The SCAD ladies set an example

John Novack, from Inspire.com, a place that organizes online patient communities around various diseases and conditions, sent me this link to a great online report entitled, "The SCAD Ladies Stand Up: Stories of Patient Empowerment."

From the introduction: 

The “SCAD Ladies” story is an extraordinary one: women with a rare heart disease self-organized online and began studying their disorder. This patient initiated effort led to physicians at the Mayo Clinic launching new research to learn more about spontaneous coronary artery dissection (SCAD).

The first essay is by Sharonne Hayes, a Mayo doctor, who notes:

Enter “patient-initiated” research. Still in its infancy, this may prove to be the new “gold standard” for the study of uncommon medical conditions.

It stands to reason that the people most highly motivated to support or to even initiate investigations of a rare condition are those personally affected and their close relatives. Our experience with the “SCAD ladies”, Katherine Leon and Laura Haywood-Cory and their online “heart sisters”, provides an example of successful patient-driven, social networking–enabled research. Our pilot and ongoing studies demonstrate that if a large organized group of patients self-identify and present themselves to researchers as study participants, a major barrier to rare disease research can be eliminated.

Delivering a patient-prioritized research agenda to potential investigators, as was done by the SCAD group, also may serve as an incentive for busy clinician-investigators and help convince them to commit to a new line of research or to this unfamiliar study methodology. Many organized patient advocacy groups have developed research agendas. However, the highly engaged and committed women who prompted the SCAD study, linked only via the Internet, demonstrated levels of sophistication and specificity in their patient-initiated research questions that were on par with those developed by formally organized groups. They had clearly done their research, and as a result, allowed this researcher to more clearly visualize the potential of success.

Check out the other essays from patients, which follow in the report.  They are well worth reading.

We will spend many years dying

Here is an excellent post by Janice Lynch Schuster on Disruptive Women in Health Care.  The occasion was Steve Jobs' death, but she draws broader lessons.

Here's the one that struck home most to me:

For many years now, I’ve written on this subject with Dr. Joanne Lynn, a geriatrician and hospice physician. In our book, Handbook for Mortals: Guidance for People Facing Serious Illness, we talk about the living with/dying of conundrum. Americans like to talk about “the dying” as if they were a different sort of person, in contrast to the rest of us, whom Joanne characterizes as the “temporarily immortal.” Once someone has been labeled as dying, we expect him or her to go about the business of doing just that: taking to bed, saying farewells, making peace with God, signing up for hospice, giving up daily routines and purpose. We think of the dying as a distinct group, with different interests, and an entirely different role to play in this life.

The fact is, for Boomers like Jobs, we will spend many years dying of something. Nearly 80 million of us are aging together, and along the way, we will accumulate illnesses of old age: heart disease, cancer, and Alzheimer’s. Thanks to modern medicine and public health, we will live for a long time with what have become chronic conditions. Where these diseases once killed swiftly and uniformly, they are now chronic conditions with which we live—and from which we die.

Bravo to Brent James

Dr. Brent James last week was awarded Columbia Business School’s W. Edwards Deming Center for Quality, Productivity and Competitiveness. As described in the press release:

The Deming Cup grew from the center’s drive to highlight the achievements of business practitioners who adhere to and promote excellence in operations – the Deming Center’s area of focus. This award is given annually to an individual who has made outstanding contributions in the area of operations and has established a culture of continuous improvement within their respective organization.

Dr. James was recognized for his pioneering work in applying quality improvement techniques that were originally developed by W. Edwards Deming and others, in order to help create and implement a “system” model at Intermountain, in which physicians study process and outcomes data to determine the types of care that are most effective.

Imagine that, improving clinical care is consistent with efficiency in the health care system.  This has to be another lie, just like that stuff about Pronovost saving lives and reducing costs by reducing the rate of central line associated bloodstream infections.  Or assertions by that trio of fraud, Spear, Toussaint, and Kaplan.

This stuff can't be true.  If it were everybody would be doing it.  Right?

Back on January 15, 2009, I published a post entitled "What does it take?", in which I expressed frustration with the slow pace of process improvement in hospitals.  What followed in the comments was a virtual seminar by some of the country's leaders in the field.  They are still worth checking out.  Brent offered his point of view:

Paul, you have put your finger on what I regard as THE core task of the present generation of the healing professions. It is very clear that we are in the midst of a transition. The term of art that is usually used to describe the present state – and which Don Berwick so eloquently explained (at least, at the level that an individual physician would experience it) – is “the craft of medicine.” It’s the idea that every physician (or nurse, or technician, or administrator, etc.) is a personal expert, relying primarily on their personal commitment to excellence. In a very real sense, every physician occupies his/her own universe, with its own reality, truths, physical constants. As a physician I might say to a colleague, “What works for you, works for you. What works for me, works for me. Let’s both stay focused on the patient – our core fiduciary commitment to put the patient first in all things – and that will guarantee the best possible results.”

David Eddy said it most eloquently: This core assumption of the craft of medicine is scientifically untenable.

As a direct result of some solid research around this fact, the healing professions are in the midst of a major sea-change, a once-in-a-century shift: We’re moving from “medicine practiced as individual heroism” to “medicine as a team sport.” The kinds of tools you’re talking about make perfect sense in a team setting, but almost no sense within the craft of medicine.

Don is right in calling it culture change. However, we are well past the tipping point. There is strong evidence that the professions have committed to a new course and are actively moving. It’s the difference between 5% of the profession “getting it” (where we are now), and moving to a point where it is standard, accepted, background business essentially all of the time.

The key change concept was perhaps best expressed by Winston Churchill: “People like to change; they just don’t like to be changed.”

I am also deeply impressed by Roger’s classic text on change: Diffusion of Innovation. He describes bottom-up change, by sharing results (both data and word of mouth) from initial thought leaders (his “early adopters”). That has worked very well for us, and makes the change fun – rather than something that a bunch of external “know nothings” are trying to do to you. 

You only have three seconds

In my continuing occasional series about entrepreneurs, I present this gentleman, a shoeshine guy at the corner of Sixth Avenue and 47th Street in New York City.  Street vendors often engage in hawking to attract business, but this fellow is a master.  As people walk by, he turns from the current customer's job, makes eye contract, and offers a pithy phrase that is meant to draw business.

"When are you going to do something about those shoes?

"Don't you love her?  What about those shoes?"

"Are you selfish?  Think of those shoes."

When I remarked on how effectively he segmented the market, (i.e., how well he seemed to understand what would work with different folks) he said, "You only have three seconds to make a connection."

It worked on me.  As I walked by, all he did was to shake his head from side to side and say, mournfully, "Those shoes . . . ."

addiction treatment advice

addiction treatment advice

Entitlement or naïveté?

I make it a practice of saying, "Yes," to any student or young professional person who wants career advice.  This serves two purposes.  One is to provide (hopefully) helpful assistance to someone starting his or her career.  The other is for me to be rejuvenated by the energy and idealism of the next generation of community leaders.

This week, a person who is involved in health care consulting at one of the big firms sought advice about how to move from that environment to a job "somewhere in the provider-payer space."  (By the way, I hate the term "space" when it is used in this manner, but I have learned to expect it from consultants and venture capitalists.)

The person thought that the ideal job would be to join the internal strategic planning group in a large academic medical center.

I advised against this.  I pointed out that such groups are often marginalized in AMCs.  They tend not to be respected by the doctors and nurses, because they are viewed as not understanding the obligations, work flows, and other issues associated with delivering clinical care.

I suggested, instead, that this person seek a "line" job in a hospital, helping to run an ambulatory clinic or some other operational role.  "Learn what it is like," I said, "to organize how care is delivered, dealing with nervous patients, stressed out nurses, and doctors with strongly held views.  Over time, you will demonstrate good work and initiative and how make changes.  Based on that, you may be asked to participate in task forces that help set the strategic direction for the hospital.  By then, too, you will be known and respected by clinicians and therefore less likely to be marginalized."

The response was firm and immediate: "No, I don't want to do that.  My salary would take a cut, plus I want to be involved at a higher level in the institution."

I was struck by this.  Just a short time out of MBA school, followed by a stint as a consultant, this person was confident s/he would provide value in the corporate planning function of the most complicated type of business in the world.  Whatever happened to the idea of starting low, learning what life is like on the front lines, demonstrating ability, and working one's way up the ladder?

Instead of being rejuvenated by the energy and idealism of someone in the next generation, I felt like I was facing an overabundance of entitlement.  Perhaps, though, I took it the wrong way.  Maybe it was just naïveté.

Texas-sized shoot-out

It has been some time since I reported on the Parkland Memorial Hospital saga.  A new article about things in Dallas draws us back to events in Texas.

Here's the title: "Ask the Editor: DMN Managing Editor George Rodrigue responds to accusations from UT Southwestern's Dr. Daniel K. Podolsky".  Here's the link.  Here's the lede:

Our Sunday story on patient safety indicators among Texas’ larger hospitals drew a rather heated response from Dr. Daniel K. Podolsky, president of UT Southwestern Medical Center. His University Hospital-St. Paul finished rather badly in the standings, and Dr. Podolsky accused us of cooking the books. His theories are incorrect – we played it straight, and we included all the necessary caveats about the limitations of our data – but maybe, if you care about journalism or health care, you’ll find our dialogue to be an interesting debate. As usual in these cases, we’ve printed Dr. Podolsky’s full comments below, along with our response.

I am sure that public relations consultants across the country are viewing this as a case study in media relations.

South Carolina on WIHI

Organizing for Health: A Story from South Carolina
November 3, 2011, 2:00 PM – 3:00 PM Eastern Time

Guests:
Rick Foster, MD, Senior Vice President of Quality and Patient Safety, South Carolina Hospital Association

Kate B. Hilton, Director, Organizing for Health; Principal in Practice for Leading Change at the Hauser Center for Nonprofit Organizations at Harvard University

Landis Landon, President, Immaculate Merchant Services; Resident, Columbia, South Carolina

In August of this year, a very different sort of town hall meeting was held in Columbia, South Carolina. About 90 people who shared the zip code 29203 sat down to talk about the health issues they faced. The list was long: lack of dental care, colon cancer, breast cancer, diabetes, heart disease, stroke, mental illness, low birth weight babies, and more. Any one of these issues is worthy of attention; indeed, in most parts of the US, you can find initiatives trying to either prevent or reduce the burden of specific diseases that affect specific individuals. But what if the approach was more comprehensive and more widespread – and, most importantly, engineered by the community itself? What if hundreds of people from across the community –representing neighborhoods and businesses and insurance companies and local hospitals and municipal offices and professional schools – all decided to band together to turn things around?

That’s what the people decided in Columbia, South Carolina, and WIHI is pleased to welcome to the program some of the key leaders behind the effort – Rick Foster, Kate Hilton, and Landis Landon – to describe their groundbreaking mobilization.

Some of the concepts and goals underpinning the Healthy South Carolina campaign are quite familiar, such as expanding the role of primary care and helping everyone become more physically active. What sets this initiative apart is the strategy. It starts with training some 300 leaders by the end of this year (2011). They’ll play several roles, but will focus in part on fanning out across Columbia, SC, to work directly with residents on creating pathways and programs to better health. There will also be a major emphasis on improving everyone’s health literacy and communication skills. And every part of the community’s health care delivery system is pledging, along with insurers, to engage in serious discussions about how to improve access to primary care, reduce reliance on emergency departments for non-urgent problems, and reduce costs.

Yes, it’s just the beginning stages and yes, it’s just one community. And no one knows whether this multi-year effort will succeed. Still, at a time when new models of better health, better health care, at reduced per capita costs, are badly needed, Healthy South Carolina is an initiative to root for, learn from, and watch. WIHI Host Madge Kaplan hopes you’ll join her and her guests on Nov 3. Invite someone from your community to tune in with you!  

To enroll, please click here.

l'equip petit

Of all the football (i.e., soccer) videos I have seen, this is the most inspiring.  It captures the beauty of the game through the eyes of the young players from a team in Spain.  It provides intense validation for those of us who coach youth teams.

If you can't see the video, click here.


l'equip petit from el cangrejo on Vimeo.

Blog roll revisions and invitation

Attentive readers will note two changes in my list of blog links (to the right.)  First, I have moved blogs related to Lean process improvement into the "Transparency" category.  The two are so interrelated that it made sense to combine them.  If you write a blog about Lean, I would be happy to consider it for inclusion.  Just offer it in a comment below.  Also, if you are part of a hospital association, hospital, or other organization that is strongly committed to transparency and have a website or a blog about that, please let me know in a comment below.

Second, I have updated several other blogs to indicate a "dormant" status.  These are blogs that have been officially closed by their writer or are otherwise inactive but have a wealth of information and interesting points of view that still deserve reading.  An example is Mike Sevilla's Dr. Anonymous.  (Mike is now over at Family Medicine Rocks, where he offers a slightly different perspective on things.)  Another is Lester Leung's Apollo, MD, which gave us a travelogue in his journey from pre-med to the beginning of residency.

Ohio steps backward on transparency

After expressing enthusiastic support for many quality initiatives by hospitals in Ohio, I must report with disappointment an action by their trade association to dismantle the state's hospital transparency website.  This article summarizes:

The Ohio Hospital Association (OHA) is backing a piece of recently introduced legislation that would free hospitals from the requirement to report performance data such as measures of heart and surgical care, infection rates and patient satisfaction.

The reason?  Alleged duplication of effort with the CMS Hospital Compare website.  According to an OHA spokesperson:

The time and effort spent on reporting the data to the state as well as the federal government reduces the resources Ohio hospitals can devote to patient care.

To which I reply, "Bull twaddle!" (This is a family blog, or I would use stronger terms.)

First, let's acknowledge that the data presented in the the CMS site is old, very old.  It accomplishes little or nothing with regard to transparency.  As I have noted:

While you cannot manage what you do not measure, trying to manage with data that are a year or two or more older is like trying to drive viewing the road through a rearview mirror. The principles of Lean process improvement and other such systems suggest that real time "visual cues" of how the organization is doing are essential. Why? Because that kind of data is indicative of the state of the organization right now, not what existed months or years ago.

Second, let's be real about the amount of time this state-run site "takes away" from delivering patient care.  This data would be collected regularly by hospitals, as part of delivering patient care, even if there were no federal or state reporting requirements.  It is not an incremental responsibility.

Next, the Ohio Department of Health says:  “It was an unfunded mandate for ODH to collect the information and make it public."

To which, I can only repeat the above, "Bull twaddle!"

Since when does a state agency get to complain about unfunded mandates from the legislature that supervises it?  (You only get to complain about unfunded mandates if a higher level of government imposes a cost on a lower level of government.)  The staff of the agency get funded every day they work there.  This is a matter of priorities.  In any event, this is a gross overstatement of the amount of effort needed for this task.

I am willing to bet that a graduate student or health care club at OSU, Case Western, or one of the other fine schools in Ohio would gladly set up and maintain a voluntary website for the Ohio hospitals.  Each hospital could enter through a password-protected portal to enter real-time data about the metrics that are of value in pursuing important quality and safety goals.  At virtually no cost.  It would take seconds, not even minutes or hours, to enter it once a month or once a quarter.  As I have noted:

Such data are collected in hospitals on a current basis. If their main purpose is to support process improvement, they do not need external validation or auditing to be made transparent in real time.

Come on, Ohio.  Don't step backward.

AMCs: Off target and lacking a sense of urgency

As noted in a previous post, I was impressed negatively by a Mt. Sinai hospital paid op-ed that extolled the virtues of academic medical centers while making no reference to the role that such centers could play in improving the quality of care delivered in America.  While acknowledging the attributes of AMCs, I said:

But these statements fail to tell the story of how academic medicine, in many institutions, is failing the American public.

It does not, for example, explain why many AMCs have been slow to adopt proven tools of process improvement to reduce harm to patients and improve efficiency. 

It does not explain the  persistent lack of transparency in many such institutions with regard to clinical outcomes, notwithstanding the documented value of such transparency in improving quality and safety. 

It does not explain why the medical schools that own or are affiliated with many AMCs have failed to train their students in how to use the scientific method to improve the delivery of care.

It does not explain the huge variation in practice among residents and attending physicians, giving lie to the concept of evidence-based medicine.  

It does not explain the reluctance of many AMCs to engage patients and families in the design and delivery of care.

A friend referred me to a summary of TEDMED talk by Daniel Kraft, which reinforced these points:   

Notably Daniel spoke about how when he finished his training at Massachusetts General Hospital 15 years ago the hospital still functioned, from an delivery standpoint, in about the same way as it does today, with specialty silos, defined training hierarchy, etc.

I am guessing that Daniel's talk was mainly on how to leverage new technologies in the health delivery system, but his observation applies more generally, too.

Ironically, one of those Mt. Sinai op-eds (John Morrison and David Muller, "Science and Medicine in the Service of Society," September 10, 2010) made related points:

Historically, medical schools emerged within universities primarily to educate physicians, yet Master’s and Ph.D. programs centered at medical schools now produce the vast majority of the scientists trained in biological arenas relevant to medicine.

All too often, these programs simply co-exist, isolated by different curricula and cultures. If we are to maximize our capacity to impact clinical practice through scientific discovery, we need to produce leaders in biomedicine and health care who see themselves as members of large, interactive teams committed to clinically relevant breakthrough science.

Meanwhile, Michael Nielson in the Wall Street Journal notes that networked science uses "online tools as cognitive tools to amplify our collective intelligence. The tools are a way of connecting the right people to the right problems at the right time, activating what would otherwise be latent expertise."

He notes, though, that this is not rewarded in the field:

Even if you personally think it would be far better for science as a whole if you carefully curated and shared your data online, that is time away from your "real" work of writing papers. Except in a few fields, sharing data is not something your peers will give you credit for doing.

How interesting that people in academic medicine are able to see the need for a more integrated, cooperative, and collaborative approach to medical training, research, and work flows when it applies to the advance of basic science and technology, but they have yet to modify the structure of their academic centers to allow such behavior to thrive.  And, beyond that, they remain blind to the idea of applying those same concepts to the actual delivery of care.  Were they to do so, we could be saving thousands of lives right now, well before the next great cures to disease are developed.

Example:  At a recent meeting of medical academic leaders, the president of one center proudly reported over the growth in faculty, in enrollment, in buildings, and so on at his institution.  Someone asked him about systematic quality improvement.  He cited improvements on Press-Ganey results, acting as though this was the surrogate for quality improvement.

Off track and too slow, folks.  Too slow.  As we have seen, if you don't start to define the important clinical improvement issues and make progress, the government will do it for you and do it wrong.

Recall what Captain Sullenberger said, ""I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country."

"We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety."

A green car!

Heavy wet snow combines with leaf-laden trees to offer an opportunity for a new paint job -- and more -- for my little Honda civic hybrid!

Danielle will find your lost pet

I have written about a number of new businesses on this blog, in health care and beyond, but none has caught my attention as much as Compassionate Pet Services.  Owned and operated by Danielle Robertson, the company helps pet owners recover their lost animals.

Danielle notes:

Losing a pet is a very stressful and even traumatic experience.  A well organized search plan provides the best chance to bring your pet home safely.  Unfortunately, most people do not know how to effectively search for a lost pet, and the advice that you receive from well-meaning people and the information that you find on the internet may be inaccurate or just overwhelming. 

Compassionate Pet Services is here to provide the services, information, and resources that you need to help find your lost pet.  I am a certified Missing Animal Response Technician and have been helping people find their lost pets since 2009. 

I never knew there was such a thing as a Missing Animal Response Technician, but Danielle actually has extensive training in wildlife management and then special training in this field of finding lost pets.  To learn more, you can check out her blog, Lost Pet Research and Recovery, and for dramatic and moving stories of recoveries, Lost Cats Found.

Here's a sample: 

Many of you may have heard about the tornado that tore through Springfield, MA, and  surrounding towns on June 1, 2011.   One man, Michael Roescher, was home with his step-daughter and their seven cats when the tornado leveled their house.  Initially he was convinced that none of the cats had survived, but then he miraculously found their goldfish still alive in the rubble.  With renewed hope and the help of many friends and strangers, Roescher persisted in his search, and he was able to find all seven cats over the course of five days and none were seriously injured.

Best of luck to Danielle in her venture, and good luck to all of you searching for your lost pets.

Addressing health care at Jewish Family & Children's Service

Charlie Baker and I shared a podium today at the annual meeting of the Board of Advocates of the Jewish Family & Children's Service.  JFCS provides a multitude of services to the community, and does so very well, and we both felt honored to be invited.  We were led in a panel discussion by Sy Friedland, former CEO of JFCS, on the topic of "What's going to happen in health care, no matter what happens in Washington?"  (You see Sy and Charlie in this photo.)

Before attempting a run for Governor in 2010, Charlie was CEO of Harvard Pilgrim Health Care, a highly respected health insurance company in the state.  In previous lives, he served both as Secretary for Administration and Finance and as Secretary of Health and Human Service for the Commonwealth.  As you might expect, he has lots of thoughtful things to say about the health care system.

I remember, during the campaign, that Charlie explained the major items of his health care platform to be increasing payments to primary care doctors and other cognitive specialists, with the purpose of giving them the chance to spend more time with patients and thereby avoiding as many referrals to higher paid specialists; pursuing broad-based transparency of cost and quality to offset unsupported reputations of certain hospital and physician groups that were thereby able to exercise undue market power; and to create coordinated medical management programs for the 120,000 dual eligible people in the state.  These are folks who are "old enough for Medicare, but sick and poor enough for Medicaid."

As Charlie noted today, dual eligible people constitute 20% of Medicare subscribers, but account for 40% of Medicare spending.  Likewise, they account for 15% of Medicaid enrollees, by 30% of Medicaid costs.  Based on relatively small pilot programs in the state, covering about 15,000 to 20,000 people, coordinated management of these patients results in service delivery at 30% lower cost than the two uncoordinated programs.  (My keen readers will quickly note that these contracts are annual fixed fee payments based on patient risk characteristics -- the one clear example that capitation can work in selected environments.)

Charlie's remarks were timely during the gubernatorial campaign, and they were more so today, in the Governor Deval Patrick has announced that he wants to create just such a program.  Charlie graciously complimented the Governor on his intentions in this regard.

That still leaves his other two items to be implemented.  Both remain excellent ideas.

Dump your old drugs safely this Saturday

This Saturday is "National Prescription Drug Take-Back Day."  This is a program originated by the U.S. Drug Enforcement Administration to fight drug abuse by adults and teenagers in the United States.  Studies show that people who abuse these types of drugs get them by raiding the medicine cabinets of their friends and family members.  To keep unused or unwanted prescription drugs out of the hands of drug abusers, on Saturday, between 10 a.m. and 2 p.m., people can safely throw away their unused prescription drugs at designated collection sites around the country.

I see a further value in that this offers a safe disposal regime for return of unused antibiotics.  If you throw unused antibiotics down the toilet, they can end up entering the ecosystem, where they can help create disease resistant bacteria or, even thought less likely, harm fish and wildlife.  In this program, they will be properly destroyed.

Also, of course, expired drugs may be ineffective or even harmful.  For example, taking expired tetracycline (an antibiotic) can cause serious kidney problems.

You can find a local collection site on this webpage.

Hospital Pumpkins

As we approach Halloween, there's been a lot of pumpkin traffic on my blog this week, linking back to this site about a pumpkin carving contest at my former hospital.  Here it is.  Some great images (one at left)!

Rational economic creatures?

I heard a wonderful talk by Abhijit Banerjee, economics professor at MIT, about his and Esther Duflo's new book entitled, Poor Economics.  Here is a short summary, accompanying this video interview of the authors.

Why do the poor remain poor despite a million different strategies to counter poverty? Well, perhaps because policies that deal with poverty alleviation are often based on cultural and literary stereotypes of how the poor are "lazy or enterprising, noble or thievish, angry or passive, helpless or self-sufficient." And therefore we often rely on over simplistic policies with readymade formulae - "Free markets for the poor," "Make human rights substantial," "Give more money to the poorest." A new book, Poor Economics, tries to make one key point - let’s stop staring at data and theories, and understand instead the coherent story of how really poor people live their lives.

The authors present several examples of policy and programmatic interventions that have failed because policy-makers do not take the time to understand how things work on the ground in these poor communities.

I am struck by the similarity to many proposed interventions in health care.  In the last several days, I have discussed this with regard to penalties for failure to meet certain metrics regarding patient readmissions to hospitals.  But it is a broader issue.  For example, a move to capitated rates of pay is viewed by some as the sine qua non of health care policy.  I have noted that there is little empirical support for this approach, even if it might have a sound economic rationale.

But does it have a sound economic rationale?

Still feeling the after-effects of a morning at MIT, where I first learned the term over four decades ago, I propose we conduct a gedanken experiment.  That is, let's consider a hypothesis for the purpose of thinking through its consequences.

I put forth the following thought experiment.  Advocates of capitated, or global, payments argue that the current system of fee-for-service medicine leads to overuse, in that doctors and hospitals have a financial incentive to conducts tests and procedures to generate revenue.  The economic underpinning of a global payment system is that hospitals and doctors are rational economic creatures.  Setting a per-patient budget, it is argued, will cause the hospitals and doctors to work within that revenue envelope to deliver care more efficiently.  They are at risk for any over-spending and they get to keep the surplus if they beat the budget.

But, answer me this.  Let's say, we have a system where, say, 25% of the patients are on a global budget and the remainder are on a fee-for-service payment plan.  

If the economic theory is correct, that the hospital and doctors are rational economic creatures, shouldn't we notice a difference within the same provider network in how the global patients are treated from how the FFS patients are treated?

Let's turn away from the thought experiment briefly to review real data.  I pose a question for my readers:  Has such a difference been documented in those systems that have this mixed payment regime?  I think not.  But if you have counter examples, please provide cites to support your answer.

But now, pretend you are running that hospital and physicians network.  As suggested above, you believe that professional ethics should not allow your system to treat people differently based on the kind of insurance plan that covers them.  So, you instruct everyone to think about all patients as though they are covered by the global fee.  You do this even though you suffer revenue losses from the FFS patients, who, by the way, remain the majority of your patients.

If we do this, haven't we just disproven the hypothesis that doctors and hospitals are rational economic creatures?

So, which is it?  Are they rational economic creatures, willing to treat identical patients differently based on pricing?  Or, are they not rational economic creatures -- treating all patients alike -- in which case the theoretical basis for global payments appears to be problematic?

Trash talk: More on unintended consequences

As we consider the issue of unintended consequences in health care from certain policy formulations, we can bring in an example from another field.  Let's review it and guess if the kind of policy questions I referenced below were applied to this case.

Residents in our city recently received this mailer:

 

It used to be that you would put your used computers and monitors out on the curb on trash collection day, and they would be carted off to be properly disposed of.  There was no extra charge, and you didn't need to call anyone in advance.  Now, you have to call a number or go to a website three days in advance and pay $12 for the pick-up.

It is easy to imagine why the new policy was adopted.  Perhaps the old approach was costing the city a lot of money, and officials thought this would work better.

But let's think through the likely result.  (Please note that I am not advocating this approach, but it seems to me to be a rational response.)  Our city employs these rather large trash bins that are mechanically lifted and emptied into a garbage truck each week.  The truck driver does not leave his perch as he rides along the street, and so no one sees what is in these barrels as they are lifted over the truck and emptied of their contents.

So, let's say I have an old personal computer and screen.  I quietly -- after dark, so my liberal neighbors don't see me -- put them in my regular trash bin, which I then wheel out to the curb in its regular location.  Next morning, the garbage truck comes by, scoops it up, and empties it into the back of the truck.  No need for a scheduled pickup.  No extra charge.  No muss, no fuss.

But maybe I am wrong.  Maybe the residents in this city are so motivated by environmental concerns that they would do no such thing.  Wait, aren't those the residents who regularly litter our streets with recyclable bottles and cans or who don't pick up the ones they see there?

I am not being critical.  I am just saying that people do what is easy for them.  When you invent a policy regime that attempts to impose higher cost or inconvenience on the citizenry, there are often unintended consequences.  I'd love to be proven wrong, but how will we know?

Here's how.  Let's see if our city's commitment to transparency extends to the effectiveness of this new approach to disposal.  It should be easy to have a section of the municipal website on which is posted the weekly summary of computer and monitor collections and payments under the new scheme, compared with the numbers collected previously.

About Careers of Business Administration and Business World

Careers in Business Administration prepare students with the skills needed to meet future business demands. This major will provide each student with a solid business core that includes a wide experience in the functional areas of marketing, finance, accounting and administration, an understanding of the business environment to include the legal, financial resources, human, ethical and international issues, expertise in information systems and quantitative analysis, and the ability to communicate, integrate and synthesize.

In the Careers in Business Administration successful organizations today recognize that the selection, development and retention of human resources is key to the success of present and future.

No organization is better or stronger than the people who make up its staff. Human Resource Management (BBH) concentration prepares students to play an important role in the process of Human Resources organizations of all types: industrial and services, public and private sectors.

A solid core of business courses provides students with a practical understanding of Human Resource Management in the establishment of a "real world" human behavior courses provide an understanding of people's actions and motivation in a of work. Students also acquire the knowledge and skills necessary to take the Certified Human Resources Professional of the Society for Human Resource Management, a leading international association. This is important for all Careers of Business Administration and business world.

Transparency in Retractions

Nature News has a very interesting article by Richard Van Noorden about retractions of scientific papers.  I hadn't thought about some of the points raised, and I think many of you will likewise find them and the associated graphic compelling.  Some excerpts:

[R]etraction notices are increasing rapidly. In the early 2000s, only about 30 retraction notices appeared annually. This year, the Web of Science is on track to index more than 400 . . . even though the total number of papers published has risen by only 44% over the past decade.

When the UK-based Committee on Publication Ethics (COPE) surveyed editors' attitudes to retraction two years ago, it found huge inconsistencies in policies and practices between journals. . . . That survey led to retraction guidelines that COPE published in 2009. But it's still the case, says Wager, that "editors often have to be pushed to retract".

Other frustrations include opaque retraction notices that don't explain why a paper has been withdrawn, a tendency for authors to keep citing retracted papers long after they've been red-flagged . . .and the fact that many scientists hear 'retraction' and immediately think 'misconduct' — a stigma that may keep researchers from coming forward to admit honest errors.

[A]s more retractions hit the headlines, some researchers are calling for ways to improve their handling. Suggested reforms include better systems for linking papers to their retraction notices or revisions, more responsibility on the part of journal editors and, most of all, greater transparency and clarity about mistakes in research.

How to Choose a Good Travel Insurance of the best Way?

Travel Insurance is a combination of trip cancellation insurance and assistance 24 hours of emergency. It helps you recover the money if, for example, you have to cancel your vacation or going home early. It is a smart buy if you have planned a holiday in the main well in advance, but the trick is to know that the policy of purchase, in your case.

1. Check your insurance policy and coverage of the credit card before you buy Travel Insurance. You may already be covered for medical expenses, tickets canceled or lost luggage.

2. Decide what kind of Travel Insurance is best for your destination (for example, terrorism insurance for your trip to Egypt, or the transport of medical emergency during their ocean cruise). Note that the cost is very variable, depending on your age, health, and the cost and duration of your trip.

3. Determine if the following is included in your policy: international medical insurance, emergency medical evacuation (including helicopter transport), accidental death and dismemberment, repatriation of remains and family benefits of travel.

4. Ask your travel agent, who buys an insurance plan for you or shop online without commission. You will find a wide selection of insurance companies of good reputation on the Web, including Travel Guard and Access America, which can reach a policy within 24 hours.

5. Make sure your Travel Insurance provider offers 24-hour hotline service. Do not buy trip cancellation insurance from the tour operator may be responsible for the cancellation, and no more than buying it will not be reimbursed for more than the cost of your trip.

RWJ seeks ideas in behavioral economics

The Robert Wood Johnson Foundation seeks innovative ideas that apply the principles and theories of behavioral economics to perplexing health problems. They are particularly interested in supporting either experiments or secondary data analyses to test innovative solutions to the challenges of obesity and consumer engagement.  Check out the details here.  The deadline for the first stage of proposals, a 1500-character brief proposal that describes your idea, is due on November 2.

Harold Miller offers advice on readmissions

If you had asked me to predict which topic on this blog would generate acrimony and criticism, I would have been hard-pressed to guess that it would have been hospital readmissions.  Recall that I expressed objections to the use of financial penalties to persuade hospitals and doctors to reduce this phenomenon.  Also, I cited a paper that showed that the data do not exist to fairly and accurately implement such a penalty scheme.  I followed this with a post citing an article suggesting that such penalties might especially adversely affect lower income hospitals.  Then, I suggested the kinds of questions that should be answered as we consider any type of public policy change.

To me, this is the kind of straightforward discussion and debate that occurs on a variety of health care issues.  Who would have thought that this might bring an accusation of "willful stupidity" and a complaint that "you have shown yourself even more opposed to universal healthcare than this relatively easy, low cost way to improve outcomes"?

The more serious commentators, though, asked, "What would you do?"  My general answer, as many of you know, is that a focus on quality and safety and clinical improvement is well within the power of each and every hospital; that such programs are consistent with sound financial planning, whether under a fee-for-service, bundled, or capitated payment arrangement; but that progress on this front demands leadership from the administrative and clinical leadership; and that such leadership must include a commitment to redesign the hospital's workflows using Lean principles or other approaches that engage front-line staff and also engage patients and family members in a respectful and meaningful way.

A more conversant observer than I, Harold D. Miller, Executive Director of the Center for Healthcare Quality and Payment Reform, offered some useful thoughts on these matters in a talk he recently gave in Oregon, entitled "Reducing Readmissions:  How Oregon can become a national leader in reducing costs and improving quality." I will present just a few slides from what is a very thorough presentation.

First he summarized  the multi-factorial nature of the problem.

Next he gave a summary of the kind of work that is currently being carried out.   He included lots of examples that I do not have space for here.

Then he pointed out that a big percentage of the readmissions are not caused by hospitals.

Nonetheless, he explained that hospitals could have a role in reducing the number of readmissions.

In the final slide in his presentation, he gave a work plan for those hospitals wishing to make a difference in this arena.  I particularly like the last bullet.

How to Invest in Investment Banking Stocks of a Way Profitable?

Investment Banking. Once upon a time, banks primarily by money from the interest on loans granted to customers. Today, there are a number of investment funds and other investment opportunities that make up much of the profit generated by banks. You can also earn money by investing in shares of banks and stock programs while keeping some things in mind.

1.- Before of invest in Investment Banking Stocks, assess your financial situation. Before you can really do much in the way of investing is a good idea to ensure that is able to cover any potential losses. Any type of investment, including shares of banks, comes with an element of risk. Make sure your investment can be covered during a crisis without causing problems in the management of their overhead and rare.

2.- Take a long look at your bank. How is the quality of the underlying loans that help to fuel investment programs operated by the bank? Is there a good chance that the institution is going through a merger in the immediate future that could negatively impact investment? The evaluation of the stability of the bank can go a long way toward building confidence in the types of investments that the bank decides to do.

3.- Knowing the investment market. Understanding whether the market is currently in a downward or upward phase may influence the bank stocks are a good idea. Take time to learn about market indicators, trends and projections, and how these factors relate to investment opportunities. The more you know, the easier it will make the right decisions.

4.- Talk to your banker. Hearing first hand how they handle bank reserves and what has happened in the past with these portfolios provides the opportunity to direct questions and get direct answers.

5.- Be sure of your level of commitment. Are there only certain times of the year in which you can opt in or out of a program of values? How much input you have on the populations that make up its portfolio of bank shares? Knowing what you can and can not do at any given point in time helps ensure you are comfortable with the concept.

6.- Do nothing until you are sure that this is the right choice for you. After all, it's your money. Make it work for you. Consider this to make a good invest in Investment Banking Stocks.

Yes, they blinked

I ran into an insurance company executive the other day who questioned whether I really thought that Blue Cross Blue Shield of MA could have done better in its recently signed contract with Partners Healthcare System here in Massachusetts.  Recall that the state's largest insurer gave away a huge rate increase to the state's dominant health care system  --  a 2-3% increase on a base that is, what, 15 to 20% higher than the rest of the market.   I said, "Whether it is fear of government regulation or a desire to go along to get along, a tremendous opportunity to truly control costs has been squandered."

This person said, "Remember, this was a private negotiation between two parties."  I allowed how I wasn't in the room, and it is easy to criticize, but, as I thought about it later, this statement alone might be indicative of why the insurance company blinked in this case.

A negotiation of this sort is never a private negotiation between two parties.  When two economic behemoths talk, there are a huge number of interested parties in the community.  And, those constituencies had already made their views known, views that could have been leveraged in this discussion.  Here are examples:

The Attorney General had pounded away two years running that a major issue facing the health care system, one that was driving up costs for the entire state, was the large disparity in rates paid to this provider group compared to others in the state.

The Governor had filed a bill to expand the authority of the Insurance Commissioner to review the rates paid by insurers to providers.  (By the way, many current and former state officials feel that the Commissioner already has that power.)

The Inspector General had expressed concerns that PHS would try to rush through a new contract before legislation passed that could limit payment increases.

Members of the legislature were publicly expressing concern about the rate disparity issue.

The insurance company had had noticeable success in marketing a tiered product, requiring higher co-pays from patients visiting the high-priced providers.

Lower cost competing hospital groups were creating ever more integrated alternative clinical networks.

Business groups in the state were clamoring for real cost controls in premium increases.  Given the unemployment situation, with people less likely to leave jobs for new ones, they felt that tiered insurance products could gain greater acceptance than in the past.

This provider group had not paid a promised $40 million to reduce insurance rates and was being derided for that delay.  It had every reason, given the pending legislation, to try to strike a deal before the law changed.  The insurance company, in contrast, had no reason to hurry.  Further, it had the moral upper hand, having forced other, more poorly paid, providers in the state to take dramatically lower rate increases.

In a public hearing about two years ago, this insurance company had said that it did not have the heft to fight the market power of PHS.  It seemed to fail to understand that the world had shifted.  If there was ever a time to go head-to-head, publicly if necessary, this was it.  An opportunity was lost.

     The pack rat gene runs in my family. My parents both had it, and I have it as well. I admit it. Recently I was visiting my mother and rampaged a little bit in her basement which is full of boxes of stuff. Some is clearly junk and needs to be discarded, but among these boxes there are treasures as well. On one stack of boxes were 3 small boxes, I brought up to see what they contained. One narrow box contained a Valentine from my father to my mother -- indeed a very fancy one that he gave or sent to her during their early marriage. Another box contained the Christmas cards my father had received the first Christmas he was in the Army in Chatanooga, Tennessee during World War II. And the third box is what I would like to reference in this post. It contained the letters sent to my mother by a British woman during the World War II years. They contain interesting insights into those times that I would like to highlight here.
     Apparently when Mom was a sophomore in high school, one of the teachers distributed some addresses of similar aged students in England that wanted penpals. Mom began writing to one Dorothy Dampier of Blackheathe, England, a little town that is really a neighborhood of London. Some of mom's friends also began to write to each other from the same town to town. These letters continued from 1932 to 1946, through several newsworthy events in addition to World War II. The early letters are typical teenage girl to teenage girl conversation. Later they center on boyfriends and work life. Then both girls marry. My father shipped out for England and was stationed outside London until July, 1944, when his 181st Engineers were sent to France and came ashore on Omaha Beach, a month after D Day. While he was near London, he traveled to see his wife's penpal Dorothy. He only had an address. He was walking up her street when a young woman stopped him in the street. It was Dorothy. She was on her way to the train to go to work. She recognized him from his pictures and of course, he was wearing a US Army uniform. Later in letters Dorothy wrote about the Blitzkrieg, and the blackouts and how hard things were during the war. Each women had child, in my mom's case, me. Mom sent ladies hosiery, cards, newspaper articles, sugar and other things that were in short supply during the wartime. Dorothy sent me (as a toddler)  a small gold toned bracelet which I still have in my jewelry box. Dorothy's letters reflect historical things such as King Edward's coronation, then King Edward's abdication to marry his commoner divorcee wife, then the coronation of his brother, Albert, who became King George VI.
      My husband and I recently saw the movie, The King's Speech. I learned that Albert, who became King George VI had a severe stuttering problem. The movie details how King George worked with a speech therapist to overcome this problem. The movie depicts Albert ("Bertie", as his therapist called him) practicing to give the speech that notifies England that they are going to war against Germany. In these letters to my mother, Dorothy remarks that she thought King George sounded very nervous during this speech. Actually as we saw in the movie, "Bertie" was working very hard to get through this speech without stuttering to badly. It was quite interesting to put our "movie" knowledge with this historical letter.
     Interestingly, I have found Dorothy on the Internet. She is still living (I think) though she is listed as living in a nursing home or group home that is designed for Alzheimer patients. I am planning on calling a phone number listed. Maybe I can leave a message for her son who is also listed as living in the same town. It is certainly amazing what can be accomplished on Internet these days. I will let you readers know if I can make some connection. That would truly be amazing.
     

Twenty questions for public policy proposals

As I re-read the comments I have received regarding my critique of plans to impose financial penalties for variations in readmission rates, I realized that my correspondents and I were talking past one another.  I was presenting views based on how to design public policy, while they were stressing (understandable) concerns about the quality and cost of medical care.  They were viewing high readmission rates as something that deserved the hammer of a financial penalty, while I was viewing the issue as one of many public policy issues surrounding the health care environment, where unintended consequences of policy intervention are something to be considered.

To help explain how I view these kind of issues, I am going to share a list of twenty questions modified slightly from those Larry Bacow used to share with his students while a professor at MIT (before heading off to be President of Tufts University.)  Even though the list is over twenty years old, and Larry might modify them even more at this point, it is still a remarkably useful framework within which to view a wide range of issues.  Some are not germane to health care, but many are. 

These kinds of questions underlie a lot of the commentary you see from me here on this blog.  Please understand that these questions, although demanding some degree of analytical rigor, are not designed to stymie public policy advances, but to focus public policy interventions in the hope of more effectively solving problems.

1.  In identifying the problem, or proposing the program, what does one hope to change?  Examples:  The overall distribution of income; the income of particular groups; incentives; resources; bargaining power; political power; competitive advantage or opportunities; a condition that afflicts some particular target population; a source of social conflict or friction; some legal, customary, or social arrangement or the legitimacy of certain actions or arrangements; values, tastes and interest; the range of choice available to some group; other.

2.  In identifying that problem, exactly what specific characteristics of the state of the world concern you, and what changes in these specific characteristics is your proposed program intended to achieve?  (Specify characteristics in terms of "final," not intermediate, objectives, e.g., the quality of life of individuals affected by the program.)

"Characteristics" should consist not only of concepts but estimates of the values of these variables.  Identify the data you use in determining these values.

Express the magnitude of the problem in terms of numbers, severity, costs, etc., and indicate the urgency or priority it should have on the agenda of those whose concern it is.

3.  What is there, if anything, about the problem or issue that makes it a matter of public concern rather than something better left to private action or allowed to take care of itself?

4.  What is it that makes the problem hard to analyze or the solution hard to apply?  Examples:  Objectives not clear; instrumental relations not clear; data not available; technological uncertainty; incentives conflict with compensatory objectives; strongly conflicting interest among parties; legal or moral or traditional obstacles; sheer magnitude or cost; jurisdictional confusion; novelty or unfamiliarity of the problem; administrative costs; incentives within administration, including possibly corruption; bad side effects; wasteful side effects; "horizontal" inefficiency; "vertical" inefficiency; political weakness of beneficiaries and advocates; others.

5.  Can you distinguish elements of the problem in terms of:  Market efficiency; administrative efficiency; equity; ethics; justice; information; technology; individual rationality, responsibility or self-control; other.

For example, would the problem disappear if you were satisfied with: The distribution of income (by income size or by particular groups); the working of the market; the equal and effective enforcement of the law; the adequacy of private insurance; the responsiveness of the political system; the elimination of specific handicaps; the goodwill of the parties involved; the state of public information and knowledge; the way existing programs are administered; the conformity of individuals to law or ethical principles; etc.

6.  What are the main changes in behavior that will be induced by the incentives, resources, information, etc., that the proposed program creates?

a.  The intended changes, without which the program serves no purpose;

b.  The undesired changes that nullify the program or elevate its cost;

c.  Changes that are neutral with respect to your purpose but that have to be allowed for or taken care of.

Distinguish the changes in behavior of the intended and unintended beneficiaries from changes in the behavior of administrators and others whose actions matter but who are intermediaries, not beneficiaries.

7.  What is it that defines, bounds or delineates the problem area of the program?  How much leeway is there in defining the problem or in the coverage of the program?  For example:  The "package" of activities involved, e.g., "medicine"; the nature of production, e.g., nuclear energy; the nature of consumption, e.g., alcoholism; the marketing arrangements, e.g., cable television; governmental jurisdiction, e.g., zoning; some connection between revenues and expenditures, e.g., social security or highway programs; the nature of the target population, e.g., the elderly; law, tradition, custom, some moral principles, e.g., adoption; other.

Is there some minimum scope or scale on which the problem has to be tackled to do any good?

8.  a.  Is the problem peculiar to the social and institutional structure of the United States or of the particular area in which it occurs, or is it a universal problem that any society must solve?

b.  How was the problem defined and handled 25 and 50 years ago?

c.  How is the problem defined in other countries or other jurisdictions, and how do they handle it there?

d.  What is new and novel about the problem or its solution?  How do the newness and novelty affect the definition of the problem, the choice of technique for solving it, flexibility or inflexibility in choice of solution, and the precedents that bear on this program or that this program will establish?

9.  Generalization of the problem:  similarities and analogies.

a.  What other problems are like this one, and what are the similarities and differences?

b.  What are the "solutions" of those other problems, and what do they suggest about solutions for this one?

c.  What is the larger problem of which this is only a part?

d.  What are the smaller problems into which this one can be subdivided?

e.  Does your problem fall into some general analytical class of problems, e.g., discrimination, public goods, externalities?

10.  What are the interdependencies between this problem and other problems, this program and other programs?

a.  The solution of which other problems will make this one disappear?

b. What other problems will disappear if this one is solved?

c.  What problems will become solvable by identifiable programs if this one is solved?

d.  What programs should be enlarged or tapered off if this one succeeds?

e.  What small problems does this one subsume?

f.  What big problem is partially ameliorated if this solution works?

g.  What problems get harder if we try this solution here?

h.  What problems are discovered if we solve this one -- i.e., what is it that we ignored that we'd stop ignoring, or begin to treat as a "problem," if this program proves workable?

11.  Is the desired change incremental or systemic?  Is the object: A Constitutional change; a major change in institutions; a shift to a new"equilibrium" that once achieved, will last; a consolidation or standardization of existing programs; an intensification or modification of existing programs; bringing old programs up to date; once-for-all change or change continuous through time; reversible or irreversible change; establishment or disestablishment of precedents?

12.  How do the dimensions of the problem and the effectiveness of the solution vary with the passage of time?  Is the problem getting better or worse over time?  Is the solution getting more effective or more obsolete over time?

13.  What checklist of techniques do you use to determine the optional ways of approaching the problem?  Examples:  Transfer payment in cash; transfer payment in kind; tax or subsidy on the transaction; licenses and prohibitions; contract enforcement; control of prices, rents or wages; insurance; information; publicity; property rights; public provisions; nationalization; provision of legal services; restructuring or a market or profession; provision of some public good or service.

What is, or ought to be, the relation of the technique or instrument to the nature of the problem or the purpose of the program?  (What techniques can be ruled out?)

14.  What assumptions, if any, about the following underlie your analysis:  Cost functions; supply elasticities; consumer preferences; market structure and market response; income elasticities of demand; price elasticities of demand; productivity trends; distribution of income, wealth, and opportunity by income size, by age, by occupation, by residence, by ethnic group; time preference and discount rates; substitutability of inputs and resources; substitution possibilities in consumption; incidence of taxes, benefits, or price changes.

15.  What determines the level of government at which the problem is perceived or the solution is initiated?

a.  Does the problem area coincide with an effective area or jurisdiction?

b.  Is multi-level collaboration or strategy involved?

c.  Is uniformity among states or regions important?

d.  Is it the nature of the problem, the nature of the preferred solution, or what, that determines the level of government or the agency of government?

e.  How much is the current definition of the problem and the current governmental action a product of historical evolution rather than of defensible choice?

16.  Identify the various interested groups that affect and/or are affected by current governmental action on the problem or program.  In what ways does your proposed program (or even your definition of the problem) reflect the need to reconcile conflicts, balance the conflicting interests, combine diverse interests in a "package," avoid drastic shifts of power, observe tradition, and appeal to diverse ends and goals?  Is the problem one that could conceivably be solved with a mix of measures that would leave nobody worse off?  Or does it necessarily detract from the wealth, welfare, power or status of some group?

17.  If you could set research in motion to help you understand this problem and its solution, what research would you initiate?  How long would it take?  Would you wait for it?  Whom would you want to do it?  What would it cost?  Would it involve assembling existing data, generating new data, experiments, regression analysis, case studies, or what?  Could you build the research into the program?  Would it be basic research or applied?  Could you count on getting the results you need?  Exactly how would your proposal be affected by the results?  What process could produce decisive evidence to establish or to falsify the more controversial hypotheses that underlie your analysis or your proposal; and can you identify what results you would take as conclusive?

18.  What mid-course corrections would you envision if your program does not work as planned?  How will you know when and if it is time to make those mid-course corrections?  How will you convince others that the time is ripe and the corrections are the right ones?

19.  a.  Assume that you held the position of one of the actors currently dealing with your problem.  How would you attempt to get your proposed program adopted and implemented?

b.  Identify a specific bet about governmental action in your policy area and the odds at which you would take  a bet that satisfies two further conditions:  (1) you believe that you can win money from your examiners; and (2) you believe your advantage stems essentially from your understanding of causal factors that your examiners might neglect (rather than any specific information you might have.)

20.  If your definition of the problem is correct and if your proposed solution is any good, why hasn't the problem been so defined and a solution applied already?