Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

Cape Cod

Sunday musings…7/25/2021

1 Frustum. Part of a pyramid or a cone remaining after the top has been cut off. No reason. Just a cool sounding word randomly encountered while reading about a new building in Chicago.

Built by stacking Frustums.

2 Volunteer. Random plant growing in an otherwise homogenous crop field. Often useful, like an cornstalk. Pretty sure I’ve mentioned this one (from my mother-in-law) previously.

Just too cool not to mention again after passing a few to and from the barn.

3 Invitations. My daughter once said of the “snobby pops”, the cool girls in high school, that they never really graduate, they just move. What she meant, of course, is that many of them never again reach the heights they perceive that they have reached in high school, and so they never really grow beyond what it was that made them popular in the first place.

They just move to a new “school” and play the same tiny games until it’s time to move again.

4 Costs. No matter how you shake it, obtaining healthcare in the U.S. costs a lot of money. Popular perception has it that doctors, and what doctors are paid, represents the lion’s share of those costs. Interestingly, no matter where I look, the highest percentage of healthcare costs associated with care by doctors (office visits, etc) is 22%. The lowest is usually somewhere around 15%. These are % of costs, not doctor salaries; one must remember that the fee you pay for your office visit does not translate directly into your doctor’s salary. Overhead expenses such as rent, staff salaries and the like come out of that fee, too.

Still, 22% of $2.5 Trillion is a lot of money. If you get in an accident, or you are diagnosed with cancer, your doctor bills are the least of your worries. Health “Insurance” was designed to cover these big ticket events. By and large, it does, if you have health insurance. Most of us won’t need this part of our policies. What those policies do is pre-pay for what is largely health maintenance, with the occasional modest trip to the repair shop (for example, cataract surgery). In these cases, even if you have a very high deductible (the amount of money you pay out of pocket before your insurance company starts to pay your bills) and you write a check for the entire amount in your bill (for example $1496 for standard cataract surgery), your insurance company has negotiated that bill way down from the “list price” (again, cataract surgery, ~$8000).

Here’s (part of) the rub: if you don’t have any health insurance, nothing from your employer or the government like Medicare, the largest healthcare organizations typically demand full price for your care. This is particularly true of our most famous non-profit medical institutions like Yale, Harvard-Pilgrim (Partners) Health, and our local behemoth the Cleveland Clinic Foundation. These institutions have taxes forgiven that are on the order of 10 times the amount of discounted care they provide to the community, even when that care is computed using their outrageous list prices.

This treatment of cash-pay, uninsured individuals by large, powerful for-profit and non-profit institutions is unconscionable.

In my reading I came across a very interesting idea. The Wall Street Journal did yet another exposé on this, once again focusing on Yale (they don’t seem to learn). A follow-up letter to the editor from Paul Horvitz, a professor at the University of Houston, offers an elegant solution: allow health insurance companies to sell products with an infinite deductible, or one that is so high that it only covers true disaster care (e.g. cardiac bypass).

Most of your insurance premium isn’t buying you real insurance; as noted above you are simply pre-paying for your healthcare services. Some of the remainder of that premium covers the processing of your claim. Neither of these expenses would be borne by the insurance company if you are going to pay for your care out of pocket. What they would be doing, though, is selling you the right to pay for your care using the rates that they, the huge insurance company, have negotiated.

Like $1496 rather than $8000 for cataract surgery.

There are certainly details that would need a bit of working out before something like this was ready for prime time. Imagine, for a moment, if this “negotiation for hire” plan was coupled with a more robust Health Savings Account, for instance. I think I’ll chew on this a bit and then revisit it when I’ve worked through some of the likely objections. It’s interesting though, and Dr. Horvitz is to be congratulated for the idea.

5 Three Rules. It’s always a huge compliment when something I’ve written or shared is passed along to another generation. Even better when the passing along is in a setting that is similar, or identical, to the original. So it is that I harken back to the days of my residency at NYU and world famous Bellevue hospital, transported by a note from my friend and colleague (and former junior resident) Dave, who has taught ophthalmology residents for 30+ years now.

Dave was a year behind me at NYU. He was (and is) brilliant in every respect, except for one, at least at that time: he was categorically incapable of holding his tongue when he was right. Mind you, Dave was (and is) right nearly all of the time. His meteoric rise in academia and the myriad alphabet organizations that run our world is testament to the fact that he has acquired this skill, acquired the ability to gauge when it will be most effective to share his thoughts and hold them until such time is nigh.

What Dave shared with a young resident in whom he sees the seeds of leadership (and perhaps greatness) were my three rules for surviving, and perhaps thriving, in an organization or institution: Knowledge is power. Perception is more important than reality. Evolution is better than revolution. Like any set of rules mine has caveats and exceptions, and it has evolved over the years. But as a strategic building block upon which you can construct your tactical responses, this list is as good as any others I have encountered. It has served me, and Dave, very well over the years.

I used to say the the more knowledge you had, the more likely you were to succeed in any organizational structure. As the years have gone by I find that the power inherent in knowledge, or more precisely information or intel, is dependent more on the quality of the information than the quantity. Being in possession of nearly all of the information necessary to make a proper decision or foray, but not holding that key bit of knowledge that forms the crux of the issue, is akin to not having any knowledge at all. Since we do not even possess the information crunching ability of our phones, Power comes from having the right knowledge. The actionable knowledge. Still, what hasn’t changed is the absolute absence of power you face when you are not read in to all of the information necessary to make the decision that is most right for you.

Once you have enough knowledge it is time to learn what everyone around you perceives. How do they see the situation? To lead one must understand not only the cold, bare reality of what is on the ground before you, but also what and how those around you THINK is the reality. I’ve admitted in the past that this, too, may fall under the “knowledge” axiom, but separating it out emphasizes its outsized importance. It’s awfully hard to lead from spot #1 to spot #2 if your group is convinced that they are presently sitting on “M”.

Finally, in general, evolution is a better route to effective and lasting change (hopefully improvement) than revolution. There are certainly circumstances where revolution cannot be avoided; I’ll leave it to you to reflect on some historical note or another that proves the exception. But there is so much damage, much of it collateral damage among “non-combatants” in revolution, that it has to be an awfully big deal bad thing you are hoping to change to lead the revolution. In our case back in the Bellevue days Dave was almost certainly trying to solve for a chronic administrative barrier to providing care or receiving an education, or both.

Once again let me emphasize that Dave was almost always right. In the end, by acquiring the proper knowledge he saw where the power to make the change lay. Seeing the issue through the eyes of everyone else involved allowed him to avoid the obstacles erected along the straightest path to success. By biting off small pieces of the problem, each small step leading inexorably to the proper change event, whatever it was that Dave sought to change was achieved in such a way that it came to be seen as the only plausible outcome possible.

While I admit a bit of “discoverer’s bias” these three rules work in almost every group setting. Work, family, your Sunday softball league…doesn’t matter. They’ve worked well enough for me, and for Dave, that they are still being passed on to the next generation of young people who will lead us all through the next evolutions.

I’ll see you next week, a week made better by the evolutionary changes you have brought about through obtaining the key knowledge necessary, and seeing the problem not only as you see it, but as others around you see it…

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