On Relationships and Death

A few weeks ago a friend of mine committed suicide. I say friend, but we definitely had a falling out and I hadn’t talked to him since he’d moved from Portland. He was my roommate here for a while and we had some disagreements on how his dog behaved that ultimately drove a wedge between the two of us. However, I really think that was just the cherry on top. Both of us were depressed while he was living here and I was in such a bad spot that I wasn’t able to be that empathetic about it. I simply was overwhelmed with my own depression. Which is why I’m getting help. I know that I’m in a position where I can and am able to get that help.

This past weekend, a rapper, Mac Miller, I’ve never heard of overdosed. Apparently, he’d been dealing with demons for quite some time. Many people are attributing it to Ariana Grande breaking up with him. They are putting this death on her. To me this is a complete in justice. Similar to the reasons what my former roommate moved out, there’s a point in your relationships that you must do what is right for you. It’s not always easy. You feel like, to some extent, responsible for their actions afterwards. Like you could have done more or something different to help with that person.

The other reason that I’m really upset by this ridiculous backlash against Ms. Grande, is that I almost was in the exact same situation. While in Highschool and in College, I had a girlfriend that was extremely depressed and suicidal. I dated her for three years. Those years were very difficult for me for a variety of reasons. My parents were going through a divorce where they were asking me for advice on what to do. I had to figure out where I was going to school, knowing I was effectively on my own to pay for it. I was dealing with her depression, and I was adjusting to the school of my choice with her paranoid and constant demands on my time.

While we were dating, I helped her decide she needed to get therapy. She went to a Psychiatrist and a Psychologist where the former prescribed anti-depressants. Nothing helped her. She decided to move down to Pitt to be closer to me. I was against it, but I was too passive because of her increasingly erratic behavior along with her continual lack of trust in me. So she transferred and it became too much for me to handle my friends, school, and no breaks from her. I eventually reached out to her parents and her best friend and let them know I was breaking up with her. After I broke up with her, she hounded me, until I talked with her Therapist. At which point I made it clear that we were truly over. It was hard. At the time it was absolutely the hardest thing I’d ever done. I was terrified she was going to kill herself.

I found out years later, by random happenstance when I delivered a pizza to her mom, that she had in fact attempted suicide. I then talked to her afterwards, since her mom asked me too. Apparently her mom found her in the bathroom having took a bottle of pills. She survived and subsequently got better. Talking with her was super difficult, because I never really was able to deal with the emotional toll of our relationship. I didn’t realize that I had worried and dreaded finding out she had committed suicide.

I had needed to get out of that relationship because it was destroying me. There was nothing else for me to do. I was a mess I didn’t really figure out how to deal with what I’d gone through until getting therapy myself. I had to end that relationship and the fact that I knew she might kill herself simply increased the time I was in an unhealthy relationship.

We cannot punish people for electing to leave a relationship because their partner is abusing them with threats or past suicidal threats. Ms. Grande was very brave in ending that relationship and likely knew the risks of breaking it off with Mac Miller. I knew the risks when I ended the relationship with my HS GF. Ending the relationship is what ultimately saved her life. She would not have gotten healthier while still being with me. I would have been miserable, depressed, and constantly on edge waiting for her to try to kill herself – which may have ultimately happened despite my efforts.

Ms. Grande does not deserve to be castigated for ending this relationship. I do not envy her, I can only imagine what I would have gone through if my GF had been successful. I know with my roommate I beat myself up that I didn’t help him enough. This decision was ultimately out of our hands despite our best efforts. Sometimes when you love someone you need to cut them out of your life in hopes that they hit rock bottom and get the help they need. Sadly, it doesn’t always happen.

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.

Colorado, guns and society

Horrible tragedy has struck Colorado. We still don’t understand what caused this man to do this. This is also the second piece on mass killings and guns that I’ve written in the past year, the Norway tragedy was only a year ago. There was some discussion after that about the ease of access of weapons in the US, but with the alleged gunman in Colorado using an AR-15 there most certainly will be discussions of re-instating the assault rifle ban that lapsed early in the Obama administration.

Let’s first take a look at some of the history of the US before moving onto anything else. The Right to Bear Arms comes from the bill of rights amended to the constitution of the United States. The reason the founding fathers created these rights stems from the injustices the colonies experienced under British rule. Preventing gun ownership caused hardships for the colonists as they were fighting with the Indians, protecting their live stock and hunting for food. Distances were much greater at the time, so you needed to be able to fend for yourselves. The founding fathers also were revolutionaries, obviously, as they had just overthrown Britain. Jefferson, in particular felt that the citizens had the right to overthrow their own government. The ability to overthrow the government is predicated on the ability to fight against the government. The right to bear arms is paramount to this capability, hence it is an essential right in our Constitution.


A lot has changed in the past 200+ years. Weapons technology is at a level that our founding fathers never imagined. Our explosives are smaller and more powerful than theirs. The sheer number of people would be mind boogling to them, as we have stadiums that can hold more people than all the population of Philly in 1776 and Houston has nearly as many people in the city as all of the 13 colonies did in 1776. The amount of damage we can inflict and the number of people that can be impacted as exponentially increased.


What has not kept up with our ability to kill and our population are our institutions. Organizations like the NRA push for looser and looser gun laws as they feel that is an unalienable right. However, they do not take on issues that lead to increases in gun violence such as prohibition of drugs (increases violence) or mental health concerns. In the United States we look at mental health issues as something to be kept quiet and to have a mental disease is to be stigmatized. These prevent people that require help from seeking the help that they need. Plus, the cost of mental health care is extremely expensive. In many cases insurance companies don’t want to pay for the cost of seeing a psychiatrist or will limit the amount of treatment a person can receive. Addressing the actual problem will do more for protecting gun ownership rights than any glib quote such as “You can take my gun from my cold dead hands” we need to understand the underlying root cause of the massacre and fix that. 


The other concern that we should all have in regard to controlling weaponry is the importance of having access to weapons when overthrowing a dictator. In the past 2 years we’ve seen many types of revolutions. Ranging from the completely peaceful to the extremely violent in Libya and Syria. In each country access to foreign weapons are making the difference for the rebels, but for the rebels to even reach the point where the international community stepped in to help them, required weapons to start the civil war. Whether we like it or not, that is the reason why the founders included the right to bear arms in our constitution. 


What we need to do as a society is to look at where our values stand. Do we feel that we should treat addiction like a crime, or like a mental health epidemic? The need for gun ownership can drop once drug issues can be dealt within our legal system instead of requiring extralegal remedies, such as killing the person that is taking your turf. Looking at how we deal with bullying and other mental health issues can prevent another Columbine or Aurora from happening again. I’m going to close this post with an interview with Marilyn Manson in Bowling for Columbine. Regardless of what you think about the man himself, or his shock rock, he is an extremely articulate speaker and asks us to look in the mirror when these tragedies happen. Our society causes them, our society can fix them.