Why Fee For Service Hurts Us: The Plain Language Version

I’ve had a few conversations recently with elected state officials, and I’m reminded that speaking plain language always helps.  Here goes:

We all agree that fire stations are a good thing, right?

And we agree that we don’t want them to be busy … 

So if the firefighters are always watching Three’s Company reruns, that would be good.  We still pay for the fire station.  We still pay the salaries.  Happily.

Therefore – paying firefighters more for fighting more fires would be silly:  their financial success would align with hardship in the community. 

But this is how we pay medical providers:  more sick people = more $$.


We have a social compact: everyone agrees that we should pay for fire stations (infrastructure) and firefighters (humans) to be ready for fires.  We all pay for this with our taxes.  It’s the most efficient way for us do this.

Shouldn’t we have a social compact that would cause everyone to agree to pay for hospitals and medical offices (infrastructure) and medical providers (humans)? This would be efficient and effective.  Then if the medical providers were idle most of the time (watching Three’s Company reruns) – it would be because the community is healthy.  Nobody would complain of reduced revenue due to low volumes of emergency department visits.  Kinda like what Maryland did.  Seems simple.  Why not?

Toyota Mirror Replacement

.. and now for something completely different.  For me, writing a blog isn’t about getting clicks, earning ad revenue (no ads here) or getting tweeted.  I write here to share insight that may be helpful to others.  I started writing this in 1999.  Topics vary, but I don’t think I’ve blogged yet about car repair.  My last big home improvement project (replacing the tank water heater with an on-demand tankless one when the former died suddenly) was well covered on Facebook.  I think my rationale there was: “hey friends, look what I did!”  Facebook is good for that.  Many people have made the tank-to-tankless conversation. The Internet didn’t need to learn that someone else did it.

But I don’t know that anyone’s done what I did yesterday and I can’t imagine that I’m the only one who has experienced the predicament.  So a blog is the best way to share a new solution to a common problem.  Others will search for the topic and some day, someone will use the information I post here and their life will be better. That is (ideally) what blogs are for.

The problem.  We have two cars and a two-car garage.  As anyone with a two-car garage knows, (especially with 20 years of accumulation) this is by definition a tight fit. A few weeks ago, the passenger mirror housing of our 2017 Toyota Highlander was damaged (the identity of the driver is not relevant to our story).  The mirror itself was ok, but the plastic parts and the turn signal light were broken.  This mirror has a “puddle light” (shines down on the ground when entering/leaving @ night) and is heated and has a blind-spot monitor and has a camera for the parking assist camera system.  There’s a lot in this thing.  

Toyota 87910-0E292 MIRROR ASSEMBLY, OUTER R

A new mirror assembly, part# 87910-0E292 is $1290 from Toyota or $863 from Toyotapartsdeal.com.  I found some used for ~ $500.  Why so much?  Because of all the “stuff” this mirror has in it – especially the camera, which can be purchased separately for many $$.

There are aftermarket mirrors for as little as $65, but they just have the mirror.  No camera, no wiring for the camera, no blind spot monitor.  Some have heat, which is valuable here in Upstate NY, and others even support motorized folding, which could have prevented this, but I’m not sure how we’d integrate that feature and control it from inside and these mirrors were missing features we have. The car’s computer complains when stuff it expects (camera especially) are not there.

As I looked carefully at the Toyota parts manual and studied the Toyota service manual (I purchased online access to it for 2 days to do my homework) it became clear to me that the parts I needed (the plastic backing, the plastic “visor” and the (mostly plastic) turn signal light) were all identical to those in the “basic” model of this mirror, part #897810-E143.  $244 from the dealer and $173 from Toyotapartsdeal.  What’s the difference (other than $690)? The less expensive mirror has few of the extras: no puddle light, no camera, no blind-spot monitor (really just a light that connects to the computer). The plastic housing is the same with two exceptions: a) At the base of the housing, there is a hole into which the assembly for the puddle light and camera fit. b) In the back of the housing, there is a hole for where the camera wiring harness plugs into the wires that come from the door.    

IMG_20200202_111738 Here’s a photo of the hole in the bottom.  The lower right corner is gone (due to the collision with the garage door frame) and in the upper right you can see some of my practice cuts.  More on that shortly. This hole needs to be precise, so the camera housing fits in properly.  Misalignment of the camera is bad:  it will mess up the collision avoidance system and the images that the parking assist monitor won’t work.  The other hole isn’t as important:  just need to have a hole there so the cable can be attached/detached. 

So the absence of a ~ 3″ x 2″ hole in the bottom of a plastic part is the difference between spending $173 or $863.  

I ordered the $173 part.  The first thing that happened was that the (very good) support team at Toyotapartsdeal.com noticed that this wasn’t the right part for my car and sent me a message:

The proper RH mirror is 87910-0E292 @ $863.21 and the cap is 87915-0E040-A0 @ $52.90.

Would you like to change your order?

My reply:

I don’t need the cap – I have one and it’s not damaged – all I really need is the black plastic housing and the part Toyota calls the visor – neither of which it seems I can buy separately.  All of the electronics work – so I’ll swap out the innards from the mirror I have and will need to cut a hole in the bottom for puddle light and camera.  Oh well.  Not perfect but better than spending an extra $700!

They checked again (I got the same email the next day) and called them to make sure we were on the same page.  

The package arrived on Saturday morning. 

Step 1: disassemble the new mirror to get the parts I want.  The key to this step is to remove the mirror itself from the housing.  This is easy but must be done right or you’ll break the mirror.  Youtube helped some here, but if you try this, do it like this and not like this. The second way – you’ll break the mirror.  I broke the mirror when I removed it from the new assembly, but fortunately, when I removed the old mirror from the old assembly, I didn’t break it (used method #1) so all was well.  Be careful.  Use your hands, not tools.  Hold firmly.  I also warmed it with a heat gun and sprayed some WD-40 in there too – thinking that softer plastic (subfreezing in the garage) and some lubrication might help.  Too many variables to know what caused the better outcome.  It worked.  

Step 2: remove four torx screws.  I’m guessing that these were torx #8.  Pretty tight but came out after some coaxing.  This holds the back housing to the visor – trapping internal parts:  the mirror arm, turn signal light and the mounting base with adjustment motor/electronics.  Once these four screws are out, the whole assembly can be (very carefully) separated with some plastic auto clip removal tools like this.   $12 on Amazon if you don’t have the kit sitting somewhere in your garage (which is why it’s so full). 

Step 3: measure, practice, cut.  At this point, I did the same on the existing mirror on the car.  What’s nice is that I didn’t need to remove the mirror assembly from the car, which means I didn’t need to remove the door panel, etc.  I removed the mirror (see above) and the torx screws, and the cap (which wasn’t damaged so I didn’t have to buy a new one for $50. After disconnecting the wires (and taking photos so I could be sure that the wires go back in the same places), the visor, mirror and housing came off easily.  Now I could carefully measure and create a paper template for the hole that needed to be in the base of the housing.  I then practiced cutting holes in the plastic on the old housing – to see what was the best way to cut the hole with maximum precision and minimal local deformation.  I tried a soldering iron with “knife” tip but a dremel tool with a tiny cutting wheel (like this) did the trick. These things break easily as they’re very thin.  I had five of them and used all five.  As you can see from the photo above – the opening has a little step-off shelf that the camera-puddle light assembly fits into.  I did my best to recreate this with a dremel grinding tip.  It almost worked: when installed, there remained a ~ 2mm gap at the leading edge of the camera assembly because the plastic clips that hold it into place didn’t “grab” tightly into the housing base.  I probably could have made the shelf deeper but I didn’t want to make it too deep as this would have weakened the plastic – might have broken it.

Step 4: make things snug.  To help this fit tight, I clamped the parts together and used epoxy to hold this thing in place forever.  Yes.  Forever.  I won’t be replacing the camera assembly.  Once the epoxy cured, I remove the clamp and was pleased to see that – while not perfect – it was pretty close.  An astute observer would see that the little shelf the camera housing fits in is a bit rough – definitely not factory-made. Oh well.  Can’t see it unless you bend down and look under the mirror.

Step 5:  put it all back together. Place turn signal light in its little slot. Go to car. Housing goes in the back, visor goes in the front, sandwiching the arm and electronics.  First, plug in the light .. then the camera – making sure the wiring harness goes through the right little slots so wires don’t get caught when mirror moves. Next, replace the four torx screws – pulling everything together.  I screwed them all in halfway – then made sure all the plastic parts lined up well – then screwed them in the rest of the way.  All good.  Now replace the mirror: attach the wires for blind-spot warning light and heater, then snapping it into place with a gentle but confident push.  Finally, the cap goes on the back and it’s done!

Tested.  Everything works perfectly.  The manual says we should recalibrate the collision avoidance system (camera alignment may not be the same).  I don’t have the software for that – so if we do it- we’ll have to go to the dealer.  Not sure how much that is or if it’s necessary.  More homework.  The images that the parking assist monitor creates are the same – no blurry gaps etc – so I think the camera – if not in the same position – is almost in the same position.

Total time from opening the box to completed project:  7 hours including dinner break, dog walk, thinking/practicing hole-cutting.  If you have to do this, I suggest:  a) practice hole-cutting ahead of time.  If you have a friend with a router (ideally one mounted or mountable in a table) this would help make a perfect hole with the right step-off shelf.  

If you want the parts I didn’t use/need – grab ’em on ebay.  I’d rather not throw them out.

Final note: Toyota – why don’t you sell the plastic parts by themselves?!  This would make such a repair quick, easy and very inexpensive. I’d have gladly paid $100 for these parts (that probably cost $5 to make) that we know you make every day but (for some reason) won’t sell unless they’re part of a $1200 (list price) assembly.  Argh.  

When sponsored CDS is a crime …

Today, The Department of Justice issued an announcement that was “the first ever criminal action against an EHR vendor.”

Criminal action

The core of the criminal action was something inevitable: the tension between better health and better profit. Here’s what I saw … all of which caused me to be not-so-surprised today when the news broke.

In 2008 I was the CMIO at Allscripts. Much of my work was focused on how our customers could use our products to improve the health of our patients. We implemented clinical practice guidelines in the software as a way to help clinical teams and patients make well-informed decisions that would improve their health. The company was doing well, but there was always pressure to find more revenue.

We had a small team that worked closely with pharmaceutical companies and generated revenue from these relationships. I wasn’t very involved with this team, but due to my ownership of many of the clinical decision support initiatives, I started getting invited to meetings we had with pharmaceutical companies. The first was an initiative that involved a company selling a statin drug. They wanted to sponsor a program in which we would use a clinical decision support notification to alert clinicians to patients who might be candidates for statin therapy but had not yet been offered a statin drug. On its face, this seemed appropriate: it invoked evidence based clinical guidance, the decision support didn’t recommend a particular medication, and the clinician could easily ignore the notification.

But something didn’t feel right about this. How would the clinician know that this CDS was sponsored by a pharmaceutical company and some other CDS was not? Should we allow the sponsorship to be secret?

And then there was the company that wanted to sponsor an alert to remind the clinician that a given patient might have untreated hypertension (this company sold several antihypertensive medications) …

And then there were more. I found myself in heated arguments about the evidence basis for many of these opportunities with some of my non-clinical colleagues. In the end, we created an objective committee to review such requests. I don’t recall that any of these things got implemented in our systems at the end of it all – but I do clearly remember that there was pressure to do so, and the dollars that pharmaceutical companies were very tempting to the company.

I talked on occasion with my counterparts at other health IT companies and they told the same stories: tempting dollars, questionable ethics. Mature companies with strong clinical leadership didn’t succumb to these temptations. Epic was even public about their refusal to even entertain the conversations. Good for them! But I wondered about smaller, hungrier companies. Could they resist?

Fast forward a few years and I was at ONC, writing the text of what would become the 2014 Edition of the Certification Criteria for health Information Technology. I wondered how we could prevent pharmaceutical companies from tempting EHR companies to do such things. There were certification requirements for clinical decision support. I knew we couldn’t prevent the business relationships (our authority was to certify the software, not regulate the business operations) but we could make sure that the systems had a capability of informing the clinician (and by extension the patient) of why the clinical decision support guidance was in the system, and what the evidence basis was for the decision support. Here’s how we explained this in the 2014 Final Rule (highlights added):

Consistent with the HITSC’s stated intent, for EHR technology to be certified to this criterion we proposed that it must be capable of providing interventions and the reference resources in paragraph (a)(8)(ii)(A) of § 170.314 by leveraging each one or any combination of the patient-specific data elements listed in paragraphs (a)(8)(i) and (ii) of § 170.314 as well as one or any combination of the user context data points listed in paragraph (a)(8)(iii)(A) of § 170.314. We asserted that EHR technology must also be capable of generating interventions automatically and electronically when a user is interacting with the EHR technology.

Last, expanding on the HITSC’s recommendation that the source attributes of suggested interventions be displayed or available for users, we proposed that, at a minimum, a user should be able to review the: bibliographic citation (i.e., the clinical research/guideline) including publication; developer of the intervention (i.e., the person or entity who translated the intervention from a clinical guideline into electronic form, for example, Company XYZ or University ABC); funding source of the intervention development; and release and, if applicable, revision date of the intervention. We asserted that the availability of this information would enable the user to fully evaluate the intervention and enhance the transparency of all CDS interventions, and thus improve their utility to healthcare professionals and patients.

We got some questions about this – but (I hope) you can see that the goal here was to make sure that any user of an EHR could easily learn the evidence basis for CDS and who paid for it. We hoped that such transparency would diminish the likelihood that sponsored CDS would inappropriately influence clinical decision-making.

Such is the ambition (and true challenge) of the government regulator. The goal is to create a framework wherein innovation is anticipated and even encouraged, while safety is enhanced and fraud prevented.

Practice Fusion was a young aggressive company – funded by venture capital and run by Ryan Howard. Ryan is a dynamic, charismatic guy who sold a vision of an EHR that could be given away and would generate revenue from advertising (like TV or gmail) and the sale of insights to life sciences companies. I first met Ryan on a trip to San Francisco in ~ 2012, when he invited me to come to Practice Fusion to speak with the team about Health IT certification and the meaningful use incentive programs. Such conversations were not uncommon – it is valuable for ONC leaders to meet with the companies we regulated. They would occasionally come visit us in DC, but meeting them on their home turf, we can meet with the folks really doing the work, and they can hear from government leaders first-hand – perhaps enhancing their understanding of some of the “why” of federal regulations rather than just the “what” that they are otherwise exposed to.

I vividly remember a lunch conversation with Ryan in which we discussed the advertising model, and my concerns about its ethics. The principle of an advertisement, of course, is that it changes the behavior of those who are exposed to it. So if I see an ad for Miller Light, I’m (perhaps) more likely to buy one. Ads work. That’s why advertisers pay to have them placed. I asked Ryan if he was concerned that there might be an ad that a doc sees some day that makes her change her mind about a prescription, and the drug in the ad causes a 1:1,000,000 allergic reaction and kills someone. Did he worry about this? Did it keep him up at night? He wasn’t concerned. “It’s still the clinician’s decision. It’s on them. If it’s not the right drug, then don’t prescribe it. Same as advertisements in the pages of JAMA or NEJM.”

Hmmm …

He wasn’t concerned. But he was concerned about revenue. And revenue was not flowing as fast as the investors had been promised it would. By 2014, the company was growing fast and had increasing revenue requirements, and while Ryan was talking about an IPO out of one side of his mouth, he was working to bring in more money keep the growing company afloat.

[Edit – 1/30] In 2015, Ryan left the company. I’ll be clear: I don’t think this happened on his watch. This all started after he left the company.

My guess is that this was when the sponsored CDS started happening. A small team inside of Practice Fusion was created in ~ 2015 and they were led by a sales executive who worked with pharmaceutical companies to develop CDS programs.

You can see a list of all of the CDS that Practice Fusion (it seems) here. When I click on “learn more” – I get a 404 error. But there are examples like this (and screenshot below) that demonstrate both sponsorship and compliance with ONC’s transparency regulation. Note how the Gaucher Disease recognition CDS bibliographic citation is listed, the developer is Practice Fusion, and the funding source is Genzyme. Connect the dots. Did they have the funding sources listed for all of these CDS interventions? We don’t know.

Interesting:

*On April 8, 2019 the following Pain Management CDS advisories were removed from the EHR:

  • Patient should be assessed for pain. Document pain scale in the flowsheets section of the encounter.

  • Patient has chronic pain and should be assessed. Follow the link to complete the Brief Pain Inventory (BPI) short form assessment.

  • Patient has pain documented and should have a pain care plan.

I do remember that I was aware of the sponsored CDS in ~ 2014, as I recall speaking with the PF Chief Medical Officer about a program that was sponsored to remind providers to immunize patients. I think it may have been influenza and/or HPV. The program was evidence-based, and it was successful: more patients got the immunizations they needed. I remember asking about compliance with the ONC certification requirements (yes), if they had an objective “approval board” like the one we had created at Allscripts (no).

The company’s drive for revenue overshadowed their legal and ethical commitments. I know that there are many people at the company who were not involved in this activity. Good people who work hard and are proud of the product they have build over > 10 years. The company is now a subsidiary of Allscripts (a fact that was oddly missing from the DOJ announcement) and I know that the Allscripts team is providing the maturity and oversight that Practice Fusion simply never had. Full disclosure: my son worked as an engineer at Practice Fusion from August 2014 until April 2018.

Lesson Learned?

Is this happening elsewhere? Has it happened to other companies? I don’t know. But if it is – I suspect they’re on notice now and I sure hope they’ll stop. I applaud the ONC and DOJ team that worked on this (and other) efforts to protect us from companies who have lost their way. Thank you!

A purpose

IMG_20191102_160523

We went for a walk yesterday. Griffin carried a stick.

Humans go for walks to “clear our minds” or “get in touch with nature.”  Dogs already have clear minds. For them, the freedom of a walking trail without security of a leash or the familiarity of a daily walking route can, it seems, be confusing.  “What am I here for?”  “Where are we going?”  “What’s our goal?”  Griffin (see photo above) promptly found himself purpose in the form of a big stick to carry.  “Now I feel so much better,” he seemed to say.

mindfuldog

Clay Christensen writes and speaks about this,  and as we ambled through the Albany Pine Bush yesterday, I realized that Griffin explicitly understood that having clarity of purpose was far better than the freedom (and ambiguity) that the vastness of opportunity offered.  The task was now clear: find a big stick and safely deliver it back to the car.  In choosing this task, he became focused, engaged and (dare I anthropomorphize?) proud.  He looked up at us as if to say “see what I have? Do you approve?  Is it big enough?”  Rather than randomly running through the woods, criss-crossing the path, distracted by new scents, distant chipmunks and blowing leaves, he maintained a steady trot with head and tail held high, and a steady gaze straight ahead, maintaining his placement squarely and very intentionally in the middle of the path.

And just as Griffin seems to seek the freedom of ambiguity yet ultimately prefer the comfort of structure, humans thread this needle every day and seem have different levels of comfort with the unknown.

An aside:

Teaching family medicine residents and medical students last week, I was struck by this variability.  Some young physicians are perfectly happy to know that they don’t know the cause of a patient’s condition, so long as it is either resolved or not caused by something ominous.  Indeed, more than one-third of the time that patients seek medical assistance,  physicians are unable to ascribe a clear diagnosis.  As I expressed to the first-year medical student last Tuesday, “if you’re not comfortable with uncertainty – don’t pursue a career in family medicine. You’ll be better off in a subspecialty like ophthalmology.”  This was not meant to deprecate subspecialists, but to recognize that the people who choose subspecialties are generally less comfortable with the unknown or unknowable.  While my counsel was expressed to her, I was also advocating for her future patients.  There is nothing worse than a primary care provider who needs to know the right answer to every question.  Indeed, cascades of testing and intervention are emotionally, physically and financially harmful.  In many cases, a physician’s personal discomfort with uncertainty is the cause of the cascades that are so common that we accept them as an unfortunate but immaleable reality. The key, therefore, is to match individuals with the work they will do most comfortably.  Some dogs would roam the forest happily.  Griffin is a dog who prefers to carry a stick.  Some physicians are comfortable with uncertainty, so will be very comfortable in primary care, while others would suffer as primary care providers, ordering too many tests, advising too many interventions, and as a byproduct of all of this, putting their patients in harm’s way. Perhaps this is the tip of a different iceberg: just as Malcom Gladwell has questioned whether we’re choosing the right law students, is it possible that we’re choosing the wrong medical students for careers in primary care?

Physicians are just a subset of humanity.  Non physicians express this variability too.  The motto of my undergraduate alma mater, Hampshire College, is “Non Satis Scire.” Translated:  “To know is not enough.” Hampshire attracts students who are less focused on getting an A+ and therefore demonstrating what they know (indeed – there are no grades at Hampshire).  Rather, Hampshire’s focus is on helping students solve problems.  This prepared me incredibly well for a career as a family physician.

Which problems should Hampshire graduates solve?  This question may be at the core of Hampshire’s rebirth.  Some have argued that Hampshire should choose an identity (social justice, environmental science, computer gaming) and focus its resources on being the best at one thing.  But Hampshire has decided instead to venture forward with confidence and – yes – uncertainty.  This will prepare its current and future students well for what lies ahead in life.  They’ll find their own stick, perhaps after a bit of chipmunk chasing.  Life isn’t a race.

I found my stick, which aligns well with the specialty that chose me, family medicine: help others achieve optimal health and happiness.

What’s yours?

 

 

 

The Rapid Cycle Mini-RFP

Like many businesses, our organization has problems to solve.  We have good people, products and processes but on occasion we decide that we need more than we have.  Our Chief Strategy Officer sometimes reminds me that my vision for our achievements might not be aligned with our capacity.  Perhaps this is the role of the CEO – to think a bit bigger than we are.  But that’s another blog post.  The point here is that we may need help sometimes.

When businesses develop strategies to solve problems, they generally adopt one of a handful of approaches:

  • Hire a person or people
  • Buy something
  • Build something
  • Try something (pilot / proof-of-concept or POC)
  • Partner with another organization

RFPs are generally reserved for big projects and evoke thoughts of 45 page .pdf documents with tens of questions and months-long processes of evaluation.

For the record, we never do POCs or pilots.  We do projects, and all projects have phases of implementation.  Phase 1 is always first, and while we can certainly kill a project at any stage, “phase 1” sends an implicit message that we’re optimistic that there will be a second phase and others thereafter.  We’re not ambivalent about moving ahead with anything.  “POC” and “pilot” send a message of ambivalence.

There’s an opportunity for organizations to use a process that’s smaller than a big RFP and bigger than a solution-focused decision.  It’s the Mini-RFP.  We’ve done a handful of these and they’ve worked incredibly well. The whole thing takes 3 weeks.

Here’s how to do it

  1. Week 1
    1. Day 1:
      1. Define your problem. This isn’t as easy as you think.  We use a modified A3 strategy approach.  You can use any approach, but be careful not to be looking for faster horses.
      2. Pick an online survey tool you like.  SurveyGizmo, Google Forms, Microsoft Forms, or Survey Monkey are all just fine.
      3. Write a set of questions that capture basic business demographics.  You can re-use these every time.  Name, URL, contact info, how long in business, etc.
      4. Write a short statement about the problem you’re trying to solve.  Work hard to make sure that it aligns with step 1 and do your best to avoid describing a product that you’ve seen that you think solves your problem.
      5. Write a set of questions that asks respondents how they would propose to solve your problem:  what do they have (people? product(s)?, processes?) that solves your problem.  It’s important to avoid leading questions that align with a particular solution you may subconsciously have in mind.
      6. Show the RFP to a friend.  Ideally, give them edit rights and ideally this person doesn’t have first-hand knowledge of the problem you’re trying to solve.  They need to be able to look at this fresh with a “beginner’s mind.”  Tell them to go ahead and fix whatever they think needs fixing in the form.  No permission required.  No time (or need) for “suggested edits.”  You’ll be pleased and surprised (and humbled) to see how your initial prose made assumptions that you didn’t see.  Let your friend fix them and leave your ego behind.
      7. Add  “Brown M & M” questions.  While the rationale here is a bit different from what Van Halen did, the idea is the same.  You need to know if the respondents are paying attention and have sufficient domain knowledge.  We use these questions when we post upwork jobs and they work incredibly well to weed out folks who respond by pasting in paragraphs from other proposals.  Instant proposal rejection is what you’re looking to enable here.  Be creative here and have fun.  One recent RFP asked if BTC, XLM, ETH or neo4J had a role in the project. We asked submitters to avoid googling for an answer.  This question was asking two sets of questions:  a) How much of a nerd are you?  (We wanted nerds) – Do you know what BlockChain is?  – Do you know the difference  between cryptocurrency and a graph database? b) Do you know that blockchain probably plays no role in this project?  (But a graph database might.)  Successful respondents get the right answer in 30 seconds because they have domain knowledge.  These should be easy questions for the right people and impossible questions for the wrong ones.  (If you use the right survey tool – you can see how long they took between questions.)  This isn’t a tortoise/hare issue.  Perhaps we’ll need to have a chat with Malcom about that.  We love tortoises.
    2. Give them 3 – 4 days to reply.  We often launch on monday.  Close Friday.
  2. Week 2  Process, review, rank, have phone calls with a few of them to get a better sense of who the people are and if you are likely to work well with them.  Pick a “winner” by Friday.
  3. Week 3
    1. Monday.  Send the lead applicant a contract. Negotiate rapidly.  Lawyers may slow you down.  The more you have templated ahead of time – the better – so at least on your side, there are no legal delays.
    2. Friday.  Execute the agreement.  Go!

#TweetRegret?

I have been an occasional Twitter user for a long time.  Indeed, I’ve used Twitter since long before you even knew Twitter existed.  I say this with some confidence, as Jack Dorsey posted the first tweet in March, 2006.  My first tweet was four months later in July 2006. I am Twitter user #1922.  Today there are over 130 million twitter users.

Twitter is an effective medium to communicate short messages to many people.

It’s also an easy way to say something  – or imply something – that you didn’t quite mean, or didn’t get to explain deeply enough.

Blogs are better.

This post is about why I should have blogged instead of tweeted.

In ~ 2004 there was a platform called blogger, created by Evan Williams.  With Blogger, one could craft blog posts and plop them on the Internet for everyone to see.  This was a new idea.  I experimented (beginning in 1999) with the medium and found that it was a good way for me to communicate with people, provoke thought, and offer insight into the work I was doing.  One day I posted an essay about EHR usability that (I thought) nobody read. Three months later, my boss called me and told me that the EHR company whose software I critiqued was unhappy with the post and asked me to take it down.

I declined.

The next day, the President of that company called me.

We had a wonderful conversation.  Then he hired me to help fix his product.  The rest is history.  My life has been very different.  This episode launched a career.  Who knows what would have happened had I not posted that critique.  I took a risk.  I wrote something provocative and it worked out for the better.

Tweets are shorter and offer less context.  A blog post (like this) gives us time to think, offer insight and provide background.  Elon Musk has cost himself many millions with careless tweets, and some (many?) people have even lost their jobs due to things they have posted online.

But there’s a positive side too.  A provocative tweet can have broad impact, can demonstrate thought leadership, and can generate conversations that make the world a better place.

Message:  be a careful but provocative tweeter.  If you choose to use this medium.

Yesterday I tweeted something (now deleted) that was provocative and perhaps not careful enough.  It described a conversation I was having with an employee of a hospital who saw the work that our organization does to improve health in our communities (and reduce hospital volume) as deliberately “harming hospitals.”  I asked if flu shots deliberately harmed hospitals too.  He didn’t reply – and I thought I was oh-so-smart.  Later in the day, I tweeted it, and a handful of people piled on about how hospitals are the problem.

But here’s the thing that I didn’t (couldn’t) say within the boundaries of a tweet.  Hospitals are NOT the problem.  Gosh – we need hospitals.  We need hospitals to be healthy.  We need hospitals to be able to invest in people, products, and infrastructure so that they are there for us when we need them – even though we hope we don’t need them.

There is a problem with the policies of how we pay hospitals today.  Yes.  There is a mindset that the hospital employee expressed that I wanted to question. Yes. Public policy that improves the health of our communities will result in reduced fee-for-service revenue for the hospital.  This can result in “harming” the hospital, but I am certain that the intention is not that that the hospital be harmed.  The intention is that the hospital migrate to new ways of doing business – to be more than a building with beds in it, but a part of the health (not necessarily the care) of a community.  To one who is part of an organization that is being unintentionally harmed by the improved health of a community, this may seem intentional, and it may feel like the hospital needs to be compensated for this harm.  My snarky response to this person (and tweeting it) was disrespectful.  I wanted him to reconsider his thought process, but perhaps I should have reconsidered mine.

What’s it like to work in an organization whose purpose is to try to put itself out of business?  We’ve not yet created a sound business model wherein the hospitals can survive in the context of falling fee-for-service revenue, but we’re asking them to do so.  That’s not good policy, and this hospital employee was just describing the world from his perspective.  This is a good thing.  My next move should have been to listen, learn from him, affirm his position and then (perhaps – if he was in a position to learn from me) offer my perspective so that we could think together about how we might solve public health problems.  Of course he doesn’t want people to be unhealthy so that they go to the hospital.  It was unfair of me to imply this (even if it was a logical extension of what he said) – it was a move appropriate for a college debate competition, not a collaborative conversation.  I’m a bit ashamed that I said what I said.  In his defense – we’ve seen very good examples of the hospitals in our community changing for the better, and the hospitals we work with are indeed migrating their work toward better health and away from more care.  It’s not easy, and I shouldn’t have poked my finger in the eye of someone doing their best to bridge the gap.  #TweetRegret  #honesty  #humility  #Alldoingourbest

 

 

It’s not a beer

When we announced a few weeks ago that our IPA had executed our first contract, I found myself explaining what an IPA is and what it does.  An IPA is a business entity that assists multiple independent organizations to contract with managed care organizations (health plans).  But it’s uncommon (unheard of?) for an IPA to work with organizations that are not physicians.  We even had to update the Wikipedia entry on IPA to clarify that physicians aren’t the only ones who can create or join an IPA.

Where we are now

We have over thirty organizations participating in the IPA.
We have two executed agreements with health plans, and expect this to grow.
We have a technology platform that connects our community.

Where we are going (and why)

I re-read the 1990’s coffee-table Book “who moved my cheese?” recently, and am now reminded of the simple (yet complicated) lessons therein. The book provides a framework for how we respond to change. A key message is that change will always happen.  If we resist it, we will become angry, fearful and confused.  If we embrace it, we’ll find new opportunities and flourish.  Our IPA is focused on helping organizations embrace (rather than fear) the change that is happening.  These changes will, we hope, help us improve the health of hundreds of thousands of people in New York and beyond.  Our plan is to continue to build relationships on both sides of this work: growing the breadth and scope of the organizations who join the IPA, and growing the number of health plans with whom we partner.

While the metaphor of a well-oiled machine is overused, I reflect that the mechanics of Alliance are running well – primarily because we have learned to anticipate and embrace change.  Indeed, our comfort with change has become our secret sauce.  The challenges of early days of start-up disorganization and growth are well behind us, and while we’ll never be perfect, and the start-up of an IPA is non-trivial, our team is working together to do our best to serve our community.  I am honored and privileged to work with such a dedicated and talented group of people.

Conferences / Unconferences

Our (amazing) team at Alliance for Better Health is planning an event in June.  The purpose is to bring together people in our community who are using the Healthy Together platform, celebrate the community’s accomplishments, and strengthen the connections so that we can find greater success in the future.

I offered a thought this morning that perhaps this isn’t a conference, but an unconference.  I wikipedia-ed (it’s a verb, yes?) the term, hyperlinked it in my email and (after sending) went back to read the wikipedia entry.  It’s accurate and (I now know) expresses a long history of unconferences.  What surprised me is that one of the first unconferences in “modern” times was in 2003 and .. I was there!  Despite a dead website, I was able to find someone’s notes on my session @ bloggercon.  It’s funny how the world is a circle.

To me, the core of an unconference is not unlike the core of a nontraditional post-secondary education, and the core of a person-centered approach to health:  the goals are defined by the people who participate rather than by the people “in charge.”

  • Students at Hampshire College define their educational goals.  Faculty, staff, technical and physical resources are all there to support (and – yes – guide) students on their path.
  • Attendees at an unconference listen, learn, and direct the course of a community of co-participants.  Organizers are there to support (and-yes-guide) but the goals of the unconference are expressed by the participants, not dictated by the organizers.
  • People served by medical care providers, behavioral health providers, and social care providers are the ones who define their own goals.  Words like “noncompliant” or even “non-adherent” become laughably out of place once we understand who is really in charge.  We physicians are (I suspect) the worst violators of this imbalance of power, as we’ve been educated to “write orders” and “define treatment plans.”  Only recently have we discovered shared decision-making.  If “primum non nocere” is really our oath, perhaps we should converge it with “non satis scire” and offer some humility: audire ad primum non nocere, quod non satis sit scire.  (“Listen to do no harm, it is not enough to know.”)

#HampForward

A few days ago, I wrote about the convergence that seemed to be happening at Hampshire College.

Yesterday, the President and another Board member resigned.  There was cheering and excitement at Hampshire, facebook, and Slack.

Why was there cheering?  Because the President charted a course for Hampshire that many in the community felt was (so far) an unnecessary last resort.  Is it possible that Hampshire would some day need to partner with another institution?  Yes.  It’s possible – after other options are deemed infeasible.  The problem here is that the community doesn’t understand how/that Miriam Nelson sufficiently researched all other options, and how she deemed them infeasible so early in her tenure @ Hampshire.

She believed that what she was doing was good for Hampshire. Some members of our community were angry at her, and I understand that anger, but I never felt it myself.  In the same way, I don’t feel happy that she decided to step down.  This has been terribly difficult for her, I’m sure.

But this is bigger than her, or any one person (or even any group of people).  Now is the time to pull together, and her departure gives us that opportunity.  The convergence I described on Wednesday continues.  On campus, several members of the Alumni Advisory Group (AAG) joined the re-envisioning Hampshire Coalition meeting. It was eye-opening for me.  These folks are serious, dedicated, and working hard to make sure that all voices are heard.  That’s super important.

And now the really hard work is ahead of us.  Here’s a rough map of all of the groups that will need to converge on what the future Hampshire College looks like, how we fund it, and how we get there from here.  IMG_3761

The AAG met all day @ Hampshire yesterday, and we’ll do so most of today as well.  We’re a diverse team – with members from each of Hampshire’s decades, expertise in many domains, and (most important) diverse perspectives on how to interpret what’s going on at Hampshire and how to respond.  We are a microcosm of the Hampshire alumni community, and what’s fantastic is that we trust each other.  Since change moves at the speed of trust, this has enabled us to move swiftly toward consensus on many issues, and enables us to bridge connections between others through the growth of such a trust network.  Much more to do, and we wouldn’t be able to accomplish any of this without our canine member @Griffin.

IMG_3783

Hampshire College: Convergence?

Yahoo! It’s Spring!

Wow.  It’s been too long since I’ve posted here.  I’ve been busy with my day job .. and writing elsewhere (some recent stuff referenced here)

Now .. the topic of today:

Hampshire College. It’s not in a good spot.  Lots of history here .. and here .. and here.  Yesterday’s Boston Globe article is a short summary of the most recent events.

Why do I care?  Because – well – Hampshire is an amazing place, doing amazing things, and the world needs it to be there forever.  I spent three years there as a student, and one year there (a few years later) teaching and working in the admissions office. I did well there, and that empowered me to do well in medical school, residency, as a faculty member and Associate Dean at Albany Medical College, etc.  What I mean when I say “did well” isn’t that I got good grades, because (for those of you who don’t know) .. Hampshire has no grades.  “Doing well”  in this context means (I think) that we move forward, have positive impact on the world, find happiness and share that positive  impact with others as widely as possible.  Hampshire discovered and fostered the “growth mindset” and reinforced it long before Carol Dweck started talking / writing about it. 

This is a blog. It’s not a facebook post, slack channel or shared strategic plan. It’s a set of observations that I’m choosing to share with you. I’m just one person. F83, P10 (That’s Hampshire-Speak for:  “I entered Hampshire in the Fall of 1983 and I’m the parent of a former Hampshire student who entered in 2010.”  I give money to Hampshire. I’m ready to give more. Some of my guiding principles for this post, and how I’ve tried to approach the current challenge:

  1. Be generous and assume best intentions. Decisions have been made. We don’t really know all of what went into the decisions. We may learn more. We may ultimately disagree with these decisions. But I refuse to judge anyone as evil, malignant, incompetent, etc. These words just don’t help. I’m going to assume that everyone here has the best interest of Hampshire in mind.
  2. Engage with shared success as the primary goal. It’s not important to be right. It’s important to listen, learn, seek understanding, and find the right path forward together.
  3. The Hampshire College that has been is not the Hampshire College that will be. Product-market fit has not been achieved in recent years. Many people will be unhappy with the changes that will need to happen.  These changes include:
    1. Administration / administrative overhead will need to change – ideally get (much) leaner.
    2. Hampshire’s educational offering(s) will need to better align with the wants/needs of incoming students. Yes. This means that some faculty won’t stay. We may love them as humans, but if they teach stuff that not enough students want to learn – isn’t it our responsibility to invest in different mentors? This concept may threaten long standing principles of academia.  So be it.  This is Hampshire.  We should do the right thing, not necessarily the traditional thing.
  4. There are some elephants (frogs?) in the room. Resolving them is going to need to be part of any cogent solution.
    1. The discount rate has been going up (and up). Translated: students who can pay full tuition are a small minority of incoming classes. The College therefore operates at a loss.  While many colleges operate this way, Hampshire’s investments (endowment) doesn’t generate sufficient revenue to cover this gap.  The endowment itself is restricted.  It can’t be used to cover operating expense. Hampshire needs to attract more students so that it can be more selective, and (at the same time) bring in more students who can pay full tuition.  
    2. Some students have not done well at Hampshire. Ideally, Hampshire is the right place for students who will excel in an educational environment that offers more freedom in exchange for more responsibility. Accepting students who can’t manage this responsibility puts everyone in a tough spot: students struggle, retention is reduced, cost is increased (see above – as discount rate goes up), and demands on faculty are enhanced (causing the College to hire support staff – and pressure to reduce faculty: student ratio). The Hampshire of the future will need to attract the students who will excel at Hampshire. Hampshire needs to be the positive choice for those who will flourish, rather than the negative choice for those who don’t fit in elsewhere.  It’s always been hard for Hampshire to find these students, but I believe that this is the only way for Hampshire to be sustainable long-term:  get more selective.  Focus on excellent applicants, not just unique ones.

What’s next?

I feel convergence in the air. There is growing consensus that an independent option may very well be viable. I see three key vectors – the latter two of which are converging:

  1. Strategic partner. I’m assuming that this is the University of Massachusetts. Sure – other options are being considered, but UMass makes more sense than any other institution. Much to work out here, and there is huge risk that the true identity/purpose of Hampshire is lost in a merger (acquisition) with (by) UMass.  
  2. The Re-envisioning project. Watch this as a good overview. It’s good. Lots of thinking and selfless collaboration went into this initiative.
  3. Hampshire2020. This project is smaller and quieter. Here’s their v1 deck. I hear there’s a V2 deck but I’ve not (yet) seen it. 

You’ll notice that the re-envisioning project and Hampshire2020 are similar. They’re both great starts, but both of them rely on huge fundraising efforts to save the day right now.  (See http://give.savehampshire.org for links to fundraising activities, and also support Davis Bates as he takes a 17 mile fundraising walk this week).  Without a massive influx of $$, Hampshire can’t stay open in a form that will be attractive to the two populations most important to its future:

  1. Donors. Humans, alumni (also humans!), foundations, and corporations. People give money for many reasons – but “save this dying ___” is rarely a compelling message. Rather – “make an investment in this ___ so that the world will be a better place” is generally much more successful.  A healthy Hampshire College is indeed something that many could / would support.  We need a clear, believable plan.  My former boss (yes – that’s another story) Vinod Khosla offers what I think is the best overview of how to pitch an investor.  We need to pitch investors with a strong story about how we’re going to make the world better with a new Hampshire College. 

  2. Students. Hundreds of thousands of these people select higher education options every year.  Yes, there are fewer of them now, but there are still plenty of them, and plenty who would love Hampshire.  Simply put, they are the customer.  They make these choices based on a set of factors that are important to them, just like the customer at a restaurant, car dealership or online bookstore. I would argue that we need a core set of product management principles to be applied here.  I’ve seen very little of this in the re-envisioning project – and only tips of this iceberg in Hampshire2020’s proposal.  What are the market requirements? What resources do we have available to meet these requirements? How is our product differentiated?  I’m concerned that we’re a bit too focused on the asset we have (the current faculty, curriculum, structure) and not the one we need.  There’s compelling evidence (enrollment is the key metric, of course) that our current product isn’t well aligned with the market.

Doing – not just talking.

I’m ready to dig in. I’m ready to join the coalition of great people working toward an independent Hampshire. I’m ready to invest my time and my money in this initiative.   What do I mean by “this initiative?”  I mean the coalescence of re-envisioning Hampshire and Hampshire2020.  I’m ready to bring what I’ve learned in ~ 30 years of work in health, health care, information technology, investing and government to help us converge.  Because we must.