Category Archives: Health care

Burning Toast: American Health System Style

Democrats and Republicans have created a health care system in the USA over the last 40 years that “burns toast” at an alarming rate. As the symptoms of their health care system are displayed they call in people to blame for burning toast.

Their participation in the “you burn, I’ll scrape” system is even worse than the normal burning then scraping process. They create a bad system over decades and ignore the burnt toast just telling people to put up with it. And when some burnt toast can’t be ignored any longer they then blame individuals for each piece of burnt toast.

They demand that those they bring before them to blame, scrape off the burnt toast. And they act shocked that the “toaster” burns toast. It is the same “toaster” they designed and maintain at the behest of those benefiting from burnt toast and of course it burns toast (those results are the natural outcome of the system they designed and maintain).

We need to fix the decades old broken toaster that the Democrats and Republicans built and have maintained. Dr. Deming called excessive healthcare costs a deadly disease decades ago yet Democrats and Republicans allowed it to continue harming us year after year and decade after decade.

We don’t need distractions blaming a few individual for what the two parties have created and maintained for decades. We need leaders to address the real issues and stop the distraction that those benefiting from the current system want to continue to see from those in Washington.

You don’t fix the system if all you do is blame individuals for each piece of burnt toast. Fixing blame on each piece of burnt toast is exactly what those that have continued to make sure the system is designed to continually burn toast love to see. It is a good way to make sure the fixes needed to the design of the toaster are not addressed. Both political parties have done well by those they receive payments from to ensure that the current toaster isn’t changed.

For decades the data shows the USA health care system costs are nearly double that of other rich countries with no better results. And we are not comparing to some perfect ideal, those efforts we compare to need much improvement themselves. So how bad much the USA health care system be to cost nearly twice as much as those systems that have plenty of room for improvement themselves?

Decades Later The USA Health Care System is Still a Deadly Disease for Our Economy

Decades ago W. Edwards Deming named 7 deadly diseases of western management. One of those was excessive health care costs. Sadly that deadly disease has become much worse in the last several decades.

Americans pay 300% more for this prostate cancer drug than much of the rest of the world

Xtandi, a prostate cancer drug co-licenced by Japan’s Astellas Pharma and Medivation Inc. was developed at a U.S. university with grants funded by taxpayer dollars. That gives the federal government the right to revoke the patent if the terms are unreasonable, said the letter, dated Monday.

“We do not think that charging U.S. residents more than anyone else in the world meets the obligation to make the invention available to U.S. residents on reasonable terms,” said the letter, which had Sen. and presidential candidate Bernie Sanders, Sen. Elizabeth Warren and Rep. Elijah Cummings among its signatories.

This specific example also highlights what I classified as a new deadly disease in 2007 – the broken patent and trademark system.

Both of these deadly diseases greatly damage the USA economy and the economic condition of USA citizens. It is disgraceful that the Democratic and Repulbican parties have allowed these deadly diseases to ravage the USA economy for decades.

The drug price situation in the USA is greatly exsaserbated by the corrupt political process. Drug companies give large amounts of cash to those we elect and then those we elect create system that damage the USA economy and provide drug companies huge extra profits inside the USA (those profits then allow the companies to charge other countries even less and still make a great return on their investment). I wrote about this in 2005: Excessive Drug Prices in the USA (and several times since then, Drug Price Crisis [2008] – it is a long term, huge economic problem for the USA).

Health care is extremely expensive everywhere. But in the USA the health care system is twice as costly as other rich countries. This is an enormous burden on the USA economy. Nothing else comes close to being as costly in terms of direct spending. And there a a great deal of other damage done that can’t be seen in just the 100% more the USA spends on health care than other rich countries spend. And the health outcomes are no better for the extra hundres of billions of dollars spent every year for health care in the USA.

The costs of decades of failure are extrodinary. We shouldn’t allow the political parties to continue to fail to sensibly address these problems. Even if we can just get to the point of costing 50% more than other rich countries our economy will be greatly enhanced, but we have not even been able to reduce the health care tax the USA health care system puts on us to just 50% more than other countries. That is a pretty sad state of affairs especially when you consider that other countries are not doing a great job – so we are twice as costly, not as some extremely wonderful amazing system but twice as costly as mediocre comparisons.

Extremely inflatted drug prices in the USA are a significant part of the problem but still only a portion of a system that has been costly the USA economy and citizens hundreds of billions of dollars a year (and untold soffuering in many other ways) for decades. We have to do better.

The Aim Should be the Best Life – Not Work v. Life Balance

My father had the most job satisfaction of anyone I have known. He had no separation between work and life. We toured factories on vacation. I visited Davidson College in North Carolina because he was consulting with a client in Charlotte before we went up to Duke and North Carolina for visits and asked the CEO what school I should visit. His grad students would call the house frequently.

Many of his best friends were colleagues. That is how I grew to know people like George Box, Brian Joiner, Soren Bisgaard and Peter Scholtes as I grew up. Various permutations of our family lived overseas based on his jobs in London (before kids), Singapore, Nigeria and China. Those experiences dramatically impacted all our lives and they were not about separating work from life.

The desire for a life embedded in other cultures and for travel drove decisions about work. He lived in Japan (because of his Dad’s job) for 2 years as a kid and that sparked his desire to do more of that as an adult.

My little brother, Justin, pushing me on a scooter at our house in Singapore.

The sensible aim is to optimize your life. Work is a big part of life. As with any system the results depend on the overall system not the performance of individual parts taken separately. Dad also died young. He was happy to have lived such a good life, even if he wished he could have lived longer he wasn’t bitter about missing anything.

When he learned he would die (of cancer) he mainly continued what he had always been doing living life and working on what he thought was worthwhile. One project he did take on, along with George Box, was creating the Center of Quality and Productivity Improvement at the University of Wisconsin-Madison. George’s speech about Dad’s work provides a nice look at how work and life – William G. Hunter: An Innovator and Catalyst for Quality Improvement.

He honestly looked back on his life and felt he had a life that few could have topped, even though it was cut short. He was certainly optimistic and positive. But my sense was this was his honest assessment, it wasn’t just some fake front he put on for others. He had been living his life as well as he could his whole life. And continuing to live it as long as he could was all he wanted to do.

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Some Thoughts on Investing from My Recent Interview

In the first few years of this blog I posted occasionally, but still much more than the last few years, on investing and economics. Now I mainly post on those topics on the Curious Cat Investing and Economics blog (see how the name and that practice are in sync with each other?).

I was recently interviewed about investing strategies and thoughts and decided to share that with the readers of this blog. Some excerpts from the interview:

I have maintained a portfolio that I call the sleep well portfolio for 10 years (started April 2005). I hardly have any turnover (under 2% annually I think) and hold stocks I would be comfortable locking in a vault for 10 years. The largest holding there is Apple, followed by Google; I also still really like Google as a long term investment. The stocks in the portfolio for the entire period are: Google, Amazon, Toyota, Intel, Pfizer…

We got out of the “Too Big to Fail” crisis, but have not addressed the core problems – and likely have made them much worse. We didn’t take the opportunity to address the financial system risks created by the actions of “Too Big to Fail” banks. And it seems to me we have left the central banks in a very vulnerable position. They have already played strategies that previously seemed impossible due to the position they were placed in, and if it happens again, what are they going to be able to do? I think the risk of massive economic failure is large enough to consider in an investment portfolio.

How would you suggest an investor guard against the potential for a massive economic disaster?

John Hunter: My main thoughts on that are to greatly value companies that are likely to weather economic calamity greater than any since the great depression. Having tons of cash obviously helps (Apple, Google…). Having a business model that puts a company in a position to make money (even if it is a lot less than they are making today) if the economy does extremely poorly, is also good (Apple, Google, AbbVie…).

It is possible for the economy to be hit so hard Apple, Google, etc. lose money. But if that happens, I believe huge numbers of other companies are going to be out of business, and the economy will be in shambles…

The sleep well portfolio has beaten the S&P 500 by about 220 basis points (on an annual rate of return basis) (see details on how marketocracy calculates returns – they reduce returns by 200 basis points to simulate investment adviser fees). The interview includes much more details as well as links to posts on my investing blog going into more detail.
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Management Blog Review 2012: Gemba Walkabout

This is my second, of two, 2012 management blog review posts. In this post I look back at the last year on Mike Stoecklein’s Gemba Walkabout blog. Mike is the Director of Network Operations at Thedacare Center for Healthcare Value.

In a very long post, Some thoughts on guiding principles, values & behaviors, he provides a sensibly explanation for one the real difficulties organization have making progress beyond a certain point (project success but failure to succeed in transforming the management system). “I’m not saying this approach (focus on tools, teams, events) is wrong, but I do think it is incomplete. I think we also need to work from right to left – to help people understand the guiding principles, to think about the kinds of systems they want and to use tools to design and redesign those systems. Dr. Shigeo Shingo said, ‘people need to know more than how, they need to know why’.
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Most managers view their organization like an org chart, managed vertically. They assume that the organization can be divided into parts and the parts can be managed separately
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It’s what they believe, and what they don’t know is that is is wrong – especially for a complex organization.
If their thinking was based on the guiding principles (for instance “think systemically”) they would manage their organization differently. They would see their organization as as set up interdependent components working together toward a common aim.”
Reflections on My (Brief) Time with Dr. Deming – “The executives thought he was pleased. When they were done with their ‘show’ he thanked them for their time, but he wanted to know what ‘top management’ was doing. He pointed out that they were talking about improvements on the shop floor, which accounted for only about 3 percent of what was important.” When executives start to radical change what they work on the organization is starting to practice what Dr. Deming taught. Mike recorded a podcast with Mark Graban on working with Dr. Deming.
Standard Work and PDSA – “What I have noticed is that sometimes people insert another wedge (shown as black) in the diagram below. So, progress gets stopped because some seem to believe that standard work doesn’t get adjusted as you make improvement.” This is a brilliant graphic including the text standard work misued. The 2 biggest problem with “standard work” in practice is ignoring the standards and treating them as barriers to improvement. Standard work should be practiced and if that is a problem the standard work guidance should be changed.

image showing how failure to adjust standard work can block progress

During the year stay current with great posts twice a month via the Curious Cat Management Improvement Carnival.

Management Blog Review 2012: Not Running a Hospital

Paul Levy started the Running a Hospital blog when he was the CEO of Beth Israel Deaconess Medical Center. Thankfully he has continued the blog, renamed to Not Running a Hospital, after leaving that position. Paul provides a huge number (the lowest number of posts in a month was 32) of valuable posts focused on health care, but worthwhile for everyone interested in improving the practice of management.

In addition to his blog, during 2012 Paul published a wonderful book – Goal Play!: Leadership Lessons from the Soccer Field. In my first 2012 management blog review I take a look at Not Running a Hospital.

Some of the thoughtful posts by Paul in 2012:

How to get better at harming people less – “Imagine what we as a society would do if three 727s crashed three days in a row. We would shut down the airports and totally revamp our way of delivering passengers. But, the 100,000 people a year killed in hospitals are essentially ignored, and hospitals remain one of the major public health hazards in our country.”
Medtronic’s Lean Journey – “They knew they would have to think big, but then sweat the details. Over time they figured out how to collaborate.
There were five stages in the process:

1 — Define our operating standards, who we aspire to be.
2 — Set a global expectation to accelerate improvement.
3 — Develop the ability to assess current state.
4 — Create ongoing mechanisms to learn and leverage to close gaps.
5 — Continually check and adjust.”
Sarah Patterson informs about Lean – “Would like Va Mason org to operate like an aircraft carrier. How to run a complex business safety.
Aircraft carrier = an airport on top of a nuclear power plant comprising a bunch of 19 year olds!

Aircraft carrier needs complete alignment with the mission. If not done well, puts others at risk.

Aircraft carrier requires an incredible commitment to adoption of standard work. Relentless focus on training.
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Create jobs that are doable. Train people to do them. Hold people accountable to them.
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Adopted TPS=customer first, highest quality, obsession w/ safety, staff engagement, successful economic enterprise
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Senior leader regular gemba rounds to view one aspect of standard work.”

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USA Spent $2.6 Trillion, $8,402 per person,17.9% of GDP on Medical Expenses in 2010

Total health expenditures in the USA in 2010 reached $2.6 trillion, $8,402 per person or 17.9% percent of GDP. All these are all time highs. Every year, for decades, health care costs have taken a larger and larger portion of the economic value created in the USA.

In 2009 the USA Spent Record $2.5 Trillion, $8,086 per person 17.6% of GDP on Medical Care.

USA health care spending grew 3.9% in 2010 following an increase of 3.8% in 2009. While those are the two slowest rates of growth in the 51 year history of the National Health Expenditure Accounts, they still outpaced both inflation and GDP growth. So yet again the health system expenses are taking a bigger portion of overall spending. This has been going on so long that the USA spends double what many other rich countries do on healthcare with no better results.

As a result of failing to address this issue for decades the problem is huge and will likely take decades to bring back just to a level where the burden on those in the USA, due to their broken health care system, is equal to the burden of other rich countries. Over 2 decades ago the failure in the health care system reached epidemic proportions but little has been done to deal with the systemic failures. Dr. Deming pointed to excessive health care cost, back then, as one of 7 deadly diseases facing American business. The fact that every year costs have increased more than GDP growth and outcome measures are no better than other rich countries shows the performance has been very poor. The disease is doing even more harm today.

Some good things have been done over the years, most notably by Don Berwick while at the Institute for Healthcare Improvement. He was effectively thrown out of office by the politicians recently. The same politicians that have through decades of such foolish acts contributed more than any other group to the broken health care system that burdens the USA today. In the last 10 years a significant amount of good work has also been done in “lean healthcare”: applying lean thinking to healthcare. But it is similar to the quote that a “bad system will beat a good person.” With all the bad systemic issues the efforts, good as they are, in lean healthcare are mainly improving around the edges. Of course, “around the edges” of a $2.6 Trillion dollar system can still be extremely valuable and important.

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More Reasons to Avoid Layoffs

Lay Off the Layoffs by Jeffrey Pfeffer

As its former head of human resources once told me: “If people are your most important assets, why would you get rid of them?”
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In fact, there is a growing body of academic research suggesting that firms incur big costs when they cut workers. Some of these costs are obvious, such as the direct costs of severance and outplacement, and some are intuitive, such as the toll on morale and productivity as anxiety (“Will I be next?”) infects remaining workers.
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research paints a fairly consistent picture: layoffs don’t work. And for good reason. In Responsible Restructuring, University of Colorado professor Wayne Cascio lists the direct and indirect costs of layoffs: severance pay; paying out accrued vacation and sick pay; outplacement costs; higher unemployment-insurance taxes; the cost of rehiring employees when business improves; low morale and risk-averse survivors; potential lawsuits, sabotage, or even workplace violence from aggrieved employees or former employees; loss of institutional memory and knowledge; diminished trust in management; and reduced productivity.
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As bad as the effects of layoffs are on companies and the economy, perhaps the biggest damage is done to the people themselves. Here the consequences are, not surprisingly, devastating. Layoffs literally kill people. In the United States, when you lose your job, you lose your health insurance, unless you can afford to temporarily maintain it under the pricey COBRA provisions. Studies consistently show a connection between not having health insurance and individual mortality rates.

Hospital Providing Better Health Care While Reducing Costs

Business Week has a good article on the strides one hospital has been able to make at reducing costs and improving quality. Hospitals: Radical Cost Surgery

Walk into Providence Regional Medical Center, in Everett, Wash., and you will see a hospital trying something different: It brings the equipment to the patient. In 2003, Providence opened one of the few “single stay” wards in the nation. After heart surgery, cardiac patients remain in one room throughout their recovery; only the gear and staff are in motion. As the patient’s condition stabilizes, the beeping machines of intensive care are removed and physical therapy equipment is added. Testing gear is wheeled to the patient, not the other way around. Patient satisfaction with the “single stay” ward has soared, and the average length of a hospital stay has dropped by a day or more.
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High quality at a low price. Every other industry strives for that combination, but a hospital that does both is all too rare. Providence and its cost-efficient brethren demonstrate that quality care can be delivered at an affordable price, provided hospitals can be persuaded to rethink decades-old practices.

The crazy world of hospital economics does not offer a lot of incentives to change. Both Medicare and private insurers reimburse on a piecework basis – known as fee-for-service – that encourages hospitals to treat more, prescribe more, and test more.
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Providence has also published data showing that infections, lengths of stay, and surgical complications have dropped since starting its own program.

But hospitalists are still controversial in many communities, because primary care physicians are wary of giving up control of their patients, along with their share of inpatient fees. Dr. Joanne C. Roberts, one of the first hospitalists at Providence, has not seen this conflict in Everett, possibly because most of the hospitalists and primary care doctors are associates at one large medical practice, Everett Clinic. That’s not true everywhere, she says. “In another community where I worked, independent doctors were pretty hostile. Everyone was trying to grab part of the money. That just doesn’t happen here.”
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In a study of 2,531 operations at Providence, Brevig reported that the incidence of transfusions was reduced to just 18% in 2007, from 43% in 2003, while the average patient stay was reduced by half a day. The changes have saved Providence an estimated $4.5 million.

Brevig has been proselytizing for his plasma practices at medical meetings, but to little avail. Only some 200 U.S. hospitals have a blood conservation program. Since patients are billed the cost of the plasma, doctors aren’t motivated to change their habits.

There are many more great examples of positive actions being taken in health care. But all you have to do is look at the overwhelming evidence of how amazingly poorly the health care system in the United States is doing to know that it is, overall, an enormous failure. For decades the enormous cost of supporting special interest groups that benefit from the current broken system have forced the rest of society to pay for their unwillingness to improve. We can no longer afford to accept the poor performance. We need to adopt the new ideas much more quickly and eliminate the taxes on the rest of society to support those that want to take an every increasing amount from society to support their outdated, failed policies.

Systemic Health Care Failure: Small Business Coverage

There are many significant problems with the medical care system in the USA. It makes sense that a system that costs over 50% more than other countries and has no better outcomes, from all that extra spending, suffers from many failures. Coverage for small business is one of the problems we face now – When Health Insurers Dump Small Companies:

In June testimony before the Senate Commerce Committee, Potter said insurers “dump small businesses whose employees’ medical claims exceed what insurance underwriters expected. All it takes is one illness or accident among employees at a small business to prompt an insurance company to hike the next year’s premiums so high that the employer has to cut benefits, shop for another carrier, or stop offering coverage altogether – leaving workers uninsured.”
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Joy Mosley, COO of Biotest Laboratories, a 77-person medical testing company in Minneapolis, recently got such a “requote” from her insurer, Medica, after an employee was diagnosed with pancreatic cancer. Medica covered the million-dollar treatment, but then said the large claim warranted $156,000 in additional premiums – a 72% increase.
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Not all entrepreneurs are equally vulnerable. About a dozen states prohibit insurers from basing premiums for businesses with 50 or fewer employees on workers’ health status. But in roughly three-fourths of the country, so-called ratings bands allow for considerable flexibility in pricing. In states with loose ratings bands, such as Texas and Nevada, one small company can be charged nearly 70% more than another. In Pennsylvania and Virginia, there are no ratings restrictions. No matter what state you’re in, ratings bands don’t apply to companies with more than 50 employees.

Just from an insurance perspective the companies are not providing what is needed. They are quick to say you can’t have healthy people remain uncovered and wait to buy insurance once for example, “their house is on fire” (they are sick). They are right. Well you also can’t have the insurance company cancel coverage during the fire and have a system that works.
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