Health Care Reform - An Information Technology(IT) Professional Perspective - The Two Main Issues
I want to make this simple and narrow down the crux of the challenge to reform this industry by providing a framework to approach the problem. From an Operational Management/Process Efficiency's standpoint, there are really only two main issues involved here:
- SERVICES/PRODUCTS
- COSTS/PRICES
We need to mobilize a nation, and eventually, a planet, to deal with health and wellness in a smart manner, or we could find ourselves dealing with a pandemic that will devastate humanity. This diary is an effort to educate people on how to do this. I am an expert on large scale Enterprise Systems and Corporate Change Management. I have a degree in this, and have done this, for 20+ years, for Fortune 100 Companies, in various industries, including both Health Care and Insurance. Over the past few weeks, I have posted a number of lengthy posts and people have been asking me to put them into a diary. I was waiting until I could properly study the HCR legislation, frame the discussion in the proper manner, and provide a vision that makes sense.
NOTE: This is a lengthy diary that includes a number of issues and topics related to Health Care Reform.
Introduction
My main focus in the HCR legislation is in several areas:
(1) as an IT Professional, studying the systems and Business Process and Data Process implications and requirements, to deliver on this piece of legislation, and
(2) as a person who has studied alternative and preventative health care methods, since I have trained in Martial Arts for 30+ years, and this has afforded me to opportunity to learn a lot about Chinese Medicine, etc ....
The Creed - The Golden Hour
In order to present this discourse with the proper perspective, I want to begin with an article on true care of health. This is acutely fitting, for two reasons, the first, is obvious, so that we all remember to focus on the REAL "INDUSTRY" PROBLEM/NEED we are solving, which is health care, and the second, is because I want to use it to illustrate how a trained IT/Systems Integrator Consultant approaches a project. Namely, we begin with a team, and that team includes a SME (Subject Matter Expert), and it is the SME that provides industry perspective, so that we focus on THE NEED, first and foremost, because we must always remember to have THE NEED drive the project, we do not want technology to drive the project. It is always the "Business Owners/Value" that drives the project, and we must constantly check ourselves, remind ourselves, of the real goals, throughout the project LIFE CYCLE, to ensure that we are actually addressing the original need, which was the charter in the first place.
THE AXIOM: We do not implement technology for technology's sake.
And, similarly, with that in mind, let me state clearly ...
We do not want to implement Insurance Reform, for Insurance Industry's sake. We are addressing health care. That was Obama's election promise, and that is what he must address. But, as we all know, this must include, Insurance Reform. However, let us be clear, the campaign said zero about preserving the insurance industry's interests in health care. The business (need) is health care, not insurance. The preservation of the Insurance industry is NOT our agenda, and the preservation of that industry's interests in the care of health may be at odds with addressing our health care needs. I don't know, maybe it is, maybe it isn't.
However ... let's all remember ....
THE HEALTH CARE NEEDS ARE ALL THAT MATTER.
I cannot stress this enough ... The goal is health care ... which is The care of our people's health. That is the need we are addressing. That is, as we say in the IT Consulting Business ... THE VALUE PROPOSITION. If we address this care of health need, and fail to address the Insurance Industry's interests in health care, we still SUCCEED. However, if we do not address this care of health need, yet preserve the Insurance Industry's interests in health care, we FAIL. The need is ... Care of Health, not the problems with the Insurance Industry, nor their interests.
And, with that in mind, there is no better place to start, than with how the military approaches health of their soldiers in the field of combat.
ANG rescue unit gets to wounded within 'Golden Hour'
Secretary of Defense Robert Gates said teams need to respond within 60 minutes from the time a nine-line medical alert drops, to wheels down and transferring a patient to a higher level of medical care -- a concept commonly referred to as the "Golden Hour."
"Speed is what's saving lives," the major said. "Getting the Soldiers who are injured picked up quickly and to the higher care they need. If we are able to get to someone within the 'Golden Hour,' then survival is pretty certain for someone."
"If our CSAR guys hadn't gotten to the Marine when they did and start medical care on him, he wouldn't have survived - it's that simple," said Capt. Jac Solghan, Camp Bastion Role 3 Hospital Aeromedical Evacuation Liaison Team flight clinical coordinator. "Following the 'Golden Rule' is giving people a chance who otherwise would have had none and (the CSAR) guys are giving us that hope for survival. Without them, countless people would now be dead."
"Per our creed, our role is to save a life in any condition," the captain said. "With so many customers on the line who need our help, it's not a burden but a welcome opportunity to go out there and help the people who need us most. Through our men, lives are being saved. There's no better reward than knowing someone will get to go home alive."
Note the creed, which I highlighted, which I will repeat ...
"Per our creed, our role is to save a life in any condition"
I am concerned with saving lives.
Consider the words of a friend of mine, a highly trained and highly educated health care industry (admin) professional, someone who taught me much of what I know about the industry ...
Why do we only allow soldiers this Golden Hour?
Who pays for it?
Alright then, give us all that moment, of total attention to reorient and repair ....
An IT Professional's Perspective
IT professionals approach situations of this nature from a Corporate Operations Enterprise Integration mindset, which involves Enterprise Architecture and Business Process Rreengineering. This is a methodology that denotes a sequence of procedures to analyze the Supply Chain, which delivers the needed products, services or resources -- Supply Chain Management. We study the needs, and then, apply Systems Design methodology with industry Best Practices to efficiently support ongoing&iterative Systems Development Life Cycle.
The Challenge
The most difficult challenge in Health Care (Health Care Reform and Insurance Benefits), has to do with (1) defining what health care coverages to include (i.e., SERVICES/PRODUCTS), and (2) what to charge for them (i.e. COSTS/PRICES). With respect COSTS/PRICES, you have (2a) the COST to charge people for their premiums/deductibles, and (2b) you have the PRICES that Health Care SERVICES Providers and Health Care PRODUCTS Providers charge.
(1.) SERVICES/PRODUCTS
Basic Health Care
With respect to SERVICES/PRODUCTS, I would suggest that ALL basic health care coverages that we know of, in all of the plans, should be included in the PUBLIC INSURANCE OPTION, as one option/plan, period. As far as I am concerned, it is pointless to have a BASIC-MEDIUM-PREMIUM plans for health care needs. Is cancer included? Or, does anyone want a slower service? How could anyone opt for anything but full coverage, of the best quality, so it is a waste to invest in devising multiple plans of this nature, when people simply need to have their health care needs supported, as needed, when needed, WHATEVER THOSE NEEDS HAPPEN TO BE, period. And, furthermore, it is an unnecessary administrative cost, to support such options.
Health Care Consultants
The PUBLIC INSURANCE OPTION should include consultations with advisers, some sort of a basic wellness discussion, not a doctor, just someone who provides overall direction on the services available, or something like the old HMO orientation nurses (see my "HMO Orientation Nurses" comment below in the ethics section), "health care consultants" who can direct and support a person's overall PATH TO HEALTH .... this will foster the wellness industry, something that is already birthing in affluent communities.
Wellness Programs/Curriculum of Wellness
We need to foster a path of health, which begins with education. This is what is behind my notion of "Wellness Programs", (or Curriculum of Wellness) which would involve Coaching, Training, Health Club Memberships, etc ... to support and foster healthier life styles. And, maybe this is not part of the "Basic" PUBLIC INSURANCE OPTION, so maybe there is a "Premium" plan, and maybe the Wellness Programs are what differentiates the "Premium" PUBLIC INSURANCE OPTION from the "Basic" one. And, the "premium" plan would have to be consciously chosen, by each person, so that people "own" their health care/wellness choices.
Note: people should be able to "change" (UP or REDUCE) their plan, at will, with no penalties, so that people can feel safe to experiment and apply themselves to a more healthy life style.
Yes, there is a cost for these sorts of enhanced preventative programs, I realize this, but there is a long term benefit that our society cannot do without. We must have a healthier society. And, all that this requires, I believe, is to make them more affordable, and then, to educate people on them. Many people would opt for them, I believe, and use them, if they were available and affordable. And, by making them a "premium" that people pay extra for, people will be more apt to actually apply themselves to the Curriculum of Wellness/Wellness Programs.
Alternative Health Care Approaches
It is my strong belief that health plans should include "alternative" medicines and experimental approaches, and maybe this can or should be part of the "Premium" plan, or part of the "basic" plan, but it should, I believe, be done in conjunction with research projects, and clinical trials, etc, ... so that the industry as a whole can evolve, and so that the cost of this evolution is covered, and so that we can all learn and benefit from new discoveries, or old knowledge, etc.
This would involve things like fees for dietitians and personal trainers, acupuncturists, Chinese herbalists, western herbalists, chiropractors, reiki, message therapy, etc. stuff that might not conventionally be included. So that, the cost/benefit analysis for these preventative measures, can be isolated, studied, etc ... and used to provide/prove the efficacy of such approaches, and to pay for such approaches, and, if/when such approaches/treatments gain wide-spread appeal, or acceptance, they can be included in the basic plan.
(2.) COSTS/PRICING
PUBLIC INSURANCE OPTION - National vs. Regional
The administrative/operational issues associated with determining COST of an insurance premium, are massive, and I assert, largely unnecessary, for a PUBLIC INSURANCE OPTION.
The choice to offer PUBLIC INSURANCE OPTION's that is "REGIONAL" based, as opposed to one single "NATIONAL" PUBLIC INSURANCE OPTION, is pointless, and unnecessarily massively costly. The "NATIONAL" PUBLIC INSURANCE OPTION is set by a congressional mandate of legislation, a piece of legislation that is consistent with what the Public was sold during the election, and thee is ZERO need to support a 52+ massively complex systems, each of which will inevitably have their own unique way of doing things, which will most likely not be able to communicate well with other regions, and this is just pointless and serves zero purpose and provides zero benefit.
NOTE: See the following section below, for a more detailed discussion of the issues related to this subject of "Regional" Pricing:
The Legislation - What does it takes to actually implement?
How are Insurance prices/costs determined?
The choice to offer "regional" PUBLIC INSURANCE OPTIONS sets the gov up for an administrative nightmare, and I assert, it is a completely unnecessary nightmare. It causes a whole host of problems, for both the administration, as well as, for the public. It makes it a problem for people when they move, often causing extreme stress ("What if I cannot get the same coverage or price in my new city?)
Everything should be transferable.
Everything should be transparent.
Everything should be uniform.
.... All COVERAGE/SERVICES in all regions are the same.
.... All COSTS in all regions are the same.
The price of the "NATIONAL" PUBLIC INSURANCE OPTION is the same for one and all, alike, but is dependent on the number of family members, only. I realize that certain prices for products/services, in each area, are different, but so what? The cost of supporting such an operation, far outweighs an incremental benefit, and it sets up a problem, a conflict, amongst regions, that does not serve any good. This is not competition, this is merely conflict. If we set the cost for premiums, NOT determined by any complex Actuarial Statistical "costing" process, the billing system/operations to support this becomes massively less complex. The cost of which maintaining from an IT and Process Management perspective, are massive and operationally crippling, since you must then, determine and manage the changing dynamics that are driving that cost, in each region.
And the benefits of such a costing measure, do not exist in this arena. You are NOT driving this by incremental costs/benefits anyway, so why set up each region to have to be beholding to a cost/pricing structure that cannot justify their outlay, since the full ROI is broad-range, societal, and long term, and is often really impacting the nation, not one single region. And though, yes, this same, or similar, data will and should be captured and analyzed, but this will only need to be done as a historical analysis, at periodic prescribed intervals, not as a part of the day-to-day operation, since it will only be used to determine aggregate trends and to discover short term problems, and to determine long term strategies.
Yes, there are costs, massive costs, in all aspects of the HCR plans being discussed, and yes, I know, the members of congress are trying to determine costs and savings, but the true ROI savings, from the long term approach, will not be realized, unless this is done correctly, with a truly holistic strategy, and then, the true savings, will not be able to seen for many years, but slowly, over time, they will be seen, so we should not be overly crippled by the process of cost justifying this, (to achieve "Budget Neutrality" etc.) any more than we were frozen by this when we footed the bill on insane wars to secure Oil in the Middle East, for USA's interests, and "sell Christianity to the Muslims!"
Ethics in Pricing
Now, the PRICE which Health Care SERVICES Providers and Health Care PRODUCTS Providers can charge, is another issue. I realize that there are many special interests who have a stake in this aspect of the debate, who want their profits to be safeguarded from this current wave of HCR. To name but only two of note, there are some Doctors who want to preserve their lucrative income and keep their rich lifestyle, (this is not all doctors, just some) and there are some pharmaceutical company executives who want to preserve their lucrative income and keep their absurdly rich lifestyle .... and to the Doctor's, I say, I respect your hard work, but this industry needs to be reformed, and if you are truly "HEALERS" and care about the healing of your patients, then let us all work together to create a system that works for everyone and does not milk the public for their health and wellness care needs. And, to the pharmaceutical company executives, I have nothing to say, other than, maybe, please wake up and pay attention, we have a nation that is being bled dry for their basic health care needs and people are dying -- the very health of our nation is at stake, quite literally, so please refrain from exercising your undue influence to derail what we must do, to survive and prevent the next catastrophic pandemic, before it occurs. Hmmm, but, speaking of the pharmaceutical company executives, that reminds me, you know, it used to be illegal to advertise pharmaceutical drugs in the media/TV to the general public, but then, it used to be "okay" for pharmaceutical companies to pay off doctors to get them push their pharmaceutical drugs, but once regulatory oversight cracked down on this practice of paying off doctors to get them push their pharmaceutical drugs, the pharmaceutical companies craftily got the previous Republican Admin/Congress to permit such ads on TV/etc .... and so, please tell me, is this ethical? As far as I aknow, this was never allowed before, and for good reason, and as far as I know, this is not allowed in any other country, and, I believe, for good reason.
But, the point is, the group that provides the "NATIONAL" PUBLIC INSURANCE OPTION must be able to negotiate fair and equitable price, period. And, it is impossible to accomplish HCR without this. Now, if certain providers need to be subsidized, for the greater good, then this should be done, so that the needed services and products to provide health are available.
Ethics in Health Care
What we need is, for ALL health care providers, to take something akin to the Hippocratic Oath.
I posted the following as a comment about ethics, on a diary last week about Medicaid, Poverty and Contempt.
This is an important cultural problem that our system seems to breed, and that we need to transform.
We need to include, in our strategy, a certain ethic of care, that is not overshadowed by the bureaucracy of care ... We need a renewed focus on the very core value, which is that of THE HEALER.
We must remember to see BOTH the forest and the trees.
HMO Orientation Nurses
The original HMO's had "Orientation Nurses" who shepherded people through the health care process, providing assistance and guidance, direction, answering questions, making sure people were taken care of, properly. The HMO's felt this was needed in the earlier era of HMO's, but as time went on, they wanted to cut corners, and thought this was no longer necessary, but quality went down without it. We need this to be reinstituted, or something like it. We need people to know, with personal attention, that they are being taken care of, that they are CARED FOR. This is where true full health and wellness care comes from. And, as a related note, this is where life style changes, to lead a more healthy life, also comes from, and this is also important, if we want to successfully provide, not only the responsive health care, but the preventative health care. And this means that, EVERY single person that interacts with a patient needs to appreciate that their primary function is TAKING CARE OF people. CARING FOR PEOPLE. EDUCATING AND ASSISTING PEOPLE. Treating people with love and kindness and respect, because without these things, people get sick, they get ill, and they get injured, and they die. I have heard too many stories like this one above, from friends in the field, and this is one of the main things we must change ... it is the spirit of our care. People are at their most vulnerable, when they are dealing with issues of health. The health care providers need to realize this and be sensitive to this. Yes, many do know this, and many are great, but some are not, and we need provide a standard, to set a new tone, so that the transformation of the industry is both in substance and form .... to heal our spirits, too, because many people often need, more than anything, to know that they are cared for, and that they have someone they can turn to, when they are ill, or when they think they are ill, or when they have a question about an illness, so that our health and wellness industry can stop illnesses before they become a problem, so that we spot and respond to and stop epidemics before they become a problem. Yes, it is that important, the little things, which breed, either, open communication, because your relationship with your "healer" (health care provider) is so nurturing and supportive, that you communicate valuable, and what might be, critical information, in a timely manner, and it is that communication, which could and will save lives, and without this, the cost could be dire. Yes, it is that important that the health care providers are supportive, at all times, in all ways, with ALL people.
The "Field of Dreams" Danger
A caveat, I would suggest, to all of the Politicians, and I do not mean this as a Republican chide, since I am, I think you gather, an ardent and passionate supporter of this initiative, (assuming it is done right), and Obama seems be wanting to do this right, and as he himself says, NOT DOING ANYTHING IS NOT AN OPTION, but ... having said that ...
I am reminded of the movie, "Field of Dreams" and an old adage we used to take from that movie and use in IT consulting ...
"If you build it, he will come"
You see, one of the most common problems/mistakes that Politicians have, and make, when they issue MANDATES, can be summed up in this very same manner, it is a naive presumption, that simply because some people in some fancy wood room in Washington DC write on some piece of paper that "such and such" will occur, that this "such and such" will actually occur, in real life.
"If you write it into a legislation, does NOT mean that it will happen, in real life ..."
We call it, in consulting, "The Field of Dreams"
I could tell you stories ... and these would be laughable, if they were not so very sad and dire.
This is a problem.
We need an administration what will OWN THIS, and ride this, as the EVANGELIST that it needs, to completion.
And, in this spirit, I know that Rep. Kucinich's "sausage" diary (The Private Mandate Sausage Machine) was criticized for several reasons, and I too criticized him, but not for the diary, rather, for not sticking around for discourse ... but, my point is, I actually appreciated his candor, (although someone said he was being defeatist, which might be true) but in fact, what I especially liked was the long term view that he was promoting, which was healthy, I believe, and correct ... from this last line of his diary ....
It will take four years for the new legislation to go into effect. During that time we are going to build a constituency of millions in support of real health care, a constituency which will be recognized and a cause which is right and just: Health Care as a Civil Right.
Yes, we DO need a constituency of millions in support of real health care! This cannot simply be something we voted for, and now expect ... yes, we should expect it, and demand it, but we also all need to work towards it, from all angles.
Cost of Good Intentions
I posted the following, originally as a comment, in response to this diary ... Dear Dems, Feed me a Sh%t Sandwich on HCR and I'll BURN THIS MFing TENT TO THE GROUND
I am reminded of a brilliant book, about NYC Politics, that I read in College ...
Cost of Good Intentions: New York City and the Liberal Experiment
Well worth the read, if you haven't ever read it or considered the ramifications of legislative measures. (It outlines the sequence of events that led to NYC becoming bankrupt, in 1975. My teacher, at the time, was one of the foremost leading scholars on NYC politics, and he told us a story of how the budget for NYC was laid out at a diner, (on brown paper bag, or the back of some receipt, or something,) the diner was the Shalamar Diner, (I used to go there, it was famous, was 1 mile from my home,) ... and these guys, basically, ran NYC into the ground, which resulted in the Fed Gov having to step in, bail NYC out of their crisis, and then oversee NYC for a numbers of years until they repaid the loans.) Hmmm, something proverbial here ....
Okay ....
Listen, I am all for Health Care Reform, I assure you, I am an ardent supporter, and I say that BOTH as an IT Professional who services this industry, and as a citizen, who could sure use some HCR, but as this diary is attempting to make poignantly clear and help us avoid, we could do more harm than good, if we do not do this correctly. Most notably, we could create an administrative nightmare, which is obviously what the Republican opponents are suggesting, and they might be right, unless we do it correctly.
As I commented previously, let us not forget proverb ....
"The road to hell is [OFTEN] paved with good intentions."
And to this end, in some respects, the Republicans' are justified in their concern, but their efforts to sabotage and poison this effort to address a very real problem are not doing us any good. Obviously, their primary agenda, demonstrated by a desire to DO NOTHING, is obviously designed simply to protect the special interests, veiled behind political and social rhetoric, inflammatory misstatements of the facts to confuse the masses, and outright lies to brainwash the ignorant, and that effort is evil, and THAT is what is skewing their debates and discussions. This and these things are derailing the much needed healthy process of discourse, and this I find most disturbing, with people like Wilson who is willing to violate such decorum to shout out a lie, himself, is just behind pale. PLEASE!
Listen, this is a massive challenge, we need VALID discussions of substantive issues, not bullshit. We do not have time for the bullshit, not any more .... (and we really never did.)
We need to have:
A) A mandate of clear goals, that addresses the needs and serve the people.
B) A realistic strategy of clear steps and resources and time-lines to achieve these goals.
Now, I want to see, not only the mandates, I want to see the strategy .... the STRATEGIC PROJECT PLAN, the MACRO INDUSTRY OVERVIEW, of the ins-and-outs of how this new industry will work, and what are the component pieces and necessary players, and what their responsibilities will be, and how they will be held accountable for those responsibilities.
I want to see thoroughness of thought, and I don't really give a fuck about "bi-partisan" crap, I care about making sure the REAL stakeholders' needs and concerns are addressed, which are:
A) the HEALTH CARE PROVIDERS, and
B) the public, i.e., the HEALTH CARE RECEIVERS,
Now, I don't give a f%ck about the concerns of the insurance industry, NO! because this industry will survive and flourish, no matter what, and they will suffer from losses, but so what. They have f%cked up this industry enough, or rather, we have let them f%ck up this industry enough, by letting them dictate the terms. That must end! Sorry, they have no place at this bargaining table. They have lost their privileges, here, by too much abuse, for too long. There are plenty of other fishes for them to fry. We need a healthy system to support the wellness of our nation and we have no time or luxury to support that failing industry's cries for salvation.
Yes, the concerns expressed by this diariest in this diary are valid, and these are potentially real dangers of what this piece of legislation might become, if we do not do our homework, and diligently and responsibly think through what each mandate entails (in order to achieve), and then what the full ramifications of each of those mandates are.
Rep. Dennis Kucinich's diary speaks of the very real truth of what very well might occur, if we do not act responsibly and with thoroughness, during this time. I speak from having implemented a number of massive change management programs, for Fortune 100 companies, and these projects fail, more often than not, but they do not have to fail, not if one does their homework correctly, and plans correctly, and that means doing the job correctly, from PHASE 0 and beyond. This means, first, as a beginning, only, agreeing to a mutual shared vision, which I know is hard enough, but then, once we have agreed upon this, then we need to outline a plan, for how to achieve those goals.
Financial Gain Agenda - Capitalism vs Socialism
There is no doubt that the global financial powers are all vying to both preserve their power-base, and further it, whenever and where-ever possible, and this is only natural, and I honestly do not begrudge any entity, be it a person, or an enterprise, for attempting to do this, this is what they should do, this is the strength of capitalism, it is where our passion lies ... this is what we want our US corporations to do ... to thrive and prosper, as long as that "INDUSTRY MODEL" that they are attempting to sell/promote/foster to/for the rest of the planet, serves people, I am okay with it, but, to do this in a manner that does not serve the greater good of the people, or to do this at the expense of the health and wellness of the people, that is where I have a problem. There must be balance in our actions, and to not care about the wellness of the people, is, I believe, foolish and short-sighted and quite frankly, it is BAD BUSINESS, it is STUPID, because to do so, will destroy us, as a humanity, in the end, and THAT is where I draw a line in the sand. I am a business man, and I have serviced the corporate enterprise sector for 25 years, and I have found many good, honest, and honorable people in that sector, and many are trying to do the right thing, and I know that many seek to demonize them, but they are usually not bad or ill intentioned people, and it is unfortunate the they have, too often, been led by ignorantly foolish leaders, and that is what I am working to change. I am not working to dismantle the very nature of our republic, which is forged in the innovative ingenuitive enterprising entrepreneurial spirit which is the heart of capitalism, but also too, I believe, we also need socialistic principles, to provide for the general welfare of the people. We need a hybrid model, I believe, to serve the greatest good, for all, because both "models" have strengths and weaknesses.
I am a strong and ardent advocate for a HYBRID Model, which supports, in some instances, a PRIVATIZED INDUSTRY MODEL, and in some instances, a PUBLIC INDUSTRY MODEL. If you are inclined, you can read this diary that I posted last October, during the heat of the election, wherein I described, in detail, what my position is, and why, and what are the detail subtleties of why it is appropriate in some instances, and not, in others.
In summary, the following two points outline the main issues ...
1.) SOCIALISM FLAW/WEAKNESS
The basic flaw/weakness in the PUBLIC SECTOR "UTILITY" MODEL, which is a socialistic system, is that it is NOT a "Least Cost Operating" Model. In other words, in the simplest of terms, it does not provide incentive to be efficient ... it does not provide an incentive to operate at the least cost that is possible ... in fact, it provides a financial reward to being inefficient ... and thusly, it fosters inefficiency, which is what we experienced in the Electric Utility Industry over the past 50 years.
Now, on the other hand ...
2.) CAPITALISM FLAW/WEAKNESS
The basic flaw/weakness in the PRIVATE SECTOR "SERVICE/PRODUCT" MODEL is that it sometimes cannot utilize the benefits of Enconomies of Scale, which sometimes only exist at the most macro level, i.e., at the societal level. Like, with respect to educating the populace, or protecting the populace, or, in this instance, THE WELLNESS OF THE POPULACE, i.e., Health Care.
Now, the problem/challenge, with respect to Health Care, is that it is not clear what aspect of HC should be PUBLIC and what should be private. And, since, I as I have explained, I believe the optimal "MODEL" should be one that includes a "hybrid" nature, the question arises ... "Where is the line in the sand?"
Now, in the Electric Utility Industry the "line in the sand" is, I believe, easy, but that is a rather simple industry model, .... but it is a good place to start, .... you see, in the Electric Utility Industry we have, GENERATION(GEN) .... and we have, TRANSMISSION&DISTRIBUTION(T&D).
T&D is the power lines, which can only be provided by a singular provider, the GOV, the "PUBLIC SECTOR" .... but the GEN (Generation) can be provided by anyone, and I believe, we need competition in this sector, we need innovation in this sector, we need ingenuity ... we need efficiency ... which we have sorely not had, for 60+ years.
Now, I realize that many, like Kucinich, are strong advocates against this, but I would argue this case with ANYONE, and unlike them, I have actually worked in this field, and so my knowledge comes from knowing, intimately, the nuts and bolts of it, not the ideologies that most people are spouting. And, if anyone wants to claim that the PUBLIC UTILITY MODEL is optimal for GENERATION, then please explain why, over the past 60 years, wherein WE HAD a PUBLIC UTILITY MODEL for GENERATION, and it FAILED, MISERABLY, to produce an efficient model, a model that supported the necessary innovation and adoption of new energy efficient technologies? Why? I will tell you why, because that "industry model" just does not provide an incentive or reward for it. Okay, now, many might disagree with me, and I have no wish to go off topic, but I did want to clarify, that if we want to be "bi-partisan" in spirit, then we must appreciate that there a valid concerns on both sides of the camp, and I do well appreciate the Republicans' concerns/fears about instituting a socialistic model, when that model failed in the U.S.S.R. ... yes, they achieved some initial major growth benefits, but they could not sustain that growth, and they could not come any where near 80 to 90% productivity/efficiency. That "model" was great to get them from 0% productivity to 60%, but that is where they fail.
Now, with health care, I do believe the "line in the sand" is the PUBLIC INSURANCE OPTION, or maybe even SINGLE PAYER, but NOTHING LESS THAN THIS, period. This is why, whenever this subject comes up, on any diary, I am adamant about this. As far as I am concerned, without, at the very least, a PUBLIC INSURANCE OPTION, this initiative will fail to achieve even it's most humble goals. It will fail. No, I have not been outspoken about SINGLE PAYER, not because I am not in support of this, because I actually am, but rather, let's "WALK" before we "RUN" .... and the PUBLIC OPTION is a good first step, along that path. And, to take on, the creation of, and instituting of, a SINGLE PAYER INFRASTRUCTURE, might be a little too much to bite off, in one shot, but then again, maybe that is what we should should for, or plan for, and it might actually be easier ... quite frankly, I am not sure, but it is worth considering. But yes, I know, that would require an even greater political battle, and for that reason alone, it might not be the best first step.
Listen, this could be a lengthy discussion, and I do not mean to digress, but I did want you to appreciate my perspective on this, since the subjects you are bringing up touch upon issues, or are suggestive of issues, regarding which many of the participants in this HCR have strong feelings, since this is exactly where the "SOCLIASM" fears rage, and I want to make it especially clear that I appreciate, what I feel, are the REAL and VALID concerns and problems that we have seen, with socialism (ie, the "PUBLIC SECTOR UTILITY MODEL"), and what it can effectively do/provide, and what it cannot effectively do/provide.
The Mandate is only the Beginning
This legislation is a mandate, only. And, while it is proper to begin with a mandate, of this sort, at the very highest level, in the most general of terms, with a direction and goal, but these broad stroke mandates, though they are good as a beginning, because you have to start with them, and you have to start some where, but there is more work to be done on defining certain components, which comes from someone sitting down, looking at those mandates, and breaking it down into the necessary component parts, of what must occur, in order to achieve those mandates (i.e., "goals"). We use the term "RIGHT TO LEFT" thinking. In other words, if a time-line of events occurs/flows from left to right, then in order for us achieve a known/defined "end" then we start from that "end" and look at the sequence of events that must occur to lead up to that end. And then, as my friend outlined, you need to assign the necessary "resources" to each of those areas, and these "resources" must be qualified individuals, and these "resources" must be sufficient to the task, and they then must be accountable to the task, and all combined, each of the relevant component tasks, must be combined into HEALTH CARE REFORM PLAN.
1.) There is data, as "information" ... (ie, intelligently organized data, at the right level of granularity, reliably timely, with quality control,) that must flow.
2.) There is the people, doing processes ("Business Processes"), performing functions.
And these two combined, equates to an "Industry Model" ... a "model/framework" that all "participants" must mutually understand, and must be: (A.) static enough, that all "Market Participants" (Insurance Companies, Health Care Providers, Citizens, etc.) can function efficiently within it, (i.e., develop efficient ways/methods to function within it), and it must be: (B.) flexible enough to support the changing, evolving, and developing needs of all of the "participants."
This is what constitutes/comprises "A PLAN!"
Now, if it sounds like I am criticizing the "mandates" .... I am NOT, these mandates are the first step, and they are a good place to start ... again, this is the only place one can start, but there is much much more to do.
Listen,
You have to approach ALL projects with a "PHASED APPROACH."
The "mandate" is, what we might call, "PHASE 0", there are many phases to any and all projects. All projects require phases, and taking things in bite size pieces is the only way to approach a project, most especially a large project, and this project is, needless to say, probably the largest project of its kind ever conceived.
Now, to whatever extent the current legislation can do the following, it will contribute to our ability to successfully achieve the goals of the legislation.
I. It must have clear goals.
II. It must allocate sufficient resources to achieve those goals, in the time allotted/targeted to achieved those goals.
III. It must assign sufficient authority (and accountability) to the appropriate/relevant/necessary resources to achieve those goals.
IV. The goals must justify the cost.
Now, PHASE 0, defines the goals.
PHASE 1, must determine what resources are necessary/ required to achieve those goals, which begins with, and presupposes that, one has figured out HOW is the best/optimal way to achieve those goals, which is, actually, an ongoing challenge, which means that, the ultimate "PLAN" must support a flexible and evolving set of "requirements"(i.e., "detail goals"), and a flexible and evolving requirement of resources. In other words, it is a never-ending ongoing "cyclical" process of iterations. Do NOT expect the initial mandates (i.e., "goals") to be sufficient, or to be expressed in sufficient detail, therefore, make sure you build into the plan, this cyclical iterative review cycle, wherein one will "REFINE" the plan, ongoingly. This must be understood.
One of the most common causes for project failure is a lack of proper "PERCEPTION" about what will be achieved, in each phase ... we call this, "SETTING EXPECTATIONS" ....
Listen, one CANNOT even begin to determine what is required for, or how to deliver on, a mandate, UNTIL AFTER one has DEFINED what that mandate is!
This is where it begins.
Now, consider the fact that we have no even determined if we are having a PUBLIC OPTION ... or who "owns" the relationship with the "customer" .... In other words, these are all different entire plans, depending on which of these one is mandating. And, of course, if one is advocating for a SINGLE-PAYER mandate, this too, is a different "plan" that requires different resources, timeline, etc. .... you get the picture.
But, so, once one has completed this phase of determining the actual agreed upon mandates, then one must think through the steps to achieving those mandates, and then, make sure that the entirety of the "charter" for this plan contains, not only, the initial mandate, but also, a mandate to support the subsequent, not yet determined, components. etc ... This is a phased approach. Now, I know that The Congress and the admin, and the public, would like this to be a one-time affair, get the "right" piece of legislation passed, and "DO THE DEED" (as they say) ... but there is more work to do in this, and all members must first agree that this is the direction we are all following, and then, all members must provide their input on what is necessary to achieve those mandates, and then proceed, in baby steps, to our ultimate goal, which is, a healthy fluidly running smoothly evolving "Industry Model."
An "Industry Model" is like a FLOW CHART, a SCHEMATIC, a diagram ... but, it is actually MANY Flow Charts, combined into one, with all inter-dependencies, connecting dots, laid out, for all to see, so that people can see what all is happening, both from the "MACRO" perspective, and from a "MICRO" perspective.
As they say ....
"The devil is in the details."
"True mastery is in the details."
Which means, we mustn't shy away from digging in to the details, since this is where both the most critical goals are developed, and it is where the crippling problems exist, and, in fact, it is the very crippling problems that DETERMINE the ULTIMATE GOALS. Of course, knowing which details to focus on, and which are unimportant, is always the most challenging dilemma, and with that in mind, let us move to the actual legislation ...
The Legislation - What does it takes to actually implement?
There are two components to any corporate change management project that must be well defined before a project can be commenced fully:
A) Business Process Management (BPM) --> Business Process Re-Engineering (BPR)
B) Data Process Management --> Data Process Flow
Now, once these two have been well defined, this leads to the next phase:
A) Data Architecture
B) Application Architecture
C) Systems Architecture
Now, this outlines of the process sounds like this is all within a "VACUUM" (i.e., wherein there are no pre-existing systems) which we all know is just not the case, so the actual process will be a bit more involved and will have to include addressing the migration strategy from existing processes and systems (See my "In Closing" section, written by my friend/associate) ... but, at least you will have a framework to begin the discussion.
And, having started with this overview/over-arching framework, with respect to each piece of legislation, I am most pointedly concerned with MAJOR components of the legislation that constitute a paradigm of INFORMATION FLOW, and BUSINESS PROCESS'es, ...
i.e.,
Who does what? and,
Who is accountable? and,
How are problems/changes handled?
The "Exchange CO-OP - Who Owns the Customer Relationship?
The fact that this "Exchange" will be a private organization, a "co-op" of sorts, within each region/state .... this is, NON-TRIVIAL. And, since this is NOT the gov, then this means that the entire paradigm will be within the spirit of "Capitalism" ... but with a CO-OP, which is run by a certain select few people, for each region, wherein each region will require its own systems infrastructure, which is also very costly and very involved. And, the fact that the PUBLIC OPTION will be just one of the "competing" players, this will, yes, ensure that there will be no MONOPOLIZING of rates, by the private participants, so this is a good thing, for advocates of market competition, but still, how one determines the cost, could still make that effort a nightmare.
NOTE: The question of who owns the relationship with the customer/ individual is one of the most critical defining characteristics with respect to the BUSINESS PROCESS and DATA PROCESS. This is non-trivial and has profound ramifications.
How are Insurance prices/costs determined?
Now, when we speak of "competitive" with respect to a given "INSTRUMENT" (i.e., an INSURANCE POLICY or BENEFITS PROGRAM) which has a "NUMBER/PRICE" associated with it, this has many meanings and many dynamics. First and foremost, we need to consider what this means, from an administrative "PROCESS" standpoint, to supported by the GOV for the PUBLIC OPTION administratively.
(c) ADMINISTRATIVE CONTRACTING.—The Secretary may enter into contracts for the purpose of performing administrative functions (including functions described in subsection (a)(4) of section 1874A of the Social Security Act) with respect to the public health insurance option in the same manner as the Secretary may enter into contracts under subsection (a)(1) of such section. The Secretary has the same authority with respect to the public health insurance option as the Secretary has under sub-sections (a)(1) and (b) of section 1874A of the Social Security Act with respect to title XVIII of such Act. Contracts under this subsection shall not involve the transfer of insurance risk to such entity.
How does that PRICE get determined, or regulated? And, by whom, and how much administrative resources/costs are required to do this? And, are those resources sufficient, or are they being laden with a task that is a beyond them, with a reasonable degree of costs, ie, is their goal a prescription for failure? Are they being set up for failure? In no uncertain terms, I am saying that the "Regional" PUBLIC INSURANCE OPTION "Industry Model" for the GOV is a prescription for failure. Each local region simply will NOT be able to provide that service in any reasonable cost effective efficient manner, it is quite simply TOO MASSIVE for any one region to do. You see, the answer to these questions are non-trivial This is very involved, far more than people realize. Consider, what are the mechanics of determining that price? If it is "regulated," which is what we are requesting, then this means there is a regulatory ruling, with "rules" that have pricing scales, which have algorithms, (ie, formulas for determining price, or limiting/capping price) ... and therein lies THE "RUB" ... How does one do that? And what about dealing with reconciliations for people transferring from one region to another? What are the pro-rating processes? Cost-back metrics? Who picks up a cost that spans multiple regions? Hmmmm, the administrative questions/challenges associated with this are already massive, without having to deal with differing regions with differing metrics and different operations, and different systems, etc ... it is, quite literally, impossible for this to succeed. Yet, the local regional people will be blamed for their failure, and the politicians will be long gone, before this becomes evident, much less, will the true cause be determined. So, let me save us all a lot of pointless mess, by avoiding that road, for it will come to no good, I assure you.
Now, if one adopts a "NATIONAL" PUBLIC OPTION, then this changes the "regional" dynamic considerably, and simplifies the process significantly. DO not get me wrong, it is still a massive effort, but this way it will be done, once, from a national operations point, and then each region will simply be a satellite operations, mirroring back to the main office. This issue of price is what must be addressed, sooner, rather than later. Remember, the price cannot be arbitrary. And, if the price is determined by a series of METRICS, then one must ask, How? Which metrics? And why? And the answers to this and these questions must be revisited, constantly -- FOREVER. That road is never-ending, and unless one simplifies it, from the beginning, it will bury the admin person who is tasked with it. Now, I realize you might feel I am belaboring this point, because I have now stated it several times, in several ways, but I want to make this point so poignantly clear that no one will question what I am saying. So, let us dig into this DETAIL:
(The devil's in the ....)
Consider the following ...
First,
(A) Is it a price related to cost?
ie, "COST PLUS"
ie,
The cost of the service, plus a percentage increase, for profit.
Or ...
Second,
(B) Is it a price related to a competitive market?
Or, Third,
(C) You price things based on "affordable" ?
Remember, the very nature of the PUBLIC OPTION is that it is intended to be affordable. It is intended to provide the basic health care services that people need, to both respond to illness, and ideally, prevent illness, with proper treatment, etc ...
So, what is "affordable" .... and herein lies the big "elephant" that needs to be dealt with ...
Again, How do you price things?
People are asking "competitive or not competitive" ... but the PUBLIC OPTION is not exactly that, it is a THIRD OPTION ... Yes, it adds a dynamic of competition to the fray, yes, but the "pricing" of that PUBILC OPTION must be set by a congressional mandate, a regulatory mandate, or someone. Who? How? When? Where? And, this is, in a manner of speaking, a paradigm shift. This is where the paradigm shift must occur. And, the full "cost" TO THE NATION is so extensively broad, across an entire nation of operations, to include all R&D, etc, that the very term "cost" is meaningless and pointless. How do you determine the cost/benefit of a war? How do you determine the cost/benefit of avoiding a pandemic that you have avoided? The answer is that you you simply cannot, so why play games with what MUST be done.
Doing NOTHING is NOT an option.
With insurance companies, they can determine "cost" in terms of payout to policy holders. And, in a limited perspective "tunnel vision" manner, the PUBLIC OPTION can apply the same metric to determine "cost" but that is simply foolish, since it does not include all that it should include to be smart with the ROI (Return on Investment) financial model, which is what has mandated the HCR and PUBLCI OPTION to begin with ... in other words, the bottom line, to me, is that the PUBLIC OPTION must be cheap, so that everyone does it, without any backlash effect, so that people embrace a health care paradigm, a healthy paradigm, to transform our nation and address these problemthis.
Now, if they have already, at inception, provided/defined, by congress, the PUBLIC OPTION rates, at a national level, then the question of "competitive rates" does not even apply.
Two items ... Systems Operations Questions
Hmmm ...
Consider, the following, from Obama's site:
I want to know more about these two items:
# Implements a number of delivery system reforms that begin to rein in health care costs and align incentives for hospitals, physicians, and others to improve quality.
What are the details of the reforms to the "delivery system" ?
# Creates an independent commission of doctors and medical experts to identify waste, fraud and abuse in the health care system.
What or how does the "independent commission" get it's information? What information does it look at? Who provides this information to them? Can a private citizen provide infromation directly to them?
Now, I realize that people have many "detail" questions, about coverage, etc, and this does, of course, concern me, as do questions about the rates, as well, but even more importantly, I am concerned with HOW those rates get determined and adjusted, over time. I am concerned with how R&D projects get funded, and what get's funded, and why? I am concerned with operational components that enable the BUSINESS PROCESSES to correctly feed the proper DATA FLOW PROCESSES, so that the proper information gets to the proper people, so the proper decisions can be made by the appropriate people who have been given the proper authority, and resources.
Was the Election's Mandate for ALL to be forced to take insurance?
Note: If the PUBLIC OPTION is forced on everyone, what about those who don't qualify for Medicaid, but can't afford health insurance either.
This is question. Are the rates they have outlined, affordable?
Now, the mandate from the election was NOT to require ALL of the public to sign up for Insurance Programs ... That was NOT the mandate ... The mandate was ONLY to provide it as a mandate for those under 25 ... I am sorry, I realize that the "cost efficiency" factor is relevant and is driving their thinking, but I am also sorry, because THAT was the voters mandate. And you cannot overlook the voter's mandate. Get the money from somewhere else. DO IT! You got far more money for these wars from somewhere else, so do it with this.
Look, let's review ...
Clinton was promoting imposing that for all, and Obama was not, and that was one of the most profound distinguishing differences between the two's health care platform, and Obama won the primary election, and now he is changing to HER plan? That would be a bait and switch, of which, the more that I think about it, the more upset I am about it. If that what get's put into place, and it does not take care of the poor who cannot afford it, then the poor will simply NOT pay for it, and there will be massive violations, and then an entire POLICE force will have to be PAID to TRY to GET people to pay for what they cannot afford, they will be living a life of truancy, and our republic will be eroded by this. This is my fear with this imposition. That was NEVER my plan or strategy. That will only feed the insurance companies even more money and not that I have anything personally against them, I do not, however, their well-being is not the charter.
The focus must be on providing HEALTH and WELLNESS CARE. Remember, THE GOLDEN HOUR!
We are focusing TOO much on INSURANCE and NOT ENOUGH on the HEALTH & WELLNESS CARE PROGRAMS and what they MUST provide. That is the VALUE PROPOSITION. That is the charter! That is the mandate! That is the need! And if the democrats do not address THAT need, then this window of time, where they have the control, will end, in abysmal failure, and whatever gains are made, will be short-lived, and the "hope" message will be destroyed and recast as the biggest lie sold of the 21st generation.
Remember, that was NOT the mandate that "We, The People ..." voted for, in our choosing Obama over Hillary ... Remember, most acutely, this was in the heat of the primary, when Hillary was promoting this, and Obama was only promoting a mandatory insurance that parents must support for children under the age of 25. We cannot betray the trust.
Now, I realize that this windfall for the insurance industry is part of the deal-making that the gov might feel they need to grant, in order to get HCR legislation through, and I know that this will make it more cost effective, in terms of the overall cost for the populace, if we mandate that everyone must get insurance, but let's be candid, who are we serving? If this is done, then this is, in effect, quite literally, a tax, and it is a tax that will hit, hardest, and most especially, the low income, and that is simply not the way to take care of the low income, who are already financially crippled. The gov needs to find a better, more fair, more equitable way, to fund this. If they do not, and if they enact legislation that imposes an undue burden upon the poor, then, let's be brutally candid, I will view this as a betrayal, and violation of our faith and trust, in a non-trivial manner. And, so will the public.
Let it be known, that if this is done, the low income will feel betrayed, because they will have been betrayed, and they will know that they were betrayed, and this will have, I believe, profoundly crippling consequences for our economy, immediately, and for generations to come. It will undermine the Democratic party's ability to sustain their hold in congress or the Whitehouse. Obama will be seen as the great deceiver. His message of hope will be seen as a lie. He will, with that one act, disenfranchise an entire young generation, myself included. It will set the tone for the 21st.
You, the Democratic Party, have been given fair warning.
Do not, I repeat, DO NOT, betray our trust.
In closing ...
A comment from a friend ...
The following is from a friend of mine, who is, like myself, an Industry Professional. He has worked personally with many of these companies you read about, with regards to this and these issues. I asked him to read the legislation and send me his thoughts. Here follows are his words ....
... and he is, like myself, a 20+ year industry professional, with even more experience in health care and insurance, than me, with the industry leaders, all the names you are well familiar with, (we were roommates for 5 years in college), now, his focus is more Project Management, and my focus is more database/systems architecture/design, and so, between us both, you will get a rather comprehensive perspective, so here goes ...
I've read through the plan. And its not a plan. Its as I thought, another set of mandates. Partly because its legislation, and by nature, legislatures don't create plans, they create mandates. Don't get me wrong, as mandates go, these are good ones. They are well thought out, and definitely in time to help the ailing masses. The challenge comes from my knowledge of the way mandates are carried out. When change is in the air, mandates invoke a change, and change agents carry out the change. Those that invoke change are rarely the ones that pull it off.
Where are the change agents here? Where is the driver, the communicator, the arbitrator, the manager, and the architect for each of the elements of this plan? Where are the ones that will make this change happen? Who are the evangelists that will keep the troops motivated to the cause? Who is designing all of the intricate elements that must work clearly together in order for a change of this magnitude to occur? Let me open it up a bit, lets dive into the details. Every insurer will have to make massive changes to all of their healthcare related products in order to satisfy the sweeping legislation. Every medical practitioner, every health care organization. That's a lot of people. Everyone of which will have to be clearly communicated with, motivated, and held accountable to their task.
It smells like Sarbanes Oxley all over again. Lots of good that did the consulting companies! Mere interpretation of what was necessary spawned a whole sub-industry of consulting practitioners.
I can tell you that the number of individuals with the change agency skill set necessary to accomplish a change of this proportion is sadly deficient. I'm an expert in my field, and have never failed a project. My only achilles heal is I'm a sucker for a challenge. I seem to be able to smell them out, and I've got to tell you, this one is a doozy! I've taken on challenges that would make the typical project manager scream in terror, and this one is one that would paralyze a Spartan.
The simply issue here is finding the team that will mobilize the necessary specialists that will be required to maintain motivation for the two to three years that is necessary to kick off the task thouroughly, and another five to ten to carry it out. Likely the larger consultancies will vie for the priveledge, and unfortunately, they will perform as they have to date; sadly, ineptly and at a great cost to their clientele, the country. As we take a look around us, at the state of the fiscal environment, and every office one walks into, we see leaderless masses, and leaders who only know how to dictate a change. Senior executives are filled with mandates, without bothering to understand what the troops are capable of. When this occurs, needless to say, strategies fail.
Well, we cannot allow this plan to fail. So, dismal as it may be, there is a way.
The tactical plan to support this strategy will have to be developed in short order, and by a team of managers and subject matter experts the likes the world has yet to see assembled in a single room. Every material health care supplier, insurer, and support organization will have to be part of the solution, cooperatively, even though it will be fiscally counter motivational for them to do so. Without the team of tacticians in place, and the cooperative environment working, this "plan" will fall apart by the way of the typical mandate, and will become the administration's undoing.
I bid you all, peace.
Arthur,
PS,
I will be offline until tomorrow morning, SoCal time, at which time, I will respond.