Work, Lean, and Health

I just visited a nutritionist today. I’ve had issues with Gluten for years and I’ve also been diagonosed with Hypoglycima which is a condition where my blood sugar levels aren’t well regulated by my body. The combination of the two has caused me no end of issues. At this point, it’s been difficult to tell the difference between a glutening and low blood sugar, at least a low level glutening anyway, a serious glutening it’s pretty obvious. I feel drunk within a few hours and then have the shits the next day or two. It’s pretty bad. Anyway, the combination has been pretty difficult to pull a part. When i have spikes in my blood sugar it makes me feel out of it as well. So, I’m going to really address both of these issues through better nutrition and probably more working out as well.

How does this connect to work and lean process improvement though? Well, at Cambia, we get a discount for eating salad’s and other healthy foods, so I’ve already been doing that, but that’s not the work connection I’m talking about. I just started reading a book called “Lean is Healthcare” which I picked up because I thought it was actually a book on Lean in Healthcare – pretty understandable confusion I think. I’ve only read a few pages, but as a lean practitioner it really ressonated with me. The premise is that Lean is a way of improving your employee’s health. Thinking about it now, it’s pretty obvious, but it definitely was an Ah HA moment when I read that.

Lean helps create flow in work. This is for both the product as well as the worker. Flow can be described as feeling you get when everything is just clicking. It’s like when a basketball player can’t miss a basic, they are in a state where they are relaxed and feeling good. It’s similar to a meditative state – think about any of the projects that you’ve gotten into and time just flew by. When you think about work, you never think about flow like that. I’m sure you’ve had bits and pieces of flow – but they don’t last very long. However, imagine if you were able to get into a job where everything you did flowed like that. Where you walked into the office and you walked out feeling accomplished, got things done, and excited to come back tomorrow.

I think there are a few companies that encourage that – companies that encourage creative coding and design are likely the best at this type of work. Why? Because they are all about thinking and connecting ideas and concepts to each other. It’s easy to get into a meditative state when you’re really jamming away at code. I feel a similar mode of thought when I’m blogging with a keyboard that works.

Work like this makes you feel better. It’s better for your health, better for your life balance, and better for your confidence. With that in mind, shouldn’t it be a moral imperative for a company to shift to enabling work like this? Work that makes you feel accomplished, healthy, and productive? Isn’t it also a financial imperative as well as all these things increase the value the company gets out of you as an employee?

I think the answer is yes to all these questions. I will be thinking about this as I work at Cambia continually driving towards for productive work and healthier stress balance for the employees.

Healthcare Exchanges offer a way forward

In my last Healthcare blog I argued that because of the structure of our payment system, the network effects of the providers, and reimbursement rules healthcare isn’t a free market. I believe that the exchanges in the Affordable Care Act aka Obamacare, actually offer a path forward that may take us closer to a freer market for healthcare than anything we currently have.

First I need to say that they are not an immediate silver bullet the exchanges only offer a way forward and do not guarantee any changes in the market. Furthermore, if the exchanges do provide the changes I’d like to see it will take time, several years in fact, for those changes to have a broader impact on the market.

What are the exchanges? They are essentially a market place where a customer can select a type of insurance with a specific network that meets their needs. How is this different than what we have had in the past? Well, typically health insurance has been only offered through your employer and you get what they offer. If you don’t have a full time job, you’re basically out of luck and paying a huge monthly premium. The exchanges level that playing field by increasing the pool of people that will be using those types of insurance and allowing across state competition for health insurance. For example, there’s only one Blue Cross Blue Shield provider across all the exchanges in the US. That’s a pretty big change.

Because there is competition based on meeting the needs of the customers there will be much faster feedback to the “plans” as they are called. If members don’t like a specific offering, they won’t make any money and the next year will be forced to make a different offering to attract more members. Furthermore, there will be switching across the plans as people realize they dislike certain features. I believe this will happen for several years until a “dominate” plan design emerges based on the success of those plans. Healthier members, low turn over, and acceptable level of revenues for the insurers. Expect these metrics to be similar to the mobile industry in the US (ARPU, Churn, etc..).

Because of the relatively fast feedback on the products in the market and the possibility to have at least three offerings on the exchange (Gold, silver, bronze), insurers can experiment with different types of plans and benefits. The most popular one at this point is something called Accountable Care Organization, which is somewhat similar to an HMO, but is supposed to be better (we’ll see). ACOs as they are called will have to keep track of the overall quality and re-admission rates with a goal of continually driving up quality of care and reduce re-admissions. Additionally, these are narrower networks of care than a traditional PPO that most people have become accustom to.

That’s fine, but that doesn’t really help with the fact that it’s a networked economy and that there’s still a huge imbalance of knowledge. Well, here’s where the insurers can changes things up. Instead of focusing on the narrow set of providers in their region, they can look to create a network based upon the specific of the member’s conditions and have those members go to the specialty providers that offer the best care for those conditions. Even if they are out of state or out of the country.

Granted this data is a bit out of date, however it’s likely to be accurate, according to the Innovator’s Prescription (pg 96) there are facilities that have become so specialized in certain conditions (hernia repair) that their cost to treat those conditions is $2,300 while a general hospital costs an average of $7,000 and has a much lower re-admission rate than the general hospital. With this in mind an insurer could use these specialty clinics and even fly their members to receive treatment and still save money.

This would dramatically change the shape of the network for the members of those insurers and improve overall care and results. It would also dramatically change the interaction with providers in the member’s region as well. Some hospitals are already feeling the pain in this such as Seattle’s Children’s Hospital (which is suing over being excluded).

I don’t think being exclusive it the right direction, I think creating a strong partnership with members through health coaching and care management can help drive better results and education between the provider, insurance company, and member.

This will require continual experimentation with the types of networks, the way the insurance companies interact with their members to take it from a confrontational interaction (from the member’s perspective), and how the providers plan to engage with insurers. There needs to be incentives to encourage providers to recommend non-traditional recommendations. Incentives to support healthy living for the members. Only experimentation in all of these areas can inform the insurers how to engage better to dramatically improve the health and reduce the cost of our nation.

Inequality, is the attention going to drive change?

In the last few weeks there has been a huge amount of focus on inequality. The attention has been riding a bit of roller coaster since the Great Recession started in 2008 when the focus was on Occupy Wallstreet and the inequality because of the action of the bankers. However, Elizabeth Warren began to really shift the conversation away from just inequality to the total system that enables the inequality. In fact, she started to argue that our minimum wage wasn’t keeping up with the rate of productivity of the economic system. As I argued in my piece on Minimum wage there’s not much impact on local jobs comparatively to the theories that minimum wage increases would dramatically increase unemployment.

However, Wal-Mart and McDonald’s brought the conversation back to the fore through the food drive for Wal-Mart employees that couldn’t afford food for Thanksgiving. According to many theories of efficiency to maximize profit Wal-mart must continually drive lower costs through less employees doing more. However, there’s been some negative repercussions to this beyond the extremely low salaries for the majority of employees, it’s also impacted the stocking of shelves which can reduce sales. Wal-Mart’s salaries and behaviors have caught the attention of professors at Harvard, recently there was an HBR Blog post about Wal-mart’s food drive – I strongly suggest reading that article. It provides great perspective about the impact of low salaries. Essentially, if the bulk of Wal-Mart employees work full time at $7.25 per hour they are well below poverty line, which means that these employees would end up getting food stamps. Employees with a family of 4 need to make at least $15/$16 per hour to be above the poverty line. That gap of $7.75 that provides food stamps and medicare for these employees. The author is arguing that these government benefits aren’t purely entitlements for minimum wage workers, but also entitlements for the companies as well.

Of course HBR isn’t the only place arguing that inequality is a serious problem. Paul Krugman, the Pope, and the recent article in the Guardian (that I wrote about in Taking the Long View) are as well. Paul Krugman arguing this isn’t exactly surprising, he’s been arguing that inequity and the result of the recession has had massive negative impact on the economy. The long term under employment of workers is continuing to cause damage to our economy.

The real question is will this conversation actually drive any change? Will we see any change in policy? There has been some recent shifts in the republican perspective of the budget. Which may actually relax the demands on cutting unemployment and other “entitlements.”  Studies have shown that every dollar spent on unemployment adds about $1.64 into the economy. So this is something that will likely have a positive impact on the economy, if we do some different thinking about what we’re spending money on. That being said, I’m very skeptical that in our current state of politics that we’ll see any serious change in how to treat economic inequity in terms of changes in tax policy which can reduce inequality.

I think that at this point it would require a serious popular swing in opinion to drive the change through the elections. In most states that are negatively impacted by inequality, this is an unlikely occurrence as they are republican strongholds.

What can we do about inequality? Well, if you’re an employer work to make sure you pay fair wages. As a consumer we can make choices to buy products at locations that provider higher wages and access to benefits – we can also chose to boycott companies that do not pay a living wage. As I explained in my article about health costs, proper healthcare reduces quality of life and reduces inequality. As a employee of a company that pays low wages, you can work to ensure all employees that work for you receive a living wage through salary increases or other support. This won’t drive systemic changes though and if we want those we’ll have to work through contact our political leaders to drive change. Without these choices we will not see changes and will continue to have inequality. This inequality will likely only get worse over the next several years.

Healthcare: the Value Stream of care

In Lean process improvement, one of the first steps you ever take is to walk the process. For manufacturing this means to go down to the floor where the product is made and walk with one piece from beginning to end. This provides the manufacturer insight into where there’s a great deal of waiting for product to come, leading to idle workers, where there’s a lot of inventory piled up – a bottle neck, if there’s a lot of rework – fixing defects like re-etching a person’s name on the back of an iPhone, and how the material flows around the floor. This works pretty well with doctor’s offices too. You can draw a map to all the different places the Dr. walks, the nurses walks, and where the patient walks. Any transportation in a Lean system is waste, so reducing that is important.

Mapping value streams essentially take this to the next level. You map all the major steps that the material that goes into your product step through before and after you. This allows a manufacturer to see all the waste before and after them, enabling them to partner with their suppliers and customers to reduce waste and unnecessary processing. For example, many of us have worked retail. Some times when you do stocking you’ll find shirts that are in bags that are in a box. This is non-value add because it’s highly unlikely that the bag would protect the shirt from getting wet in the case of a flood. So, it’s a waste of plastic for the bag, putting the bags on the shirts, and removing the bags from the shirts are all waste. Which increases the cost of a shirt. However, there’s a beginning and end of the value stream likely starting with cotton and ending with the final sale to the customer. In the case of a can of cola, it takes 319 days from the mining of bauxite to the consumption of the cola with only a total of 3 hours of actual processing of the material (Lean Thinking, Womack).

Value Stream for a can of cola through bottling (Womak Lean Thinking)

Why such a long introduction? Well, the value stream for healthcare is completely different. The beginning is when you’re born and the end is when you die. Otherwise, every activity you partake in impacts your health and the eventual cost of any episode of care. An episode of care is what happens when you directly interact with a provider, hospital, or health insurer. Arguably, these are the exception to your normal behavior and take you out of your normal routine.

Thinking about health in a value stream like this is non-intuitive for providers and insurers alike. As both have accounting practices and treatment plans that focus mainly on the episodes of care and minimize the remainder of the activities a member does. Thinking in this manner places more importance on preventative care, longer term plans for mental and physical rehabilitation, and care networks for long term diseases. This is a serious shift that is starting to occur in many insurance organizations, but aren’t very effective yet. The most effective portion of those three are the networks of patients that have a similar disease, such as Crohn’s Disease.

I believe that looking at care in this fashion will help redesign the manner that care is designed as it will focus on different portions. As my friend Rachel pointed out, behavioral health issues are typically undervalued in the value stream of healthcare. However, with this model long term care issues should be given priorities as they impact the highest percentage of the value stream. It would also force insurers and providers to look at addressing care holistically and providing the best care in the best way when they can. Sending patients to clinics that can quickly treat conditions as cheap as possible.

I’m extremely interested in how this will play out at my company as we think more holistically about value streams for health care. Checkout my last two blogs about health care:
http://scitechkapsar.blogspot.com/2013/11/heathcare-how-insurance-company-decides.html

http://scitechkapsar.blogspot.com/2013/11/healthcare-why-do-we-need-medical.html

Healthcare: Why do we need medical policies?

In my last blog post, I discussed how US health insurance companies decide what to pay for, what information they need to make decisions on paying for care, and some of the ways they go about making those decisions. I only briefly discussed why medical policies are required and why there’s a lot of complexity around health care. I hope to shed some light on this and help people understand the difficulty that both Providers and Insurers have in dealing with the cost of health care.

First, not all diseases are equal. This one is pretty obvious, but I’m not even talking about how severe the diseases. That’s vitally important of course, but even a “minor” disease can lead to long term impacts to quality of life because we don’t know how to treat the disease. In some of these cases it might just be embarrassing, such as if I eat Gluten and I’m out and about the next day. I’ll probably have some serious issues and won’t be able to enjoy myself while I’m out. There are two reasons for that. One, it’s not really obvious what condition I have. Two, there’s no treatment to allow me to eat gluten other than “avoid” wheat, barley, and gluten. Which in many cases is rather difficult.

This brings me to the second reason why there’s a lot of difficulty – it’s difficult to even diagnose what disease people have. So, for gluten issues you have only a few options, one is a blood test to looking for an immune response to a gluten or to have a colonoscopy to see what sort of damage has been done to your large intestines. Because of this lack of precision, in many cases it can lead to the matching the wrong treatment for the right disease, vice versa, or wrong treatment for the wrong disease in the most extreme cases.

Precision of Diagnosis and Precision of Treatment matrix

In the above picture from “The Innovator’s Prescription” it’s clear which diseases are “better” to have, those in the upper right. While those in the lower left are much harder to treat and have less consistent outcomes. For anything in between the cost and quality of care is really dependent on the experiences of your provider. I believe that this is where insurance companies can add a lot of value. Using medical policies and partnering with providers they can artificially expand the experience of a provider through providing the latest scientific research and results for a treatment and disease interaction. This will help allow providers to focus on care while getting the latest medical news from their network of insurers.

This really puts the model on it’s head as the provider can take advantage of the diverse networks they are part of to learn different components of research based on the focus of those providers. I think that a true partnership between insurers and providers really will drive down health costs.

This complexity is unfortunate, but is truly part of our human condition. One way to reduce costs is to increase the amount of research that pushes care into the upper right from the bottom left. Otherwise, it’s difficult for an insurer to determine which providers are taking advantage of patients and which ones are honest. There’s imperfect information on both sides and the patients pay for it in the long run.

Heathcare: How an insurance company decides to pay for what

As many of you are aware, I’ve left the high tech sector and have moved to work for a Health Insurance company. Since my job is to analyze processes and improve them using Lean process improvement methodology, I have a pretty unique insight into the broader workings of my company – which will only grow as I expand Lean through more parts of the company. As a note, these views are my own and do not represent the views of Cambia Health in anyway. I believe that it’s important to help educate the broader public about what happens when you want to have elective care or even while you’ve been admitted for care – either after an elective procedure or in an emergent case.

I know I’m opening a can of worms here, so I think it’s important to note that these are truly caring individuals that want their members to receive the best care. However, they are also put into a tough position because health insurance is a contract and your employers negotiate types of care that will be paid for within your health insurance plan. Furthermore, as a way to control the amount of money the insurer pays they will “manage” the type of care that is being provided to a member. This of course is the part that people hate, my doctor says this should be done, so it should be paid for by insurance company! Well, yes and no.

In some cases your doctor may recommend a specific type of treatment that you actually need, but your insurance company won’t pay for it! Why not? Well, there could be a few reasons. First, you may not actually have the benefit. For example many cosmetic procedures aren’t covered and aren’t part of your benefit package, or maybe you’ve already exhausted the benefit for instance number of days in a skilled nursing facility. Unfortunately, insurance premiums are based upon the amount of benefits that you could use and the total amount of risk that you are to the insurer. Which of course is difficult, because a person may need that care, but they didn’t pay to have all of it fully covered. The other unfortunate portion is that most people truly don’t understand what their benefits are, which makes this even more difficult. This of course goes back to Prospect Theory where insurance companies are acting as much more rational entities than their members, which leads to a definite imbalance of understanding and event potentially power in the relationship. Humans don’t read all the contracts and Econs do – insurance companies are Econs extremely rational (in the economic sense) when dealing with contracts and risk.

The second case where an insurance company won’t pay for a service relates to medical necessity. This is the part where providers get really upset with insurance companies. Essentially, this is a case where the insurance company is using a combination of medical research to create policies with criteria for procedures. So when you are trying to receive care, the Diagnosis is less important than the service that your provider selects for you. Diagnosis plays a larger role whenever the insurance company recommends alternative methods of care that lead to the same level of care but typically cost less – either to the member, insurance company, or both.

This requires the provider to submit clinical information to justify that procedure. Some of this requirement may actually drive up costs because the provider may have a great deal of intuitive experience with a specific type of diagnosis and knows that the best treatment is X. However, the insurance company requires that for procedure/treatment X that tests a, b, c must be run with results q, r, s. Based on the combination of the results the insurance company determines if that procedure is medically necessary or not. This works really well when there’s very clear medical research and clear correlation between diagnosis and treatment. It doesn’t work as well for less precise treatments such as behavioral health – which is much more trial and error and requires a lot of time.

Who creates the medical policies though? A combination of research clinicians, internal MDs, and providers – if they are insurance company specific policies. However, there are more general policies that are recognized and used for inpatient Medicare and Medicaid. These may have more input from the people using them. Policies take time to develop and typically lag the latest research. However, in many cases these policies may represent more knowledge about a specific treatment methodology than a general practitioner or even a specialist can know because of the breadth and depth of medical knowledge.

I will discuss more topics related to healthcare and how these impact costs over the next few weeks.

Ethics in Science

So, right now the UK is in a big uproar about ethics in science. There have been parliamentary hearings which have deeply concerned scientists. In one opinion piece from the guardian the author argues that it’s been too long going that the scientific community has been able to function without some sort of regulation. Scientists of course object to this. Because there is a method to the manner in which they work. Many, from the tone at the hearings, feel this is another assault on the scientific community.

However, it maybe that there’s some scientific work that is more likely to have fraudulent activity in it. Today the Guardian published an article about scientific ghost writers. Scientific Ghost writers can come in two forms. The first is harmless where the author is really the person that got the funding. Depending on the journal these authors are either the second or very last author on the paper. This is normal, as typically you’re working in that person’s lab and they are paying you. So they should get some credit for the work done as they may also have had an advising role. The second kind of ghost writing is much worse. These writers were in no way associated with the research and their names are put on the article to give it weight, or if they were the ones supposed to be doing the research and some one else did it. In the Guardian article they are focusing on clinical trials for medicines.

This isn’t the only country where fraud, exaggerating claims or ghost writing occurs. Although, the UK has had one of the most famous cases with the retracted article linking MMR vaccine to Autism (meaning it was fraud). This also happens in the US and in many clinical trials. In fact a Greek doctor has made it his mission to unearth clinical trial fraud and really understand what was going on there. The Atlantic had a great write up about this in November of 2010. The doctor  Ioannidis has been making a career out of debunking claims as well as researching the causes of these problems. He argues that the double blind clinical trial isn’t giving us the best results we could possibly be getting in medical science. Although, he doesn’t offer a huge amount of alternatives. 

The New York Times also ran a story about in September of last 2010 about some of the ethics behind clinical trials. This article discusses how two cousins ended up in the same trial and one cousin was given the treatment and the other was not. It was a story that was really questioning the ethics of the clinical trial, because it was obviously working. However, pushing through these treatments without fulling testing them can be just as dangerous. Granted these people were near the end as it was. The cousin that didn’t receive the new treatment died from only getting the chemo.

One the one hand we want to get promising medicine out as fast as possible. However, we want to ensure we are properly testing these medicines to ensure safety. This leads to a great deal of ethical concerns. For promising medicines do we make exceptions? Do we allow fully untested medicine into the wild? These are difficult questions. From an ethical and moral standpoint allowing a patient to die because of a randomized test is very questionable, which is what happened in the case above. However, in some cases rushing through medicines like these end up causing deaths in other manners. In the case of Vioxx this is exactly what happened. In many people it reduced the risk while in others it out right killed them. Where is the balance? I think this is why the UK is pushing for more oversight in these cases.

*Note: my dad, a nurse practitioner pointed out that i was slightly wrong about Vioxx. He’s correct. There were more ethical problems than the fact it was a bad drug. Simply the creators of Vioxx hid the fact that it impacted african americans differently than white americans. If Vioxx hadn’t done this it wouldn’t have been a problem for the drug to stay on the market. If you want to read more about Vioxx there’s a chapter in the book Denialism By Michael Specter

In my next blog I’ll discuss scientific fraud and ethics in other fields.