on the idea of Accountable Care Organizations (ACO's). President Obama thinks they will reduce health care costs, providers have been reorganizing to take advantage of the opportunity, and bloggers have praised them. Even the event planning industry loves them as it has spawned a whole new line of conference opportunities.

To those who have not been following the ACO's like fantasy league baseball owners follow spring training, an ACO is an old idea that aligns the financial incentives of providers and payers. It provides a global budget for managing the care for Medicare beneficiaries. This rewards providers for efficient health care or keeping patients healthy rather than lots of invasive procedures. Medicare projects that it will save $510 million over a 2 year period. However, the release of the proposed ACO rules by Center for Medicare and Medicaid (CMS) at the end of the March had the same effect on the party as urine in the punch bowl. Or as my blog title foreshadows, it's like Weekend at Bernie's 2 where providers realize that participating in an ACO is like partying with a dead guy. It's a lot of work, not a lot of fun, and starts to smell after a while. In summary:

Lots of work: To participate in an ACO, providers will need more reporting, IT systems, have to develop some insurance functions, and build up the infrastructure to better track patients health. This is not unexpected and was part of the ROI analysis. What pushes the amount of work over the edge is the governance requirement. There must be a separate Board of Directors that runs the ACO that includes patient representation. This is a common aspect of Federally Qualified Health Centers and also the most challenging requirement to meet. Creating a separate governance board with complete control removes a lot of control from the providers who are launching a new venture. It's not easy to give up control of something that requires this much investment.

Not a lot of fun: The fun in ACO's was the opportunity to get paid more treating Medicare beneficiaries through shared savings compared to a benchmark. However, CMS took away the fun or opportunity to make more money by doing the following:
  • The benchmark or cost target that providers have to beat to make additional money is the current Medicare benchmark for the geographic area. For providers in the Northwest where benchmarks are very low because they are historically low cost areas, that means limited opportunity. For providers in Texas and Florida, where the benchmarks are very high because these are expensive areas, there is opportunity. However, these providers get paid enough by Medicare already so there is not the incentive. In other words, providers that are well-organized and poised to form an ACO have little room to get additional money. The wide variation in geographic payment for Medicare has been a continual problem and removes a lot of incentive from the ACO.
  • CMS also keeps the first 2% of any savings. Therefore, providers have to lower costs by greater than 2% in order to get additional payment. Or yet another barrier to participation. That's like having to watch Weekend at Bernie's 2 before you get to watch the first one or just turn off the TV.
Smelling like a corpse: Given the current structure, there is a risk that no provider group will apply to the ACO's. The current rules went over like a fart in a spacesuit to the 10 provider groups that participated in the original Physician Group Practice demo. If those provider groups who are the most likely to be successful aka make additional money in this model don't participate, who will? This would be a large blow to the Obama administration's vision of designing a more efficient health care system.

Hope or Yes we Can:
It's too easy to write a critical blog post about how a new idea in health care might not work. Any blogger who writes such a critical post should either balance it out with a solution or some really good colonoscopy or animal husbandry jokes. Since I don't have any new jokes, I'll pick the solution option.

Despite the fact that CMS has made participation in an ACO as appealing as a colonoscopy, this model represents the best solution to the US health care system. The fee for service model has proven to be unsustainable. Others besides CMS, like large employers or unions will start to demand this type of model from insurance companies and provider groups. While the revenue opportunities in an ACO are not good, there are not any better revenue opportunities elsewhere. Provider groups can no longer compare opportunities to today's payment but should compare it to the future payment opportunities. Provider groups who can organize under an ACO structure and lower health care costs will be more viable in the future. Those who cannot and expect to continue to be paid at today's levels will become just like the main character/corpse in Weekend at Bernie's.

Provider groups best option is still the ACO model. If CMS can't develop a good structure, that presents the opportunity for the health care industry to develop its own.

Monday, April 11, 2011

Ryan's Field of Dreams while Oregon is not just waiting for them to come after Building It

Last week, representative Paul Ryan released a budget proposal that was called everything from "interesting" by Ezra Klein to "bold" and "game-changing" by Fox news. The popular sports analogy was how Ryan changed the playing field on the health reform debate with his hail merry. My mixed sports analogy would be that Ryan punted to the Field of Dreams where he thinks that if he builds it, they will come.

Ryan's proposal specifically "would provide Medicare beneficiaries with lump-sum vouchers to buy private insurance and turn Medicaid into a block-grant system." States would get $11,00 per Medicaid beneficiary and the federal government could cap its exposure to health care costs. In other words, the federal government is turning its health care programs from a defined benefit to a defined contribution program and getting out of the health insurance business.

I used to think that block grants were a good thing because the word block has positive connotations. It makes me think of a block party or playing with blocks. The idea that the government gives you a block of money and a lot of freedom also sounds appealing. However, I have realized that block grants should really be called blockhead grants because they are generally used for programs that the granter doesn't like. That's why block grants won't cover the actual costs of the programs. Calling the programs, "Hey blockhead, how much money do I have to give you to go away? That's it? Great!" would be too honest and the acronym would be too long.

Ryan's idea of vouchers and block grants for Medicare and Medicaid is nothing new. Democratic and Republican politicians have proposed these ideas since 1981. What would make this proposal interesting is if Ryan attempted to design a market that would create an incentive to participate in these programs and provide care. That is the challenging part and why this is just another example of Republicans punting on actually coming up with a solution for the health care system. It will shift costs to employers who will become a main source of health insurance for older workers or beneficiaries who won't be able to cover their health care costs. It does nothing to change a fee for service system that will respond to lower payments with higher volume and more invasive treatments that get higher reimbursement.

The state of Oregon is seeking federal waivers for its Medicare and Medicaid funding in order to design a real system of health care. Waivers doesn't have the same warm and fuzzy feel as block grants. However, it's better because with waivers you actually get the same amount of money as before. Oregon is taking the ball and running with it by designing a care delivery system to support it called Coordinated Care Organizations (CCO's). They are similar to the federal governments Accountable Care Organizations (ACO) with 2 key differences. Patients select their CCO in advance and have a relationship with the providers while patients are assigned to an ACO retrospectively and don't have the same provider relationship. The other difference is that one starts with C and the other stars with A. I really wish Oregon could come up with a BCO acronym since they skipped that letter but the only one that I could think of was Boring Care Organization.

The relationship aspect of the CCO gives the organizations an opportunity to attract patients to join. The CCO's will start by serving the growing Medicaid population (which will become 30% of Oregon's under 65 insurance market in 2015) but will have business steadily funneled to it by the state government bodies like the Oregon Healthcare Authority. For example, the state has indicated that they may only contract with CCO's for the lucrative public employees insurance. That is how the system creates incentives to participate in providing care to difficult populations like Medicaid and Medicare. This is very different from Ryan's plan to have these beneficiaries fend for themselves with a 50% off coupon.

This Oregon proposal is something that I would call bold and game changing.

Wednesday, March 30, 2011

Wrestling with the Individual Mandate or We still Don't Know what kind of Health System we Want

As a nation, we do not know what we want our health system to be when it grows up. We are still using our health system as a source for our own fantasies and shortcomings. The fantasies are on such a grand scale that we expect our health system to be like James Bond with better abs when it grows up.

Allow me to step down from my somewhat random analogy. We still have the illusion that we can provide health coverage and access to care for everyone, keep it affordable, and not make any sacrifices like increased wait times for services, no longer offer the most invasive option possible, or not have an individual mandate. We have delayed tough decisions under the delusion that wellness, better chronic disease management, and Electronic Medical Records will result our health system being affordable, high quality, and with access for all. The reality is that health systems can usually only offer two of the three.

The sacrifice of the individual mandate is the topic of this blog post. Those who are still reading, probably realized that from the title and are now glad that I finally got to the point. Economists have explained that an individual mandate is required in order to have affordable universal health coverage. The healthy, like James Bond, has to pay into the pool to support the sick and those who are not really really really ridiculously good-looking. However, politicians continually look for a way to remove the watered down individual mandate that is included in health reform. This shows a continued inability to make tough decisions about what we want our future health system to look like. The current individual mandate is a $700 fine which should hardly dissuade the die hard libertarian from not buying insurance. That individual can continue to not buy auto insurance, not wear a helmet while riding a motorcycle, not pay taxes, or refrain from bringing samurai swords on a plane or any of those other things that individuals are currently mandated to do by law.

This post on the individual mandate is mainly driven by Senator Ben Nelson's request to the Government Accountability Office (GAO) to see alternatives to the individual mandate. Now, given Nelson's history with the Cornhusker Kickback, his request for this analysis could be driven by a desire to fry up some more pork for his state or campaign contributions. Nelson never seems to have a position that he doesn't use to gain some benefit for himself. However, I'll assume that Nelson's inability to make hard choices about our health care system matches others. The GAO alternatives to the individual mandates can fall into the following categories:

Just another form of an individual mandate that will maybe convince those who aren't paying attention that it's not an individual mandate. It's kind of like reducing the number of uninsured by just changing the definition of uninsured to those whose religion forbid accessing medical care.
  1. Impose a tax to pay for uncompensated care (How is that different than the current $700 fine other than it's called a tax?)

  2. Restrict access to some federal benefits to people with insurance (whose value might be around $700?)

  3. Require or encourage credit-rating agencies to factor in insurance status in credit ratings (and the impact could be greater than $700 for those whose credit rating results in a higher interest rate for their loan)
General proclamations and principle like "We support preventive medicine and ice cream for kids on hot days" that don't really mean anything. The only thing they offer is something that everyone can agree on.
  1. Conduct a public education and outreach campaign

  2. Provide broad access to personalized help with health coverage enrollment by creating access points such as pharmacies, schools, and grocery stores (How about bars, shooting ranges, and casinos which is where those who won't buy insurance are more likely to hang out and be drunk enough to maybe sign up?)

Ideas that insurance companies really like but don't really help the public or solve the problem.

  1. Modify open enrollment periods and impose penalties for late enrollment (Insurance companies love this provision because it creates an incentive for people to preemptively sign up for insurance and stay enrolled longer. However, it doesn't work for the average citizen because this would mean that all of us who have insurance through our employers should start thinking about enrolling in individual insurance just in case we lose coverage. Open enrollment works in Medicare because the market is static. Once someone has Medicare, they always have it. The individual market is much more fluid since people will switch between Medicaid, Employer, and Individual insurance.)

  2. Allow greater variation in premium rates based on the enrollees' age to get more young and healthy people to sign up (Insurance companies would love to have lower prices for the young and healthy which means higher prices for the old, sick, and those who are not really really really really ridiculously good-looking. The problem is that it's hard to get the price low enough to be appealing to the young and healthy while keeping the price affordable for the old.)

Ideas that don't really have anything to do with the individual mandate but address other issues.

  1. Facilitate auto-enrollment for employer-sponsored coverage (If employees are not signing up for their health insurance, it's probably because they can't afford it or don't want it and are the type that need an individual mandate.)

  2. Pay insurance agents and brokers a flat fee rather than commissions to help people enroll (The Exchanges and brokers' inability to demonstrate their value proposition may eliminte the entire broker and producer industry. This provision is a life preserver for the industry. It is also duplicates the Exchange and doesn't address the core problem of individuals who don't want to enroll in insurance. The flat fee should be given to the young and healthy who enroll instead.)
Every country has struggled with balancing access, cost, and quality. The United States believes that it is exempt from those struggles which is why it wrestles with tough choices like an individual mandate. However, these 9 alternatives are not really alternatives at all. When we finally realize that we need to make sacrifices and tough decisions, the United States' health care system will be all growns up.

PS If anyone has been wondering where Roll Away the Dew has been in the month of February and March, I got hooked on the Office and spent my free time watching the series. I have watched 131 of the series 136 episodes so I am preparing myself for life after the Office. Thanks to those who are still reading.
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