In: Revolutions

Two excerpts from Clay Shirky’s piece on newspapers (though it’s applicable to health care and more):

Revolutions create a curious inversion of perception. In ordinary times, people who do no more than describe the world around them are seen as pragmatists, while those who imagine fabulous alternative futures are viewed as radicals.

That is what real revolutions are like. The old stuff gets broken faster than the new stuff is put in its place. The importance of any given experiment isn’t apparent at the moment it appears; big changes stall, small changes spread.

Preparing for international health care

Portfolio offers enlightenment on the emerging reality of international health care:

UnitedHealth, which has over 70 million Americans under its care, has already moved to make Bumrungrad International hospital in Bangkok “in network.” When Aetna, with 37 million members, bought the overseas insurer Goodhealth Worldwide last year, Aetna’s CEO explained the move by saying that globalized surgery is “an important emerging trend.” The company has already started a pilot program to send patients abroad for hip and knee replacements.

The big question: does medical tourism remain a classroom discussion or has it now entered the boardroom?

Is anyone raising concerns about the U.S. health care system’s inability to compete (even relatively closely) on price with worldwide providers at the organizational level?

The most important part of the Portfolio story is this seemingly innocuous sentence:

Surgeons in the United States hate the idea.

Physicians make the health care world go round, that’s no secret.  Surgeons will be impacted most by borderless health care.  That means the delivery system will pay serious attention when surgeons’ viability starts to be threatened (now?).  A concerted response at that point may come too late.

The time to think about this/act on this is now.  Some health care will always be delivered locally, the frailty of human life demands it.  The value proposition of primary care is such that it will remain cost-effective (and time-effective) to deliver those services stateside further into the feature than surgical care (for now).  Aside from these caveats (hardly safe scenarios, for what it’s worth), all is fair game for international disruption.

Hopefully health care deals with it more successfully than the domestic auto industry.

Control does not scale.

The definition of a traditional hierarchical organization includes the hospital as an example.  That’s a problem because our society has entered a new age.  The world is messy and getting messier.  Extolling the good is becoming more difficult.  Jeff Jarvis:

So now, we’re digitizing and connecting in an age of abundance. There’s an abundance of good and of crap but, he says, we’re much better at dealing with the abundance of crap. Yes, we filter it, kill it. David [Weinberger] says that when there’s an abundance of good, our institutions are not built for it. “Control does not scale,” he says, “except at tremendous human costs.” Damn, he’s good at setting down the clear law. Control does not scale. Next: “The mess is essential.” The mess is the better reflection of who we are.

Hospitals, in the effort to rid the environment of messiness, control.  They control messages, processes, people, patients, service, etc.  But as Mr. Weinberger so efficiently proclaims, “Control does not scale.”  Hospitals today are not built for the wild environment in which they have begun to operate.  That means a tough road ahead.  Because control as a business model is eroding quickly.  The response, of course, will be more intense efforts to control.  The transition to a completely open model is something that most hospitals are not equipped to handle: in systems, management, and practices.

Who is good at the open model?  Google.  Granted the company was founded on open principles but there are lessons to be gleaned from their operation.  Jeff Jarvis and his new book “What Would Google Do” to the rescue (it was released this week and could become the bible from which to learn from).  An excerpt from the book’s first chapter:

That world is upside-down, inside-out, counterintuitive, and confusing. Who could have imagined that a free classified service could have had a profound and permanent effect on the entire newspaper industry, that kids with cameras and internet connections could gather larger audiences than cable networks could, that loners with keyboards could bring down politicians and companies, and that dropouts could build companies worth billions? They didn’t do it by breaking rules. They operate by new rules of a new age, among them:

  • Customers are now in charge. They can be heard around the globe and have an impact on huge institutions in an instant.
  • People can find each other anywhere and coalesce around you—or against you.
  • The mass market is dead, replaced by the mass of niches.
  • “Markets are conversations,” decreed The Cluetrain Manifesto, the seminal work of the internet age, in 2000. That means the key skill in any organization today is no longer marketing but conversing.
  • We have shifted from an economy based on scarcity to one based on abundance. The control of products or distribution will no longer guarantee a premium and a profit.
  • Enabling customers to collaborate with you—in creating, distributing, marketing, and supporting products—is what creates a premium in today’s market.
  • The most successful enterprises today are networks—which extract as little value as possible so they can grow as big as possible—and the platforms on which those networks are built.
  • Owning pipelines, people, products, or even intellectual property is no longer the key to success. Openness is.

The mess is essential.  Openness, too.

Push pause, it’s time for your appointment

Health care delivery is going to look tremendously different in the near future.  More evidence, this time from Nintendo Japan:


It was inevitable we guess what with everyone plus your grandma using the Wii. Now Nintendo Japan has announced a new Wii “Check-Up” channel that acts as a health guidance system between you and health professionals.


Developed along with Hitachi, NEC, Panasonic and an unnamed health insurance company, the service will offer a communications space where users can get advice from health professionals using the Wii Fit and NEC’s mobile phone platform. Fit users have had success in the past using the system as a method for getting in shape, and now the check-up channel looks like a valuable enhancement.

A passionate organization in a passion-based economy

The Business Innovation Factory’s Saul Kaplan sees a lack of passion in the world today as a result of the evolution to a knowledge-based economy:

We need to move from a knowledge-based economy to a passion-based economy. Who gets excited about a knowledge-based economy? Where is the passion? I have spent a ton of time and effort to rally the troops. If I am honest, people just haven’t connected emotionally. The knowledge-based economy has given us the tools we need but has fallen short in solving the real issues of our time including health care, education, energy independence, public safety, and quality of life. These are all systems issues that will require systems solutions.

A lack of passion in health care.  It’s a disturbing thought.  And it’s right on point.

To be sure, health care careers demand passion.  John Bogle in Enough!:

Contrast the businessmen and businesswomen with others who are chasing what I believe are the real rabbits of life—physicians and surgeons and nurses…  Perhaps these responsible, dedicated souls earn our respect because they serve our society knowing that accumulating great wealth is almost out of the question, that great fame is rare, and that great power–at least temporal power–is conspicuous by its absence.

But there is a problem in the health care organization today.  The practice of health caring is divine, it’s also draining.  It is inspirational, yet demanding.  Many, many great people in this industry do great things every day, very, very passionately.  Many also struggle with frustrations—the cause of which most can be blamed upon the system that we operate in: it makes many silly business practices necessary.  The system can also make “doing the right thing” very difficult to do.

This is where the modern health care organization falls short: it fails to allow for passionate people to be completely passionate about their work.  The very existence of an organization should serve as insulation for the front-line workers inside the organization from the frustration-making realities of the outside.  More often than not, they don’t.  As a result, workers driven by passion often are not.

It’s difficult to determine where the passion is lost.  Talk to most students looking into medical school/nursing school/health administration/etc. (+ early careerists) and you will find that most are idealistic and altruistic in their endeavors.  They are passionate about helping patients heal, about fixing health care, about doing good for the world.

Once the realities of the system come into focus, however, those feelings seem to subside and the health care world suffers because of it.

To be sure, passion still exists for today’s health care worker—on an individual level.  It is passion exuded despite extreme distraction.  The health care worker today is passionate about caring for the individual patient but remains burdened by the business reality frustrations of the industry.  For health care to be great, for the individual organization to be great, passion for what health carers do must be exhibited at the system level.  For it is fact that any progress–any innovation–made in health care delivery will surely be driven by the care givers.

While the modern health care organization is largely responsible for the apathy produced within its bounds, it also happens to be the lone (for now…) solution.  Mr. Kaplan:

If your organization is blindly vested in the way you do business today, it is a good time to explore and test new models and systems with a clear passion at the core. If your organization is determined to resist change, move out of the way because the wisdom of crowds has learned how to mobilize behind a compelling passion. These new purposeful networks will not be stopped.

So are you trying new things?  Are you testing new models?  Have you even thought about such problems within your organization?

Many organizations are trying to find “innovative” ways to bring new nurses on board.  Tactics include giving away gas cards, trips, and vehicle leases…

How about allowing and promoting and creating the most amazing culture ever to be experienced in a health care organization?  An organization where workers can passionately carry out their day-to-day life saving/changing/improving activities?  Workers are finding more desirable outlets for their skill, for their passion, everyday.  They will continue to do so.  Difficult worker shortages will only become more common.  Proper attention to this matter needs to be made.  Building an organization that people desire/long/dream to work for starts with leadership.

Mr. Kaplan for a final thought:

Systems level innovation requires passionate leaders and organizations that are committed to a cause. Passion-based organizations stop at nothing to accomplish their goals and are able to attract people and resources to their causes. A passion economy can arise that unleashes both a new era of prosperity and solutions for the big issues of our time.

Passion-based organizations are a supremely great idea and they require passionate leadership to blossom.  More important, though, are the people caring for patients.  Executives can preach passion from the ivory tower (surely some do) but the passion-based organization is about (all about!) the front-line (read: most important) workers.

Commitment from them is essential, don’t ignore that.

All too many have.

Cost Cutting America: from the blue collar trenches to the corporate world

The venerable Reader’s Digest took a shot at health care cost cutting a few months back.  They have some good ideas (although mostly what we’ve all heard before, still worth the read): manage chronic conditions, improve quality, e-prescribe, collaborate more often, etc.

RD also takes aim at individual behavior (personal responsibility!!): pay workers for healthy habits, use retail clinics for the small stuff, set health goals and make them public, visit physicians virtually, …

The best, though, is the magazine’s plan for making thinking healthy a habit: our schools.  RD says we need to reward healthy eating, rescue recess, and expand gym class.  They very correctly note that today’s generation of children has a real risk of living shorter lives than its parents. There is plenty of room for local health care organization community involvement at school.

It is striking to listen to/read the number of pundits (professional or not) suggest ways to start fixing health care…and yet we lack widespread concentrated efforts on taking action.  Maybe we need a national agenda with a health care czar (it’s a nation of czars, now) to spur the movement (the proverbial nudge) and incent action.

On a related note, The McKinsey Quarterly reports (free reg. req.) that we (USA) overspend on health care by $650 billion annually.  The biggest culprits: outpatient care ($326 billion), pharmaceuticals ($98 billion), and administration ($91 billion).  Again, nothing Earth shattering but plenty of opportunity for transformation.

Proving Innovation: Business Innovation Factory

The Business Innovation Factory is very cool:

An independent, non-profit organization launched in 2005, the Business Innovation Factory was founded to enable collaborative innovation. The BIF idea is simple: create a platform where public and private sector partners can collaborate across boundaries to focus on big win projects and deliver transformative innovations.

We believe that more organizations would innovate if they had access to a safer, more manageable environment to explore and test new ideas–a real world laboratory where organizations can keep current models producing while they design and test new ways of delivering value.

They call their work Innovation@Scale:

The only practical way to accelerate collaborative innovation is to test new business models in a smaller, more manageable environment. Given its location, size, and accessible public and private sector networks, Rhode Island’s unique ecosystem provides the optimal conditions to explore and test new business models. BIF offers members access to this unique innovation test bed, a capability we call Innovation@Scale.

Because of the never-offline/mistake-averse nature of health care, proving innovative ideas in manageable environments is a necessity.  It seems a practical model; one that would benefit a consortium of hospitals/health care organizations who may not independently have the resources for an innovation center.

As it happens, the BIF is working on the Nursing Home of the Future.  Read about it here.  Their pragmatic approach to solving problems is a welcome addition to the solving-health-care debate and provides a model to thinking about bettering the entire health care industry.

Just making sure…

How would you reform health care?  What do you think is health care’s most significant problem?  It’s greatest opportunity?  If you could change one thing about the way health care is delivered in this country, what would it be?

Any of the above (or extension thereof) should be a part of every conversation with any new perspective health care hire.

The answers are not not of much importance.  Heck, the ideas discussed could be as good as prohibition, it’s of little interest (unless it’s really good!).

All you want to know is that a candidate has ideas.

Why?  The money-makers have very little time left enjoying our current system of care (“enjoy” used in the lightest terms possible).  We’re going to need a healthy mix of new thinkers with new ideas to mingle with the wily veterans to help us through the nasty transition.

The demise of personal responsbility and the necessity of reinvention

A few months ago I visited my primary care doctor.  Fortunately (or not) he knows that I’m pursuing a career in health care administration and so I receive the longer than the (less than) standard 10-minute primary care visit.  That extra time is spent discussing health care reform, not my health (still, very valuable, especially since listening to insight provided by physicians like himself will be important to my future financial health).

We got to talking about pay for performance and physician incentives.  His (very accurate) contention is that payers cannot only hold physicians accountable for better outcomes, they must also (very accurately) hold patients accountable for personal decisions affecting those outcomes.  While measures are beginning to do just that, we have a very long, long way to go.

The problem is one of culture.  Long a nation of personal responsibility (“pull yourself up by the bootstraps”), we’ve (the U.S. of A) recently (it’s probably been a long trend downward) entered an era of diffusing responsibility that is having an extraordinary impact on our health.  Whether or not you are a proponent/evangelist of the consumerist movement in the health care industry, agreement must be reached on this point: personal responsibility in daily decisions of health must improve (greatly!).  It is becoming clear that increasing the financial burden on patients to incent more healthful decision making isn’t creating the dramatic improvements necessary.

We’re obese (and getting larger).  We don’t do well with preventative physician visits.  Our eating habits are atrocious.  We exercise dramatically less than we watch television.  We’re becoming more dependent on drugs to correct the problem.  It’s getting really, really bad.  Modern medicine has been the saving grace of many, many patients.

Current events are only decreasing the notion of personal responsibility.

Our banking system will (hopefully, hopefully) be made all better by a government cash infusion of billions of dollars (one that cost more than the Marshall Plan, Louisiana Purchase, trip to the moon, savings and loan bailout, Korean War, New Deal, Iraq War, Vietnam War, and NASA’s entire lifetime budget COMBINED!) after many people made bad, bad decisions.

The (not-so) Big Three are asking for money, too.  This one is going to cost significantly less than the above (reportedly only $10 billion…for now, the charade that was flying on private jets and then driving to D.C. was obviously realized) for companies that badly managed the move toward fuel-efficient vehicles (not to mention their only very recent introduction to good design) in an industry that some say won’t survive (that’s capitalism, by the way).

Our local governments are in trouble, too.  States across the nation are preparing for record-setting shortfalls.  Some mayors have even asked for bailout assistance.  Philadelphia mayor Michael Nutter said, “I want to make sure that cities and metro areas are at the table, that their voices are being heard, that our challenges and problems are well understood, so that we can get relief.”

Many people are looking for relief.  It must be one of those “do as I say, not as I do” moments.

The problem here is that a cash infusion into our personal health can’t fix our health problems.  While the government can try like heck to fix the economic problems we currently face by printing more money, we can’t create more years of life when we reach the unhealthy point of no return.

We need nationwide behavior change.

Even bariatric surgery patients must change their diets; for even after a surgery if a patient returns to eating habits of old, the weight will come back.  A heart bypass surgery patient must change food intake and exercise habits.  The same can be said for any number of current health care procedures.  But the point is, as our collective health worsens, we must start taking action before we have to undergo medical/surgical treatment.

But how, one might ask?

Invest in primary care.  Seriously invest in primary care.  Whether it is done through loan forgiveness or more closely aligning specialist and primary care physician salaries or some other tool (the debate can be had), it must be done.  That less than 10-minute face time with a primary doctor, inexcusable.  People listen to doctors.  Look at me, I’m writing about it after conversing with my primary care doctor.  Start the behavior change in the exam room.  Obviously we need to invest in a personal responsibility campaign, too.  We also need to properly incent patients to follow marching orders (trips to Hawaii? shopping sprees? money off premiums/co-pays/deductibles? community recognition? it’s obvious reduced life expectancy isn’t a big enough stick…).  I look forward to hearing about what other ideas you may have.

Let’s get back to personal responsbility.  It truly is the only tool that will save us.  Diatribe over.