The Value of Introverts

One of the few things the Disease Management Care Blog enjoys more than talking about itself is reading about itself.  That's one reason it's downloaded Susan Cain's Quiet: The Power of Introverts in a World That Can't Stop Talking. 

Aside from feeding us introverts' narcissism, Quiet is a worthwhile read.  It describes how Dale Carnegie helped undo the American culture of "character" in the first century, and paved the way to our second century culture of "personality." The DMCB admires confident showmanship as much as anybody, but the bad news is that there is little correlation between a leader's bravura and a leader's success.  In fact, it's the quiet and unassuming leaders who seem to have a better track record.

No wonder brainy competent experts like Tom Nichols are so upset that no one is prepared shut up and just take their word for it. As the 24-7 news cycle is coarsened by blustery talking heads and perpetually outraged social media, notions trump knowledge.

On the other hand, JAMA's Bob McNutt points out in The Health Care Blog that expertise can be put to good use when it informs individual decision makers.  If the DMCB is reading this right, experts need to not only be expert, but able to efficiently convey their knowledge for maximum impact one person at a time.

Which leads the DMCB to offer two insights:

1. Board of Directors and C-suite leaders would be well advised to think long and hard about the risk of "group think" that can arise from a charismatic and convincing leader.  Let that dominate your company's strategic planning and you expose your company to a concentrated unforeseen risk, including a classic Black Swan event.  Seek out that quiet person in the back of the room with a contrarian perspective and listen for ways to keep your options open.
 
2. The new definition of expertise is to not only be truly expert but to be able to convey your insights convincingly and quickly in a few paragraphs, a short email or within a 140 character "tweet."  The DMCB suspects that persons who can combine both skills will prevail in today's media markets, the public square and in business settings.  Electronic communication and social media - which engages persons one individual at a time - are leveling the playing field for wise introverts, which is good news.

Of "Antifragile" and Accountable Care Organizations (ACOs)

Emboldened by yesterday's economics post on the U.S. "headwinds" that are marginalizing the "fiscal cliff" negotiations, the Disease Management Care Blog now turns it's attention to a magnificent new word:

"Antifragile."

That's the term invented by Nassim Taleb in his latest book. In it, he counterintuitively suggests that political, business and economic systems can benefit from recurring and unexpected mishaps. The sucess of antifragile systems is based on their fragile constituents that rise and fall on their own merits. One "antifragile" example is the local restaurant industry in many large cities. It may be beset by recurring single unit bankruptcies but it ultimately provides the marketplace with a dependable set of gustatory options every Saturday night. 

The converse are "fragile" systems that are ironically made up of highly stable individual units. An example is the highly regulated U.S. banking industry, which amply demonstrated its collective vulnerabilities in the 2008 crash.

The terms "antifragile" and "fragile" speak to the threat of unknown and potentially catastrophic "Black Swan" risks, such as torrential superstorms and toxic mortgage assets.  Many New York restaurants rebounded (by candlelight), while the banking industry almost took down the entire U.S. economy.

The erudite Dr. Taleb often turns to mythology, molecular biology, physics, history and more to make his points, but the DMCB is naturally thinking cinema.

In The Godfather, after the Corleone family goes to the mattresses, Clemenza explains periodic war between the New York families is a good thing because it gets rid of a lot of "bad blood" (the Mafia is antifragile).

In the silly Underworld vampire movies, chief bloodsucker Viktor condemns the successful liaison between his race and the werewolf "Lycans" as an "abomination" that upsets centuries of rigidly enforced stability (vamps are fragile).

In one of the Star Trek movies, engineer Montgomery Scott deftly disables a new star ship after pointing out "that the more they overthink the plumbing, the easier it is to stop up the drain" (warp drive-enabled space ships are fragile). 

And finally, Pandora's ecosystem in the movie Avatar may be teeming with all manner of scary survival of the fittest, but its antfragility is what ultimately prevails against the despicably avaricious humans.

Which makes the DMCB naturally worry about fragility of accountable care organizations, which are arguably comprised of highly stable hospitals and clinics in an intensely regulated environment.    While you may be tempted to tut-tut the DMCB's antifragile infatuations, recall AHERF's spectacular failure and the Medicare Health Support Demonstration disaster.  When they started out, both were the darlings of health policy makers and both were torpedoed by large and unexpected catastrophes that were only identified in retrospect.

What Black Swans could take some ACOs down?

Many savvy DMCB readers may disagree about ACOs, but you have to admit, "antifragile" will be a great word guaranteed to impress colleagues, co-workers and bosses.  For example

"Broadening our provider network to those three new counties may be risky, but it'll make our managed care organization more antifragile!"

"Buying a single source electronic record will reduce our health system's antifragile competitive advantage!"

"By limiting my access to modern electronic gadgetry, the DMCB spouse is risking a system-wide entertainment failure of epic antifragile proportions!"

And so it goes......



 

Ten Predictions for 2011

The Disease Management Care Blog was interviewed today on blogradio by Gregg Masters of ACOWatch. If you missed it, the podcast is linked below. The audio can be accessed by clicking the "play" arrow button toward the left side of the badge. Think of it as informative background talk complimenting that extra cup of caffeine as you clean out your email inbox.

In the podcast, the DMCB makes a brazen prediction:

1. CMS will delay the targeted January 1, 2012 start date for Accountable Care Organizations. Note that none of the proposed enabling regulations have been released as of this writing. The DMCB calculates that the a) time required by CMS to solicit, digest and respond to the follow-on public commentary to the proposed rules, plus b) the the inability of most ACO wannabes to plan and organize in the time remaining, makes the current ten month window a daunting proposition. Toss in hostile Congressional meddling as well as growing uncertainty over the fate of the ACA and the deadline has now become practically impossible.

While it is at it, the prescient DMCB has some other audacious predictions for 2011:

2. While healthcare-based social media will continue to expand, its full potential as a catalyst of personalized patient behavior change will be hampered not only by the uncertainty imposed by the privacy restrictions of HIPAA, but "no you can't" Homeland Security concerns over Twitter encryption.

3. Donald Berwick will be confirmed by the U.S. Senate as Administrator for CMS. Republicans will use Dr. Berwick as the poster boy for their newfound - if cynically opportunistic - bipartisanship because a) it's just a matter of time until the Administrator's independent streak begins to vex the Obama Administration, b) the shrewdly targeted use of CMS' grants will curry favor with key individual Senators and c) health care reform is enough of a target rich environment without picking on Dr. Berwick.

4. Reality will not only continue to intrude into the naive enthusiasm over the electronic health record but rear its ugly head in the emerging evaluations of the Patient Centered Medical Home. Both will disappoint when stakeholders seek "proof" of increased quality and lower costs.

5. Speaking of health care costs, they will continue to go up a rate that exceeds the general rate of inflation. That's because, despite health reform, the twin inconvenient truths of our advancing age and voracious appetite for technology refuse to go away. That being said, opportunists will continue to blame the health insurance industry.

6. The population health management (PHM) née disease management industry will continue to hold its own thanks to the grudging acceptance of nurse-based care management as part of the suite of services required to manage insurance risk. Vendors will also have the advantage of being able to couple or decouple PHM with other sophisticated wellness, prevention and health promotion programs.

7. The term "disease management", despite the DMCB's vast supportive readership, will not be resurrected in policy parlance. It will, however, also refuse to die.

8. A political stalemate will prevail as socially-minded progressives and market-minded conservatives battle for the hearts and minds of the body politic. Conflicting public opinion surveys, a divided government and the slow march of the ACA through the appeals process will not lead to any winners or losers. Deciding that will have to wait until 2012.

9. Ours is a time of "Black Swans." Despite our scientific modernism, our worldwide interconnectedness has ironically made us ever more vulnerable to unknown unknowns like pandemics (H1N1), economic dislocations (mortgage meltdowns) and political revolutions (Egypt). Compounding our budgetary travails, another **Big Event** is going to further distract the Administration and Congress from taking constructive action on health reform.

10. The Disease Management Care Blog will not achieve the popularity or the revenue potential of the Huffington Post, leading to further DMCB spousal skepticism over the merits of this whole blogging thingy. She will be unimpressed by the hundreds of thousands of hits, the thousands of return readers, the growing number of links to media outlets such as New York Times, The Washington Post and the Wall Street Journal and vast blogging income amounting to the tens of dollars.

Listen to internet radio with ACOwatch on Blog Talk Radio

McAllen Texas and Healthcare Utilization: A Function of Statistical Variation, Not Poor Policy

How about McAllen Texas? Readers may recall that locale* was the topic of an essay in The New Yorker magazine by the impressive surgeon-essayist and Democratic advisor Atul Gawande. The McAllen 'hospital referral region' has the dubious distinction of having been identified by the Dartmouth Atlas as being close to the top nationwide (pretty cool graphic) for the amount of total fee-for-service Medicare dollars spent per beneficiary in 2006.

The DMCB’s first reaction was “so what?”

It took a second look when that hapless locale was seized upon by Peter Orszag of the Office of Management and Budget (OMB), Consumer Reports and some notable blogs as the symbol for all that ails American healthcare. Commentators are accusing the ‘McAllens of this country’ of consciously and unconsciously economically ripping off the system with precious little quality to show for it.

Yet, the dubious DMCB remains unexcited about Dr. Gawande’s faux discovery and disappointed that others haven’t considered the most likely cause of McAllen’s outlier status. Is there something really special about McAllen or is something else going on?

To illustrate the point, conduct a thought experiment by imaging many bags of pennies (to pay the primary care providers), quarters (for the rest of the physicians) and dollars (yes, they are available as metal coin) for the hospitals suspended above a huge map of the United States. Mentally open the bags, releasing coins that fall, clatter and roll across the map. Since the distribution of the coins is random, some areas of the U.S map will have no coins, others might have just pennies, others may have dollars and pennies, some will have all three and a few will have lots of all three. Somewhere on that map, however, there will be a pile of coins that is bigger than the rest. Perform the same experiment using Monopoly style plastic clinics and hospitals across a board-map and the same thing will happen. In these thought experiments, the area of the map with the extreme outlier status happens to be McAllen*.

It’s hard for non-statisticians/non-economists to think of human behavior in markets as being ‘randomly’ distributed around an average, but it’s true. The best (painfully so) examples of this are the performance of mutual funds, as well as what happens to losing vs. winning teams and their professional sports coaches . The same is true in healthcare: given the overall upward growth in the number of hospitals, specialists and clinics with an inevitable distribution (both high and low) around that trajectory, it is statistically inevitable that there will be a McAllen somewhere in the United States.

It is the nature of our minds to believe there must be something “causing” outliers. In other words, there must be something about McAllen that attracted all those coins, right? The DMCB, in reading Dr. Gawande’s article, thinks that may be true in Miami (which is number 1 in the U.S), but it doesn’t think that's the case for McAllen as described in the New Yorker magazine article. The gumshoe M.D. reporting clearly shows the McAllen providers are mystified by their status. It’s not as though they planned to take advantage of the system. In fact, they didn’t. That’s because it’s all random.

This is important because most healthcare providers involved in quality improvement learned long ago that ‘identifying’ and then ‘managing’ outliers with targeted interventions is a poor way to promote overall system improvement. Outliers naturally regress to the mean over time and they're not the problem anyway. Rather, the trick is to reduce overall variation around the mean (reducing the standard deviation) and to move all providers toward a better average level of behavior. That’s a lot of complicated work that, frankly, isn’t as enthralling to editors or the readers of The New Yorker. It's too much work.

While popular media can be forgiven for using simplistic descriptions of extreme outlier anedotes to pander to a political agenda, the DMCB isn’t too sure about Dr. Gawande. However, the DMCB is most frightened by potential reaction of the OMB. Short of complete central planning for the entire health care system, random distributions of performance, expense, quality, claims, satisfaction and countless other measures around a mean will be unavoidable. Of all persons, Dr. Orszag should understand that outliers are an ironic certainty, not evidence of malfeasance. Most are anomalies, not proof of anything. They are, in short, interesting, but not lessons and certainly not the stuff of policy making.

*correction: McAllen is not a county in Texas.

The Housing and Economic Recovery Act Teaches the DMCB What It Will Take to Achieve Healthcare Reform

When the Disease Management Care Blog watched the closing U.S. Senate debate on the Housing and Economic Recovery Act, it wondered if advocates for federal healthcare reform aren’t lusting for the same Congressional bipartisanship and alacrity. While all political hands were on deck for the mortgage crisis, healthcare languishes. How so?

While not having the information and experience of the insightful denizens of Healthpolicyland, the DMCB drew some lessons from watching C-Span’s broadcast of Senator Dodd’s speech on the Act. It gave good insight into what it takes for him and his colleagues to come into work on a summer Saturday morning:

Follow the money: when both Wall Street and Main Street are economically threatened by a pressing crisis, Government acts.

Implications for healthcare reform: while both Wall and Main Street don’t like it, the price of health care is still a burden, not a crisis. It’s also relatively slow moving, versus the nightly news spectacle of overnight bankruptcies and waves of foreclosures. It’s unclear what it will take to turn the health care burden into a threat.

Follow the voter: middle class persons and retirees, making up the bulk of registered voters, were not only watching their real estate values decline, but the contagion was hitting their 401Ks. They were not happy 100 days before the November elections.

Implications for healthcare reform: until the middle class and retirees really care about all those uninsured, they’ll have trouble remembering just how many million there are, let alone what to do about it. Sure, they know health insurance is expensive, but so is everything else. Next.

Everyone wins: Wall Street gets federal guarantees while distressed homeowners get a chance to refinance. The aura of government involvement is intended to inject confidence back into the markets, stopping the slide in real estate and equities. The politicians can claim there was action, even if things continue to slide.

Implications for healthcare reform: what proposal promises premium relief for business, a margin for insurers, choice for consumers, buy-in from the physicians, viability for the hospitals, cover for the politicians and breathing room for pharma?

No big money: as the DMCB understands it, Block Grants provide some requisite pork, but it appears the Federales have little appetite for big-bang spending. Instead, they like increased Government oversight, regulation and bureaucracy.

Implications for healthcare reform: does anyone seriously think the U.S. Congress has the stomach to pass a large spending bill?

The DMCB was also struck by the decline in rhetoric over who to blame in the week leading up to passage of the Act - such as lobbyists, big mortgage lenders, housing speculators and unwise consumers. The DMCB will use this as a prognostic sign in the coming health care debates. If the volume over ‘special interest lobbyists,’ ‘greedy insurers’ or ‘evil pharma’ is high, serious reform is probably far away.

Consider this cold dose of reality from Victor Fuchs this Health Affairs piece. Using his logic, mortgage reform benefited from the three-fold alignment of special interests, the pain of continued inertia and increasing unity. In contrast, healthcare reform is still currently batting zero out of three. The election of a new President and the creation of a Senate supermajority In November are unlikely to change that.

Toss in preoccupation with the economy, the environment, Iran, Iraq and Afghanistan. Mix thoroughly, place in a pan, bake in a pre-warmed oven at 350° and decide for yourself how likely health care reform is in the short term.

+++++++++++++++++++

In a prior post, the DMCB mentioned 'The Black Swan.' This is an extremely interesting book about the underappreciated role of remotely possible and unforeseen events in a world that operates as if everything can be arrayed around a mean with a standard deviation. 'The Black Knight,' the very successful ‘Batman’ movie not only possesses eye candy and displays the late Heath Ledger’s considerable acting skills. It also showcases the contrast between the coin-flipping reliance on choosing between two known alternatives (by Two-Face, a former district attorney from Mediocrestan) and the catastrophes possible when the unmanageable unforeseen happen (thanks to the Joker, who was raised in a dysfunctional household in Extremestan). To top things off, there is even a display of the Prisoners’ Dilemma.

Definitely worth seeing.