I've been there, just as anyone has. Seduced by the idea that I can both listen to my coworker and keep working on my emails. We all do it. We all think that we're so busy we must do it. But I began to realize I wasn't good at it. As the leader of my business, I wasn't doing the most important I could be doing: listening to my people. Sure, I was in the room with them when they were talking, but that's not listening. Then one day, a coworker came into the room and told me I wasn't listening. So I hit ctrl-alt-dlt on my CPU to make sure I heard him. We had a good serious conversation and he walked out happier than I had seen him in a long time. I realized I needed to listen better. I hit ctrl-alt-dlt the next time another coworker came in and saw the same response. Now I do it every time. Then I added taking notes on my iPhone with Evernote. So I challenge all of you... In one on one's, in meetings, turn off (silent mode) your iPhones, close your laptop lids. Actually 'be in the meeting.' Everyone in my office now knows i have an open door policy, but to let me finish the email or whatever piece of work I am doing before they start talking to me. I finish, I hit ctrl-alt-dlt and then I focus on them. I've learned I am not a good multi-tasker. Are you?... really?
Is It Time To Rebuild & Retool Libraries?
Make magazine (one of my favorites) has a great article on the current state of libraries and suggestions for the future. The library, though in it's current carnation a dinosaur, is an incredibly important social resource at all economic levels. With two little ones now, I can't tell you how important our Carnegie library is to us in Pittsburgh.
But a new future is needed. Make puts forth a new future, of course biased towards 'Make' shops. But I could see this as my children grow up and we continue to find new resources for their minds to grow. Is It Time To Rebuild & Retool Public Libraries And Make “TechShops”?
blog.makezine.com/archive/2011/03/is-it-time-...
blog.makezine.com/archive/2011/03/is-it-time-...
Making Kids Work on Goals (And Not Just In Soccer) - Lean helps in our daily lives too
In a great article in the Wall Street Journal today, the author describes how a philosophy of small goal setting is helping out children perform better in and out of school. They work with coaches at the schools to set a small goal; once achieved, they set the next goal.
I am a huge advocate for Lean practices. It is our mission at Mobile Aspects to help make hospitals leaner and safer. As I look around, I see different version of Lean being performed everywhere I look. I believe not only our hospitals (and our Children's performance in schools) can be made better by lean, but also how we do in our daily lives.
Making Kids Work on Goals (And Not Just In Soccer)
http://online.wsj.com/article/SB20001424052748704758904576188453057819300.html
Doctors try new models to push health insurers aside
Seattle-based Qliance Medical Management's three clinics typically charge a patient about $65 a month for unlimited access to the practice's 12 physicians and nurse practitioners. (Fees vary depending on the level of service and the patient's age.) Office appointments last up to an hour, and clinics have evening and weekend hours, with e-mail and phone access to clinicians as well. Routine preventive care and many in-office procedures are free; patients pay for lab work and other outside services "at or near" cost, and they get discounts on many medications.
The average $700 to $800 per patient that Qliance receives annually in membership fees is up to three times more than a doctor in a standard insurance-based practice might make per patient, says Norm Wu, the company's president and chief executive. "So we can have a third the number of patients and get the same revenue per clinician, but with much less overhead," he says. The approach, he says, allows Qliance to funnel more money into the care itself - through longer office hours, for example, or better diagnostic equipment.
Bruce Henderson joined Qliance when its first clinic opened in 2007. Although at the time he had health insurance through his job, Henderson, now 63, was soon laid off. Now he pays Qliance $79 a month for primary care and carries a catastrophic medical plan with a $10,000 deductible, for which he pays $225 a month.
Henderson has high blood pressure, high cholesterol and Type 2 diabetes. Working with his Qliance doctor, he switched to lower-cost medications and reduced his monthly out-of-pocket costs from $500 to $100. He goes in regularly for blood work and exams to keep his diabetes in check. Periodically he also has early skin cancers removed and last month was in three times for a cyst removal. "The doctors will sit there with you as long as you need them to," he says. "They don't rush in and out."
A 2007 Washington state law encourages "innovative arrangements between patients and providers," such as direct-pay primary care.
There are 15 other direct-pay practices in Washington state, according to a 2010 report to the legislature from the state's insurance commissioner. Some are more conventional "concierge" practices, which are aimed at well-to-do patients, charging as much as $850 a month for personalized, high-touch services. But the biggest growth is in practices that charge fees in the $85 to $135 range, according to the report.
Although Washington state may be a hotbed of direct-pay activity, primary-care physicians in many other states are offering similar services. At Access Healthcare in Apex, N.C., for example, members pay $39 a month plus $20 per visit for unlimited primary-care services, says the practice's founder, Brian Forrest. Having run the subscription-based practice for 10 years, he is now expanding and expects the first franchises to open this summer.
Forrest, a physician, says that half of his clients have insurance, with their typical copayments for primary-care visits averaging $35 to $50. "For lots of insured patients, it's actually cheaper for them to see us," he says.
Washington state's representatives in Congress and its governor, Chris Gregoire (D), successfully pushed to involve direct-pay practices in the federal health-care overhaul. Under a provision in that law, insurers selling plans on the state-based insurance exchanges that will open in 2014 will be allowed to "provide coverage through a qualified direct primary care medical home plan . . . ."
As envisioned by Qliance, direct-pay practices like the one it operates will link to custom "wraparound" health insurance policies that would pick up where Qliance leaves off, providing specialist care, hospitalization and the like.
"What we're inventing here is a new relationship between primary care and insurance," says Garrison Bliss, chief medical officer for Qliance Medical Management. Patients would essentially have two monthly health-care fees: one that they'd pay to a doctor's office for their primary care and another they'd pay to an insurer for all their other care. Providing better primary care should reduce insurance claims for emergency care and hospitalization down the road, Qliance's Wu says.
This idea raises a host of questions, policy experts say, including how direct-pay primary-care practices could charge monthly fees for preventive care services that under the new law are supposed to be provided free.
Some experts have more fundamental reservations about this approach. While agreeing that the current payment model for primary care doesn't work very well, Robert Berenson, a fellow at the Urban Institute, says "it doesn't make any sense" to provide primary care outside the health insurance system. "This is not going to work for a lot of patients who can't afford the out-of-pocket subscriptions."
This column is produced through a collaboration between The Washington Post and Kaiser Health News. KHN, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health-care-policy organization that is not affiliated with Kaiser Permanente. E-mail questions@kaiserhealthnews.org
Norm Wu, the company's president and chief executive: "So we can have a third the number of patients and get the same revenue per clinician, but with much less overhead."
The Young And the Perceptive
Chicago
IT has been more than three years since the beginning of the Wall Street financial crisis, yet we continue to hear about new evidence of glaring errors and widespread misdoings. Even the smartest minds in finance are left scratching their heads: how did we not catch any of this sooner?
When I hear this refrain, I am reminded of Boris Goldovsky.
Goldovsky, who died in 2001, was a legend in opera circles, best remembered for his commentary during the Saturday matinee radio broadcasts of the Metropolitan Opera. But he was also a piano teacher. And it is as a teacher that he made a lasting — albeit unintentional — contribution to our understanding of why seemingly obvious errors go undetected for so long.
One day, a student of his was practicing a piece by Brahms when Goldovsky heard something wrong. He stopped her and told her to fix her mistake. The student looked confused; she said she had played the notes as they were written. Goldovsky looked at the music and, to his surprise, the girl had indeed played the printed notes correctly — but there was an apparent misprint in the music.
At first, the student and the teacher thought this misprint was confined to their edition of the sheet music alone. But further checking revealed that all other editions contained the same incorrect note. Why, wondered Goldovsky, had no one — the composer, the publisher, the proofreader, scores of accomplished pianists — noticed the error? How could so many experts have missed something that was so obvious to a novice?
This paradox intrigued Goldovsky. So over the years he gave the piece to a number of musicians who were skilled sight readers of music — which is to say they had the ability to play from a printed score for the first time without practicing. He told them there was a misprint somewhere in the score, and asked them to find it. He allowed them to play the piece as many times as they liked and in any way that they liked. But not one musician ever found the error. Only when Goldovsky told his subjects which bar, or measure, the mistake was in did most of them spot it. (For music fans, the piece is Brahms’s Opus 76, No. 2, and the mistake occurs 42 measures from the end.)
Goldovsky’s experiment yielded a key insight into human error: not only had the experts misread the music — they had misread it in the same way. In a subsequent study, Goldovsky’s nephew, Thomas Wolf, discovered that good sight readers report that they do not read music note by note; instead, they rely on their recognition of familiar patterns and on their ability to organize the music into those patterns and dependable cues.
In short, they don’t read; they infer. Moreover, this trait is not unique to musicians: pattern recognition is a hallmark of expertise in any number of fields; it is what allows experts to do quickly what amateurs do slowly.
Goldovsky’s insight offers a useful metaphor for understanding the crisis on Wall Street: Not only did hedge-fund managers, bankers and others misread the danger involved in many of their investments, but they misread them in the same way.
As Paul E. Kanjorski, a former congressman who served on the House Financial Services Committee, put it, “Why does it appear to the general public that all the finest minds in finance missed the most obvious?”
It appears that way because they did miss it. These types of errors are most likely to be discovered by those who, like Goldovsky’s young student, look at the world with new, unblinking eyes.
In 2009, for instance, a first grader in Virginia noticed that a popular library book depicted a meat-eating dinosaur as an herbivore. A year before that, a fifth grader from Michigan discovered an error at a Smithsonian exhibit that had gone undetected for 27 years.
And in 2007, another error was caught, this time by a 13-year-old boy in Finland. The mistake involved an image of a submarine that a Russian TV company had used to illustrate a report about a Russian submarine voyage to the Arctic. The image, distributed by Reuters, was used by news outlets around the world. No one noticed anything awry. But the boy, Waltteri Seretin, did. The sub, he thought, looked suspiciously familiar. His suspicions were right: it was a film clip taken from the movie “Titanic.”
Unlike the Titanic, the stock market appears to have righted itself — even as many investors remain underwater. It may be too much to suggest that we let adolescents run Wall Street (assuming, of course, that this isn’t already the case). But it wouldn’t hurt to let them check the math.
Joseph T. Hallinan, a former reporter for The Wall Street Journal, is the author of “Why We Make Mistakes.”
via nytimes.com
Its amazing to me how in today's world, the amazing human mind is now being "thrown under the bus." I find it incredible how the human mind, in connection with our input mechanisms (see: the 5 senses), is able to make sense of a world so rich and do so much. Part of it comes from our ability to infer. Human beings are great at this. Whether in sight, or in conversations (not just a sense, but a combination of hearing, speaking and computing) our ability to infer is incredible. Recently, Watson, the IBM invention, has taken the world by storm, by beating some champions of Jeopardy. Good for Watson and IBM. The problem is, the world is bigger than a game show. It is taking in input 100% of your time, computing through them, making decisions. A computer will never do that to the extent a human can. Human beings are amazing and I am thrilled to read more into the cognitive study and neuroscience behind how we work and tick.
The insanity of health care pricing: Alice in Medical Land #leanhealthcare
The insanity of health care pricing, aka Alice in Medical Land
February 28th, 2011 by
David E. Williams of the Health business blog
One of the interesting things I learned in business school is that not only is it typical for a business to earn 80 percent of its profits from 20 percent of its customers, but that 75 percent of its customers may represent 120 percent of its profit. In other words, not only are some customers more profitable than others, but a fair fraction of the customer base is unprofitable. This kind of pattern is evident in a normal (i.e., non-health care) business. The main drivers are usually cost of customer acquisition and cost to serve. For example, some customers demand a lot more service than others and some customers that cost a lot to bring on only buy once. Price is usually a secondary factor, with more powerful or shrewder customers negotiating discounts.
Once businesses understand their true costs and profitability by customer segment they can take steps to improve profitability. For example, if customers recruited through advertising on Facebook are unprofitable, the company can advertise elsewhere. If some customers use a lot of service, the company can start charging for service explicitly.
Health care is a lot weirder than that, as Ambulance-Bill Chasing in the Sunday Boston Globe Magazine illustrates. A non-health care person wrote about how he tried to understand the bills for his mother’s ambulance rides to and from the hospital. The more he dug, the more bewildered he became:
As a reporter, I’m used to dealing with complex material, but this drive down one of the countless, curvy roads that merge into the Health Cost Superhighway left me both more informed and more confused. Maybe it really is easier to remain clueless and indifferent about our medical bills. The alternative, as a friend who has spent decades in the health care trenches told me, is “to be clueless and terrified.”
The gist of the story is:
- A public (Town of North Andover) ambulance charged $650 for a 4-mile trip to the hospital. Medicare and supplemental insurance will pay $316 and $79 respectively, or $395 in total
- A private (Patriot) ambulance charged $1153 for the return trip. Medicare won’t pay, because it doesn’t consider such trips medically necessary, and Patriot is apparently allowed to charge his mother the full amount. However, they are only planning to charge her $257
Here’s the interesting nugget:
So if Patriot is unlikely to collect its initial steep fees, why bill for them in the first place? Because in this Alice in Wonderland health care world, some people actually do pay them. Car insurance companies, for example, may cut such checks when their clients are in accidents, a windfall [the ambulance company owner] says he needs to offset lower payments from Medicare.
The example here isn’t particularly extreme, because the $1153 for Patriot is only about 3x what Medicare pays. It’s not unusual to see health care charges at 5x negotiated rates. What’s interesting is that there are still quite a few health care businesses that operate in this mode, earning a modest margin on their core business that’s reimbursed by Medicare and commercial insurers with which they have contracts, losing money on the fairly high percentage of patients who don’t pay anything –either because they’re uninsured or just don’t pay–, and making almost 100 percent of their profit on the occasional out-of-network sucker whose insurance pays full boat or who actually pays the bill himself or herself. Some ambulance companies operate in that mode as do other businesses, such as kidney dialysis centers and providers of mail order medical supplies.
It’s not healthy to operate in such a skewed mode, where the normal 80/20 rule cited above doesn’t apply. Price transparency and consumer-directed plans can make some impact here.
However, global capitation would be even more effective. Not only would it give provider systems (such as Accountable Care Organizations) the incentive to negotiate with ambulance companies and their ilk, it could also encourage a more rational view on utilization. If that ambulance trip home really wasn’t medically necessary, why not call a cab instead for $10? Even throw in a nurse or attendant for another $50 or $100 to help mom get settled back into the home…
Posted in Economics, Hospitals, Physicians |
No Comments »
Daring to Practice Low-Cost Medicine in a High-Tech Era | Health Policy and Reform
A child with chest pain or tics, a toddler who is limping, a 12-year-old girl with abdominal pain or headaches, an infant whose fever does not respond to antibiotics — these are age-old challenges that pediatricians face. I have been teaching pediatrics to residents and medical students for more than three decades, but over the past few years, as I’ve watched trainees at work, sitting at their computers, and ordering and monitoring tests, I’ve grown worried that the practice of medicine has tipped out of balance.
Recent advances in scientific knowledge and technology have resulted in the development of a vast array of new tests, new pharmacologic agents, and new diagnostic and therapeutic procedures. These are so accessible to us in the United States that few of us can resist using them at every opportunity. By being impatient, by mistrusting our hard-earned clinical skills and knowledge, and by giving in to the pressures and opportunities to test too much and treat too aggressively, we are bankrupting our health care system. Ironically, by practicing this way, we are perpetuating serious economic and racial disparities and have built a health care system that rates in the bottom tier among all developed countries in many categories of children’s health outcomes.
Most doctors are intensely risk-averse. We don’t tolerate uncertainty. Not wanting anything bad to happen, we reflexively overtest and overtreat in order to protect our patients — and ourselves. We feel judged by everyone — ourselves, our colleagues, our patients, the health care system, and the lawyers. The meaning of “first do no harm” has changed for us. We feel that “doing everything” is the best practice and the way to prevent harm, and we believe that it will shelter us from blame. We order tests and treatments because they are available to us, well before their importance has been established, their safety has been determined, and their cost–benefit ratio has been calculated.
The evaluation of a child with fever and cough is a good example. There are many possible causes, and we have a huge battery of available tests that might give us potentially relevant information. But why should we no longer trust our physical exam, our knowledge of the possible causes and their usual courses, and our clinical judgment? How much will we gain by seeing an x-ray, now, and how likely is it that the result will necessitate a change in our management? How dangerous would it be if we chose to perform certain tests later or not at all? Might our residents not learn more by thinking, waiting, and watching? Who is actually benefiting when we order a test — the patient, the laboratory, the drug company, the health plan administrators, or their investors? And who is losing health care as we spend these dollars? We need to ask these questions of ourselves and our residents at every step of the clinical process.
I believe that we must rediscover the value of clinical judgment and relearn the importance of the personal, intellectual, scientific, and administrative thought that is central to the best practice of medicine. We need comparative-effectiveness research, as well as cost-benefit and long-term–benefit analyses, to inform us how to integrate traditional clinical skills with the use of new tests and therapies. Our time and attention have been diverted to the task of sorting out data instead of sorting out what is important to our patients, their families, and the community at large. This new style of test-avid, cover-all-possibilities practice is bankrupting our health care system and depriving many families of access to health care and a medical home. Not having a medical home can be as devastating as not having a physical home. If children have no primary care, we have no way to prevent their asthma attacks, poisonings, obesity, or suicides, and if they are unimmunized, they may spread vaccine-preventable illnesses to their young siblings and aged grandparents. Society as a whole is the loser.
We as clinicians must change our practice patterns, but first the medical community, through standard-of-practice guidelines, must give us permission (or better yet, encourage us) to practice in a less costly way, so we don’t feel we are expected and incentivized to order expensive tests or treatments. Similarly, clinician-teachers must develop the confidence (or be given the imperative) to teach students, residents, and fellows how to practice in the most knowledge-based, least invasive, most frugal fashion possible and to seek input from physicians with more clinical experience when they feel the urge to order a test or initiate a treatment.
Education of the public is also critically important. We need to admit to our fellow citizens that the United States, despite its wealth, technology, and research expertise, is 21st in the world in terms of many indicators of health, and we must convince them that population-wide changes designed to improve health outcomes would be in everyone’s best interest. We need to teach our patients that more medicine is not better medicine, that it is poor health care for doctors to order too many tests or too many interventions, and that costly efforts do not equal better health care. As we address their personal needs, we need to explain to our patients that we have to use new medical technology with care and wisdom. Indiscriminate health care spending is not fiscally sustainable at a national level and actually hampers the achievement of many universal health benefits.
Every participant in our health care system must focus on ways to optimize health while decreasing cost, at every step of the process. We need to change the financial incentives currently embedded in health care reimbursement systems that reward the use of tests, procedures, consultations, and high-cost therapies. And finally, the legal system needs to be more restrained about pursuing lawsuits when a difficult diagnosis is missed or a treatment fails, to diminish the pressure on health care providers to practice expensive, defensive medicine at every turn.
These are major changes, but today we are far from providing good care for all our citizens and far from achieving health care equal to that in many other countries. We need to incorporate more realistic clinical, scientific, and financial information into practice in order to bring our health care practices, and our health care system, back into balance.
This article (10.1056/NEJMp1101392) was published on March 2, 2011, at NEJM.org.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org.
Source Information
From Boston University School of Medicine, Boston.
TED2011: Dan Ariely Talks About the Biases We Don’t Recognize - Health Blog - WSJ
By Shirley S. Wang
The Health Blog has written a lot about conflicts of interest. At the TED2011 conference, Dan Ariely, a behavioral economics professor at Duke, talked about how hard it is to detect our own subtle biases.
Ariely, a burn victim, recounted how one of his doctors called him into the office and announced he was going to improve Ariely’s life. The doc was going to make Ariely’s face more symmetrical by tattooing little black marks on the side of this face that no longer had hair growth so it would look like the stubble on the other side.
The head of the Center for Advanced Hindsight (motto: “Research into what might have been”), Ariely was skeptical and asked many questions, including what would happen when he aged and his stubble became white. Ultimately, he decided not to go through with the procedure. Ariely said the doctor responded with a big guilt trip.
Puzzled about why his doctor cared so much, Ariely asked the doctor’s colleague and learned that his doctor needed him to be the third burn victim to undergo this procedure so the doctor could publish a paper on it, a conflict of interest that the doctor hadn’t disclosed.
But everyone is subject to this kind of bias. Later, Ariely was looking at some data from a study he was conducting and noticed a participant in one of the two groups yielded data that was unexpectedly poor. Ariely also noticed that participant was significantly older than others and also may have been drunk when the experiment was conducted.
Ariely was about to simply drop the individual as an outlying data point when he realized that if the man had been in the other group, the resulting data would have supported Ariely’s hypothesis. In that scenario, Ariely realized, he probably wouldn’t have been so quick to drop the subject as an outlier.
Realizing he had a bias — wanting his findings to appear a certain way — and a conflict of interest not unlike that of his doctor, Ariely decided to re-run the study.
Only by recognizing that we’re susceptible to conflicts of interest can we try to prevent them from happening, says Ariely.
Image: iStockphoto
Correction: An earlier version of this post incorrectly stated the institution where Ariely is a professor.
via blogs.wsj.com
Subscribe to:
Posts (RSS)
