JetBlue's Dave in the air

Back in April, 2008, I wrote about JetBlue's use of homesourcing:

The idea is simple and elegant. For some staff functions, those relying mainly on computers and telephone, why not allow people to work from home and avoid the mess of commuting? Also, people who are otherwise tied to home for physical or family reasons can be active members of the workforce and get better jobs if they are permitted to work from home.

We tried a variant of this at our hospital, and while it could not be expanded to the full extent of the reservations assistants at Jet Blue, the concept showed some promise for the health care sector.

Anyway, because of this and other things, I had always admired Dave Barger, JetBlue's President and CEO. What a pleasure, therefore, to run into him on a flight earlier today and have a chance to extend my appreciation in person.

Based on my conversations with the staff, he is very well regarded as a CEO, displaying a real concern and affection for the people who work in all capacities in the firm, and joining in to help out as a flight progresses and on the ground. You see him here with Kiwi flight attendant James Harbour.

Update from Cape Verde

You may recall a post from November, in which I described a mission from BIDMC to Cape Verde. Well, I had the story a bit backwards. I thought it was initiated by the doctor, but the impetus actually came from one of our interpreters. In any event, these wonderful people together did good for the community. It is a lovely story.

Here's a video update. If you can't see the video, click here.

Time for the wisdom of the crowd

On the post below, "nonlocal MD," a regular contributor, asks:

I would next like to see a series on how you think all this could be done better, perhaps drawing on your international experiences.

And Barry Carol says:

As I understand it, the German population is generally satisfied with their healthcare and health insurance system. However, people can opt out and access more comprehensive private insurance if they want to and can afford to. About 10% of the population chooses the private system. One way or another, the wealthy and upper middle class will always be able to trade up creating, in effect, a two tier system. Personally, I don’t have any problem with that as long as what’s available to the bulk of the population is widely perceived as “good enough.”

Here is my reply, to you and to her:

Dear nonlocal,

It is not a question of doing better: It is the political imperative at work. My purpose in writing about all this was to describe the natural sequence of events.

As Barry suggests, people are generally content with this kind of system. The broad base of the population, the voters, gets security and a plan that is "good enough." The wealthy buy the "upper tier" plan.

It's the same as coach and first class on airplanes; Ford and Lexus in cars; McDonald's and luxury restaurants.

For years, we have rationed primary care in the US based on income. Now, like Europe, it will be reversed: We will ration high-end care based on income.

An underlying problem remains: There is little about the new order here in the US nor the European system that has dealt with the need to improve quality, safety, transparency, and promote continuous process improvement. And so demographic cost pressures will continue to build on both sides of the Atlantic. Governments and other payers will try to use the hammer of rates and regulatory changes to accomplish the kind of process improvement that can truly create better value for the population. That will fail. Those changes should come from the medical profession, but that profession has been recalcitrant and engaged in denial. We have seen that over and over: "The data are wrong" or "Our patients are sicker."

Changes are most likely to come as a result of strong advocacy from patients who are more and more empowered because of the internet and social media. In health care, the future is Egypt -- if and when the patient advocacy community gets its act together.

Places like Institute for Healthcare Improvement and the Joint Commission will finally succeed at their jobs when they facilitate the engagement of those thousands of people throughout the country. But you can not "own" those individuals or prescribe the approach that should be taken: You have to cede control of the agenda to let the wisdom of the crowd come through.

Paying more for the amenities you may never need

Let's continue our discussion about the future of employer-based insurance products in the US. We have talked about a general shift of employer-based plans to insurance exchanges and Medicaid; about a shift of retiree health benefits away from employer-based plans; and a move to reallocate risk away from insurance companies and towards doctors and consumers. What's left?

Well, as the commercial insurance pool shrinks and as subsidies for government-chartered or government-paid insurance products diminish, the norm for the general public will be a "dumbed down," lowest common denominator kind of insurance. With accountable care organizations and a move to bundled or capitated payments, limited networks will come into play. Deductibles and co-pays will rise to discourage people from using health care services. Likewise, if you choose to go out of network for your care, you will see higher personal charges.

But the potential for market segmentation never disappears. What will you do if you are an employer who wants to retain an insurance plan to attract workers in competitive fields? The answer may be to provide your staff with a "privileged access product," something that we have seen in Europe. (There, government-sponsored insurance can leave out a lot of items that are routine in the US, and rationing by congestion of high-end services is more commonplace.) The idea of this kind of privileged access product is to address the insecurities that people of means may have about the new environment. They want to assure themselves rapid access to the services they want, including the latest technological advances. They also want extra amenities like private rooms and other concierge type services.

It is a recognized phenomenon that people, especially people of means, are willing to pay more for amenities they may never need. So, look for such high-end specialized product offerings, especially in companies where well-paid workers in demand by competing firms represent a significant share of the workforce.

So, when you put this all together, we will likely see a move towards a more egalitarian (government provided or government-influenced) offering of insurance products for the majority of the workforce, combined with a less egalitarian offering of premium services for those with higher incomes. As I suggested years ago and reiterated last year, expect a convergence of the US and European models:

I predict . . . that the systems will start to look more and more alike over time. Pressure in the US for a more nationally-determined approach. Pressure in Europe for more of a private market approach. It shouldn't surprise us to see this convergence. After all, the countries are dealing with the same organisms, both biologically and politically.

Latke vs. Hamentashen, The Great Debate

There's serious work that goes on at MIT. And then, thankfully, there is not.

A debate was held to determine which is superior among two traditional Jewish foods: The latke (a potato pancake served during Hanukah) or the hamentashen (a prune-, poppy seed-, or apricot-filled triangular pastry).

(Wow, you should have seen what the Blogger spell-check suggested for some of the words in that sentence! Latte, larked, Hank, lamentation, fomentation, emendation, among others.)

Back to the debate. Six of the world's greatest scientists joined Rabbi Michelle Fisher, executive director of the MIT Hillel, to offer their "proofs" that their assigned food was superior to the other. It was heartening to see the degree to which academic credentials and principles of scientific discovery were applied to this high purpose. One participant was Robert Weinberg (Course 7*), a Founding Member of the Whitehead Institute, and a pioneer in cancer research most widely known for his discoveries of the first human oncogene — a gene that causes normal cells to form tumors — and the first tumor suppressor gene. "Trust me, I am an expert," he noted. When facts faltered, character assassination was brought to bear. Said Weinberg of the other side: "Remember, in debates like this your opponents' motives are ultimately vastly more important than the arguments they make."

The other participants on Team Latke were Sanjay Sarma (Course 2) and Allan Adams (8). Team Hamentashen comprised Steve Wasserman (20), Shaoul Ezekial (16), and M. Fatih Yaniak (20).

A secret ballot was held at the end. Not a paper ballot. Audience members promised to bend their heads down and look at the floor as Rabbi Fisher asked people to yell, first, if they liked latkes, and, then, if they liked hamentashen. You can see the result in the video below.

A reception followed the debate, with samples of both treats.

If you cannot see the video, click here.



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* Unlike other colleges, MIT departments are called "Courses." Courses are called "classes." All Courses have an English name, of course, but are usually known by their number. To make it trickier, the designations have changed over the decades.

Power -- er no, risk -- to the people!

What will be the biggest trend in the health insurance business over the coming years? A tendency to shift risk from the insurance companies to the public.

How fitting for a sector that was created to manage risk to do this.

Why is it happening? Even before the recent health care legislation in the US, insurance companies were looking for a way to shift the rising cost of medical care to others.

This trend will grow because of provisions in the new law for benefit mandates, floors on medical loss ratios, guaranteed issue, and medical underwriting represent a challenge for payer balance sheets. Insurers will want to shift those risks away.

And -- as we have discussed -- so will employers, who will want to shift their insurance obligation for current employees and retirees to others.

Who's left? Ironically, it is the participants in the health care marketplace who are most unsuited to bear risk -- individual doctors and consumers. This will come in the form of global payments, higher deductibles, and higher co-pays.

These will be portrayed as means to greater efficiency and consumer-directed health care. And perhaps they are. But they are also a veneer that hides the fact that a large portion of the actuarial risk of care will be shifted to individuals. The insurance industry was designed with reserve requirements and a capital structure that acted as a shock absorber for the vicissitudes of risk. Consumers and doctors do not have that back-up.

Alan MacDonald, head of the MA Business Roundtable, makes this shift clear in a discussion about Governor Patrick's proposed legislation:

Up until now, where the insurer in the health plans accepts the risk of making sure the payment is there to cover the expenses. When we have a global payment, a payment is made to the organization, and that accountable care organization is responsible for the care. They've received the payment already, and so the risk is that more care is required than is covered by the global payment, so they would have to have a reserve to take care of that. (Dig Boston, Volume 13, Issue 8). Emphasis added.

There has been no talk of reducing the capital requirements of insurance companies in return for this shift in obligation to individuals. Are they going to be permitted to maintain large capital reserves, on which they earn money, while their liabilities diminish? Who will ensure that the savings that insurers gain from these changes will be passed through in lower rates to consumers?

On a lighter note, comedian Brian Donnelly is quoted in the same newspaper -- perhaps displaying greater insight that he knows:

I've been looking at the new health care proposal and I'm not sure what's going on. Most of it feels like that part in the "Star-Spangled Banner" where no one knows what it is and you sort of mumble through. I feel like there could be magic involved.

Spreading knowledge that matters

Back in January, I wrote about a great example of a locally produced, informative and engaging newsletter produced by Samantha Riley, Head of the Quality Observatory at NHS South East Coast, and her colleagues. The latest edition has just been published.

There is a nice article by Roger Halliday about self care, with the following introduction:

When people take an active role in managing their health, this tends to lead to them having better health, better experience of care and using fewer healthcare services. This finding seems intuitive and indeed is backed up by a significant body of research. The challenge is how to make this happen. If you are struggling with this challenge, this product may be something to help.

This free to use product gives local commissioners the likely demand for, costs, cost savings and patient benefits of self care education, tailored for their area. It makes the business case for you and indicates the best value spend on this theme given local circumstances. It uses the latest national and international research combined with local data, though you can change the assumptions to explore options.

Again, I offer it as an example of the good work that can come out of a dedicated cadre of people seeking to improve the quality of care and the work environment at a hospital.