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.
More on Isolation and Addiction

More on Isolation and Addiction

I previously wrote about pain medicine ideas that Sam Quinones presents in his book Dreamland. He is critical of the idea that we can take a pill to alleviate chronic pain without making substantial changes in our lives to address the root cause of our pain. Even if we can’t completely stop chronic pain by changing our habits, our environment, and our lifestyles, Quinones shares information which suggests that our experience of pain is connected to many parts of our lives, and that we can change how we think about and relate to pain, even if we cannot eliminate it completely. This is a holistic approach to pain and pain management that Quinones thinks is a crucial piece for understanding our nation’s current opioid epidemic.

 

Chronic pain and its mismanagement is a common route to opioid addiction. Quinones views opioid addictions similarly to how he views chronic pain. In his book he writes, “Chronic pain was probably best treated not by one pill but holistically. In the same way, the antidote to heroin wasn’t so much Naloxone; it was community.”

 

Naloxone is a drug that helps prevent opioid overdoses by binding to opioid receptors in the body to block the effect of opioids like heroin. This drug has helped save thousands of lives, but on its own it won’t stop addiction. Quinones argues that a big problem with addiction is the way in which we hide it from others, whether it is addiction to drugs, gambling, or something else, we don’t allow anyone to know about our addiction. Without talking about addiction, without acknowledging that it has had impacts on our families and lives, and without having meaningful connections with others, we languish in our isolation and addiction.

 

The argument that Quinones makes in his book is that we need more community. We need more things in our lives where we interact meaningfully with others. We need to find more ways to be in service to other people, to work together for meaningful causes, and to have greater social connections with the people around us. By developing meaningful relationships with others, we provide community for everyone, and that helps push back against the forces that drive toward isolation and drive many of us toward substance addiction. Community provides us the space to discuss our challenges, our addictions, and our discontents, and hopefully gives us the chance to build constructive spaces in which we can connect and find solutions to problems that we cannot find in isolation.
Humans are Not Automobiles

Metaphors and Similes of the Human Body

Human beings think in metaphors and similes, especially when it comes to thinking about ourselves. We come to understand one thing by comparing it to another, and we describe something as being like something else, to help us understand how we should relate to it. A metaphorical way of thinking that Sam Quinones is critical of in his book Dreamland is the description of the human body as an automobile, or more generally as a machine.

 

We think of ourselves as if we were the most advanced technologies we have developed. We imagine that we could have parts swapped, that we just need little tune-ups here and there, that all we need is a mechanic to tinker with a few things and we will be back to running smoothly if we are ever out of whack. However, this metaphor, like all metaphors, is an incomplete way to understand the reality of what we are.

 

Our minds are only so good at holding lots of complex information. We use metaphor and simile to simplify our thought process. Metaphors and similes serve as heuristics to understand and conceptualize complex structures and relationships, but they don’t actually capture the full scope of reality. To say that the human body is an automobile, or operates as an automobile, misses key aspects of human dynamism, plasticity, adaptability, and function. We respond to the world and our environments, change and adapt to new settings and structures, and move in ways that no machine that we can create today can. We share some things in common with machines, but we are not machines.

 

In Dreamland, Quinones quotes a physician at the University of Washington Center for Pain Relief named John Loeser who explains why this type of thinking is dangerous, “Usually the patient says, ‘I come to you, the doctor. Fix me.’ They treat themselves like an automobile. People become believers in the philosophy that all I need is to go to my doctor and my doctor will tell me what the problem is. That attitude has been fostered by the medical community and Big Pharma. The population wants to be fixed overnight. This is the issue we addressed with chronic pain patients. They have to learn it’s their body, their pain, their health. The work is done by them.”

 

The automobile metaphor manifests falls apart when we project a quick scientific and technical fix for ourselves. The idea that all we need is a special additive to make our body work better is what fuels our desire to have a pill to solve all our medical problems, and it is emboldened by the idea that we are basically automobiles.

 

We always compare ourselves, our brains, and our bodies to the highest technology of the time. If we don’t consider ourselves automobiles anymore, we probably think of ourselves as technical space ships or precision fighter jets. Humans once thought of the brain as a complex system of pulleys and levers, and now we think of our brains as supercomputers.

 

What Quinones uses the quote from Loeser to show is that we are living systems. We are not machines that can be isolated from our environment, tinkered with, and tuned for optimal performance. We have to be responsible for how we live and the systems, structures, societies, and institutions that we all build and live within. If we don’t truly think of ourselves as more dynamic than machines, and if we don’t consider our interconnectedness, we will never understand ourselves properly, and we will never fix the problems we face, like chronic pain. We will turn to cheap tricks and remedies, and we will face the consequences of living in a way that praises quick fixes and pills to try to solve our problems.

Cities Suffer From Loss Aversion

“Many U.S. cities are, in essence, a fact-free zone when it comes to public assets. They have little knowledge of the assets they own and the market value of those assets, either under current or altered zoning regimes. Ironically, U.S. cities know what they owe (such as pension liabilities) but not what they own. Rectifying that disconnect is the first step toward sane and sensible public finance,” write Bruce Katz and Jeremy Nowak in their book The New Localism.

 

Katz and Nowak highlight the ways that local and regional governments in cities and metropolitan areas are establishing new networks to develop innovative solutions to global problems that have vexed state and national governments since the early 2000’s. Cities are reinventing ideas of governance and finding ways to adjust to the challenges they face in a way that larger governments seem to be unable to do. One area that is holding most city governments back, however, is financing.

 

Local government financing does well when the economy is strong and when people are moving to the area to create and fill jobs. However, when the economy is weak and people are moving away, local governments cannot keep up. Cycles of strong and weak economies have lead to the situation that Katz and Nowak described in the quote I used to open this post. Cities focus on their liabilities and worry about the costs and expenses that pile up and become major obstacles whenever the economy turns south. The authors argue that these pressures can become a singular focus for local government officials, preventing them from thinking clearly about the opportunities they face while limiting their creativity to adjust to new economic conditions and develop innovative solutions.

 

I don’t find it too surprising that city governments are more worried about what they owe than what they own. I am currently reading Daniel Kahneman’s book Thinking Fast and Slow and his descriptions about the way people respond to potential losses seems to be right in line with the behavior that Katz and Nowak describe for our city governments. We feel a loss of $100 as equal in terms of pain as we feel joy from a gain of $200. That means our losses are twice as painful as a gain is joyous. Mayors, city managers, and elected officials have their jobs on the line and can be held responsible for economic forces that are far beyond their control. This is likely a big part of what leads to this risk aversion among our local governments, and why so many of them are focused on what they owe and what could go wrong in a downturn. The narrow focus that this creates for governments, however, is likely to exacerbate any economic shocks that they do experience. By failing to plan and think big, city governments are failing to get the most out of the assets they do have, and are failing to build a buffer of protection for themselves and their residents if an economic shock occurs.

 

The solution that Katz and Nowak provide is a structure of new networked governance, where governments are able to provide the authority and base funding for projects and ideas, but private organizations can manage public assets and capitalize on charitable and foundation giving for more risky projects. This opens an avenue for bold movement that risk averse elected officials and public agencies could not approach. It allows cities to maximize their assets, rather than forget about them altogether.

Who Does What in Society?

The New Localism by Bruce Katz and Jeremy Nowak is titled as if it were a new development in local governance and problem solving, but the authors suggest that New Localism is really more of a return to historical problem solving and idea formation. Over the last few decades, the national government has captured more attention and focus in national media and public debates about problems, policies, and solutions. However, it has always been the case that the place where people actually experience and live out any problems, policies, or solutions is in a local context. We have all felt the disparity between regions when an economy is “strong” or “in free-fall.” We know that things can be great for our neighborhood, but a total train-wreck in the next, town, or even just a few blocks away.

 

Katz and Nowak reassert the importance of local action and problem solving. The authors describe a current phenomenon in the United States where people, businesses, non-profits, foundations, and civic groups are rediscovering local authority and collaborative institutions to achieve meaningful goals at the local level where people live and experience the problems we actually face.

 

Katz and Nowak write, “Correcting the confusion over who does what in societies is an essential act of civic education and a necessary first step toward national progress.”

 

Countering the intuition that solutions must be national is an important first step toward addressing our real problems. Learning what it means to be connected and organized locally to implement solutions quickly with the support of the public and private organizations is the heart of New Localism. Deferring action toward higher levels of government is effectively an abdication of the authority and ability of local actors to make changes that work in their region. A standard playbook and actor chart cannot be developed across all cities and communities, but each individual community can rediscover the impact that local individuals and local businesses can have moving our societies forward.

 

What the quote also addresses is the confusion we have over who can and should take action in problem solving. It is easy to think that a problem is the responsibility of someone else and that some other governmental agency or some other public actor will step in to make a change. It is hard to remember that it is the people experiencing the problem and living in the area where the problem exists who are the ones that can best respond. Businesses often complain about regulations or public decisions, but don’t always make the investments in the institutions which make those decisions. Citizens often complain about an issue, but don’t often form a group or make decisions that would actually address the issue. We don’t have a good sense of how the public can work with government or how communities can organize around a solution to make the places we live better places to be. Everyone is busy and under a lot of pressure, so learning how things work and taking the time to be involved is understandably challenging, but bringing visibility to the roles that we need citizens and businesses to play in problem solving is important as we rediscover what local governance looks like.

Problem Solving to Fit the World

In The New Localism Bruce Katz and Jeremy Nowak argue that political decision-making, solutions to complex problems, and innovations in progress and economic development occur more at the local level than at the national level in the world today. Their argument is that national politics is complex and cumbersome, with too many large and disconnected voices and opinions to tailor policy solutions to problems in ways that actually make sense. More local structures, on the other hand, are better suited to find and implement real solutions to the specific problems taking place in a given region.

 

“Cities and other localities,” the authors write, “can craft and deliver better solutions to hard challenges since they match problem solving to the way the world works – integrated, holistic, and entrepreneurial rather than compartmentalized and bureaucratic.”

 

Sometimes we think about our challenges and problems as being distinct from each other. We tend to think  the opioid crisis is a healthcare failure, that unaffordable rent in San Francisco is a housing policy failure, that a factory closing is an economic failure. We try to find individual solutions to each of these problems such as, introducing databases to monitor opioid prescriptions, or capping the price of rent in a city, or by trying to attract a new business to fill the old factory with tax breaks. In reality, however, all of these policy areas are interconnected. Economic development can influence the price of housing, and stable housing (or the lack thereof) can influence community dynamics which make people more or less likely to misuse drugs. Trying to tackle any individual problem from a broad national level, without considering the specific details that contribute to the problem in a given place would be unlikely to succeed.

 

Local problem solving, as Katz and Nowak suggest, is able to look at problems in a more comprehensive way since it tailors solutions to the local environment. Solutions can be integrated instead of compartmentalized and localities can bring entrepreneurs into the fold to mix business interests and development with social responsibility and support. The policy that is likely to succeed in reducing opioid misuse San Francisco is unlikely to be the same solution that would succeed in Dayton, Ohio, but both communities could share what they learn and take advantage of local resources to build coalitions to address the problems in a manner consistent with the local experiences. National level policy cannot introduce such individualized solutions and cannot be as responsive to the local variations on a given problem.

Designing for Two Goals

“Savvy institutional designers,” Write Kevin Simler and Robin Hanson in The Elephant in the Brain, “must … identify both the surface goals to which people give lip service and the hidden goals that people are also trying to achieve. Designers can then search for arrangements that actually achieve the deeper goals while also serving the surface goals-or at least giving the appearance of doing so. Unsurprisingly, this is a much harder design problem. But if we can learn to do it well, our solutions will less often meet the fate of puzzling disinterest.”

 

In public policy research, there is a framework that is used to understand the legislative process called the Social Construction Framework (SCF). When examining the world through the SCF, we look at the recipients of particular policies and ask what social constructions are at play that shape the type of legislation surrounding these recipients. We also group the recipients into four broad groups: Advantaged, Contenders, Dependents, and Deviants.

 

Advantaged are those who have strong political power and public respect, like veterans and small business owners. Contenders have lots of political power, but are not viewed as warmly in the public eye, such as big business or unions. Dependents are socially sympathetic groups that don’t have much political power, such as sick children who can’t vote but evoke sympathy. The final group, Deviants, are socially scorned and politically weak, such as criminals or drug users.

 

The way we think about who belongs to which group is a social construction. That is, we attribute positive or negative qualities to groups to make them seem more or less deserving. Businesses always highlight the jobs they bring to communities, the innovations they create to make our lives better, and the charitable activities they contribute to. This is all an effort to move from a Contender status to an Advantaged status. Similarly, we see movements where people look at drug addicts and criminals in new ways, seeing them more as victims of circumstance than as entirely bad actors, moving them from Deviants to Dependents.

 

The reason this is important is because we introduce policies that either reward or punish people based on the groups they belong to. It all ties in with the quote from the book because we can either openly distribute a reward or punishment or distribute it in a hidden manner. Our policies might have stated explicit goals, but they may also provide a big business a hidden tax break. Our policies might be unpopular if they directly provide aid to former felons as they leave prison, but offering policy that is nominally intended to help the poor may provide a greater benefit to formerly incarcerated individuals than anyone else.

 

Hanson and Simler call for more sophisticated policy design that addresses our stated high-minded motivations and at the same time helps fulfill our more selfish and below the surface policy goals. SCF is a powerful framework to keep in mind as we try to develop policies and think about ways to actually enact policy that has both open surface level implications and addresses our deeper hidden purposes. This can, of course, be used for good or for ill, just as the tax code can be used to hide tax breaks for unpopular companies or help new homeowners, and just as social programs can be used as cover to assist individuals who are typically seen as Deviants.

Solving the Wrong Problem

I work for a growing but still small tech start-up in the healthcare space based out of the bay area. The company has a great mission and is amazing to work for, but we have certainly had a lot of growing pains and unanswerable questions over the last four years that I have worked for the company. One of the biggest challenges we have faced is making sure we answering the right questions and getting the right solutions to the right problems in place.

 

Michael Bungay Stanier looks at these types of problems and takes them on in his book about coaching, The Coaching Habit. His book is full of recommendations to be a more effective coach and manager, and one of the benefits of his techniques is an improved understanding of the problems and questions that organizations must face. In the company I work for, things have always been in flux, and that means that sometimes it is hard to know what the real issue is and where we should be focusing all of our energy. If you polled the entire office about what the biggest problem is right now, you would get different answers from everyone. Bungay Stanier described the situation like this:

 

“You might have come up with a brilliant way to fix the challenge your team is talking about. However, the challenge they’re talking about is most likely not the real challenge that needs to be sorted out. They could be describing any number of things: a symptom, a secondary issue, a ghost of a previous problem which is comfortably familiar, often even a half-baked solution to an unarticulated issue.”

 

Effective leaders don’t just jump in when a team is discussing the issues they are facing and they don’t just take on all the problems in an attempt to solve everything themselves. Good leaders try to drill deeper to understand what is really at the heart of the collective issues facing the team, and then work to empower the team to tackle the problems they face. In my next post I’ll describe the conversation that Bungay Stanier recommends to help us find the right problem to solve, but for now I’ll describe the question he uses to get to the heart of the issue, “What’s the challenge?”.

 

In my career I have solved a lot of problems and fixed a lot of issues, but often times I have spent a lot of energy on problems and issues that end up not being very important. Something might be a little bit off and something might be an inconvenience, but that doesn’t necessarily mean that I need to spend a lot of effort fixing that individual thing. Perhaps what everyone complains about is frustrating and annoying, but it may just be part of a larger problem or something that would go away altogether by solving a bigger picture item. This is definitely an area where growth is possible for me, and is something that all organizations struggle with, especially if we are quick to action and don’t make real efforts to dive further. Asking ourselves and our team, “What’s the real challenge?” and looking upstream from the stated problems to possible larger causes is one way to make sure the work we do matters and is one way to galvanize our team around the most important solutions.

A Great Start to a Coaching Conversation

The Coaching Habit by Michael Bungay Stanier is not just a book with a few good theories about coaching. Bungay Stanier includes a lot of specific words, phrases, and conversation examples to help you see concrete ways to improve your coaching. One example that Bungay Stanier includes is a quick way to get a coaching conversation moving in a clear path to help you discuss the issues that are driving the challenges for the individual you are working with. His quick start question is as follows:

 

“So there are three different facets of that [the problem the individual said they are having] we could look at … the project side — any challenges around the actual content. The people side — any issue with team members/colleagues/other departments/bosses/customers/clients. And patterns — if there’s a way that you’re getting in your own way, and not showing up in the best possible way. Where should we start?”

 

What I love about this question is that from the start, it disentangles different parts of a problem that anyone may be facing. In my own life, and in listening to others, I have noticed how frequently all of these different issues seem to meld together and become overwhelming. By disaggregating each piece of the problem, you can begin to look at individual items in a manageable way. It is a lot easier to begin to look for things that one can change or adjust, when you take the pieces one by one and fit them back together.

 

This question also helps to steer coaching conversations away from becoming venting conversations. I really struggle in my relationship with my wife with handling conversations about the challenges she faces. One of the reasons is because I don’t handle venting well. When my wife wants to vent and tell me about the issues and challenges she faces my natural reaction is to simply tell her what she should do as if I was some sort of magic profit who could solve all her problems. Of course, my views of her challenges are not actually accurate and my advice giving does not work in these venting conversations. By steering questions away from venting using the approach that Bungay Stanier suggests in the quote above, we can heave more productive conversations focused on what really matters. A coaching session will be useless if it becomes a venting session. The other person may feel better temporarily about having a chance to vent, but nothing will actually be solved and their possibly mistaken perceptions will in a sense be validated by being heard.

 

The questions that Bungay Stanier presents in the quote above keeps us focused on specific issues in a solutions oriented direction. The questions also show that there are different aspects of our problems that need to handled in different ways. By working with the individual to acknowledge the self originating aspects of their problem, you get them to refocus on themselves and their growth without blaming other people for their challenges. The other pieces of the issue can be also worked on in a more objective manner when we are not looking at the whole.

Bargains

In his book about the BP oil spill in the Gulf of Mexico, author Joel Achenbach explains the steps that were taken by both BP and the United States Government to solve the problem of the broken well leaking oil thousands of feet below the surface.  Our government eventually established a think tank task force of the best scientific minds in the country to address the problem in part by viewing it from new and unique perspectives.  One of the scientists brought on board was Dr. Steven Chu from Stanford University, and Achenbach explains why he was such a good addition to the team by referencing a graduation speech from Dr. Chu that outlined the way he thought about interacting with others in  the world.

 

In his speech Chu said, “In your future life, cultivate a generous spirit. In all negotiations, don’t bargain for the last, little advantage. Leave the change on the table. In your collaborations, always remember that ‘credit’ is not a conserved quantity. In a successful collaboration, everybody gets ninety percent of the credit.”

 

I really enjoy what Dr. Chu states in his quote and I think our society would benefit from hearing his quote more often. Whether it is scientific discussion, presidential politics, business negotiations, or marriage, trying to win any negotiation and take 100% of the credit will cut out some of the people with interest and input in the discussion.  Trying to instead find the best path to move forward while presenting an honest and valid view of world will help all parties advance.  Dr. Chu was invaluable to the BP oil spill team of scientists because of the way he could help arbitrate discussions and ideas for shutting the well. He was quick thinking, witty, encouraging of discussion, and also had everyone’s best interest in mind.

 

What the BP oil spill crisis showed was that no one could take 100% of the blame for the disaster, and that no one could take 100% of the credit for its solution. When we narrow our view of the situation we start to look at the problem in a black and white view, and we instantly start to assign wholesale blame and complete credit to single actors. We are much better off if we learn from the mistakes and see the ways in which everyone shared in the decisions that lead to the disaster, but also recognize the ways in which everyones’ actions lead to a joint solution.