Status Quo in Healthcare

Status Quo in Healthcare

How can we really make change to the United States healthcare system? Dave Chase, in his book The Opioid Crisis Wake-Up Call argues that changes to the system need to come from private businesses, because private businesses are responsible for the health insurance coverage for over 50% of American’s. If business don’t take action and demand changes, Chase argues, then the system will not have enough strength to push against the status quo of rising costs and stagnant productivity within healthcare.

 

A quote from Chase about changing the American healthcare system reveals something larger about public opinion and the status quo in American public policy in general. Chase writes, “This book focuses on non-legislative strategies since the politics of health care are fraught with pitfalls. As we know, the best way to perpetuate the status quo is to politicize a topic – and nothing is easier to politicize than health care.”

 

I think Chase is correct about politicization and the status quo in the United States. Our country has deeply internalized ideas of liberal and conservative and wedded those ideas to the Democratic and Republican parties. This means that if an idea is taken up by a party, if it is politicized and adopted by a party, then it instantly becomes an identity marker, and people who might not have had a strong reason to care about an issue, suddenly find it to be a maker of who they are and what groups they belong to. Politicizing an issue in this system virtually guarantees gridlock, preventing any legislative action on the issue.

 

Private businesses, however, can make changes without relying on a 50% majority vote (or 2/3rds majority vote in congress). Throughout the book Chase presents economic and moral arguments for businesses to take the nation’s opioid crisis seriously, and uses it as a wake-up call to show businesses how our healthcare system is failing individuals, and ultimately failing the companies that hire those individuals and provide for much of the healthcare that individuals receive (or fail to receive). Public action is hard, so in many arenas, private action is the best chance for making the changes we want to see in the world.
Scale versus replication

Replication Versus Scale

I used to work for a healthcare tech company based out of San Francisco, and the word scale was almost a mantra. Whenever we did anything, from a small policy to the introduction of a new product or service, the question was always, will this scale? It is an important and crucial question for a growing organization. Before anything was introduced, we always considered the future, whether the new process would work if we had more customers, more covered lives, more emails, and more work. If the amount of effort, oversight, and individual contribution was too high, then we new we were not looking at something that would scale. We needed processes where the amount of additional work would be negligible as we grew, that was the key to scale.

 

For many organizations, however, scale isn’t necessarily the most important goal. Instead, the focus is on replication, to grow and expand in new spaces, new markets, and new products. Replication is something different than scale. While scale sought to reproduce the same outcome, the same process, and the same expectations in all settings, replication takes a slightly different approach to the same end goal. We still want the same successful outcome, but the goal doesn’t include having mirrored consistency in approach with diminishing marginal effort for each new customer. Replication is adaptable to changing local conditions.

 

Dave Chase describes it like this in his book The Opioid Crisis Wake-Up Call, “Replication varies from application to application; scalability seeks to apply the same things everywhere. This distinction is a subtle but absolutely critical success factor.”

 

In retail, social media, and chain restaurants, scale is crucial. You want every coffee you order at Starbucks to be the same, regardless of whether you are at the first Starbucks in Pike Place, or a brand new Starbucks in a Las Vegas suburb. You want your eggplant Parmesan at Olive Garden to be the same today and next month, and social media companies want everyone to have the same account set-up and access settings so that it is easier to manage all the companies, individuals, and organizations that create accounts. Scale makes things consistent, reduces administrative burden, and keeps costs down.

 

Replication is more adaptable from region to region, setting to setting, and industry to industry. The goal might be very similar, say to reduce healthcare costs, but the organizations and spaces might vary dramatically, say from nursing homes to companies offering remote medical second opinions. What Chase argues is that many healthcare organizations shouldn’t get too caught up on scale, and should focus more on replication. Hospitals can learn from nursing homes and replicate the approaches they take to improve patient adherence to medication regimens, knowing that there is some overlap and some divergence in their patient populations. Health plans can replicate patient education models that hospitals find successful, even though the patient education from the health plan will take place in a different form and space.

 

Scale dictates what should be done to create exact copies of a process with diminishing marginal costs, but replication is necessary when dealing with multiple confounding variables in dynamic and ever changing spaces. Scale might be needed for economic success at national and multinational levels, but replication provides the flexibility and creativity needed for success when a cookie-cutter model can’t be followed.
Businesses and Healthcare Solutions

Businesses and Solving Healthcare Problems

We often overlook businesses when we think about the problems in American healthcare and how we can fix the issues that plague our system. But about half of all American’s receive their health insurance as a benefit provided by their employer. Businesses purchase and provide health insurance for millions of Americans, and must think about employers and the plans they offer when we think about the problems in the American healthcare system.

 

Everyone will tell you that healthcare is complicated. We know that insurance is hard, getting to a doctor can be hard, understanding what you have to pay is hard, and trying to guess what kind of plan you need for the next year is hard. All of this makes the solutions to our healthcare problems hard, but for a majority of Americans, the person who is shaping the structure in which they will make these decisions and figure out what is available to them is someone at their job. And for a lot of those Americans, the person at their job is probably in HR, and their main goal is not to find a great healthcare solution for the employees, but to just not get yelled at by the CEO for raising health insurance coverage costs and to avoid being yelled at by unhappy employees. Nevertheless, businesses can step up and play a role in making changes for the positive in the American healthcare system.

 

Dave Chase in his book The Opioid Crisis Wake-UP Call writes, “The opioid crisis is a complicated issue over 30 years in the making. But companies have played a major role in creating and sustaining the crisis. And a vanguard of employers are realizing that they have a major role to play in solving it, and that the solutions fall well beyond what the government alone can do.”

 

Companies, since they control the healthcare of half of Americans, can start making real changes to the care available to people. Employers who set up their own plans can make primary care access, physical therapy, and nutrition services virtually free to their employees. By providing a greater selection of preventative services, they can improve employee well-being and reduce the likelihood that an employee will deal with chronic pain and develop an opioid addiction. This is an over-simplified example of what companies can do, but it is important that we realize that the employer is a major player in the fight to improve the American healthcare system, and if we don’t step up to demand better from our employers, we won’t see the changes we want.
Disruptive Innovation

The Basics of Disruptive Innovation

In his book Deep Work Cal Newport shares a story about Clay Christensen, the Harvard Business School professor who coined the term disruptive innovation. Its an idea I like quite a bit, especially since it is a big concept in healthcare right now, and I focused quite a bit on health policy and dabbled slightly in healthcare economics during my graduate studies.

 

Newport describes the basics of disruption like this, “entrenched companies are often unexpectedly dethroned by start-ups that begin with cheap offerings at the low end of the market, but then, over time, improve their cheap products just enough to begin to steal high-end market share.”

 

In this model, Uber wouldn’t be a disruptive innovation. Uber didn’t do anything to dramatically change the world of taxis. They sidestepped a lot of entrenched thinking and decided that laws and regulations didn’t apply to them while introducing badly needed technology to the world of taxis, but they didn’t offer a new cheap version of the service to gradually build upon and improve.

 

An example of disruptive innovations that I like, that I learned about in a healthcare economics class, is Bose headphones. Bose is producing headphones that have impressive noise cancelling, noise isolating, and noise amplifying technologies. They are certainly not cheap consumer products, but compared to highly technical, very expensive, and highly individualized hearing aids, they are. They don’t do everything that a hearing aid does now, and they don’t provide quite as good of a hearing experience for someone who relies on hearing aids, but they do seem to be able to compete at the lower end of the market. For people who are currently priced out of hearing aids and people who don’t have complete hearing loss but maybe should start considering hearing aids, Bose headphones seem like they can help. They can cancel competing sounds and provide just enough amplification and isolation to improve some people’s hearing…even if hearing aids would be a better long term solution.

 

The concept is important for several reasons. If you are a business executive, you need to know what is happening in your market space, and you need to know when someone is coming along to provide a cheaper service that might one day compete with you directly, or steal your market share. Also, from a regulatory standpoint, understanding disruptive innovations and where they may be occurring is important. If people are ditching their pricey hearing aids for less effective Bose headphones, are they putting themselves at risk while driving or navigating busy environments? What happens if a disruptive innovation guts an industry, and leaves people with disabilities who relied on the high priced product’s level of support and customization without a suitable product or service?

 

We should keep disruptive innovations in mind because they can unlock new potentials (we do a lot with our phones in ways that are quicker but not always as user friendly as old standard alternatives) but can also be dangerous for individuals and markets (should we really allow anyone to use a phone to scan their eyes to get a new glasses prescription?). Thinking about disruptive innovations helps us think about current social and economic trends, and it also forces us to be more considerate of others. We have to balance and weigh the interests of business, the interests of new consumers, and the interests of vulnerable populations when we think about where a disruptive innovation could push a market.

Marginal Charity – An Opportunity for Big Business

Big businesses strive for efficiency. If something can be reduced, eliminated, streamlined, and automated then at some point it will be. Each tiny advantage can be huge at scale, and can mean the difference between growing and laying off employees. Flaunting success, hiding failure, and maximizing at the margins are standard business operating procedures, but they create a void that could be filled for companies to do meaningful things that can be viewed in a charitable light. In The Elephant in the Brain, Robin Hanson and Kevin Simler talk about “marginal charity” an idea that you can do something that economically doesn’t add much cost to your own life, only marginally diminishes your efficiency, but provides a big element of charity to the business you are already doing.

 

In the book, the authors consider a high rise apartment building. Say 10 floors is the height to shoot for in order to achieve maximum efficiency. There may be situations where adding one more floor would not increase the cost by a significant amount, but would reduce the efficiency that the building owners and property developers expect from the complex, especially if the final floor was developed to allow for more low-income/affordable housing. Adding this extra story doesn’t make sense in a pure efficiency model, but if you are trying to add a touch of charity to the business you are already engaged in as the developer, you can do a lot of good by providing many additional affordable housing units with little marginal cost to yourself.

 

Hanson and Simler write, “In terms of providing value to others, marginal charity is extremely efficient. It does a substantial amount of good for others at very little cost to oneself. (In other words, it has an incredible ROD [Return on Donation]).” Finding a way to add a little extra while taking away from your own individual efficiency may make the entire system a bit more equitable, and a bit more efficient as a whole. Small tweaks to how to do things and create the systems that shape our lives can help provide for greater long-term benefit even if they slightly limit what is possible for us now.

 

Since we are not all property developers, we won’t all have this type of chance to make a big difference through small actions in a business context. But we can think about marginal charity in our own lives and try to set up systems and structures that help us default toward charitable behavior. I don’t think this looks like donating a dollar to the thing the grocery store check-out system asks you to donate to (I’d recommend saving that money and making a single larger donation to a charity featured on GiveWell), but it may look like picking up bottles or trash along the street you already walk down every day. It may look like increasing your recurring donation by an additional $5. It may look like making personal choices that add a little extra cost, but reduce energy use, plastic use, or single use item consumption. We can think about charity on a marginal level, encourage others to do so, and that will help build a spirit of looking for those marginal charity wins. They may not change the world, but they might help set up a culture and system that will.

Overly Reliant on Outside Influences

One of the draws that I have toward stoicism is the idea that both good things and bad things will happen around me, but that I can always decide whether something is good or bad and how I will move forward from the good things and bad things that happen around me. My reactions are something I can control even if I can’t control the weather, the person who cut me off on the freeway, or the economic downturn that sinks my business. In stoicism, I have found a set of tools for objectively viewing the world and developing an inner ability of focus and calmness.

One of the authors who taught me a lot about stoicism is Colin Wright and his book Becoming Who We Need To Be is a somewhat stoic look at the forces in our lives that shape the people we are becoming and how we can respond to those forces to become people who are well equipped to do the important things to help society become a better place. In one chapter of his book, Wright highlights an idea that many companies, industries, and professionals in American society now operate on a business model based on making us feel small. The business model positions the company, coach, or set of coaches as the only thing that can take us from where we are to where we want to go. Wright references certain types of gyms, certain health restaurants, and in some cases our coaches, mentors, or guides from the self-help world. In his book he writes, “I’m not saying there’s anything wrong with self-improvement. … But I am saying that when we become overly reliant on outside influences, encouragement, and incentives in how we feel about ourselves, we open ourselves up to abuse and mistreatment. We open ourselves up to being manipulated.”

Business models that rely on customers becoming reliant on them put us in a position where we cannot walk away. Their goal may seem like it is to provide great kick-boxing workouts or to help motivate people to get in shape and make good decisions, but what is really happening is the development of a cycle of dependency and the development of personal identities that don’t operate without the business at the center providing the affirmation that one is living properly, doing the right things to be healthy, and taking the right steps for a validated life. Stoic philosophy turns this business model on its head by suggesting that we already have all the means within the faculties of our minds to be fulfilled. We don’t need to tie our self-value and self-worth to the praise of another person. It is not up to money, social status, or the number of mornings at the gym which determine whether we are living the right life. We have value by virtue of being a human being and we can use tools around us to improve our health, try to reach out goals, or build a community of like-minded individuals, but we don’t have to tie our entire identity and value as a human to these industries in order to define ourselves and become valuable and meaningful.

Coaching Tactically and Coaching Strategically

I work for a tech start-up in the heath care space and within our company (at least in our office which is lead by a couple of former Microsoft ninjas) two key buzz words are tactical and strategic. I was not sure exactly what these words meant and how they were used in business until I had a very specific meeting with our site director who was at one point my manager for roughly 6 months. I was in a one-on-one meeting explaining some challenges that I was facing in my role. Every day I was reacting to problems that bubbled up and needed my immediate attention, and I was not quite doing anything that would get ahead of those individual problems and solve the long term issues that created these acute problems. My boss at that point described the difference of thinking tactically versus strategically.

 

The daily grind and the individual problems that scream for our attention create the tactical work. The long term planning and insightful problem solving that stops those problems is the strategic work. The tactical is important and takes a certain set of skills, but the strategic is the differentiator — what separates the average companies from the excellent companies, what makes the top employees stand out from those who show up each day and punch a clock. What I was learning in that one-on-one was the difference between the two types of thinking. Now, when I look back at that coaching session, I also  see two different coaching styles at work.

 

In his book The Coaching Habit author Michael Bungay Stanier makes a distinction between two types of coaching: coaching for performance and coaching for development. He describes the two styles and approaches in the following way, “Coaching for performance is about addressing and fixing a specific problem or challenge. It’s putting out the fire, or building up the fire, or banking the fire. It’s everyday stuff, and it’s important and necessary.” In this quick quote he is describing tactical coaching. How can you help an employee, colleague, or friend navigate the individual challenges that are popping up in front of them and how can they get through those obstacles? Bungay Stanier continues, “Coaching for development is about turning the focus from the issue to the person dealing with the issue, the person who’s managing the fire. This conversation is more rare and significantly more powerful.”

 

The second quote is about coaching strategically, helping the individual see not just how to overcome one challenge, but how to adapt and change what they are doing, the process they work with, and how they are approaching obstacles to make them better in the long run. It is a focus on the individual and their growth as opposed to a focus on a problem and how to address that problem. Thinking strategically requires awareness and understanding of common threads between problems and issues, and that is what you are trying to build in the other person. You are working with them to find the areas of growth for them that will connect the dots in their own life and story, and you are working with them to shift their perspective to solve long term problems and not immediate issues. This is what my boss was doing with me when he explained the difference between thinking tactically in my daily work and angling myself and my operations to be more strategic.

Create Great Work

A real challenge across the globe in the coming decades will be helping people find ways to do meaningful work. A lot of our work today really is not that meaningful, and as more jobs can be automated, we will find ourselves with more people looking for meaningful work. Helping people find meaningful work will preserve social order and cohesion and will be crucial for democracies, companies, families, and societies as a whole as we move forward.

 

Michael Bungay Stanier looks at the importance of meaningful work in his book The Coaching Habit suggesting that coaching people is easier and better when you are helping someone with meaningful work. When you give people tasks and ask them to do meaningless jobs, you will never get the most out of them and you will never inspire them to go above and beyond. He writes, “The more we do work that has no real purpose, the less engaged and motivated we are. The less engaged we are, the less likely we are to find and create great work.”

 

The company I work for makes a real difference in the medical world. Our work leads to better health outcomes for patients and families and it is easy to see how our work has real purpose. But even within the work that I do, there can be tasks and responsibilities that seem unnecessary or burdensome. These little things can build up, and even within a good job they can begin to feel tedious and disengaging. To combat this, my company encourages efficiency and automation within the important things that we do. We are encouraged to think about ways to improve systems and processes and to find new ways to do things better. It is the autonomy and trust from our leadership that helps us stay engaged by allowing us to continually craft our jobs to an optimal level.

 

Not everyone is in the same situation that I am in. Many companies hold people to specific processes and inefficiencies, perhaps just to see how conformist and loyal individuals are to the firm. This holds back growth an innovation and demotivates and disengages employees. As this happens to more people and as meaningless tasks are displaced to robots, we will have to find new ways to motivate and engage employees, because our employees are our fellow citizens, and because motivation and engagement can be thought of as a public good. We all rely on an engaged citizenry for our democracy, and work helps us feel valued and engaged. How we face this challenge as individual coaches and as companies will make a big difference in how engaged our society is in the future. One approach is to help ensure everyone on your team and everyone you coach understands how their work contributes to the overall mission and goals of the firm. This does not simply mean that you hand everyone a nice slogan about why their position and duties are important, you must actually show how the company plans to move forward and how the department and the individual will contribute to the new direction. A recent challenge for myself that I have been thinking about is how you direct resources and attention to groups to also signal their importance. Without the leadership demonstrating how specific work contributes to overall goals and without time and attention appropriately directed to an individual or department, even important work can begin to feel meaningless or forgotten, and firms and societies will never benefit from the innovation and dedication of great work.

Owning Our Mistakes

Fred Kiel gives a few examples of what it means to be a great leader for a company in his book, Return on Character, where he focuses on the ties between strong moral values, success, and leadership. One of the examples he gives of what it means to be a leader who focuses on ethical and moral strengths involved owning up to our mistakes and being honest and forgiving with ourselves and others when we make mistakes.

 

In his book he tells a story to focus on a fictional character who does not receive a promotion. The character then begins to examine himself through a process of self-reflection to understand how he can change his behaviors and actions to enhance the skills that he had already developed. One area he identified for growth involved abandoning his habit of creating excuses for mistakes and failures, and working to better accept his errors. Kiel uses the simple example to show how an individual can become a stronger leader by beginning to better understand their mistakes and take responsibility rather than pushing blame onto others. Kiel’s character began to see that accepting his mistakes and forgiving himself for his errors made him a leader with stronger character, helping him connect better with those in the workplace. Kiel wrote of his fictional character’s change, “By owning up to his own mistakes, he would communicate to others in a very powerful way that he cared for them as people. He was telling them that he’s no better than they—that he shares a common humanity with them.”

 

By being honest and leading with character Kiel explains that we become more likable as people. Those around us with whom we work, spend time with, and live with will find us to be more complete when we acknowledge our mistakes. If we do not honestly address our mistakes then we put ourselves above others on a pedestal of perfection, and we fail to recognize an important part of our humanity.

 

Kiel also suggests that owning up to our mistakes helps make us better leaders and  more successful individuals. Failures and errors are things we will all experience and being able to recognize those shortcomings in a safe way will help us move forward. This part of his message reminds me of the advice that Bob Schacochis shared with James Harmon for him to publish in his book, Take My Advice. Schacochis writes of his early days working as a carpenter, “When it comes to making mistakes a bad carpenter and a good carpenter is the same. The only difference is, the good carpenter figures out how to correct his.” What he is saying is that we will all have errors along the way, but to truly be good we must recognize those errors and take the time correct them, allowing us to grow.  We can’t expect to be perfect and we can’t expect others to be perfect, but we can expect everyone to own up to their mistakes and to find ways to correct their errors.

Compiling a Coherent Life Story

One characteristic that high performing and morally focused CEOs have in common is an understanding of their life story and the events that happened in their life, shaping them into the people they are today. This idea is a cornerstone part of Fred Kiel’s book Return on Character. Kiel researched successful companies and CEOs trying to identify the importance of strong moral judgement, personal ethical behavior, and ideas of responsibility among company leaders.  He found that CEOs who displayed strong moral character and built leadership teams that mirrored their approach to relationships and ethics, outperformed those who were self focused and did not apply rigorous moral standards to their work and companies.  The businesses led by these moral CEOs had employees that felt more engaged, and productive, had better relationships with the communities in which they served, and had loyal customer bases. All of  these benefits stemmed from the CEOs high moral standards and made the companies more successful.  A key aspect in the lives of the CEOs who led these high performing companies was self-reflection and self-awareness.

 

Kiel argues that you cannot build a foundation of strong moral habits and characteristics without reflecting on what has impacted your life and led in you in a direction where you become more considerate, looking beyond your own benefit to see the world from multiple perspectives.

 

“Uncovering the sources of your character and moral habits is, in many ways, an essential element of compiling a coherent life story.  By piecing together a clear picture of how you formed your understanding of the world, you can identify the source of the negative ideas, emotions, or responses that may be promoting those aspects of your character that you need to address.”

 

This process of self-reflection is challenging, but what it uncovers are the motivations that push us to action and drive us toward goals which we were not aware of.  To avoid becoming self focused and acting in only your own interest one must truly examine how they define success, and where that definition originated. If we are chasing a certain lifestyle, a certain size of house, or a certain car just to show others that we have become successful, then we are acting out of a misplaced motivation.  Our motivation is based on what others see as successful and we are trying to act in a way to impress and show others that we are valuable, ultimately pushing us to be more interested in our own success than the success of the bigger organization in which we fit.

 

Contrasting this vision of a self-focused individual, a CEO with a strong moral character would have at some point recognized what drives their motivation and their definition of success, and they would have realized that it can be toxic to act out of motivations defined by another individual.  To truly follow ones passion and find a better aligned level of success, it is important to know what pressures society, parents, friends, and others have placed on us.  We may want to reach a certain level in our career to impress those who are in our social group, or we may be trying to reach standards of success presented to us in advertisements. A virtuous leader would understand their own vision of success, and find a goal that aligns with their inner self and is worth driving toward. Their life story would help them understand where they are, where they want to go, and how to move forward in a way that returns the benefit to everyone.