Health Care Bills/Law

The Senate's passage of the the first major overhaul of the US health insurance patchwork in over four decades is significant. I have spent the past dozen years learning how we came to have the crazy quilt patchwork we have. I have also read many journal articles about what the states have experimented with to work around it. A minor point, but I have concluded that health insurance is misnamed, and we would be better served to call it Injury and Illness insurance, because that identified the conditions that activate the coverage, like fire insurance covers in case of fire, flood insurance in case of floods, and so on.

First, some history. Unlike all the other national healthcare systems one hears about in other countries, the US tangle is 86% private insurance. And will remain so. This comes from the historical incident—and accident—of health insurance starting to circumvent limitations on salaries imposed by Congress during WW II. Large employers wanted to lure top talent with health insurance and other benefits. They began as an enticement. The Supreme Court gave it's blessings and soon the unions understood this could be something they could negotiate for their members, and well, the race was off and running.

Besides the money at stake (taxes, all the medical professionals, insurance and pharmaceutical companies' profits, the tax deductability of premiums, etc.) working folks like you and I have expressed strong preferences for the comforts of our current arrangement. The overwhelming majority of people with employer-based insurance like what they are able to get now. Polls and political commentary show that we want to keep our current health professionals, we want to have a lot of choice and access to specialists, we want to brag about having the latest techno gizmo used on us even if not exactly medically necessary.

There is also a curious lack of care about costs built into the current patchwork. Sure, at the aggregate levels everyone can see the costs of health services and insurance rising and rising. But savings won't happen in the aggregate on most things: physicians in particular has thought of themselves as businesses for decades and many are motivated by the profit motive. Insurance companies love having all that money to play with. So the savings will have to happen at the point of service.

Just recently, I had an eye exam and needed to get my prescription lenses updated. I went to several brick and mortar frames and lenses stores. At each I was asked if I had insurance as a first question. I said I was self-insured and using my flex plan. The lowest bidder for just two lenses in existing frames was $240. The highest was close to $600 for just the lenses. Online, frames with the lenses go for less than $50. The price where insurance was expected to pay is close to 5 times higher!

Another quick example, when doctors order tests to "rule out"conditions of illnesses of very low probability the cash still flows into their pockets and to every along the testing and reporting back chain.

The Massachusetts Example

When MA set the bar in 2006 for what can be enacted into law to reduce the number of uninsured people, it accepted that most people receive health insurance from their employers. They also accepted that people without insurance do get the emergency care they need when the circumstance are dire enough: accidents, drug or alcohol overdose, sever physical symptoms, etc. That care costs someone something. The prime motives in the legislation was to reduce the number of MA citizens without insurance and to get more people in for care at an earlier stage of their injury or illness.

Several things happened in MA that failed to happen in Congress. First, the opening salvo in that state was the Roadmap to Coverage (R2C) white paper jointly sponsored by Blue Cross and Blue Shield. In a tightly reasoned and carefully calculated document, the R2C laid out the current costs being borne in MA for health care services to people who had no insurance.

So the R2C said, look, it costs so much to provide this care now. How is this being paid for? it asked. Here's how: uncompensated services from healthcare professionals, write-offs by hospitals, various subsidies, lost time at work, etc. Then the R2C took a clever rhetorical turn. It made a series of proposals for insuring more people, and with each proposal it showed how many people the suggestion would cover and how much it would save or transfer from elsewhere in the medical care patchwork.

To encourage preventive and regular care (from the Western medical model point of view), it proposed people with publicly supported insurance have a "medical home," that is, a designated clinic or doctor where they would go to receive care. To sweep in the last few people not caught by its other strategies, the R2C proposed subsidized premiums and as a last resort, a tax penalty on anyone without insurance who did not qualify for a waiver. If, the R2C said, MA put these ideas into place virtually everyone would have coverage.

Congress seems to be stumbling towards what MA has demonstrated without the benefit of something like the R2C proposal in front of opinion leaders and the media.

From reading blogs and talking to people it seems everyone will find something to be unhappy with in the final bill and law that will ultimately get passed. Maybe that's as it should be, as we're all in this together and everyone should be required to do their part.

Where's the Healing Belief?

[This case study shows one successful example of Neuro-Linguistic Programming (NLP)]

Sophie (all identifying details are changed) complained one evening about her disappointment that specialists couldn't operate on her ears to end her stuttering. I perked up, and told her I am a Master Practitioner of Neuro-Linguistic Programming (NLP). I have used NLP to help people heal allergies, performance anxiety, dyslexia, overeating, tobacco addiction, and the inability to experience orgasms. I shared a few stories about my work and offered to trade sessions: her motivational interviewing skills for my NLP skills.

Warning! Don't start that way—my bragging may have incited her, unconsciously, to "knock me down a peg." A better path would have been to direct her to articles on NLP and stuttering for her to evaluate before agreeing to my help.

We agreed to trade four sessions. My sessions with her were difficult. She really believed in the numbers and diagnoses offered her by western medical science. For the third session I came ready with a method to try. She only went through the motions without imagination, intention or investment. She smiled as we finished as if to say, "Is that the best you have?" and admitted that she really hadn't been into it.

Here I paused for a long time. She believed that experts shouldn't have to stop and think (remember that poor start!). I defended my right to think, and kept thinking.

Something very powerful sat behind that smile. She said she felt her problem had a biological cause, meaning that it was permanent and unchanging. Yes, that was the belief. Thus the desire for surgery because that would be a biologically-based intervention.

But, she had already mentioned two counterexamples (instances when the problem didn't occur). I reminded her, "If, as you say, it is biological and something that never changes, then you should stutter all the time. The biology should prevent you from talking fluently to animals or fluently when imitating someone."

Her turn to pause. She admitted that was right. She said I had destroyed the belief structure she had built her whole life around. I apologized for destroying her belief (this time remembering to stay one-down and cautious). That ended the third session. We never had a fourth.

When we crossed paths two months later she spoke fluently. I stood amazed. "I want to thank you. I've gone from about 70% fluent to 90-95% fluent. And I was totally resistant!" she beamed. What made the difference? "When you helped me realize that it wasn't biologically based."

Many people limit their ability to permit a change (that is, healing) because their belief about their suffering only includes a few ways a change process might work. Bringing the client face-to-face to times when the belief does not hold true may be the only key she needs for her transformation.

Everyday Leaner

Anything done more than once can benefit from kiazan-taking a few moment to think about how to eliminate waste. Normally conducted by a group, anyone can look around for ways to streamline their work. For one of my projects I had the task of summarizing five winning proposals in a contest to suggest transforming our health care insurance mess. That's another area full of waste but not a topic for today.

For the first 40 page proposal I tackled I followed these steps:

1) I read through the proposal and made margin notes appropriate to the five sections of my final summary: Executive Summary, Financing, Delivery System, Management and Migrating the System.

2. Went through proposal a second time and typed in what I had found into a computer. Each heading had a page and I moved back and forth in the file to the appropriate page as I moved through the proposal.

3. Edited my document for formatting, spelling, readability, grammar, etc.

This process took 9 hours, an hour more than the 8 hour my client and I had estimated. I felt mentally wiped out.

As I sat in kaizan, I saw that most of my time was spent sorting and placing sentences in the right section. I also noticed I had to work my way through the proposal twice. In a previous project I had discovered the one click paragraph sorting function in modern word processing programs.

What if, I imagined, I dealt with the proposal just once. To do that I had to sit at the computer and enter sentences as I went. And, if I let the computer do the sorting, I just needed to make a table and put a symbol in the first column. So X would show a sentence that would go in the executive summary section, M would later find its way to the management section, and so on.

I could see a need for one more column for a secondary sort (showing if a sentence should be closer to the top of the summary or nearer the bottom). The outer columns served as scaffolding and would ultimately be removed.

My next proposal, just 20 pages, took just under 4 hours using this scheme. Makes sense if the first one took 9 hours and was 40 pages. But it felt much easier and I ended up with my mental juices still flowing. Actually, parts of me disbelieved I'd actually done the work right because it felt so easy.

So the new steps became:

1. Read proposal and type notes and quotes in one long three-column table.

2. Highlight the whole table and sort on the first and third columns. This put it in order by section and within section.

3. Remove first and third columns.

4. Convert from table to text.

5. Continue with editing and finishing steps.

As I type this I can envision a system that eliminates the use of tables. This would be an advancement as then I could compile a summary in any text program or even email and later sort it all using my word processor.

Office tasks are the next frontier for the application of lean concepts. With this project, the first 40 page document took me about 9 hours, the other four, including a 200 page book, took about 4 hours apiece. From a potential total commitment of 45 hours lean thinking shrank my work down to a total of 25 hours, an improvement of almost 45 percent. Looking only the 4 I applied my lean thinking to-my work withered from 36 hours to 16, a savings of 56 percent. And preserving my mental health was a surprising bonus.

Soft? Skills

I've deconstructed my reaction to "soft skills." Partly, I dislike people labeling other folks work in any less than equal status terms. Who gets to do such labeling? It's disrespectful.

Semantically, hard has two antonyms

HARD <---> SOFT

HARD <---> EASY

If both Soft and Easy have the same antonym then subliminally

SOFT = EASY

So soft skills must be easy skills, not worth paying attention to, much less paying for.

With all the emphasis of the privileged 'hard skills' like math and engineering we drift further from sheltering everyone and openly celebrating our interdependence. Perhaps this imbalance is silently dissolving the love that binds us to each other and all living things.

Never to criticize without offering an alternatvie, we can call these skills what they are: people skills, communication skills, negotiation skills. Human skills. Loving skills.

Daily Lean

I am an self-taught when it comes to Lean Production. This is one of the names given to the revolutionary (still) insights generated by the Toyota car company beginning in the 1950s. It is also called Toyota Production Method (TPM) and Continuous Quality Improvement (CQI), Just in Time, and other names.

One part of the philosophy of lean is try out the small adjustments, if they work, keep them until more adjustments occur to you. Here's an example.

I ride my bike as transportation. I have enjoyed this activity in two cities. I have to lock the bike whenever I leave to have a good chance of seeing it when I return.

This requires a lock and key. The key hangs on my lanyard along with my whistle around my neck. When I use the lock the cord wraps and hooks sometimes around anything available, causing frustration and delay.

So, I get a new bag that has a two-part key chain. The type where you can detach the keys from the ring.

Enter creativity :: I moved the detachable key ring to my lanyard.

Now, it's very easy and I had to adjust to the change (remember to use it).
That was success for about three weeks, when more creativity :: I could delete the detachable key ring and use the lanyard clip that's been there all along.

Now I lock my bike and there's no tangled lines and accessing the key and replacing it takes just a few seconds.

This Page Intentionally Left Blank

Sometimes I get formal material in the mail purporting to give me information I need to make some complicated decision like how to vote my six shares of a stock. As I slog through mind numbing financial/legalese I come to a mostly blank page with this right in the middle ...

This page intentionally left blank.

And my head reels. This page isn't blank at all—There's a sentence right in the middle of it! Another example of how we drive ourselves batty. A better way?:

On this page? 

Just three lines. 

Now, go on.

Double Yes, Part II

After writing my first blog on the double yes syndrome (July 6) I have begun to notice it's effects on other areas. One is pooled money: when a group has contributed dues/taxes, etc. into a common pool, the fiduciary managers of that pool of cash act in ways collectively (which means by vote or consensus of the separate individual leadership group) that most of them would not behave privately. Often this means spending the groups money at a higher level than they would with their own funds.

Another instance of the double yes (DYes) is when a decision is made by a group. In Single Yes (SYes) micro-cultures the members participating in the discussion put their best thoughts out ahead of the decision. They attend to the accepted process and work within it. This is the intent of Roberts Rules of Order and other parliamentary systems.

But watch with the DYes: the group decides, and then continues to hash out the decision! Say a condo meets at its annual meeting and decides that a longer ladder for accessing its flat roof would be wise. All quickly agree. One of the members, not necessarily on the board, continues with the research of the ladder and locates a modern ladder that could serve. Suddenly there's a flurry of concerns about unauthorized access. In DYes micro-cultures that is perfectly acceptable and not a cause of friction or notice even. For those raised with a single yes this is troubling as it shows once again that a decision in DYes culture is the START of discussion, while a decision in SYes cultures ENDS discussion and starts action.