Why Health Care Reform Will Cause More ER Overcrowding

By RangelMD

Contrary to popular belief, those without health insurance are not flooding emergency rooms as a consequence of being cut off from routine and preventive care. Actually, frequent visitors to the local ER are far more likely to have insurance according to a new review of 25 studies on ER use published since 1990.

Frequent users account for about 8% of ED patients but 28% of visits. Although frequent users are not a homogeneous group, 60% are white and their average age is 40. Roughly 60% are enrolled in Medicare or Medicaid.

The uninsured do not dominate EDs; 15% of frequent ED visitors have no coverage, the study found. Only about 2% of uninsured adults visit an ED four or more times in a year.

Medicaid and Medicare beneficiaries younger than 65 tend to follow the “if you build it, they will come” economic model of health care utilization. Without insurance, people tend to avoid large health care costs for everything except actual emergencies. Given an entitlement in the form of low cost government health insurance, they tend to seek out care for every ailment like a millipede with a thousand-for-one free shoeshine coupon. This phenomenon was clearly seen in the disaster that was TennCare, Tennessee’s attempt in the later 1990s to expand their state Medicaid program to cover everyone under the age of 65.

It’s unclear why public insurance beneficiaries tend to be ER “frequent fliers” at much higher rates than those with private insurance. Undoubtedly, those in lower socioeconomic standing tend to be in poorer health, have more chronic health problems, and hence be more susceptible to the consequences of risky behavior and poor health decisions. But most of these frequent ER fliers with public health insurance have primary care doctors so having access to care should not be the problem.

Or is it?

Even with public health insurance, these patients are still likely to be victims of poorly designed, underfunded, and overcrowded health care systems in intercity and impoverished rural areas.

Public insurance programs like Medicaid usually pay health care providers a fraction of what private insurance policies do and so there are usually significant shortages of physicians in communities where these patients live. What access does exist tends to be either private clinics where the doctor runs a treadmill style practice of seeing 50 to 60 patients a day for less than five minutes a visit in order to maximize profit or there are public clinics staffed by health care providers on salary who have neither the incentive nor the time to provide quality care for a population that is often plagued by multiple chronic health problems.

Either way, getting an appointment to see a health care provider in an undeserved area for an acute illness is often an exercise in futility. Few of these clinics offer after-hours or acute care same day service so often patients have no choice but to visit the nearest ER, even for something as trivial as a bad cough. Without additional funding incentives to expand urgent care access in these areas, the hospital ERs remain the only facilities that are designed and staffed for this purpose. And it’s only going to get worse.

The Patient Protection and Affordable Care Act may pour hundreds of billions more into expanded Medicaid, Medicare, and subsidies for health insurance to help cover up to 35 million more Americans. Presumably, many of these patients will enter into the same poorly designed, underfunded, and already overcrowded health care systems, thus worsening the situation, and leading to more ER overcrowding.

That expanding health care coverage would lead to more ER overcrowding is paradoxical until you look at the reasons for why ERs are overcrowded in the first place. The solution to the problem caused by the solution to inadequate health care coverage is to adequately fund community health systems in order to provide incentives for the private sector to build more urgent care and minor emergency centers.

This, in turn, would hopefully take a large amount of the load off the ERs so that they can concentrate on actual emergencies. Unfortunately the Patient Protection and Affordable Care Act seems poised to do exactly the opposite; to provide just enough funding to get more people into these systems but not near enough to expand the infrastructure of these systems.

Does Quality Follow the Money?

By Dina Overland

The health reform law places a lot of value in pay-for-performance insurance programs as a way to improve the overall healthcare system while decreasing costs and improving quality care. Policymakers believe insurers can incentivize doctors and hospitals through financial payments to ensure their patients don't get sick (or sicker than they already are).

Sounds good, in theory at least. But does it work in practice? A new study of the British pay-for-performance practice says no. The study, published in the British Medical Journal, examined the impact of performance targets on quality of care and outcomes among almost 500,000 British patients with hypertension over seven years. The authors didn't mince words when they concluded that the assumption that pay-for-performance benefits patients with hypertension is "questionable at best."

So, is all the hype about pay-for-performance insurance programs inaccurate? The answer is a definitive ... maybe.  

Many other studies have reached different conclusions. One determined that pay-for-performance programs seem to be having more of an impact on clinical quality and cost control than they had in the past. Conducted by MedVantage and the Leapfrog Group, the study's key results included that 56 percent of health plans believed clinical quality improved in 2008 among doctors participating in P4P programs. This compares with only 37 percent of plans that saw such improvement in 2006. Also, 25 percent of plans said P4P programs lowered physician costs in 2008, compared with just 15 percent in 2006.

Some of the improvement seen by health plans may be taking place because providers are investing more in meeting P4P goals. For example, 39 percent of plans said investment in health IT rose among participating physicians, compared with 14 percent two years before, according to the study.

Pilot pay-for-performance programs also have achieved cost-saving success. Last year, CMS concluded a four-year demonstration project involving 10 physician groups that, according to the agency, saved $38.7 million in Medicare expenditures. To date, the project has realized $98 million in savings, and its participants have qualified for more than $78 million in incentive payments.

"Based on what we have learned so far, we know the healthcare industry can meet high standards for improving quality of care while saving Medicare money," CMS Administrator Donald Berwick said when announcing those results.

If CMS is behind Medicare pay-for-performance programs, then I think it's likely here to stay--at least in the current dialogue of how to reduce healthcare costs while still improving quality of care and outcomes. Right?

But then there are studies like the one conducted by the Rand Corporation, which found medical disparities between poorer people and racial and ethnic minorities may increase with performance-based payments. Researchers concluded that average-sized physician practices serving the highest proportion of vulnerable populations received about $7,100 less annually than other practices. That difference could be even larger if greater amounts of money are put at stake in future pay-for-performance programs, the study authors said.

Other research shows that, rather than encouraging providers to shift resources toward overall quality improvement, pay-for-performance may instead only persuade providers to focus on narrow, incentivized areas. That's because they're only being rewarded for achieving specific health outcomes.

So, what's an insurer to do? Perhaps they should proceed with caution, fully recognizing the limitations of pay-for-performance and, when required to implement such programs, attempt to address the shortcomings

Be an Optimist Without Being a Fool

by Heidi Grant Halvorson

There are quite a number of motivational speakers and self-improvement books out there with a surprisingly simple message: believe that success will come easily to you, and it will. There is one small problem in this argument, however, which unfortunately doesn't seem to stop anyone from making it: it is utterly false.

In fact, not only is visualizing "effortless success" unhelpful, it is disastrous. This is good advice to give only if you are trying to sabotage the recipient. It is a recipe for failure. And no, I'm not overstating it.

But how can this be? Isn't optimism a good thing? Yes it is. Optimism and the confidence it creates are essential for creating and sustaining the motivation you need to reach your goals. Albert Bandura, one of the founding fathers of scientific psychology, discovered decades ago that perhaps the best predictor of an individual's success is whether or not they believe they will succeed. Thousands and thousands of experiments later, he has yet to be proven wrong.

But there is an important caveat: to be successful, you need to understand the vital difference between believing you will succeed, and believing you will succeed easily. Put another way, it's the difference between being a realistic optimist and an unrealistic optimist.

Realistic optimists (the kind Bandura was talking about) believe they will succeed, but also believe they have to make success happen — through things like effort, careful planning, persistence, and choosing the right strategies. They recognize the need for giving serious thought to how they will deal with obstacles. This preparation only increases their confidence in their own ability to get things done.

Unrealistic optimists, on the other hand, believe that success will happen to them — that the universe will reward them for all their positive thinking, or that somehow they will be transformed overnight into the kind of person for whom obstacles cease to exist. (Forgetting that even Superman had Kryptonite. And a secret identity that took a lot of trouble to maintain. And also relationship issues.)

One of the clearest illustrations of the dangers of unrealistic optimism comes from a study of weight loss. Psychologist Gabriele Oettingen asked a group of obese women who had enrolled in a weight-loss program how likely they felt they were to reach their goals. She found that those women who were confident that they would succeed lost 26 pounds more than self-doubters, as expected.

But Oettingen also asked the women to tell her what they imagined their road to success would be like — if they thought they would have a hard time resisting temptation, or if they'd have no problem turning down free doughnuts in the conference room and a second trip to the all-you-can-eat buffet. The results were astounding: women who believed they would succeed easily lost 24 pounds less than those who thought their weight-loss journey would be no walk in the park.

She has found the same pattern of results in studies of students looking for high-paying jobs after college, singles looking to find lasting love, and seniors recovering from hip replacement surgery. Realistic optimists send out more job applications, find the courage to approach potential romantic partners, and work harder on their rehabilitation exercises — in each case, leading to much higher success rates.

Believing that the road to success will be rocky leads to greater success because it forces you to take action. People who are confident that they will succeed, and equally confident that success won't come easily, put in more effort, plan how they'll deal with problems before they arise, and persist longer in the face of difficulty.

Unrealistic optimists are only too happy to tell you that you are "being negative" when you dare to express concerns, harbor reservations, or dwell too long on obstacles that stand in the way of your goal. In truth, this kind of thinking is a necessary step in any successful endeavor, and it is not at all antithetical to confident optimism. Focusing only on what we want, to the exclusion of everything else, is just the kind of naïve and reckless thinking that has landed industry leaders (and at times entire industries) in hot water.

Cultivate your realistic optimism by combining a positive attitude with an honest assessment of the challenges that await you. Don't visualize success — visualize the steps you will take in order to make success happen.

Heidi Grant Halvorson, Ph.D. is a motivational psychologist, and author of the new book Succeed: How We Can Reach Our Goals (Hudson Street Press, 2011.  Her personal blog, The Science of Success, can be found at www.heidigranthalvorson.com. Follow her on Twitter @hghalvorson

Are Happy People Dumb?

by Shawn Achor

"Happy people are not the smart people."

I was talking to a stock trader shortly before giving a lecture at a large bank in New York. I think he thought I was a fellow trader, but I felt a little awkward at this turn in the conversation... as my lecture topic was the research case for happiness.

"Happy people are the ones who don't get it," he continued. "Happy people just don't understand how the markets are working or how the company is not working..."

These sentiments are not uncommon. I believe we have a cultural assumption that happy people are anti-intellectual, delusional, or shallow. We've all heard the saying that "ignorance is bliss."  But, in truth, society has a fundamental ignorance about bliss.

Here's part of the problem. Everyone knows someone who is brilliant and unhappy. And everyone knows someone who is successful and not happy. I encountered both types frequently in my research at Harvard and in Fortune 500 companies, and when you see these two types of individuals, it is easy for us to assume that happiness has nothing to do with success or intelligence, or is even antithetical to it.

On the contrary, a decade of research suggests that both of those individuals (smart/unhappy, and successful/unhappy) are actually significantly underperforming what their brain can do. We know this partly because if you raise their levels of positive emotion, their cognitive abilities and success rates go up. The real story of happiness is that every person has a range of potential — in terms of intelligence, athletic ability, musicality, creativity, and productivity — and we are more likely to achieve the upper bounds of our brain's potential when we're feeling positive, rather than negative or neutral.

For instance, dopamine, a neurochemical released by our body which helps us experience enjoyment and happiness, has an ancillary benefit: it activates the learning centers of the brain, allowing our brains to become intellectual sponges.
You've seen this in the past. If you crammed for a test in school and were stressed about it, you probably do not remember the information even three days later--even if that information would have been helpful at your job or if you had to battle Watson on Jeopardy.

But you probably remember song lyrics from a decade or more ago, and your brain retained that information even if it is useless to you (unless you do a lot of karaoke). You remember that information partly because of the musical patterns and partly because your brain's learning system was activated by dopamine.

In psychological experiments, a "prime" causes a person to experience an emotion; then we see how that new state affects their performance. You can prime people to become more altruistic by giving them something small yourself. When you prime a four year old child to be happy — by asking them to think of their happiest memory — their spatial memory increases dramatically, allowing them to put blocks together up to 50% faster than children at neutral. Doctors primed to be positive come to the correct diagnosis 19% faster when primed to be positive as opposed to negative. Salespeople have 37% higher levels of sales when optimistic. In fact, a meta-analysis of employees at companies reveals that nearly every single business outcome improves when a brain is positive. Happiness is a significant advantage.

In fact, happiness is the single greatest competitive advantage in the modern economy. Only 25% of your job successes are predicted based upon intelligence and technical skills, though we spend most of our education and most companies hire based upon this category. The "silent 75%" of long-term job success is based upon your ability to positively adapt to the world: optimism, social support creation, and viewing stress as a challenge instead of as a threat. 

Perhaps that stock trader meant that happy people are shallow and just don't realize that there are problems in the world. We often erroneously think that the "deep" people are the ones who brood. The darker the movie, the less redemptive the ending, the more artistic people think it is. The more messed up the painter or the musician's life, the more creative we assume they were. But this is not true. It requires an incredible amount of depth to be positive and hopeful in the midst of adversity. In truth, negative emotions stem from the most primitive part of the brain that responds to fear and threat. Seeing the negative is easy; formulating a cognitive strategy about how to positively respond to challenge requires much higher-order functioning in the brain.

Researchers like Barbara Fredrickson have found that when we are negative, our brains resort to "fight or flight" thinking about the world. But when we are positive, our brains "broaden and build" allowing us to create new patterns of success and widen the amount of possibilities our brains can process.

If you want to see what your brain is capable of today at work or school, try to raise your level of happiness before tackling a challenge. For a list of suggestions for happiness boosters, check out this video or this list.

Given all the research about the happiness advantage and how positive brains reap higher business outcomes, the conclusion is clear: it is smart to be happy.

Should I Become an Entrepreneur?

By Jeffrey Bussgang

When to become an entrepreneur is a common quandary for many. For whatever reason, this issue has come up a great deal recently (recession-driven workforce dislocation?), so I thought I'd share a few thoughts that might help frame this critical decision.

I have concluded that being an entrepreneur is an irrational state of being. If human beings were purely rational, evaluative, value maximizing individuals (see HBS Prof Michael Jensen's paper on self-interest and human behavior (link PDF)), they would not start companies. If they sat down and did the expected value calculation by laying out the probability-weighted outcomes of being an entrepreneur as compared to taking a safe job, it would not pencil out. 

Yet, entrepreneurship is not simply a rational journey. It is one that is defined by passion and personal satisfaction that transcends purely financial analysis. And, of course, there is always the hope for the big payout, no matter how long the odds.

Despite popular wisdom to the contrary, age is not a major factor in the decision to start a company. The Kauffman Foundation reports that the median age of founders is 39 - right at the midpoint of a typical professional career - and 69% are 35 or older. Another study by Washington University professors of 86,000 science and engineering graduates showed that age was not a significant predictor of becoming an entrepreneur.

So when should you become an entrepreneur. Here are the kinds of questions you should ask yourself:
Do you have an idea that no one can talk you out of? When you bounce your start-up idea off your spouse, friends and trusted advisors, are they able to raise enough objections that you begin to doubt whether the idea has merit. Getting honest, objective advice can be hard because the people you are likely to go to care about you and may be afraid to tell you what they really think for fear of offending you. Thus, you need to get feedback from objective parties (e.g., advisors, experts, prospective angel or VC investors with whom you don't have a deep personal relationship).
Do you have a partner you trust with complimentary skills? Starting a company is a lonely adventure. Having a partner that you can trust and whose skillset and experience is complimentary to yours can be a huge functional and emotional benefit. 

Are you prepared to endure with modest or no salary for a few years? Founding a company often means making personal sacrifices and below-market cash compensation. All the talk about "lean start-ups" (which I'm a big fan of) sometimes obscures the practical reality of what it means to eat through your personal savings. 

Are you bored with your current work environment/life situation? There is nothing boring about being an entrepreneur. More apt adjectves might include stimulating, engrossing, obsessive, exhilarating, nerve-racking - but not boring. If you are tired of viewing your work as a chore and if every day is a bit of a grind, then entrepreneurship is for you. I find that the intrinsic motivation behind an aspiring entrepreneur is sometimes the simplest - because it's fun. Seeking fun can transcend all other factors.
Do you perform best in the absence of structure? In my book, Mastering the VC Game, I describe a metaphor for the three stages of a start-up: the jungle, the dirt road and the highway. In the earliest stages of a venture - the jungle - there are no clear paths available and the skills required are to thrive in the midst of the chaos. For those who possess that makeup, being a start-up executive is an excellent fit. But for those that like clear paths with little uncertainty and a great deal of structure - the highway - an early-stage venture will feel like a very uncomfortable environment. 

Reflecting on these questions, I find it intriguing to reflect on what kind of environment - either from the perspective of parents raising their children or policy makers thinking about encouraging entrepreneurial ecosystems - can be created to foster more entrepreneurship? HBS Professor Noam Wasserman is writing a book called Founding Dilemmas which is coming out later this year (I've read early drafts and believe it will be a must-read for entrepreneurs). In it, he quotes career guru Dr. Tim Butler who points out that signals from parents, mentors and local leaders have a large influence on whether people chose to become entrepreneurs. "We receive very powerful messages [from those around us] about what's important, what success is, what failure is, what counts for achievement and what doesn't. "

Celebrating entrepreneurial success stories in our culture and putting folks like Steve Jobs, Bill Gates, Larry Page (the new Google CEO!) and even more accessible, local heroes on magazine covers and in front of audiences is obviously a huge factor. Every college kid in America looks at Mark Zuckerburg and thinks, "Why not me?" Why not, indeed? 


Jeff Bussgang is a general partner at Flybridge Capital and an Entrepreneur in Residence at Harvard Business School. He is author of the book, Mastering the VC Game.This post originally appeared on Jeff's blog, Seeing Both Sides

How To Measure Success

By Simon Sinek

This journey I’m on is a deeply personal one. When I put words to this thing called the Why, it completely changed the direction of my life. Not a single thing I’m doing these days -- not the speaking, not the book, not even this column -- was a part of any plan. How could they be on a plan? I couldn’t even imagine them. With all that has happened in the past few years, someone asked me a question recently that really made me think: “How will you know when you’re successful?”

I know there’s a difference between being successful and feeling successful. And if you ask me if I feel successful, the honest answer is “not yet.” By most standard measurements, I am enjoying more success now than at any other time in my life, but I still don’t feel successful. This is what makes the question so fantastic. If the goal is to feel successful, what is the measurement we should use to achieve that feeling?

The most common standard measurement is money -- our bank accounts. That’s how so many people measure their success today, so perhaps it works?

I went to an event for high-performing entrepreneurs and the question was asked of the room, How many of you have achieved your financial goals?  Amazingly, 80% of the room raised their hand. Then the question was asked, “how many of you feel successful?” and 80% of the hands went down. This example alone shows that there is little to no connection between the standard measurement of success and the feeling of success.

I for one have never been motivated by the money.  Most years, if you were to ask me how much I make, the genuine answer is that I have no clue. I usually find out the answer to that question once a year, at tax time, when my accountant tells me. And if money were the only measurement, we’d all have a number in our minds that, if we reached it, we’d stop working. And most of us don’t. No matter how much I make, I don’t want to stop working. Money doesn’t help me answer that question.

Some would argue that you’re as successful as the company you keep. Certainly there is a connection between our friends and who we are. James Fowler talked about it a couple of years ago in a piece called “Do Your Friends Make You Fat?” But can we really measure our success based simply on the company we keep? For example, are Vincent Chase’s buddies in the HBO series Entourage successful because they hang out with someone rich and famous? Most of us would say no. Sometimes the opposite happens. Sometimes spending time with someone who is perceived as “successful” can make us feel less successful. The irony is that regardless of how successful we think someone is, we don’t actually know if they feel successful.

Over the past year, I’ve had the opportunity to spend time with people I never imagined even meeting. At two events this week, for example, I shared the stage with The Tipping Point author, Malcolm Gladwell, and David Bach, author of The Automatic Millionaire, respectively. It was so exciting to spend time with them and it was fantastic to get to soak up some of their genius. I cannot dispute that having the opportunity to work with them certainly is an indicator that things are moving in the right direction, but it didn’t make me feel successful. For me, the best thing about spending time with people I admire is the opportunity to ask them questions and learn from them. Though spending time with them doesn’t make me feel successful, their ideas and their thinking absolutely contribute to making my own work better, which, of course, helps me advance. But it doesn’t yet answer the question.

My friend Georgia Hurd is not famous. She’s not rich. And she’s not yet attained the success she desires. She moved to Los Angeles to become an actress and has been working really hard to achieve her dream. She has been through some hard times. Money has been tight. Her work schedule often hurts her social life. But she perseveres. Her work ethic and her drive are amazing. She is so focused on where she wants to go. It is inspiring. After a couple of years of pushing and lots of wondering if it would ever happen, she’s starting to get some momentum. This week alone, she was called in to do a modeling job for American Apparel, she had some fantastic auditions and people are starting to take notice of her. What Georgia has found is momentum. It is that momentum that makes her feel good. It is the momentum that makes her feel successful.

This is my measurement: momentum. That’s what I want to track and measure. Money and the people I meet are stepping stones, indicators that momentum is building -- but it is the momentum that makes me feel good.

Studies show that over 90% of Americans don’t feel fulfilled by their work. Think about that. The vast majority of Americans go home at the end of the day without the feeling of success. I imagine a world in which that statistic is reversed. That most people go to work every day to a job they love and go home at the end of the day feeling fulfilled. That’s the world I’m working to build. My contribution is to share a message that can help make that dream a reality. But only when others join me in this cause; to help spread the message; to build the companies that people love to work for; and to choose jobs based on how the job makes them feel, not simply how much it pays, will this dream become a reality.

I know momentum is building. That, more than any other measurement, makes me feel successful. So what of the original question, “How will you know when you’re successful?” The answer:  When I reach a level of momentum when the movement can advance without me -- then I will feel successful.

Where Do Ideas Come From?

I thought today's Seth Godin blog was worth re-posting.  If you're not currently subscribing to his feed or following him on Twitter, you're missing out.  Catch him at @thisissethsblog and/or at http://sethgodin.typepad.com.

Just a reminder, to follow and learn from blogs, my recommendation is set up your Google Reader and subscribe to as many as you can handle.  Then set up iGoogle as your desktop where you can plug in the Reader, your blog, and other things like ESPN.com.  You choose.  What I like about the reader is I can research hundreds of articles at a glance, yet read only what applies to my interests - all without cluttering my inbox.

Where do ideas come from?

1. Ideas don't come from watching television

2. Ideas sometimes come from listening to a lecture

3. Ideas often come while reading a book

4. Good ideas come from bad ideas, but only if there are enough of them

5. Ideas hate conference rooms, particularly conference rooms where there is a history of criticism, personal attacks or boredom

6. Ideas occur when dissimilar universes collide

7. Ideas often strive to meet expectations. If people expect them to appear, they do

8. Ideas fear experts, but they adore beginner's mind. A little awareness is a good thing

9. Ideas come in spurts, until you get frightened. Willie Nelson wrote three of his biggest hits in one week

10. Ideas come from trouble

11. Ideas come from our ego, and they do their best when they're generous and selfless

12. Ideas come from nature

13. Sometimes ideas come from fear (usually in movies) but often they come from confidence

14. Useful ideas come from being awake, alert enough to actually notice


15. Though sometimes ideas sneak in when we're asleep and too numb to be afraid

16. Ideas come out of the corner of the eye, or in the shower, when we're not trying

17. Mediocre ideas enjoy copying what happens to be working right this minute

18. Bigger ideas leapfrog the mediocre ones

19. Ideas don't need a passport, and often cross borders (of all kinds) with impunity

20. An idea must come from somewhere, because if it merely stays where it is and doesn't join us here, it's hidden. And hidden ideas don't ship, have no influence, no intersection with the market. They die, alone.