Friday, October 30, 2009

Home Care Spared in Recent Massachusetts Cuts

More deficits, more proposed reductions. With Governor Patrick's announcement of budget cuts yesterday, all eyes were on where the cuts are expected to take place. Fortunately, home care and home health were spared. The only material cut came in the form of a $3.5m drop in the HHS administration budget. Expect more reductions, however, if the revenue picture doesn't improve soon.

Health Care Under Pressure... from Health Care

Grant Thornton, LLP, just released the results of their annual survey of financial executives. It's interesting to note that 38% of the health care CFOs and controllers said they expected their organizations' hiring to increase over the next six months; this compares to 24% of financial managers from all industries. Other responses indicated that health care leaders are more concerned about economic pressures than the average across all industries surveyed. Of the 846 surveys received, 31% of the health care managers expected their organizations to raise prices within the next six months, compared to 22% of the national sample. Here's the punchline: 83% of health care financial executives named increases in employee benefits costs as the most significant factor in prices increases. Executives from other industries? 77% felt that the most significant pressure would come from employee benefits increases. Some are suggesting there's irony here in that the health care leaders have a higher degree of control over the very phenomenon they cite as a concern. Perhaps, but I think it's more likely that they are more sensitive to and aware of the likely upward pressure on costs. Read the full article here.

Wednesday, October 28, 2009

Why the Insurance Industry is Good for America

BNET has posted a piece summarizing research from the Dartmouth Institute showing that "among states with the top 10 insurance market concentrations, all but Rhode Island showed lower than national average levels of Medicare spending per enrollee in 2006. In seven of the 10 states, spending was at least 10 percent lower than the national average." Counter to other research (and, in a way, common sense), it seems that lack of insurance industry competition does not necessarily drive prices up. This certainly runs counter to my post below. See the full article here. So the question remains: will weakening or strengthening the insurance industry help reduce health care inflation? If a public option prevails in the current reform debate, there's pretty good evidence that the industry will be weakened... so, we'll see soon enough.

Why the Insurance Industry Hates Health Reform

According to a recent "Business Week" article, the U.S. insurance industry is one of the least competitive markets in the country. The article notes that this lack of competition may be a key factor contributing to the sharp increases in premiums. The industry has responded to President Obama's attempt to create a "public option" by agreeing that reform is needed, and also by politely disagreeing with the assertion that a cheaper, high quality public option would not devastate the industry and cause mayhem with risk selection, throwing actuaries everywhere into fits of despair. They also forecast an inability to fairly compete with a government backed plan that will not have to abide by the same rules as private companies. More here.

Listening to the CEOs

There are plenty of good books ("Good to Great" by Collins and "CEO Logic" by Johnson come to mind) on the topic of executive leadership, but no one ever learned to ride a bicycle from a book. So... I took the opportunity over the past couple of weeks to talk to health care CEOs. Some of the discussions were quite formal (I felt like Larry King) while others were more casual. In some cases, the intention was preannounced, namely that I wanted to pick their brains on what they had learned since becoming CEO. At other times, the discussion began differently and meandered toward this topic. One CEO leads a $6m organization, another a $2b sprawling company. Some lead not-for-profits, one a for-profit. A few had been hand chosen and one was specifically groomed for the job. Two had been hurled into the position unexpectedly when their current leader vacated the job suddenly (one died at her desk). I found the discussion helpful, fascinating. In the last few meetings with the CEOs, I jokingly stated that I ought to post what I learned to a blog. At the time, I had no intention of doing so.

Funny how life turns out, though. Here's a blog and here's that post. In no particular order, these are 10 lessons I gained from listening to the CEOs:

  1. It actually is lonely at the top. For most of your career, you have the luxury of thinking, "well, if I was in charge, I would...". Several of the leaders spoke of becoming acutely aware of this fact and needing to adjust. Seeking interested, but uninvolved, peer groups was recommended as the antidote.

  2. Understand the culture. It's easy to form quick impressions and to feel the need to act quickly. Better to listen and learn and gain the pulse of the organization first, then act.

  3. Don't wait too long. A few CEOs bemoaned the fact that they did not make changes early and act upon their first impressions. If #2 and #3 seem a contradiction to you, it did to me too. When asked about this, the CEOs stated that it is a good idea to be clear on expectations... to establish the fact that you will observe and learn for, for example 3-6 months... and then be prepared to act.

  4. It's all about vision. Leave operations and day-to-day matters to those who understand them better than you do, but be clear about your vision for the organization. Talk it up. Everyone inside the organization needs to have little doubt on where you see the company headed.

  5. Be approachable, be personable, be yourself. Too many leaders feel as though they are at the top of the organization and need to act like it. That means, some say, that it is important to put some distance between yourself and those around you. People in the company will understand that you are busy and sometimes flying from meeting to meeting, often outside of the company... but they would like to know that you are present and that you have a good sense of how the organization actually works. And they want to know you are a real person.

  6. If you don't know the answer to a question, say you don't know. Seems basic, but several of the executives mentioned this.

  7. Narrow the focus. It's easy to become overwhelmed with everything that's happening in the organization, to try to address every single problem and to make inroads on all of the key strategic initiatives. Instead, it's far better to pick your top 2-4 goals and to focus more specifically on them.

  8. Adapt. Establish goals and make sure you stick to the ones that are "make or break" for the organization, but as the environment evolves and as you learn your job, don't be afraid to take a step back and to adjust as needed.

  9. Be external. It's hard to develop and move toward a vision if you are disconnected from the outside world. BUT... there's a fine line here, as you can easily become too oriented to what's happening externally and lose touch of the internal reality of your company.

  10. Stay ever connected to your customers. Make sure that their voice is the loudest one heard inside the company.

It was a great and unique opportunity to have been able to discuss these lessons with the CEOs, many of whom stated that they appreciated the opportunity to reflect on these issues.

Tuesday, October 27, 2009

Had an opportunity to wander around the Cape with my 15 year old son. Here are a few shots.

Saturday, October 24, 2009

What can cell phones teach us about health care?

It just worked. The iPhone from Apple. You've seen the ads and they're all true. It's cool and it works. It just simply works. When I wanted to make a call, I made a call. Emails? Flawless Exchange integration with my company's server and no IT professionals were hurt in the making of that movie. Surfing the web? Sure, all the time. When I was traveling with my son through the American West early in this past summer, I clicked on the free application (you do understand that there are thousands upon thousands of apps available right on your phone; most are useful and most are free) to locate the nearest restaurants of the exact type we desired. Last Spring, as my family and I were rushing from the Starbucks near Central Park to the venue where "Wicked" was playing, we used the built in GPS function to chart our progress on the avenues as we navigated toward the theater. Text messaging? Sure. Fun games? Occasionally. Everything fit together like a glove. It just worked.

Fast forward to two weeks ago and my new position required a move to Verizon. Verizon does not (yet) have the iPhone so I became acquainted with the Windows Mobile 6.1 smartphone, smartly entitled the HTC Touch Pro 2. Windows Mobile was originally built for a stylus (remember those?), though Microsoft has made some, repeat some, progress toward implementing a touch interface. Apparently everyone has seen the iPhone commercials showing all the neat acrobatics you can accomplish with just your index finger and so all the competitors are moving in that direction. HTC clearly does not think that Microsoft has moved fast enough, and so it has introduced something they call the Touch Flo interface, which sits squarely atop Windows Mobile (aka WinMo). Because the wireless functionality of this combination is sorely lacking, my company has rightly selected a third party service called Good, which I can confidently state is anything but. Here's the problem. WinMo, Touch Flo and Good all have their specific roles. All are capable, slick bits of software code all hoisted upon the Touch Pro 2 frame. But, sometimes these particular kids don't like sitting together in the back seat of the car, and so they fight.

When I need to make a call, sometimes Touch Flo wins by making me use its visually appealing tuxedo black skin, which my index finger is happy to be acquainted with. But, and I'm not sure precisely why or when, WinMo's avocado green interface wins out, forcing me to try to use my finger, but the tiny dialogues and buttons work only if my finger was the width of a pencil tip. Enter the stylus. WinMo's core applications, which are always left standing at the altar by the favored Good applications, try so hard to get the job done. Touch Flo, thinking that WinMo is in charge, features those apps on its home page. But, that's of no use as the Good apps (requiring a completely separate and mind numbingly time consuming launch in order to access) are the only ones that synchronize with the servers at work. Oh, and web surfing? Right. Talking on the phone? Make sure your cheek doesn't rub against the phone as you'll most assuredly accidentally make the phone do something you don't want it to do. And the notifications. Yes, the notifications. Something angry pops up on the screen (regardless of whether you're actually using that screen for another purpose) constantly telling you that you're hovering near somebody's wireless network. Do you want to join? Do you? Do you? Click me. Now. Ugh.

The individual applications are all decent. In fact, they're more than decent. But it's the connection between them that is the problem. And the fact that this works for our company is testimony to the capabilities of our IT staff... who, by the way, are beginning to move us in a different direction as we speak.


I met Margaret in the waiting room of the cancer center where I worked. Margaret didn't mind sharing her story and I didn't mind hearing it. Margaret has had a number of health problems through the years, but none as concerning as the one she was now facing. Previously, she experienced diabetes, an irregular heart rate requiring ablation procedures, and a dizzying array of prescription medications which Margaret was increasingly having a hard time keeping straight.

Six months earlier, when she experienced a cough that wouldn't quit, Margaret was sent for some tests and ultimately the spot on her x-ray proved to be cancer. It's been a tough six months for Margaret. Two surgeries, yet more prescriptions, radiation therapy and now chemo. She has seen more doctors in six months than she had seen over the course of her earlier nearly 70 years. And it was all bewildering to her and to her family. The cancer treatments were causing dietary problems which impacted the diabetes. A new medication lowered her heart rate, causing blood pressure woes. Given her irregular heart rate, Margaret needed to see her cardiologist, though unfortunately he had recently moved to the West Coast and she wasn't as fond of her new doctor. She did love her radiation oncologist, though, describing her as "caring and very organized." Margaret's eyes watered when she told me that she brought all of her health issues to this doctor even though she fully understood that the oncologist was only prepared to deal with the tumor. "I find this all so confusing. I wish the doctors would talk to each other once in a while."

Margaret's profile and experience demonstrates the complicated nature of medical care today. Highly specialized systems of care have emerged to contend with an exponentially expanding body of knowledge about medical conditions and treatment possibilities. Unlike the local doctors who visited our parents in their homes and who could be counted on to deal with any and all situations as they arose (however superficially), today's medical response is fragmented and the various elements do not always "talk to each other"... making patients, such as Margaret, feel as they are experiencing what Dr. Gary Gibbons, Quincy Medical Center CEO, describes as "conveyer belt medicine."

You'll no doubt see that I'm drawing a parallel between today's health care system and the Windows Mobile-Good-Touch Flo saga I described above. Can an iPhone equivalent be possible here?

Well, we're getting there. Health reform will probably move us toward "accountable care organizations" designed to better coordinate the entire package of services across a wide array of providers for patients such as Margaret. The movement to global capitation will (yet again) attempt to do the same thing. Electronic health records, long the Holy Grail of health care, will also push us in that direction.

The local larger systems are working hard on this very quest. Atrius Health and its Epic system is probably closest but the Partners system is far from conceding this race. There is much talk about investing in electronic health record technology in the current reform debate and opportunities will exist for providers, technology vendors and payers to collaborate to move us closer still. But, as long as the separate parts continue to look and act like separate parts, we'll get no closer to eliminating conveyer belt medicine.

Someone will come up with the iPhone equivalent in health care. And whomever that is... will win.

The favored season

If you are a photographer (I am), then you need to have your camera with you at all times (I do) during the Fall season. Has this been a particularly yellow Autumn?

A blog? Seriously?

I know. I get it. Getting into the blogging business is as easy as signing up for a free email account or a portal site, like Yahoo or Google. A username and password that you don't forget and then just 5 minutes in front of the by-the-numbers set-up screen and you are officially a blogger. But, having something to say is an altogether different thing. A search on any of the major blogging engines reveals a graveyard of good intentions, much as you'll find exercise equipment under blankets of dust in bedrooms and basements across America.

Sometimes, you don't know if you'll use the stationary bike until you give it a try.

So the question is: do I actually have anything to say?

I'm joining the venerable Visiting Nurse Association of Boston & Affiliates ( in less than a week as the new President & CEO. Based on the early feedback from industry contacts, comments from current and possible customers, one Board meeting and several conversations with members of the "VNAB" team, I'm going to find myself in a variety of situations and considering a number of issues pertaining to home health care, health care in general, and policy and payment issues of varying importance and impact.

"VNA CEO", the name of this blog, will be a place to record what I learn and what I think. I'll also post some of my favorite photos (as I'm an avid hobbyist). And there will be posts pertaining to some of the causes I support.

We'll see how it goes.

And if this actually works, maybe I'll take the boxes off the treadmill in my garage and give that another shot too...