Category Archives: Management

Fixing Healthcare in America

First in a series

To correct healthcare and get costs under control, we must first acknowledge, then change the healthcare industry’s unique and outrageously dysfunctional business model.

  1. Physicians and other practitioners who decide which resources will be used in a hospital are often neither the direct provider, the one who pays, nor the beneficiary of the service. Basic economic rules, therefore do not apply. Medical tests, which are intended to provide information that will in some way impact the patient’s course of treatment, don’t. Many test and other procedures are ordered even when the outcome of the test will in no way affect the treatment of the patient or its results.
  2. Medical products and services are priced without any rationale. Often, prices are set artificially high in order to allow large discounts to insurance companies. This means that patients without insurance can be charged list price; eighty dollars for an aspirin or $100 for a BandAid®. Hospitals, which were once a ministry, stewardship, or public service have changed their priority to the bottom line. Some hospitals now own and operate their own collection agencies augmented by a small army of lawyers to guarantee that they collect what they have billed. This is why it is not uncommon for a small-town hospital to have millions of dollars in the bank—and still retain their not-for-profit status.
  3. And the insurance companies that get those big discounts? The hospital needs a staff of trained bureaucrats to generate the paperwork that is sent to the insurance company in order to receive payment. Payments may not be received for several months (for the MBAs out there—remember the first rule of finance—a bird [dollar] in the hand is worth two in the bush [accounts receivable]). When payment does arrive, administrative staff must reconcile the payments and file additional paperwork as necessary. All this adds to the hospital’s costs without adding any value. The insurance companies, on the other hand, are usually quite profitable, even after spending a lot of money on lobbyists. But just like Don Corleone said, “It’s nothing personal, it’s strictly business.”

So, what do we do?

First, it would be valuable to have the physicians evaluate how tests really affect the outcome for their patients and develop appropriate protocols. Malcolm Gladwell relates an excellent example in his book, Blink. The cardiology staff at Cook County Hospital was able to reduce tests while simultaneously improving patient outcomes.

[Gladwell, Malcolm (2005). Blink: The Power of Thinking Without Thinking. New York: Little, Brown.  ISBN 0-316-17232-4 (Especially the chapter on Cook County Hospital Cardiologists)]

Second, revise medical pricing so that it reflects reality—and that must include adequate margin to offset costs for necessary but expensive services. Emergency rooms are expensive to operate while an intensive care unit for patients suffering from burns is actually cost prohibitive. However, hospitals have an obligation to the community to provide necessary services—either directly or by affiliation—to the community. The community, in turn, must ensure the hospital is resourced to provide a wide range of services. If hospital prices reflected cost plus a reasonable margin to offset other costs, and everyone paid the same price—patient or insurance company, it might lead to more rational decisions—outcomes first, but economics as a consideration. If Grandpa—God love him—is a 96-year-old heavy smoker with high cholesterol and other morbidity factors who was hospitalized because of a stroke, a battery of tests that will not affect his quality of life or his longevity are not appropriate, and the insurer should not be expected to provide carte blanche payments. However, if the prices are realistic, the family may decide that they would be willing to pay for those additional procedures on their own.

Third, emphasize cooperation over competition. Is there any other business, other than hospitals, that would allow someone to work in their facility AND directly compete with it? Radiologists have their competing imaging centers, surgeons may have their private surgery centers, etc. Should specialty practitioners be entitled to benefit from the hospital’s patients and compete with the hospital for those same patients? It should be the practitioners’ choice—one or the other, but not both.

Two excellent resources for these issues are:

Brill, Steven (2015), America’s Bitter Pill: Money, Politics, Back-Room Deals, and the Fight to Fix Our Broken Healthcare System. New York. Random House. ISBN 978-0812996951

Rosenthal, Dr. Elisabeth (2017). An American Sickness, New York: Penguin Press. ISBN 9781594206757

If you want to fix American healthcare, pass this along to your friends, neighbors, doctor, etc. I’ll get a lot of hate mail, but we need to have the discussion.

More to follow.

THE Interview

Today, an interview with a man who needs no introduction. Good evening sir.

Good evening. It’s a pleasure to be here.

The world today is chaotic, yet in other ways, not so much. It was not that long ago—less than a century—when a number of nations were either at war or threatening war.

It has calmed down a bit, but one never knows when some radical leader will appear, appeal to those who have nothing to lose, and create all kinds of mayhem.

As the leader of the world’s only superpower, you have, in many ways, a responsibility to keep some semblance of order in the world.

That’s much easier to say from the chair you’re sitting in than from my chair. It’s a lot of responsibility to commit our blood and treasure to some fracas in a far-off land. Maintaining a military that can accomplish that is expensive and complex. When we station troops in some trouble spot, we still have to keep them supplied with everything from food to weapons. That supply train itself is expensive. People forget that our troops are stationed around the world—Europe, Asia, Africa.

Not to mention the fact that your primary duty is keeping the people back home happy.

The economy is always a major issue with the citizens. Everyone wants protection, good roads, and plenty of fresh water, but no one likes paying for those services through their taxes.

And then there’s politics—a truly demanding and dangerous game.

Dealing with politicians is different than dealing with any other group—they’re all trying to hang onto their power, and line their purse. I swear, there are senators that would stab me in the back, if given half a chance.

Well, let’s hope that they never get such a chance. I know your time is precious and your schedule full, but I do wish to thank you for taking time today.

The pleasure is mine.

Ladies and gentlemen, let’s have a round of applause for the most powerful man in the world—Julius Caesar.

My Computers Are Out to Get Me!

I may have mentioned that I had to rebuild my desktop computer and replace my notebook/laptop/whatever they’re called this year computer.

I try to backup my data regularly. I have a scheduled routine to backup my laptop to one of the large hard drives on the main computer in the house. I also have a separate hard drive especially made for backups that I use about once a month.

Suddenly, with a number of computer based issues staring at me, I get the message on my laptop that the hard drive is full.

Now, I know Windows 8.1.a.(3)[4]—or whatever—is a memory hog. So is Norton 360. And then there’s Office 2013, and I did start my taxes with TurboTax, but c’mon!

I usually have to upgrade the hard drives and RAM in computers, so this was not the biggest surprise, but still… so I ordered a 1 terabyte disk to replace the 500 gigabyte. When it arrived, I turned the computer over, ready to open the little access panel that laptops have so you can replace the hard drive. The one next to the panel to upgrade the memory chips.

No doors.

It turns out that this major manufacturer* of home and office computers has decided that the consumer really doesn’t need to be able to upgrade. The entire computer must be disassembled; the bottom removed, the keyboard removed, the upper case removed. Therefore, they must expect us to purchase new computers every few months or send the unit out for professional repair.

You have got to be kidding me.

I Googled how to disassemble and reassemble the computer and figured that if I had to take the whole thing apart, I might as well expand the RAM as well, so I ordered the memory chips.

When the chips arrived, with my son’s help, we got the computer disassembled, upgraded and reassembled.

Take that you customer hating engineers and bean counters!

Oh, and the reason the hard drive was full so quickly? Remember how I conscientiously backup my data? Well, the special backup drives have a program included; and if you do not have the hard drive connected when it’s time for a backup, it just copies all the data on the C: drive to the (ready for this) C: drive. I erased all these convenient programs and reverted to Windows built in “Backup” program.

 

 

*I won’t name the company, but since IBM was known for having signs on the wall saying, “Think,” this company put signs on the wall that said “Invent.” There’s no proof that the signs now say, “Screw the customer.”

New Laptop–My Discussion with HP & Microsoft

In the middle of my last on-line class, both my desktop and laptop computers died. I scrambled, and I first purchased a laptop while rebuilding the desktop. The desktop stays on my desk, the screen is larger (important for old eyes) and is closer to the printer (important for old knees). Both computers have their place, along with my weather computer (http://wx.com/ke8yn), my microcontroller and ham radio programming computer and my tablet. Having this pompous opinion of myself and my knowledge of computers, I thought that the mega-giant-oligopolistic-corporate-executive business typhoons would appreciate a customer’s honest reaction to their products.

The review I wrote was straightforward. I sent it to Meg Whitman, CEO of Hewlett Packard, and to Satya Nadella, CEO of Microsoft. I told them that I would be printing my letter and their response in my blog in a week. Actually, it’s been slightly over a week.

Here’s what I wrote:

An Open Letter to Microsoft & Hewlett Packard:

My old computer (a hand-me-up from my wife) started having issues. It began to claim that its CPU usage was too high; guess what? So is mine.

So I purchased a new HP Computer using an Intel CORE i3 with Windows 8.1. I found one computer online, but it wouldn’t be delivered in time. So, in order to get the computer in a timely manner—in other words, so I could complete some work before I got in trouble for being late, I stopped at the local store. The computer I was originally looking at was an online item only, and they had nothing similar, so I ended up spending twice as much as I intended. Mechanically it is sort-of, kind-of a nice computer with touchscreen, reasonable battery life and everything.

So, given that I ended up with a new toy, why am I not totally jazzed?


Windows 8.1.

When Windows 8 came out, I paid for 4 licenses, all of which I eventually removed, returning the computers to Windows 7. One computer did not have Windows 7, so I had to spend between one hundred and two hundred dollars to get a copy of Windows 7. If you have to do that, might as well get Windows 7 Ultimate—the top of the line.

The new computer came with Windows 8.1, and I did not have time to find, purchase, and load Windows 7, so Windows 8.1 it is.

I have tried to use Widows 8.1 as intended, using the tiles and applications. Unfortunately, the applications in Windows 8.1 apps are much, much slower than accessing things directly on the Internet. This does not seem like progress.

Incidentally, I have a Kindle and a cheap Android tablet, both of which I use regularly and neither of which operates so slowly.

Now I’m sure you can give me a thousand reasons why this happens. I’ll save you the trouble – I don’t care.

If something is inconvenient, I don’t like it. I don’t care whose name is on it. I don’t care that Bill Gates is still alive and Steve Jobs is dead. I wouldn’t even care if Grace Hopper, Ada Lovelace and Alan Turing reached back from beyond the grave and were the primary authors.

I know that Windows 10 is coming out soon. However, after paying for copies of Windows ME, Windows Vista and Windows 8, I can’t help but wonder if you release lousy products on a regular basis, just to force us to upgrade to something that works.

I’m getting better at Linux, but is it too much to ask for Microsoft to produce a customer friendly product and not charge and arm and a leg for it? Are huge corporations like Hewlett Packard held hostage to Microsoft and unwilling to either seek out an alternative or to pressure Microsoft into producing a quality product?

I anxiously await your reply.

Sincerely,

Steve Nowak

steve@sfnowak.com

http:sfnowak.com

 

Ms. Whitman did not personally reply, but one of her people did. The original reply had a small typo, as opposed to my note which was rife with typos. They corrected theirs. Here’s the response from Hewlett Packard:

Hello Steve Nowak

Hewlett-Packard Executive Customer Relations received your message along with the attached letter providing feedback about your experience with Windows 8.1 plus other operating systems you’ve used in the past, and your disappointment in the functionality and performance of the current software that was preinstalled on the HP notebook you recently purchased.

Thank you for your communication. We appreciate input from our customers. Your concerns and comments will help as the company makes marketing, service, or delivery decisions in the future.

To get assistance for a product/and or warranty related situation, the phone number to call HP’s support division is 1-800 474- 6836 or you can refer to HP’s website via www.hp.com

For other company inquiries, the phone number to reach our office is 1-800 756-0608 option 7 Monday-Friday from 8:00am-5:00pm Pacific Time and our agents will address or direct the matter accordingly.

Kind Regards,

Yun Sil

Hewlett-Packard Company

Executive Customer Relations

Email: email.ecr@hp.com

The response from Microsoft, on the other hand was, ” .”

Mama Jo

Jo wasn’t really her name, but only a few of us knew her real first name and kept it as an insider’s joke and a secret among friends. However, Jo soon became “Mama Jo” to thousands of Sailors and their families.

Around 2007, I had returned from overseas and many Sailors were sent to work “boots on the ground.” It became apparent that the rules, regulations, procedures, and administrivia weren’t equipped to handle Sailors operating outside their normal channels. “Sailors belong on ships, and ships belong at sea!” we were told. Unfortunately, the enemy didn’t agree, and the war was in the desert. Dirt sailors took on whatever duties their nation required. Unfortunately, this meant they no longer fit neatly into the Navy system.

Families no longer had a command to which to turn when there were problems with pay, military housing or whatever. Add to that the wartime toll on marriages, and it was a mess. The Navy Times had articles and letters describing how Navy families whose sailors were serving in the sandbox had nowhere to turn and how they felt—and were—abandoned.

I happened to be in command when we had over one thousand Sailors in theater, so I was suddenly “the expert” for “Boots on Ground Sailors.” The wife of the Chief of Naval Operations saw the problems and took the issue of family problems personally (and my sincere thanks to you, Mrs. Mullen, for caring) and so I was told, “You’re our troubleshooting expert – fix it.”

I confess, throughout my career my Sailors were more important to me than the officers. The officers were my friends and colleagues, and I love them as brothers and sisters. It was my Sailors, on the other hand, who got the job done. They depended on me to shield them from the bullshit but missions that were successful were due to the Sailors, not the officers. I was committed to the Sailors and their families, but this war presented a Herculean task. There was almost no one who could help me tackle this.

Then came Jo.

Jo’s husband had been an Air Force Colonel. She was the only one in the command who was (slightly) older than me (I think). She had been a successful business consultant who shut her business down immediately after 9-11 in order to help our men and women in uniform. There is no one individual who has done more for our men and women in uniform than Jo.

Now there are some who believe that Jo hated me. I love this; if she didn’t get the cooperation she needed from a particular command, she would explain to them, “Well, I’m sorry that we haven’t been able to resolve this, because my Captain is going to be calling your commanding officer and it’s going to be ugly. I have to work with this guy every day, and I can tell you that when this is over, you and I are probably both going to both be in big $#!+. What? You have an idea? Why, yes, I think that might work!”

“Sir (always Sir, dammit), if you hear that the USS Whatever thinks you’re the world’s biggest pain in the ass… (add smile here) it’s my fault,” and I knew that some family had been taken care of.

Jo always threatened to buy a parrot and teach it all the things she said to her kids so when she died the parrot would be passed on and continue to repeat (in her voice) her favorite sayings. She never bought a parrot.

I did. I’ve had parrots before, but Jo provided the tipping point.

There are families who have survived storms, wildfires and tornadoes, thanks to Jo. Together we set up systems to meet returning Sailors as Thurgood Marshall in Baltimore, Norfolk International, and Naval Air Station Norfolk. Not everyone appreciated the importance of this, and it was an uphill battle, but Jo was there.

Sailors who worked with her know she was the first one in and the last to leave. When others arrived, there was coffee already started, and her desk always had a jar of candies. I preferred peanut butter cups, which mysteriously appeared in the freezer of the mini-fridge at my end of the building.

Some people are known for great discoveries and inventions. Others leave great wealth. The best way to describe Jo is with a prayer often attributed (albeit incorrectly) to St. Francis of Assisi; the author doesn’t matter – what matters is that Jo made it happen.

Lord, make me an instrument of Your peace;

Where there is hatred, let me sow love;

Where there is injury, pardon;

Where there is discord, harmony;

Where there is error, truth;

Where there is doubt, faith;

Where there is despair, hope;

Where there is darkness, light;

And where there is sadness, joy.

O Divine Master, Grant that I may not so much seek

To be consoled as to console;

To be understood as to understand;

To be loved as to love.

For it is in giving that we receive;

It is in pardoning that we are pardoned;

And it is in dying that we are born to eternal life.

 

Jo, when we meet again in the next life, we’ll pick up where we left off, except we’ll know our men and women are cared for, and I’ll finally get to meet your husband. In the meantime, know how much everyone appreciates the footprints you left behind.

Fair winds, following seas and peace, Jo.

Oh, and by the way, Mr. President, if for some reason you might be reading this blog and you’re looking for a hero to acknowledge – Jo Carter.

CDC and Ebola

Spanish flu treatment center Smithsonianmag.com

Spanish flu treatment center
Smithsonianmag.com

My congressman ran a poll asking his constituents if they were confident in the Center for Disease Control’s (CDC’s) ability to combat Ebola. He’s probably sorry he asked, because this is how I responded. Obviously these are my own opinions (aren’t they always?), although I did try to check basic facts (number of dead in World War I, etc.)

I spent 30 years in the healthcare industry, starting off in a technical clinical discipline, and later, after completing my graduate degree I moved into management and was a Fellow in the American College of Healthcare Administrators. My current position includes support for emergency management.

CDC is very good at doing certain things, but their best work has involved basic research, which doesn’t mean “simple” but getting to the root issues behind a scientific question. Basic research is often the most result oriented because instead of jumping to a search for the solution, it instead focuses on learning about the problem without preconceived notions. The classic example was when Dr. Fleming noticed that something was affecting the other bacteria in his experiment. By studying this “something” he discovered penicillin.

It appears that in recent that the attention of the leadership of the CDC has been drawn away from basic scientific research and become more focused on political issues, which well may have impacted their effectiveness. For example, there are reliable reports that CDC has spent significant effort to shut down doctors who believe in treating chronic Lyme disease. Some physicians believe that the organisms that causes Lyme disease, and an associated disease, babesiosis can become dormant in a patient, but when triggered by trauma, or other events, the symptoms become active again. Although not scientifically proven, patients have reported improvement when treated with a regimen of certain antibiotics and anti-parasitic drugs.

The CDC has not proven these conditions do not exist, which is understandable given that it is impossible to prove a negative. However, they have taken this issue on as a crusade and allegedly gone so far as to classify this as a Homeland Security issue in order to justify the use of legal authorities and law enforcement techniques.

Unfortunately, they have not been quite as enthusiastic at adhering to basic, proven infection control techniques they haven’t exerted the same amount of effort to adhere to basic protocols resulting in the exposure of CDC personnel to anthrax and the loss of at least one container of viable small pox. Incidentally, small pox was the first chemical weapon when the blankets of small pox victims were given to Native Americans, thereby intentionally introducing the disease to the indigenous population of North America.

I’ll give the CDC the benefit of the doubt. I think they can handle this IF the politically appointed and wanna-be-police types get out of the way. Should we cut off contact with western Africa and deprive them of essential expertise, medicine and equipment? I think not. While it may be politically unpopular, until effective treatments or vaccines are perfected, quarantine may be the most logical step. The health professionals actively working with Ebola patients at the handful of designated hospitals are the best trained and equipped. However, mistakes are made, equipment fails, and while the doctors, nurses, therapists and technologists may follow the protocols correctly, is it possible for a housekeeper or a maintenance person to become infected? I think so.

It may be wise to quarantine people who have been exposed to Ebola. The Ebola hospital staffs may just have to live and work within the confines of the facility for the duration. It’s an inconvenience but our military men and women have been living with such inconveniences for the past eleven years, all the while being shot at, rocketed, mortared and the target of suicide bombers and IEDs.

If the USNS Comfort and USNS Mercy – the Navy’s 1200 bed hospital ships are not being deployed elsewhere, they could provide medical care as well as quarantine. Those exposed and being monitored would not have to live in military austerity, but instead could be housed in nicer accommodations to make the experience less painful; a hotel leased by the government, or perhaps a cruise ship. Nice accommodations, but safely out of circulation until everyone is sure that the individual is not infected

If everyone exposed to Ebola were quarantined for 28 days, it just might prove to be significantly cheaper to pay for lost wages and accommodations for these people than to let the disease spread. If the CDC puts the science and safety first, they’ll succeed. If the politics and power struggles take precedence, stand by. Those who do not study history are doomed to repeat it. The “Spanish” flu of 1918 is estimated to have killed between 50 million and 100 million; by comparison, the total death toll of the Great War (World War I)— all military and civilians—is estimated at 43 million.

Bottom line—let the scientists do their job.

Windows 10

Not the real logo  - or is it?

Not the real logo
– or is it?

After the fiasco of Windows 8, Microsoft has decided to forego Windows 9 and jump right to Windows 10. There may be several reasons for this:

  1. By skipping a number they can bypass all the customers who would suggest that Windows 9 was just the repair for the Windows 8 disaster and should be free.
  2. They’re emulating the observation that until the reboot, fans had noted that, “Even number Star Trek movies don’t suck.”

Good luck with that.

Here’s my well-worth-the-price free advice.

There’s a time for a tool that has a wide range of capabilities. I love my Gerber that fits in a small holster on my belt and can be configured as pliers, wire cutter, screwdriver, bottle opener, knife, etc. If you reference “Swiss Army knife” people immediately visualize the hand red handled tool and the concept of versatility. Both are wonderful products, but if I were being wheeled into surgery and saw either of those on the tray, I’d run out of the room, even if already under those high power pre-op drugs.

Neither a man nor a tool can be all things to all people.

So, last night I rooted my tablet that I use for software defined radio to allow it to speak Linux as well as Android.

Maybe Redmond should review the following educational video (85 seconds).

Shimmer

https://screen.yahoo.com/shimmer-floor-wax-000000185.html