Where have all the good leaders gone?

My theme for this month has centered on our need for better leadership to guide us through the challenging times ahead in health care. To close out the month, I will add one more post on the topic before I get back to more Medicaid-specific items.

One nice - and eerily prescient - book from 2007 (pre-recession) was the one by Lee Iococca, "Where have all the good leaders gone?" The first paragraph below is by no means subtle: (more)

Am I the only guy in this country who's fed up with what's happening? Where the [bleep] is our outrage? We should be screaming bloody murder. We've got a gang of clueless bozos steering our ship of state right over a cliff, we've got corporate gangsters stealing us blind, and we can't even clean up after a hurricane much less build a hybrid car. But instead of getting mad, everyone sits around and nods their heads...

Now some may say that health care is different - that people are not widgets - but experience tells otherwise (see yesterday's post on Don Berwick). In fact, the more complex a system is, the greater there is a need for good leadership so that incentives are aligned toward the attainment of a common purpose...a purpose more than just money.

After my earlier post on Servant Leadership, a good friend (thanks CHL) sent me the link to an excellent article published in the Archives of Surgery way back in 2002. The article is titled "The Power of Servant Leadership to Transform Health Care Organizations for the 21st-Century Economy." It is an excellent read on what makes a good leader and the implications for health care delivery systems.

One of the "dirty little secrets" acknowledged in management programs but rarely admitted in public is that management is the most disposable layer of any organization while knowledge workers form the most valuable layer. That is why the executives at well-run organizations tend to follow the credo "the greater the leader, the greater the service." Whether it be a family, church, company, or government agency, it would be wise for all of us to remember and follow this credo.

So let's stop sitting around nodding our heads and start demanding better...starting with ourselves. ~BAA

Why we need Don Berwick leading CMS

For those who do not know Dr. Berwick, he is a professor of health care policy, pediatrician, and cofounder of the Institute for Healthcare Improvement (IHI). He was also one of the first and most effective voices to call for quality improvement in the health care system and many of us have followed the numerous, significant successes of IHI for almost 20 years.

There are about a bazillion articles on Dr. Berwick on the web but below you will find some interesting recent interviews and articles that highlight why Dr. Berwick’s leadership is exactly what we need right now.
· Interview/Audio on the 5 Million Lives Campaign at Healthblawg(2008)
· Interview “A Deficiency of Will and Ambition” in Health Affairs (2005)
· Interview/Video on innovation in BusinessWeek magazine (2008)
· Article “The Revolutionary” in Boston Globe (2004)
· Article “Dirty Words in Health Care” in Boston Globe (2008)

And for those who have never seen what has been described as the first “viral” video in health care, Dr. Berwick’s “Escape Fire” address at the 1999 annual meeting really hit home. I don’t have the video but the Commonwealth Fund published a report on the presentation, which should be required reading for anyone working in health care. But below, you can find another nice video of Dr. Berwick from IHI's annual meeting last year.



Now what really sets Berwick apart is that he has the best balance of gravitas, commitment, and understanding that is necessary to reform our health system. Some say he is primarily associated with hospitals but his efforts span the health care system...one just hears about his work with hospitals the most. He is not a political opportunist or an outsider perched high atop an ivory tower but a leader who has worked from within to help providers continually improve their performance without finger-pointing. Berwick, as all quality practitioners, does not blame individuals, but the system at large and often uses the quote “every system is perfectly designed to achieve exactly the results it achieves.”

This explains why Berwick is somewhat at odds with current CMS efforts to measure and penalize individual physicians. He believes incentives should be used for systems of care – not for individual practitioners and he has some pretty heavy hitters backing up his belief. Management and quality gurus WE Deming and Joseph Juran pointed out over 30 years ago that most of the possibilities for improvement lie in action on the system as opposed to individuals. Berwick also believes that the current proliferation of measures (there are now over 1000) leads to a “data smog” that keeps us from focusing our limited resources on those health objectives that really make a difference. Thus, Berwick epitomizes the balance between the “art” and “science” of health care as summarized in the famous Einstein quote "Not everything that counts can be counted, and not everything that can be counted counts."

Berwick also understands the balance between the science of “hypothesis testing” and the science of “continuous quality improvement.” It is interesting that the same management methodologies that have fueled well-run organizations over the past 20 years (e.g. lean manufacturing and six sigma) are almost completely lost in health care. This is understandable because health care entities do not typically compete on quality and price when much of their payment is dependent on Medicare and Medicaid fee schedules. But for those health systems who value improvement, Berwick’s IHI has worked to highlight, promote, and support their efforts. One example is Virginia Mason Medical Center, who has successfully implemented lean manufacturing principles to center care around their patients (see article from Seattle Post-Intelligencer).

We can leave the politics to the politicians but as we go down the path of serious reform, I want someone who has Dr. Berwick’s qualities at or near the head of the table…and you should too…the health of our country depends on it.

[Homework: while working on another project I worked to reconcile the fact that about 85% of all health care costs can be attributed to individuals (i.e. risk factors like obesity) and the rest to the system with Deming/Juran’s experience that 94% of improvement opportunity resides with action on “the system” and the rest to individuals (i.e. they are flipped). When doing this, I had my “a-ha” moment but would like to hear the thoughts of others on this]. ~BAA

Re-orienting how we think about entitlement reform (Updated)

Remember the old phrase "it's the economy, [bleep]?" Well, it is still priority one for the new Administration but a new phrase is taking shape for today's "White House Fiscal Summit." That phrase is "it's Medicare and Medicaid, [bleep]." And since Medicare-aid plays in the private market, that really means "it's health reform, [bleep]."

[OK, I fess up, I edited out all the 'stupids' as I kept wincing every time I looked at the screen. ~BAA]

As pointed out by Ezra Klein in his column at the American Prospect, the phrase "entitlement reform" is one of those loaded phrases that sends shivers down the spine of half of the population but the phrase has been nuanced to mean something a bit different in the new Administration, "health reform." Below, are some excepts from Ezra's column:

What everyone agrees on is that the thinking entered government in the person of Peter Orszag. In 2007, Orszag was named director of the Congressional Budget Office. From that perch, he brought Kogan and Horney's thinking to the halls of Congress. Orszag liked to show a particular slide in his public presentations and speeches that broke down the interplay between the government's various fiscal commitments:

Government spending and Social Security, it says, will hold relatively constant in coming years. It's Medicare and Medicaid that chew up federal spending.

This graph, however, could be used as evidence for a simple focus on Medicare and Medicaid. The programs are unsustainable. They need to be slashed. The next slide in Orszag's presentation is titled "misdiagnosis the problem." The fiscal threat, it argues, is not more beneficiaries or the type of beneficiaries that are the factors internal to Medicare and Medicaid. It's the cost per beneficiary. Orszag has a graph for this, too:

And since Medicaid and Medicare pay for health services on the private market, this can only be fixed through broader health reform. Orszag now directs the Office of Management and Budget. He will lead today's "health care" breakout session...

Fiscal responsibility, in other words, is no longer a stand-in for entitlement reform. In Obama's Washington, it means health reform.

The White House blog has a post including the President's statement and Q&As and the Washington Post posted a summary of the break-out sessions from the summit today. ~BAA

New edition of Health Wonk Review (2/19/09)

The Health Wonk Review (HWR) is a hosted summary of the best health blogs in the country during the previous 2 weeks and the current 'anti-SPAM' edition is posted at the InsureBlog by Henry Stern, a benefits specialist in the world of insurance (nobody ever called him CLU-less...bah dum dum).

Well, MedicaidFrontPage is up next and we will host the next HWR on Mar 5th. Until then, enjoy. ~BAA

How about a side of Servant Leadership with our reform?

Anyone who has worked with a government program will appreciate the NASA video below on 'servant leadership' (see Wikipedia article). Anyone who has worked with me knows that I am a big proponent of this type of leadership, which is all too lacking today, whether it be with Wall Street banks or government agencies.

Basically, NASA charged some of its leaders with understanding what had gone wrong with its culture. The resulting analysis found that the Agency had grown too political and bureaucratic and had disregarded crucial input from engineers that could have averted serious recent mishaps.

The training video, which was written and filmed by four-time astronaut Andrew Thomas, is a dramatization of many experiences but includes a significant amount of real dialogue. It follows an engineer as she gets bruised-up trying to bring innovation to the table.



From an NPR write-up of the video:

Howard McCurdy, a space policy expert with American University in Washington, D.C., has written about how NASA's original high-tech culture has become more bureaucratic. He says that what struck him is that the managers in the video didn't engage in technical discussions. Instead, they focused only on the administrative process.

"That's not the kind of agency you would like to have running rocket programs," says McCurdy. "It might be OK for Social Security check disbursement, but it sure isn't going to be good for rocket science."

It would be helpful for HHS and state Agencies to do the same 'gut check' (see recent post by Kip Piper at the Piper Report). I have found the '80-20' rule applies to goverment just like everywhere else in that 80 percent of government employees are dedicated, talented, and professional. The real opportunity is with leadership.

Let's hope that the new Administration fills its management ranks with 'servant leaders' and not political opportunitists. Note, in the end, the engineer goes to work for Google, who loves her idea and plans to sell it back to NASA. Classic... ~BAA

President signs bill to renew and extend SCHIP (Updated 2/9/09)

I am a day late and a dollar short today but late yesterday, President Obama signed H.R. 2, which amends title XXI of the Social Security Act to extend and improve the States Children's Health Insurance Program (SCHIP) [see AP article]. Also on Wednesday, The President issued a memo rescinding an August 2007 letter the previous Administration sent to States that restricted their ability to cover additional children under SCHIP.



At the signing ceremony (see video), the President stated "The way I see it, providing coverage to 11 million children through CHIP is a down payment on my commitment to cover every single American."

The SCHIP success builds some much needed momentum for reform, especially given the withdrawal of Secretary-designate Daschle early this week. In a post at his authoritative Managed Care Matters blog, Joe Padua noted "the fact that this initial bill passed with some bipartisan support is a positive signal for reform advocates."

But it remains to be seen how states will pay their share for expansion. As first reported in an article from Florida Health News:

Given that Florida lawmakers are whacking about $2.8 billion out of the current budget today -- the Senate has already passed it -- and perhaps $6 billion in the spring session, it's hard to see where the match money would come from. That's what prompted Chief Financial Officer Alex Sink and Congresswoman Kathy Castor from Tampa, to come up with a proposal.

They hope to persuade President-elect Barack Obama to waive the matching requirement for states that have at least a 10 percent budget deficit for the upcoming fiscal year and a large percentage of their children without health coverage. Florida meets both standards by a large margin, with a deficit for next year that could amount to one-quarter of general revenue, Sink and Castor said.

Also, a subsequent article from the SunSentinel included a telling quote from Sen. Nan Rich (D-Weston), "Where are we going to get the money? It won't matter that they fixed this if we don't have the money to draw it down from Washington."

Personally, I can't think of a better way to stimulate a state's economy than an immediate 220% return on investment but SCHIP expansion comes at the expense of Federal taxpayers (which means all of us). Put another way, if a state does not take advantage of the expansion, it is only subsidizing other states that do. ~BAA

New health wonk review is up!!! (2/5/09)

The Health Wonk Review (HWR) is a hosted summary of the best health blogs in the country during the previous 2 weeks and the current edition is posted at the Health Business Blog by David Williams, a well-known strategist in the world of pharma, biotech, and medical devices. Enjoy. ~BAA

Rikki Tikki Tavi part deux – hopefully thissss time the COBRA wins

If you ever lose your health benefits provided through an employer (e.g. you leave your job or have other qualifying events like reduction in hours or death of a policy-holder), you get notified that you can choose to continue these benefits if you agree to pay the entire premium (plus an administrative fee).

This continuation of coverage is often referred to by its acronym COBRA, which comes from its authorizing statute, the Consolidated Omnibus Budget Reconciliation Act of 1985 (see Department of Labor website).

Most of us have never really paid attention to COBRA – because we didn’t need it. But times sure have changed. In fact, when I play word association with COBRA, visions of the Chuck Jones’ cartoon Rikki Tikki Tavi come to mind (the YouTube video is below for those of us who remember the days when cartoons were still special annual events).

COBRA sounds great, right? Well, as usual, perception does not match reality. Two reports from noted organizations, the Commonwealth Fund (report) and Families USA (report), point out that COBRA coverage is just too expensive for those with the least ability to pay. The Commonwealth Fund found that with COBRA, a person typically pays four to six times their previous contribution at a time of sharply reduced income and a summary of the Families USA report by the St. Petersburg Times put these numbers in stark contrast for Floridians:

Florida is one of nine states where the average premiums for family coverage under COBRA equal or exceed total unemployment benefits. The state's average COBRA premium for family coverage, $1,037, represents 102.4 percent of the average unemployment monthly benefit, which is $1,013.

Thus, it is not surprising that only 9 percent of the unemployed actually take advantage of COBRA. Fact is, employers largely shield employees from the full cost of our inefficient health care system. Albeit, this shield is increasingly cracked as companies lose their competitiveness internationally and more and more risk is pushed downstream to employees (see January 21, 2009 post by Jane Sarasohn-Kahn at Health Populi about the growing affordability gap in health care).

In their paper, the Commonwealth Fund recommended substantial financial assistance of 75 percent to 85 percent of premiums could help laid-off workers maintain their commercial coverage and the American Recovery and Reinvestment Act of 2009 (H.R. 1) - the stimulus bill passed by the House last week - includes provisions that subsidize 65 percent of a COBRA premium and allows states to provide temporary optional Medicaid coverage for the unemployed.

Both of these provisions will help provide coverage to those that need help the most but it is important to note that neither of them address the other two legs of the health reform stool – overall cost and quality. For example, a recent report by the U.S. Public Interest Group noted that without significant health system reform, health premiums will double by 2016, which means any gains for COBRA in the stimulus bill will only be watered down in the long-run by an inefficient system.

Let’s hope that in the larger health reform dialogue, the COBRA beats Rikki Tikki Tavi and becomes a viable part of the labor market so that human capital has the flexibility to go where it gets its greatest value - without worrying about affordable health care coverage.

[As a matter of full disclosure, I currently receive benefits through COBRA as my application for a small group policy has been caught up for months in the opaque world of medical underwriting.]