It’s Fall – Time for Talking Turkey about Healthcare…

We need to talk about healthcare, the role of funding, the need for healthcare teams, and core infrastructure from workplace culture to technology.  Parts of this post began as a comment in Employee Benefit News, a LinkedIn group.  Let’s start with the money.

There’s a pattern here—banks collect a 5% margin on health insurance cash flow.  This is not small potatoes.  Healthcare insurance, mostly self-insured employer costs, was about 33.5 percent of the $2.3 trillion spent on healthcare in 2008, i.e., almost 70 percent of the half of health cost not paid by Medicare and Medicaid (see National Health Expend Data). This annual $770 billion allows the 5% margin to feed some $38 billion into the banking sector’s P&L statement.  And, the annual $770 billion flow is money banks can invest in securities markets, or can lend.

Due to fractional reserves (banks can invest or lend all but a fraction of underlying deposits, or borrow against them), the health insurance cash flow running through the banking system supports the investment banking business with leveragable deposit volume that can be further leveraged by securitizing assets; or in making loans.  Banks make more money on a transaction basis by taking investment banking risks—very profitably, as long as the music plays.  As a result, banks tilt the huge insurance deposits toward leveraged securities investments; less so toward lending so long as lost jobs, constrained wages, underwater mortgages, and debt repayment limit non-luxury consumer demand and overall business hiring.

As for healthcare itself, the banks have no direct dog in the healthcare cost problem stemming from craft-based operations in the healthcare provider world.  If anything, insurance volume for costly health care feeds the deposit volume for banks.

And like banks, the health “insurance” (subscription) firms also don’t really have a dog in the healthcare cost problem as long as they pay out 80% of their revenues to hospitals and other providers.  The 80% is the minimum subscriber firm payout under the Affordable Care Act (ACA), and thus of course is the target maximum payout.

As provider health bills rise, subscription firms just need to hike their rates to hit the 80% payout target.  However, recently subscription firms were near a 75-78% payout ratio.  Therefore, current subscription firm rate hikes indicate they anticipate continued billing hikes by providers struggling to use craft-based work units to handle previously uninsured low and middle income patients.  By the time the ACA payout target takes effect, the subscription firms will be close enough to paying out 80%, such that provider billing increases will soon render subscription firms compliant with the ACA’s 80% payout.  And then the tit-for-tat provider billing pass-through to subscription firm customers will continue.

Upshot—the healthcare billing and payment cycle is a process with no brakes, even under the ACA’s 80% payout basis.  The only way to apply brakes on health costs is to deal with the craft culture at the healthcare operations level.  Even Medicare for All, while ameliorating healthcare access problems, could not alone address the operational cost bias built into underlying craft medical practices.

Toward this operational craft practice issue, it’s important to note that hospitals have worked hard to modernize their work.  However, what has taken place is an abundance of excellent tools wielded by individual craft practitioners in very small-team environments (the term “silo” often applies here).

The work tool ramp-up in an expanding work place that continues to apply processes rooted in standalone craft skills is a perfect recipe for aggressive unit cost growth.  Patient care accountability needs a preventive care population culture, healthcare teams, team hand-offs, and transparent HIT resources including analytics, remote monitoring, voice and image telemedicine, and public key performance indicators.  Especially for specialty and hospital care, teams need process coaches (Atul Gawande in Personal Best, The New Yorker, October 3, 2011) and bundled payments adjusted for severity (Jeff Goldsmith).

Let’s look a bit more closely at the connected ideas of healthcare teams, team hand-offs, transparent HIT resources, and process coaches.  This array encompasses patient-centered and geographically transparent operational team support and hand-off capability from public health teamed with primary care docs, through potentially dispersed specialist support teams and hospital and clinic team operations.

Here’s the message – what is needed are location independent healthcare teams and team hand-offs as the core entities of accountability for patient care.  This refines and extends an operational viewpoint from ideas also discussed by Arnold Relman in the New York Times Book Review for October 27, 2011.

The team accountability process builds on a sequence of team-based activities.  Appropriate teams need to be engaged from early in the public’s entry in prevention and wellness action, before matters become chronic or involve hospitals.  This means applying teams that connect prevention, public health, and general practitioners to stop a population’s emerging chronic conditions, one patient or population group at a time.  For patients whose diseases progress into mature conditions requiring specialty care and perhaps acute hospital care, the specialty and hospital stages need a patient navigator team, a care coordinator team, and a meds management and treatment discharge-followup team (30-day recidivism, anyone?), enabled by end-to-end global EMR resources and whole-treatment episode analytics.  The specialty care and hospital stages may enter a penultimate team care zone in OR and ICU activity.

Across the whole sequence, especially for specialty and hospital care, the stages will need process interpretation and continuous learning.  This means a funded coaching resource.

More about coaches and payment, then we’re done for the moment.  Coaches enable the healthcare team members to continue growing in situational skill and refinement across the whole team care process, from prevention-wellness to public health to surgery.  If coaching seems both pointless and admitting to a lack of skill that will induce lawsuits, it’s useful to see the reference above to Atul Gawande and his New Yorker article, Personal Best.

The other matter—payment.  In a team environment, each whole specialty and hospital care episode needs to be funded as a bundled payment adjusted for severity (as above, see Jeff Goldsmith).  Why?  Because the overall care process needs to be paid for as an efficiently integrated built process that generates production function value as a joint product, not for each disaggregated nut and bolt in the process.  For example, key care components include transparent EMR resources and multiple whole-episode analytics that enable seeing each team episode in context with others.  And to address costly outlier episodes, team-based care organizations will need stop-loss insurance (a form of reinsurance) at the individual and group level, incentivized by premium discounts for groups with better actuarial performance records.

Real payoffs stem from smarter systemic prevention-wellness action and healthcare for regions, residents, workers, and employers—better health, reduced benefit expense, reduced absenteeism and presenteeism, increased work team productivity and more focused learning capability, a more resilient and competitive global presence, leading to more jobs and better pay.

So, this has been quite a trip.  The point being that prevention-wellness care and healthcare are a major Wicked Problem, i.e., with many moving parts and participants.  Absent a serious effort to approach the task with humility, curiosity, determination, fortitude, and respect, from the inside as much as from the outside, we could end up poking the shared bear until it eats us up.

From Pat to Newt to Sarah: Marriage Vows to Death Panels and Back

Recently diehard Christian, tele-evangelist and the man who talks to God at least once a day, Pat Robertson, told America that it was completely acceptable to divorce, put aside, renounce your vows, go have a fling with someone else, call it what you will, if your life-partner has Alzheimer’s. Here are some YouTubes of it.

The logic is this: People with Alzheimer’s are dead and gone, anyway, so your wedding vows are dead and gone with them.

But they’re not dead and gone legally because custodial care is still required and someone has to pay for that custodial care and if the law can find you, it’ll be you.

So despite Pat’s best wishes, you’re not really divorced, separated, or able to put them aside in their moment of greatest need.

Unless you’re Newt Gingrich, I guess.

What? You’re surprised that church and state aren’t as separate in America as we were taught?

Light at the End?

I would love to offer an easy out for this. One of the most horrible experiences of my life was working with the family of an Alzheimer’s patient, being with them when he had a brief moment of lucidity.

He suddenly looked up at all of us. We could tell by the look on his face that he recognized us, he knew who we were. He smiled and there was warmth and intelligence in his eyes.

Then he looked down at himself, at the hospital pajamas and bathrobe he was wearing, at the pastel blue polyfoam slippers on his feet, then he looked around at the others on the ward, at the nurses, the doctors, the other patients, the walls, the windows and beyond.

He looked up at us again, his smile gone but his eyes still bright, still knowing, his face now wrinkling with an understandable confusion, “Where are we?” with the emphasis on “we”, his family recognized as being there with him.

Then he noticed the hospital bracelet on his left wrist and turned it with his right hand so he could read it.

He looked up at us, his eyes wide, his face flushed, drained, colorless but his eyes still full of life, of hope, of sanity, of love.

His head shook ever so slightly, ever so slowly, denying what his senses were telling him and he whispered, “No,” a request, a plea, a desire.

Then a look of exquisite, incredible, undeniable pain. A tear slid down his face., “Oh, god. No,” he said as his face went blank once again. His eyes dulled and he was gone to us once again. As it turned out, he was gone to us forever. He never returned that I know of although we continued to visit him for his remaining time.

Or the End of Light?

So if someone has Alzheimer’s, it’s okay to put them away.

Oh, heck. Let’s do the same for terminal cancer.

Or heart disease.

I hear bubonic plague is making a comeback…

How about…AIDS?

Oh, wait…we already went around the circle with that in the 1980s. That was when nobody could get funding to research it because it was 1st a disease only homosexuals got 2nd a disease only third-worlders (read “People of Color”) got but by golly when that first white, all american heterosexual male got AIDS (and purely by accident you know he wasn’t fooling around or nothing like that) didn’t available funding go through the roof?

The above anecdote reminds me of a MADTV skit from way back. Somebody wakes up in the President’s bed in the White House. There’s a Secret Service man sitting there. “How did I get here?” asks the man. “You were elected.” “The last thing I remember was my fraternity kegger.” “Yes, you ran for President on a dare. Nobody took you seriously but everybody under 35 voted for you. You’re in your third term.”

“Third term? How’s that possible?”

(and here’s the kicker) “In your first term you promised a cure for cancer. You took the ten richest men in America and injected them with cancer. We had a cure for cancer within six months.”

Beloved Death Panels

I won’t get into how Pat Robertson’s words violate Christian theology. I’m more taken by how this plays against the relatively recent hubbub over Death Panels.

And I won’t get into how idiotic and false that concept was, I’m only addressing that it got air time — heck, I’m writing about it now, aren’t I? — and that patterns form around things.

I would be truly surprised if a Democrat made similar comments about Alzheimer’s or Health Care Reform — not saying they won’t or haven’t already. I don’t know if such is the case, only surprised if it’s happened or would — because such thinking simply isn’t in the Democratic concept-space (the Democratic mindset couldn’t easily incorporate such phrasing).

And readers, I really want to see counter evidence of this. Please let me know if Democrats have publicly made such statements.

But Wait! There’s More!

Let me share something with you from all my training, something therapists pay close attention to when working with people and something that shows up in NextStage’s Principles as the admission of things; it’s one thing to think something, it’s a completely different thing to say that thing and it’s an indication of conceivable action if that thing is said out loud to others.

Let me explain it this way.

1. We can think of something pretty horrible to do to someone else. Most people have all sorts of behavioral, social, cultural and perhaps religious filters that kick in and stop things from getting beyond the “thinking” stage.
2. However, once we voice it and even if we voice it to ourselves, our minds now recognize that horrible thing as being “out there”, hence much closer to being real, hence our actually doing that horrible thing in reality. Most people who don’t stop at 1 above get here and know they should seek counseling. Maybe work’s not going well, family life isn’t going well, whatever, and they know they should get help and do.
3. But once we say it outloud in front of others, we’re seeking a) peers and b) support for our potential acts, for validation, for “buy-in”. It’s become a “Who’s with me?” type of thing and this is where individuals either decide to act psychotically or create a mob to take part in their hate- and/or fear-based action.

   Note that we don’t place acts of kindness, generosity, altruism, … in this category because such acts of supported by those same filters mentioned in 1 above.

4. And therapists, law enforcement, security, etc., all know that once that horrible act is voiced in front of at least one other person it has gone from “probably won’t” to “conceivably could”.

So Pat, Sarah, Newt (obviously from history) and who knows how many other Red Staters are willing to put Granny to death or at least put her away because she’s inconvenient for them.

Because they were able to say it out loud in front of others, they are able to do it. They are seeking buy-in for an act they can conceive of themselves doing.

Okay, Back to Reality

Nah, not yet.

I mean, it’s okay to renounce/ignore your vows but it’s not okay to have an affair?

Only in America.

A friend’s 87 year old uncle recently married his 83 year old girlfriend because he was tired of the neighbor’s snide comments. Uncle Henry and his girlfriend had been living together for seven years and had had it with all the gossip and innuendo. That and they couldn’t bear the thought of their children going through life labeled as “bastards”.

As I said, folks, only in America.

Okay, Now “Back to Reality”

Sorry, Pat, sorry Sarah, sorry Newt and sorry, anybody else who takes exception. Love doesn’t die. It never goes away. We know this from neuroscience, from psychodynamics, from more disciplines than the three of you could get together and name, probably.

Love can change, though, over time. People can grow in different ways and in different directions. If two people agree their time is done, so be it and more power to them. Recognizing that they’ve changed and it’s time to move on is, in itself, an act of love.

As I wrote above, love can change.

But it never dies.

So if you want to renounce your vows, divorce your partner or kill or otherwise outsource your granny, at least do it while they’re still around to recognize your act.

Don’t hide from them. What, their dementia and decreasing health were a surprise? You’re shocked, shocked you tell me, to learn they’re more a burden than blessing?

Where in your vows, Pat and Newt, does it indicate you can take off when things are less than optimal?

Where in your thinking, O’ Great SixPack Queen of the North, does it indicate that the right to informed consent equates to euthanizing a loved one?

But wait…Newt and Sarah, at least, are politicians. Maybe I was the fool to expect more…

In my life I have known many people who claim to be Christian. I have known very few who genuinely follow Christ or his teachings, one of which is “You can’t hide your completely, unequivocally, horribly selfish and cowardly act from God.”

I mean, you do remember your God, right? The one who wrote and said all those things about Love?

Unless you think your God’s already pulled the plug on us, or, in Pat’s case, Christ has divorced his church because the church’s actions, obviously, demonstrate it’s cogento-absentia…

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The Archeology of a Life

This past weekend Susan and I drove one of our favorite backroad paths through NH and VT. We’ve taken this trip about twice a year for the past five or six years, the first time a happy discovery, the rest a delightful escape from whatever’s happened the day, the week, the month before. It’s beautiful and idyllic, old towns, small towns, towns where church suppers and grade school fairs are still important events and where oaks and elms and pines are taller than the tallest white church steeples and the dead of all wars are honored equally in a single graveyard beneath a well worn flag. Some of these towns are on dirt roads still, an indication of how little traffic and visitors they get.

This trip we noticed a greater than usual number of yard and garage sales. One, there was enough traffic through these small towns to warrant the effort?

But more important and two, why now? What was different this time through? Were we simply more attentive to such things? Were they always going on and this was the first time we drove through at the correct time to see them?

Researchers, we stopped at a few and talked to folks. But not before doing the required bargain searching. In northern New England (and perhaps elsewhere), there’s a protocol to such things. You don’t just stop, get out of your car and start talking. You must demonstrate the proper level of interest or you’re just a nuisance and northern New Englanders are amazingly intolerant of such people.

So we looked for missing Rembrandts and stolen Michealangelos, for D.B. Cooper’s parachute and the Pope’s Nose, picking up a few things and putting them down. I went through old books, more interested in inscriptions than the books themselves.

And at a certain point, we started seeing what was out for sale rather than looking for something worth buying.

Lives.

Lives were on sale. Histories of families and individuals, for a dollar and on display. I was reminded of Hemingway’s response when asked to write the shortest story he could — “For sale. Baby shoes. Never worn.”

Training as an archaeologist kicked in. What could I tell about the society, the people, the culture, based on what I was discovering on this “dig”?

As is common to such things, both quite a bit and not much. In groups, get a large enough sampling from the same era and area, and you can tell quite a bit about the culture, about their society, beliefs and so on. But as individuals? Sans context there is no real content. A shaped shard may or may not be a bowl and only has value if someone decides so. In it’s time it had value to those individuals who used it. We know this because it was found where different aged individuals gathered rather than discarded in a place where we found common trails — indicating traffic — but pieces and piles — indicating refuse rather than re-use.

“Do you have yard sales very often?” I asked. No, they replied. “What’s prompted you to have one now?” Time to move on, they said, time to lighten their loads.

Was this the reason archaeologists could find massive debris fields spanning hectares and ages then nothing? Did societies decide it was time to move on, to lighten their loads? It took our ancestors generations to realize agriculture involved some horticulture, that land had to rest and refresh so it could be reused. We know this from seeing changes in cooking methods and waste products preceding whole societies moving on. At a certain point and in the relative blink of an eye, most cultures began staying put, recognizing letting some land lie fallow allowed for greater harvests each year there-after.

Right now one of the big pushes in marketing and advertising is Green. Everything needs a Green tie-in, some kind of Re-use factoid needs to be part of the pitch.

Probably because with a 7B+ planetary population, we’re running out of 1-use land. In a culture where everything is designed to be disposable, land, still, is not.

Whole societies still move on as mentioned above. Instead of picking up whole tribes and moving on — somewhat impractical these days when nations are still defined by ethnic and racial rather than ideologic boundaries — they’re moving from financial munificence to obsolescence. This is a move of psychologic, of cognitive, landscape, not geographic landscape. Several European countries and the United States are moving from wealthy nation status to greatest debtor status.

But debts of this nature never appear as ledger lines in accountants’ books, they show up in political and business machinations.

The ledger lines are still there, it’s how the debt is written off that’s changed.

But the moving on of whole societies? That remains. Whole cultures move on. We don’t learn to re-use so much as we learn to use something we didn’t use before. Example: the US moved from a gold standard to an imaginary one in 1972. Currently the US dollar is worth what the world market says it’s worth. Of course, the world market has a definite stake in making sure the US dollar has significant value because the world market is currently holding most of the US’ treasury bonds, hence if the world market decides the US dollar is worthless then their investments in treasuries are also worthless. For that matter, no countries are currently using the gold standard. Nothing backs up their “dollar” except what they and others claim it to be worth.

This “it’s worth what I say it’s worth” concept shows up in garage and yard sales all the time. Something I want is marked for $5, I pretend not to be interested and say “I’ll give you 50¢ for it.”

Depending on weather and time of day and mood of seller, I may get a bargain or I may be told to push off. It’s happening right now in real estate. Property being sold for $300k is being bought for $125k. People who had something here move on to have something there.

What will the long-term memories of our lives be at this point in time? What will the archaeologists find in one-thousand, two-thousand, two-hundred thousand years? If everything is disposible except the land, archeologists will determine a people highly in flux, mental wanderers with no place called home for long, who decided to go green while refusing to lie fallow.

Pity, that.

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Come on by and say hello.

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“Does pushing the elevator button more than once make it arrive faster?” (When Applied Logic Fails)

The title to this post is the quote currently used in my email signature file. I’ve written and presented a number of times on using email signatures to drive business and how they’re one of the original forms of social media.

People regularly respond to my email signature quotes. This tells me lots of them read beyond the email body itself and thus all those links in my signature file (I’ve included today’s email signature at the bottom of this post as an example) are seen. I’ll bet they’re acted upon more often than most people would expect because I’ll also receive emails from people who write that they’ve clicked on a link in my signature file, so on and so forth.

But today I got a response that really threw me.

I read your quote and laughed because the answer is so obvious. Everybody knows pressing twice makes the elevator come faster. You press the button and wait, sometimes 15-20 seconds and nothing happens. The lights don’t change and the elevator doesn’t move from the floor its on. You press it again and it begins its descent with 3-5 seconds. So the total time from the second push to the elevator stopping for you (not counting any stops it makes for other people) is maybe 30 seconds, the total time from the first push to the elevator stopping for you (not counting any stops it makes for other people) is

Time from second push to stopping on your floor + time from first push to second push

and this always has to be greater than the time from the second push to the elevator stopping for you.

Come on, J, you’ll have to come up with better problems to solve, LOL.

When I strain myself, I mean, when I literally pull a mental muscle, I can almost understand where they’re coming from.

But, as they say, I doubt the elevator stops on her floor.

Budda-boom!

Zeno would be proud of her, don’t you think?

Budda-bing!

Email Signature file example:

Does pushing the elevator button more than once make it arrive faster?

Joseph Carrabis
CRO and Founder, NextStage Evolution
Senior Research Fellow, USC’s Annenberg Center for the Digital Future
Senior Research Fellow and Advisory Board Member, Society for New Communications Research
Scientists Without Borders

NextStage Evolution, LLC
49 Brinton Dr
Nashua, NH 03064-1274
603 577 4575 voice, 603 791 4627 fax
You can find me on Twitter, FaceBook, LinkedIn, YouTube and Skype (as nseJDC).

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To 4ths of July that Can’t Be Remembered

NextStage’s Research team recently posted Michele Bachmann Fundraising versus Campaigning on our Politics2012 blog and my contribution was one phrase, “the halcyon days of memories that never were.”

It is a beautiful summer day as I write this. I’m sitting at an outdoor table of an Italian cafe in a small New England town, waiting for a friend. The just-before-noon crowd is hopping and scurrying, lunches in boxes, lunches in bags, waitresses bringing lunches to the other outdoor patrons. Each one that passes is an aromatic delight of peppers and pestos and pastas and cappicolla and prosciutto and bread and garlic and espresso.

I close my eyes to better delight in the smells and hear the wind rustling the trees. My eyes still closed, I kid myself that I hear the cumulus clouds, great white billowing beasts with high-wind driven cirrus wisps above them, parading past me several tens of thousands of feet up, sunlight streaming down and hurrying them along. It is a kite-flying day and temperatures are Goldilocksish, neither too hot nor too cold, just right. When I open my eyes the trees perform a green skirted hula for the clouds.

At the table next to me, three middle aged women — one white, one black, one blonde, two in business suits and one in jeans — talk about jobs and husbands and lovers, their voices lower when they suspect I’m paying attention. In reality I’m just smiling at the day.

I passed through several small New England towns on my way to this outdoor table as my penchant is to take country roads rather than highways, my desire to see, to learn and study, an old teaching that “My journey is my goal, my path is my prize” and that things can happen without me. Each town had several signs alerting townspeople to 4th of July fireworks celebrations several days hence, each small town it’s own style of sign.

All these things are creating a memory I wish I had.

A memory of 4ths of July from a youth that never existed. Fourths of July were race, creed and color never mattered because they were caucasian, European and white.

The halcyon days of memory.

My New Hampshire neighborhood is multi-ethnic, multi-racial, multi-creed and multi-colored. Yet when we gather for neighborhood parties (usually a “ChiliFest” although there are no Mexicans here), creeds and colors and races don’t seem to matter. My Nova Scotia neighborhood is also multi-this and multi-that but less so by a factor of ten. The US may be a melting pot but Canada (up until recently, anyway) smelts its citizenry and often forges them in ways the US can’t.

The halcyon days of memory.

The neighborhoods I grew up in were All American even though we all spoke with an accent. Each house waved its flag proudly and each house had lost someone in any of a World War, Korea and in my generation, Viet Nam (I never took part). Wars moved from places we knew because they were our race, creed and color to places we didn’t, to other people’s lands.

Parades and fireworks displays were demonstrations of courage and triumph and The American Way. Now they are opportunities for advertising and insurance claims and politicking. Stores were closed on the 4th so everyone could listen to the high school band and wave at uncles and fathers riding the VFW float. Now stores have regular hours and there’s no money for bands and riders on floats have to sign liability waivers.

But I am older now. I recognize in these latter day things an American Way that probably existed just as well as those I remember but was too young to understand.

Ah, those halcyon days…

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Come on by and say hello.

Sign up for The NextStage Irregular, our very irregular, definitely frequency-wise and probably topic-wise newsletter.
You can follow me and my research on Twitter. I don’t twit often but when I do, it’s with gusto!
Have you read my latest book, Reading Virtual Minds Volume I: Science and History? It’s a whoppin’ good read.

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Combating Evil With Good

A deliberately provocative title for a possibly mundane post, yet I’ve often learned that the best way to combat things that displease us is via mundacity, so be patient with me and let me know if my offering passeth all understanding for you.

Early last Saturday morning, a neighbor brought in a grounds crew to do some mowing and trimming. A team of three young, tanned and able bodied gentlemen, tshirts, cuttoff jeans, workboots and sunglasses all, and each with an incredibly loud piece of equipment, two riding, one strapped to his back, and they had at it.

Early last Saturday morning.

Even earlier last Saturday morning I was already awake. Sometimes I get up early to read on the backporch and listen to the birds, squirrels, chipmunks, bees and the rest of nature fighting for survival.

I heard the truck and trailer drive up and clatter, bang and backfire to a stop. I looked around our neighborhood. No shutters open, no shades up, no blinds withdrawn, no dogs barking, no cats meowing, no children bicycling, no basketballs a’ bouncing, no baseballs a’ batting. It was…

Early last Saturday morning.

About a mile from my house is a donut shop. While my neighbor came out of his house in his bathrobe and slippers to talk to the grounds crew, hair askew and sleep still muddling his eyes, I got in my car, drove to the donut shop and returned with five large black coffees, sugars, creamers and a dozen donuts. My neighbor was still talking to the grounds crew when I drove down the street.

Early last Saturday morning.

I parked in my driveway, gathered the coffees and donuts and walked across the street. My neighbor and the grounds crew were standing in a loose semicircle looking at and talking about my neighbor’s yard, the other half of the circle was taken up by their trailer and equipment. Their semicircle opened a bit as I approached and I assumed the six o’clock position.

“You guys like some coffee?” I didn’t wait for an answer, I handed them each a coffee, the “man-in-charge” first and my neighbor last as the coffees went from 12 o’clock to five, and I put the box of donuts, opened, on their trailer. “Help yourselves. I got a variety. Sure to be something you like.”

All offered their thanks. We chatted. For about an hour. Sipping our coffees, munching on donuts, listening to the dogs start their barking, the cats start their meowing, the basketballs start their bouncing and children start their playing.

By now Susan (wife, partner, all things bright and beautiful) had raised the shades and opened the blinds, a sign her Saturday had started quietly and peacefully, as all civilized Saturdays should.

I took the last swig of my coffee. “I’ve held you guys up long enough. Have a great day and don’t work too hard.” They offered grateful thanks. I don’t know if my neighbor was being charged by the hour or by the yard and I heard him comment “Yeah, he’s a good neighbor” as I walked away.

Many Years Back…

…I would walk a mile in the mornings. This was before the donut shop appeared, our neighborhood was still young and grounds crews weren’t needed. One street on my route always had a bit of litter on it. After a week I decided to take a kitchen garbage bag with me and pick up the litter on my walk. There was an ice cream stand next to a ball park on my return route and I could drop the trash in their bins if I didn’t want to carry it back.

I noticed a young boy and his father on these walks. They also noticed me and we got in the habit of waving to each other as neighbors often do. The occasional “Howdy” and “Hello” and “Beautiful day for a walk” and such and nothing more.

Then one day I noticed them ahead of me on that street, garbage bags in hand, picking up litter before I had a chance.

A month or so later a few streets more were looking cleaner as I walked.

Wicked Problems, Mundane Solutions

This blog has described some phenomenal challenges prevalent in today’s society. Brother David Morf’s Winning on Health and Economics for Real post is an example of such and I applaud him. It’s a worthy and passionate read.

And while we’re busy creating ACOs or waiting for others to create them, go buy a box of donuts for those who irritate you. Pick up some litter for no other reason than you like clean streets.

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Winning on Health and Economics for Real

For the past several years, I’ve allied with a team working to adapt the US healthcare system to serve both population health and regional economic health.  Here’s the current picture…

The US Centers for Medicare and Medicaid Services (CMS) recently issued draft rules for Accountable Care Organizations (ACOs).  As discussed here and here, ACOs seek to reframe care for payors, patients, practitioners, and regional populations.

Here’s how it works.  The ACO rules aim at improving Medicare operations.  However, to accomplish change in that very large piece of the US healthcare puzzle, the entire medical system must evolve across age groups, even though ACOs exist in the formal CMS framework only to serve better the Medicare population.

As a practical result, ACOs function like “Medicare for All” for systemic healthcare operations, but without a population-wide funding element.  It’s a separate matter that funding for the Medicare program itself currently is under attack.

There’s a clear way forward without attacking ourselves—use the ACO conversation to achieve population-wide growth in jobs and wages through sharply improved global competitiveness and economic expansion.  The approach is to supply what the ACO rules leave out of the picture.

We’ll need to take a step at a time.  Here’s the two-step…

First, the Goal…

The goal for the way forward is for regions to create ACOs intentionally targeted to reduce the largest uncontrolled cost items for most private and public employers and regional economies – employee overhead cost, and unrealized regional increases in productivity, competitiveness, pay, and jobs.

And then, Getting There…

Getting to more systemic regional healthcare linked with regional economic value says healthcare operations, and population access and support, will need to become more coherently connected.  What does this mean?

• ACOs need to be sponsored by private and public employers, employee groups, and regional economic and workforce agencies, as well as by hospitals and Managed Care Organizations such as HMOs on a systemic regional basis; and
• ACOs need to be oriented at the day-to-day working level around the regional population and the individual patient—not primarily around doctors, dentists, pharmacists, therapists, hospitals, or health payor subscription (insurance) firms.

Clearly and most certainly, there will be medical professionals, hospitals, and payors – but just like successful service and manufacturing firms and public agencies, they will face the implicit and explicit demands of the people at hand.  This means ACOs will need to face the patient and the population—both individually and regionally—much more deeply through a daily workflow orientation toward team-based care.  This will take a fresh regional flexibility, new to healthcare, but very familiar to the public-facing teams and the process-facing teams in firms, agencies, and supplier organizations.

You may wonder if I’m off my rocker.  Not in the least.  Let’s look at the picture.

The ACO rules leave out the direct connection between the vision of “accountable care” for all, and the vision of a globally much more competitive US economy based on becoming the world leader in regional system integration.  This matters because healthcare affects 17% of the US economy.  Competing nations spend only some 8 to 10% of their economies on healthcare and enjoy healthier populations.

It’s clear that US employers, employees, and regions have a global competitive stake in successful region-wide ACOs for efficient and effective operational implementation and positive population-wide health outcomes.

We know from working models that the link across regional health and regional economic value can be made with regional employers, employee groups, business associations, economic development agencies, stop-loss insurors, and public-private coalitions.  We can apply this experience within the ACO rules.

We know how to apply the operational and strategic lessons learned from employer and healthcare projects to achieve state, regional, and local health and business advantage.  The key step is for regional employers and economic and workforce organizations to connect with the economics and operation of population-wide, systemic regional care.  The connecting step unbundles into three core goals…

• Team care system entry, coordination, medication management, and discharge;
• Patient navigation and population-wide healthy behavior “nudge” assessments, credits, and first-level distance access for preventive, wellness, chronic, acute, and public health care; and
• Transparent electronic health records access to medical records for all care.

Why take this connecting step?  Because regional systemic action, added to the ACO model, will do three sets of things…

• Sustain lower overhead cost;
• Increase population health, workforce productivity, global competitiveness; and
• Grow jobs and take-home pay for more sustainable, resilient consumer demand.

Two quick stories make the point, highlight the process, and lead to lessons learned.  The two stories are Keene 2020 in New Hampshire, and Ontario’s Local Health Integration Networks (LHINs)—Ontario’s own ACO initiative.

Keene…

The Keene 2020 story includes local business involvement in the medical center steering committee, but omits the personal nudge tools from Hannaford and the collaborative care practices from Asheville.  As a result, Keene succeeded in its hospital outreach to the community, but did not connect medical system change with ACO-enabled population-wide change, which is key to lifting a regional economy.

Ontario…

In contrast to Keene, the LHINs in Ontario are a success story for building the critical bridge linking regional health and regional economic value.  The LHINs lead to Ontario’s Mosaic of Stroke task and the Health Transformation Transition & Transformation Learning Project.  Ontario promotes “Quality Universal Low-Cost Health Care” as a regional economic asset.

And Lessons Learned Are on the Move…

We’re bringing here the lessons learned from the Keene, Hannaford, Asheville, and Ontario stories.  These stories show that moving forward will require change.

The approach is to offer direct value across an entire region to small and medium employers and employee groups by offering direct value to employees, members, dependents, and their communities.  The ROI stems from two sources – direct cost advantages in systemic health care workflow, and region-wide productivity gains from healthier work teams and more alert training participants due to reduced absenteeism and (especially) less presenteeism.

Presenteeism is working while unwell, or while preoccupied by unwell dependents.  Work teams multiply member effort.  Teams also suffer team-wide on the downside if members are sick or off their game.  See here, here, and here for productivity gains from systemic employer healthcare initiatives beyond supply chain price bargaining.

The regional productivity aspect offers value to larger as well as smaller employers.  Smaller firms are the engines of invention and growth, and larger firms are the drivers for delivering large-scale prosperity and employment.

The results are hugely worth the effort.  Failure to act will reduce the ability of regional economies to succeed in US and global markets as offshore firms leverage the cost and health advantages that our healthcare process now surrenders.

The critical alignment from the US 2015 program is the ability to extend the Accountable Care Organization framework into a regionally systemic healthcare modernization and economic growth program.  This is an opportunity to leverage ACOs as regional assets for a serious kick-start to population health and economic value in the regions and states of the US.

A Good Day for a Quick Walk

Just taking five to savor and share the moment.  Nothing earthshaking.  It’s simply a beautiful day here in Western Massachusetts for a short walk.  It’s time for a walk.  Cool, clear, slight breeze, sunny, still some snow in patches in the shady places.  Interesting to see the melt pattern.  The patch patterns highlight where sunlight energy abounds or not.  Not always obvious otherwise to see where the energy works or doesn’t.

The snow patches also highlight places coming into early spring, some sooner than others, some with early green and some with interesting leftover hardy weeds.  There are patterns in lots of things.  Surprising what turns up as thoughts touch on topics crossing the mind while you walk.

Today I’m turning over how the promise and the mixed recovery in this spring day echo our wide-area mixed willingness or not to adapt core social infrastructure to continually evolving conditions.  That’s a stretch!  Well, this is like a walk around the neighborhood.

Each plot of land is different.  You can see patches like healthcare, energy, weather, marriage, drugs, taxes, transportation, housing, farming, food, education, war, peace, and the tug-of-war across State Dept policy, DOD money, and conflicted beliefs in people and fear – good grief, there’s a lot on the plate and a lot to do.

Shifting gears here.  As it walks about its own wider neighborhood, this Center for Adaptive Solutions keeps putting energy into social, health, and economic dynamics.  The world is an amazing place, and it’s worth it to work at its grace notes.  Gives the day some zip.  Thanks for sharing this walkabout with me.  Enjoy your day too, and the best to you, your friends, and your kith and kin.

(Too Much) Information Can Be Dangerous, Period

(I want to skip the boring stuff, Joseph. Just send me to the nitty-gritty.)

I read Dr. Lent’s Information Can Be Dangerous to Healthy Decisions and smiled. His opening line, “Information is generally viewed as a good thing” comes from a worldview where…where…well, I’m not really sure where. I know he and I come from different disciplines and sometimes our conversations hearken back to the microbiologist and the anthropologist having lunch; The microbiologist calmly checks her watch and states, “I have to get back and destroy a culture”, the anthropologist goes into shock.

Based on what Dr. Lent writes, I understand his worldview. I also appreciate his examples from neuroscience researchers. I’ve written about how people deal with information (and how it affects them socially and personally) in several places (see link list below. I was writing about this stuff back in 2007. I’ve either got to learn to hold things several years or grow more comfortable being years ahead of the crowd. Which would you prefer?). In addition, I’ve written several scientific papers on Shannonistic, Semantic and Semiotic Information Mechanics and quite a few whitepapers that use these disciplines in a business paradigm (again, see the list below. We’ve been at this for a while now).

When Information Overload Gets Personal

A fellow I’ve known for several years wanted a personal training from me on NextStage’s PersonaScope Tool. I suggested a group, webinar style training and this fellow again requested a personal training so we could go over how to use NextStage’s PersonaScope directly in his business. I don’t usually give personal trainings and as NextStage bills for my time, I had to make some decisions about how such a training should occur. After a little internal haggling, NextStage came up with a solution — a deep discount for my time and the price of the tool’s use. I sent this suggestion off.

What I got back was terse and hurtful. This isn’t my opinion, we have tools that determine such things from a neutral standpoint (maybe you’ve heard of them?) and the tools indicated this fellow wasn’t being pleasant in his response.

But these same tools also indicated this fellow was harried, hurried, distracted, frazzled, frustrated, … all symptoms of information overload.

In short, this fellow wasn’t responding to my offer per se, he was responding to everything going on around him and I got in the way. There was more information coming at him (lots more than my email) than he could comfortably integrate and it got dangerous (he lashed out).

A very similar thing happened when I asked someone to be a commentator on NextStage’s Politics2012 Blog. The response was out of synch (not to mention out of proportion) to the request. We talked, this person admitted there were other, unrelated things going on, and I offered “We respond in the moment with a lifetime of experience.”

What Dr. Lent said

Dr. Lent makes three suggestions in the Healthy Information for Decision-Making section of his post. They’re excellent suggestions and I’ll spin them a bit to make them applicable to individuals instead of groups.

1) Invite your own, internal, diverse group of stakeholders to take part in your decision. In other words, slow down, take time to consider your response, and look at it from all sides, not just your own. In the end, your side should rule and your “side” will be a demonstration of the kind of person you are, so be aware (NextStage has a set of Principles that help us make decisions as individuals and as a company. Feel free to use them or not as you require).

2) Only consider the information that’s relevant to the decision being made. I know of several people who play chess in their minds when dealing with others. They literally go through a “I’ll do this then they’ll do that then I’ll do this then they’ll do that then…” for days and weeks prior to making a decision. I believe there’s a problem when one’s life gets that complicated. Any information that’s not relevant to the decision at hand is a distraction.

Now, careful readers may note that suggestions 1 and 2 could be in conflict. At first, yes, I’m sure.

So Practice!

3) The more important a decision, the more time you should give yourself to make it. You’ll notice that this suggestion is both the result and the cause of suggestions 1 and 2. Eventually decisions that were incredibly difficult to make become instantaneous. People are amazed at your ability to reach conclusions both rapidly and accurately.

What they won’t notice is that you’ve probably been analyzing things long before they became aware a decision was necessary.

And again, this comes with practice(!).

If nothing else, making these suggestions part of your life’s practice might save you from sending potentially embarrassing if not destructive emails.

Information Can Be Dangerous to Healthy Decisions

Information is generally viewed as a good thing.  And the more information the better, particularly when facing some decision. Today we have Google and Wikipedia and Twitter and a hundred other ways to access more information quickly on any given subject than ever before in the history for the human race.  Surely we should be making better-informed and wiser decisions.

Unfortunately, this is not the case.  The sheer glut of information can work in funny ways to impede good decision making.  There are two basic threats posed by information:

• Too much information
• Too little diversity of information

Too Much Information

Recently, I was talking with a group preparing for a meeting on streamlining various organizational functions.  They wanted to make sure everyone had the “facts” on the situation … in fact, dozens and dozens of pages of facts.  Their only concern was that not many people would read the information before the meeting.  I agreed with their concern, but I also had more basic and more serious concerns about the effective use of information in the meeting.  A recent article in Newsweek (March 7) called I Can’t Think! outlines the challenges posed by too much information.

“Trying to drink from a fire hose of information has harmful cognitive effects.  And nowhere are those effects clearer, and more worrying, than in our ability to make smart, creative, successful decisions …. The booming science of decision making has shown that more information can lead to objectively poorer choices, and to choices that people come to regret. It has shown that an unconscious system guides many of our decisions, and that it can be sidelined by too much information.”

The article reports the work by researchers like Angelika Dimoka, director of the Center for Neural Decision Making at Temple University.  By studying brain functioning during decision making with more and more information to absorb, her research shows that “with too much information, people’s decision make less and less sense.”  Basically, the rational part of our brain simply begins to shut down.  The term “information overload” with its connotations of electrical overload and blown fuses may be more accurate than we all thought.

Too Little Diversity of Information

A second difficulty comes from too little diversity of the information.  That is, no matter the quantity of information, it will do little good if it mostly supports one perspective on the subject under consideration.  Unfortunately, we seem to be particularly good at stacking the information deck in our favor, as it were, without regard for the value of diverse views.

In an earlier blog (Saving Congress from Breathing Its Own Exhaust) I explored some aspects of this and noted a piece by New York Times columnist David Brooks who wrote, “we live in a country in which many people live in information cocoons in which they only talk to members of their own party and read blogs of their own sect.  They come away with perceptions fundamentally at odds with reality…”  (March 11, 2010, Getting Obama Right).   He was referring mainly to political decisions, but this is equally true in any area of decision-making about things that matter to us.

Healthy Information for Decision-Making

Since many of the most important, and most complex decisions are those that are(?)made in meetings, I will suggest three ways to use information in a healthier way.

1) First invite a diverse group of stakeholders to the meeting.  The diversity of their perspectives will help to ensure that decisions are based upon a broader consideration of variables.  Diversity may come from differences in functional specialties, levels of authority, and views of the issue.  But most important, the diverse views must all be heard and respected if the meeting is to arrive at a wiser decision.

2) Second, don’t overload the meeting with a large quantity of new information.  Some new information may be critical to framing the context of the decision to be reached, but too much detailed information brought into the meeting just to be sure everyone has the facts on all areas under consideration can lead to muddled thinking and/or various unhelpful emotional reactions.  Instead, trust what people already know.  With a diverse group in the room,  draw upon the power of their collective knowledge through dialogue and an appropriate means of reaching a decision.  Use the power of the internet to look up any specific information as and when it is needed.

3) Finally, don’t rush to closure on an important decision, particularly one where new thinking or creative insights are required.  Research, and perhaps your own personal experience, shows that more creative decisions can be reached when there is an opportunity to let the problem incubate without consciously working on it.  “Sleep on it” is actually very good advice when trying to reach an important decision.  In a meeting, this may mean planning not to reach closure before taking a break for lunch or dinner.  Instead, tell people you wish to complete the discussion when you can come back with a fresh mind.  During the “time away” from the decision you are unlikely to forget that it is unresolved and your mind will keep working on it. As one source put it, “the Zeigarnik Effect is the tendency to experience intrusive thoughts about an objective that was once pursued and left incomplete.”  When you return to the decision with a “fresh mind” you are not coming back to the same point you were at when you left off, but instead you have the benefit of the new thinking that has been going on while you (and the meeting participants) were doing something else.

Now I trust that Joseph, CAS’s local neuroscientist, will add his own perspective on the role of information in decision making.