Student Perspective

Building an Exchange Strategy Part II – Understanding Your Political Climate

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Posted By  Errol Pierre

By 2014 there will potentially be a health benefit exchange in every state across the country. Like snowflakes no exchange will be alike and politics will play a pivotal role in the differences found between them. While the healthcare reform bill signed into law requires the establishment of exchanges, the details of operation have yet to be determined. In fact, in March 2012, the Department of Health and Human Services (HHS) provided 600 pages of additional guidance to the states. The guidance given was more of a framework while much of the particulars were purposefully left out. This has made the role of the individual State Governors ever important. They are now in a position of power and play a very integral role in bringing exchanges from a theoretical policy concept to a legislative and operational reality.

Right or Left
At a high level, left leaning blue states will design their exchange to be an active purchaser. This will allow the Governor to take an active role in the day to day exchange operations. Under the direction of an exchange board, most likely selected by the Governor, these states would choose precisely which insurance companies participate, the types of policies sold, the rates of the selected products, and how enrollment and eligibility of those enrolled would work. In some more aggressive instances, states could even negotiate pricings with doctors, hospitals and pharmaceutical companies in the very same ways insurance companies do today in the private sector. This is obviously foreign territory to many of the states pursuing such a model. Nonetheless, proponents of the model see value in such an approach believing more oversight will lead to more affordability and better health outcomes in the long run.

Right leaning red states on the other hand will opt for a facilitator model. The state will merely be a marketplace for health benefit transactions between consumers and insurance companies to occur. They will set the high level guidelines and guardrails and merely outline the rules of engagement. Much of the market dynamics will be left up to private insurance and market forces to sort out. Benefit design, rate approval, distribution strategy, the “off-exchange” marketplace, and pricing will all be left up to “the invisible hand” of Adam Smith’s market forces. The idea of competition lowering healthcare costs has been refuted by the likes of many including Alain Enthoven – the father of managed competition – and Kenneth Arrow – the pioneer in research on asymmetric information as a market failure in healthcare. Nonetheless, American capitalism seems to have trumped over such doubts in these states. As a result, the role of government in these exchanges will be as minimal as the healthcare reform legislation will allow. There are already mandates that must be in place for each exchange. For example there must be four benefit categories ranked by actuarial values labeled bronze, silver, gold, and platinum for simplicity. The legislation also caps insurance company profit at 20% before operating costs are factored in. Lastly, the legislation requires health insurance companies to accept all enrollees and requires that the ratio between the pricing of the healthiest and the sickest consumer not exceed a 3 to 1 ratio. All in all, governors of these red states feel too much regulation stifles competition and the reform bill already has enough rules. As such, they are reluctant to add any further requirements on top of the federal ones. In this role the state will play referee rather than player/coach.

Politics at Play
State by state, there will be different shades of blue as states consider the ramifications of building a health benefit exchange. Health insurers must be prepared to understand how these different shades will impact the development of health policy. Vermont, for example, will be one of those very bold blue states. On May 26, 2011, Governor Peter Shumlin signed into law a historic universal healthcare bill which would cover every citizen in the state under a single payer system called Green Mountain Care. It will be in place by 2017 and the state has been drawing down federal funds from the national health reform bill as it prepares.

Like blue states, there too will be shades of red. Arkansas is a perfect example of a bright red state. Legislative opposition to a state run exchange was so great, Jay Bradford, the State Insurance Commissioner, had to  start preparing for a federally run exchange. By law, when a state cannot come up with its own legislation to run an exchange, the federal government is required to step in and set one up. Ironically, legislators that are so vehemently against Obama’s healthcare reform legislation will end up with a federally run exchange led behind Kathleen Sebelius, the current Secretary of Health and Human Services and former democratic Governor of Kansas.

Understanding the political environment of your state of operation is paramount to assessing the viability of a successful exchange strategy for a private insurance company. An active purchaser model lends itself to be a market where the constraints may be too great to be successful and sustainable. If the market is too controlled, healthcare coverage quickly becomes a commodity and erodes the levers of differentiation used to be competitive. Health insurance companies could come to the conclusion that participating in such a state will not be viable and opt to stay on the sidelines. However, the state would technically have the right to mandate (either directly or indirectly) insurance company participation, which could turn the state into a defacto-single payer.

On the other hand, a facilitator model lends itself to be the more favorable for an insurance company to operate within. However, a state that has done everything to obstruct healthcare reform progress like Arkansas is just as dangerous. It most likely will end up with a federally run exchange which could potentially be more burdensome than a facilitated one a red state would have had the option to create.

Errol Pierre works at a large insurance company focused on business development, sales, and strategy for employee benefits. He is currently pursuing a degree in Health Policy and Management with a specializing in health finance. He can be reached at errol.pierre@nyu.edu

 


It’s a Rotten Apple for NY’s Small Businesses: A look at health care regulations that uniquely contribute to high health insurance costs in NY

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Posted By Errol Pierre

Want to start a small business and help our staggering economy? Think twice about NY. Studies continue to show that affordable health coverage is the top concern for small businesses in this state. Contrary to popular belief health insurance profits and administrative costs barely contribute to the rising cost of coverage representing only 6% of total health spending. Despite this reality, this is exactly where policy makers have focused their time and energy with a desire to rein in costs. Profit margin in the NY small business insurance market is among the lowest in the country. In fact, many health insurance companies in NY are losing money, barely breaking even, or attaining modest 2-3% margins. Instead, we should focus on the big ticket items. That is, let’s focus on the factors that are unique to NY that contribute the most to higher costs. If modified to match national standards, these factors could substantially reduce insurance rates in this state making affordable health coverage available to more small businesses and in effect, more New Yorkers. After all, small businesses are the engine of the NY economy and the catalyst for NY job creation.

The primary driver of high insurance premiums in NY is the unusually high cost of health care delivery. NY is one of two states (California being the other) that lead the nation in spending at $163 billion per year. Each New Yorker makes up about $8,300 in annual health care costs per year; 22% higher than the national average. However, NY’s high spending rates have not translated into healthier New Yorkers. NY is only in the middle of the pack when it comes to quality (21nd out of 50 states). The state comes in dead last (50th out of 50 states) when it comes to avoidable hospital use. Statistics continue to show that hospital care is the #1 contributor to total health care spending in the America and this is exactly where NY has its problems. As health spending increases in this state, the price to insure New Yorkers increases as well.

Why is this happening?

Here are several regulatory factors unique to NY that exacerbates the high cost of coverage listed in order of magnitude:

High Medicaid Enrollment – A huge detriment to the affordability of small business health insurance rates is the number of New Yorkers enrolled in Medicaid. Of the 10 states that lead the nation in health insurance rates, high Medicaid enrollment is a reoccurring theme among them all. 1 out of every 4 New Yorkers receiving Medicaid benefits making it the 6th highest of any other state. Despite not leading the country in Medicaid enrollment, NY is the highest spending Medicaid state in the entire country. This means we are paying more per person without offering better care. In its meager attempts to rein in these high rates of spending, NY continually cuts the payments given to hospitals and doctors that provide care to NY Medicaid enrollees. These cuts set off a chain reaction causing hospitals and doctors to subsidize patient revenue losses with income from patients that have private insurance. This disproportionately impacts small businesses because there are fewer tools at their disposal to combat cost shifts. As a result, NY is the 2nd most expensive state for small business health insurance in the country averaging $554 a month for an individual and $1,455 a month for a family. How does that compare to the rest of the country? NY rates are 30% higher than the national average.

SOLUTION:  NY should immediately implement the recommendations from the NY Medicaid Redesign Team formed under the leadership of Governor Cuomo. The #1 cost contributor to small business health insurance is its subsidization of Medicaid spending in the state. If NY wishes to attract and retain small businesses, it must enact legislation that stops it from being the highest spending Medicaid state in the nation.

Pure Community Rating – NY stands alone as the only state that requires health insurance companies to charge all small businesses purchasing the same plan in a similar region the same price regardless of business size, demographic makeup, industry type, or health history. The other 49 states allow pricing to differ on a variety of factors which provide lower rates for healthier, younger, and even larger small businesses encouraging enrollment. Enrollment from diverse companies balances the insurance risk pool making coverage affordable for all. Inherent to the smallest of companies are higher operating costs and more fluctuations in health status and demographics which cause pricing for this population to be higher than average. However, because of this law, NY must charge all small businesses the same price regardless of size. This has caused NY to be the highest priced state in the nation for companies with 11-50 employees, which becomes a huge disadvantage for the NY economy.  Small businesses in this segment size represent more than 60% of the total small business workforce in NY making neighboring states like CT, NJ, and PA more attractive to larger small businesses. When fewer small businesses opt to offer coverage and the ones that do are smaller in size, the cost of insurance drives up at even faster rates than the normal health trend.

SOLUTION:  Adopt “modified community rating” as outlined in the federal health care reform bill which allows small business rates to vary by age and  tobacco use. This will allow more favorable pricing that will attract a both larger small businesses that employ more people and attract younger/healthier New Yorkers into the insurance risk pool.

Hidden Taxes – The single largest small business tax in NY is on private health insurance coverage. NY collected over $4.1 billion in revenue through these various taxes, fees, and assessments in 2011. Private health insurance has historically been targeted for solving state budget deficits. As such, these taxes have increased year after year adding more than $500 million to insurance costs since 2007. No other state has such an onerous tax burden and it is only likely to get worse as Federal health care reform is implemented. Both Health Benefits Exchanges and Market share assessments will result in more taxes imposed on the privately insured).

SOLUTION: Make New Yorkers aware of the taxes, fees, assessments hidden in health insurance rates. New Yorkers have a right to know where tax revenue for the state is generated.

o   $2.33B was raised by surcharges placed on hospital and health services given to consumers of private insurance

o   $1.16B was raised by an assessment based on a health insurer’s enrollment

o   $353M was raised by taxes placed on the prices commercial insurance companies charge their customers

o   $270M was raised by assessments on health insurance companies to fund running the Department of Financial Services

o   $240M was raised by an assessment based on a health insurer’s enrollment to specifically fill NY State budget shortfalls.

Benefit Mandates – NY has a laundry list of over 40 specific conditions and treatments that all health insurance policies must cover by law, regardless of an employee’s health needs or preferences. Compared to states like Idaho (12 mandates) and Alabama (18 mandates), NY is one of the states that lead the nation in mandates. These mandates in many instances supersede Federal standards, increasing NY’s health care costs by more than a 12%. In fact depending on the mandate, insurance costs can increase between 1% and 5% for each additional mandate.

SOLUTION:  Change the current set of benefit mandates that exceed the Federal standards to be “made available for purchase” rather than being mandated for inclusion in all small business plans offered.  This will allow employers to choose the plan that best suit their business needs. Larger employers that self-insure have been able to free themselves of many burdensome and costly mandates through ERISA rules which have not created a level playing field and disproportionately impacted smaller businesses.

Health Insurance Rate Review (Prior Approval Law) – In 2010, NY passed a law requiring all small business insurance rates to be approved by the Department of Financial Services. It also requires that $0.82 of every $1.00 in revenue be spent on medical care. As feared, this new rate approval process has become highly politicized rather than being a true actuarial exercise. First, $0.82 is higher than the federal requirement of $0.80 found in the recent health care reform legislation. Secondly, insurance companies in NY spend closer to $0.87 of ever $1.00 in the small business market and after operating costs, profit margins average only 2%. These actions create a hostile market place for competition and have led to fewer insurance companies offering coverage to small businesses in NY.

SOLUTION: Remove the onerous and political nature of rate increase reviews and improve the timeliness of state decisions

Individual Market Failures – Health insurance coverage for an individual in NY exceeds $1,000 a month in most cases. These rates are almost 60% higher than those for small businesses, causing some individuals who are priced out of the marketplace to form phony small businesses to avoid the high costs and market failures of the individual market.  As a result, insurance companies inadequately price small business insurance coverage to properly reflect the risk.

SOLUTION: Enact a “facilitated model” for health benefit exchanges as outlined in the health care reform legislation. This will increase competition and fix the individual market by removing the restrictions of plan options that must be sold in the state. Today, NY requires all health insurance companies to offer basic HMO and POS products that costs more than $1,000 a month for an individual. Fewer regulations in the pricing and the plans offered to individuals would unleash the creativity and innovation found in products health insurance companies sell to larger businesses.

SOLUTION: Modify the NY “Young Adult Option” law that allows unmarried young adults through age 29 to purchase health insurance through their parent’s plan. This law should be modified to lower the cost of insurance to adequately reflect the health status of an average 29-year-old. Today, the pricing reflect the health status of the current population, which is much older and less healthy, making it unaffordable for many young workers in NY.

The NY Dilemma

Based on a 2010 AHIP study below, NY health insurance pricing is more attractive to the very small businesses that cause rates to sky-rocket. This is an unsustainable state of affairs that only hampers NY’s ability to have a strong and fast economic recovery.

Premiums by State, 2010 (Top 5 Most Expensive States)
       
Small Employers w/ 26-50 employees Avg. Monthly Premium
  State

Single

Family
1. New York

$565

$1,485
2. New Hampshire

$512

$1,345
3. Nebraska

$443

$1,164
4. Illinois

$435

$1,147
5. California

$428

$1,125
Avg. United States

$406

$1,065
   

Small Employers w/ 11-25 employees Avg. Monthly Premium
  State

Single

Family
1. New York

$577

$1,514
2. New Hampshire

$523

$1,374
3. Nebraska

$449

$1,179
4. Massachusetts

$439

$1,153
5. Illinois

$438

$1,151
Avg. United States

$419

$1,100
   

Small Employers w/ 10 or fewer employees Avg. Monthly Premium
  State

Single

Family
1. Nebraska

$579

$1,519
2. Massachusetts

$545

$1,430
3. New Hampshire

$539

$1,415
4. New York

$536

$1,408
5. Florida

$489

$1,283
Avg. United States

$446

$1,172

AHIP Small Group Health Insurance in 2010: A Comprehensive Survey of Premiums, Product Choices, and Benefits, July 2011

Errol Pierre works at a large insurance company focused on business development, sales, and strategy for employee benefits. He is currently pursuing a degree in Health Policy and Management with a specializing in health finance. He can be reached at errol.pierre@nyu.edu


SOTU: What Obama Didn’t Say

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Posted By Errol Pierre

President Obama filled up close to 90 minutes of TV airtime giving his 3rd State of the Union Address last week. With 6,953 words (about 12 pages) to choose from political pundits filled the airwaves all across the country with animated reactions commenting on everything from the details of his plans to his tone, his demeanor, and overall performance. But all too often we forget that with great orators, it is more important to focus on the words that were not said than the ones that were….

Here are the facts:

- “Health” was used only 7 times during his speech (roughly 0.001% which takes up less than 1 line on a page).

- His comments regarding Healthcare made up only 332 words. That represented 4.7% of his speech (about a page and half). A little better but still severely lacking in substance.

How can that be?

- Health expenditures in this country represent more than 16% of our GDP while the average percentage among high income nations is roughly 10%.

- 13.1 million Americans lack a job but more than 50 million Americans in this country lack health insurance. Doesn’t healthcare deserve more attention?

- Since inauguration, he has spent 60% of his time in office getting what he called his #1 domestic policy agenda, healthcare reform, passed through Congress. If you recall, he entered office on January 20, 2010 and healthcare reform was passed on March 23, 2011. So 15 out of his now 25 months were dedicated to the pursuit of universal healthcare.

- Lastly, most of the popular provisions of the law have already been instituted. Millions of young adults in their twenties have been able to get insurance through their parents. And even more promising, no child under 18 can be denied coverage for pre-existing conditions.

So why were there so few words on healthcare? Discussing income inequality yet avoiding healthcare is not having an honest discussion about the problem. America spends more money on healthcare than any country on the planet. What is not widely known are the percentages spent by the government versus the private sector and how that impacts the American pocketbook. This country is actually on par with other high income nations spending 7.4% of their GDP on government health expenditures like Medicare, Medicaid, and Veteran healthcare. For a comparison, countries like France (8.7%) and Germany (8.1%) are at higher levels with government run universal healthcare. However, when it comes to expenditures from the private sector, America spends an additional 8.5% of its GDP representing almost half (52.2%) of total health costs for the entire country. That is 4 times higher than most like nations. In fact those private sector figures put us in 50th place between Rwanda (49th) and Gambia (51st) according to the World Health Organization.

WHY IT MATTERS

Most Americans get health insurance through their employer leaving American businesses on the hook for large portions of the country’s private health expenditures. It’s been the catalyst for corporations moving jobs overseas. It’s why the United States Postal Service is teetering on the edge of insolvency. It’s why America bailed out General Motors and restructured their Union contracts to be the #1 car company in the world again.

Most Americans work for businesses with 200 or more employees. According to the Kaiser Family Foundation, 99% of the time these businesses are offering health insurance to those employees. The foundation goes on to highlight that the cost of these employer health plans have gone up by 113% over the past 10 years with employers paying close to 73% of those costs on behalf of their employee population. As a result they have shielded much of the exorbitant healthcare increases from their employees. This has had grave repercussions to the average American salary. You cannot talk about income inequality and ignore non-salaried benefits like health insurance. These increases have poked huge holes in the bucket of funds that corporations use to payout employee compensation. You also cannot blame health insurance companies for these increases either. Their profit margins barely surpass 4% compared to pharmaceutical companies that enjoy 15% margins. The blame really goes to the actual cost of providing healthcare.

The U.S Social Security Administration has tracked the national average wages in this country since 1951. In 2001 it was $32,921. In 2010 it is $41,673. So despite the increases in health insurance costs, wages have still gone up 27% in the past 10 years. American employees however have seen 131% growth in the amount of money they must contribute to their health plan. It has gone from $1,787 in 2001 to $4,129 in 2010. So Americans have literally went from paying 5% of their salary on health insurance to 10% in 10 years not even accounting for the increase in co-payments, deductibles, and out of pocket costs.

If you truly want to tackle income inequality, look no further than tackling the increases in healthcare spending. Healthcare reform did not go far enough on this issue. It increased access via health exchanges, protected more patients via insurance regulations like profit ceilings and mandated benefits. But it did nothing to tackle costs. Even worse, our healthcare system will continue to shield costs from the consumer by giving subsidies to lower income Americans so that insurance can be more affordable. But these subsidies are paid for by taxes and fees levied on health insurance companies ($60 billion), on Americans with rich “Cadillac” type health plans ($32 billion), on pharmaceutical companies ($27 billion), and on high income earners use of hospitals ($210 billion). The only problem with these types of revenue streams are the laws of economics. Since individual Americans and large businesses will be required by law to purchase insurance by 2014, they as consumers will be more inelastic than their suppliers. In the end most of these taxes and fees will be passed on to the most vulnerable consumers further eating away at their hard earned income.

President Obama concluded his healthcare remarks conceding that he was “willing to look at other ideas to bring down costs, including one that Republicans suggested last year — medical malpractice reform to rein in frivolous lawsuits.” The only problem is here is the sad reality. According to the Kaiser Family Foundation only 11,000 malpractice claims were paid in 2009 amounting to $3.6 billion. That sounds like a big number but it is only 0.2% of total U.S. health costs. So the only question left is how much medical malpractice reform could help to actually close the income inequality gap. Well, the average malpractice suit is only $11.99 per capita, putting $12 bucks back in everyone’s pocket. I guess the good news is this kind of policy change would help fight the common cold giving every American the extra disposable income to buy a bottle of Robitussin from CVS.

Errol Pierre works at a large insurance company focused on business development, sales, and strategy for employee benefits. He is currently pursuing a degree in Health Policy and Management with a specializing in health finance. He can be reached at errol.pierre@nyu.edu

 


Building an Exchange Strategy Part I – Changing Your Vantage Point

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Posted By Errol Pierre

Health benefit exchanges are set to be fully operational by 2014. As part of the Patient Protection and Affordable Care Act (PPACA), these exchanges seek to be a marketplace for consumers to purchase affordable coverage. Subsidies to reduce both the cost of insurance and the out of pocket expenses from copayments and deductibles will be available to eligible consumers as well. Estimates suggest close to 30 million Americans will find coverage through this avenue lowering the uninsured rate to 3%.

These exchanges will revolutionize the way health insurance companies operate. Most Americans receive insurance through their employer. As such, insurance companies have built their world around marketing to them rather than directly to individual consumers. Over the years, insurance company processes, products, and strategies have all conformed to employer choice and preferences. Even the way customer service is organized and how information is shared caters to an employer-centric business model.  However, by 2014 health insurance companies will need to operate differently to capitalize on the million of new health consumers entering the market.

Consumers purchase products much differently than employers. Consumer motivation is largely based on personal preferences and emotions while companies make rational decisions based on economic value.  So business to consumer (B2C) marketing has been much more demanding and onerous than business to business (B2B) marketing. Health insurance companies as a result have gotten away with minimal efforts in advertising using business publications and newspaper ads that reach CEOs, CFOs, benefit consultants, and decision makers. Marketing campaigns targeting decisions makers has been an easier road to handle than attempting to market the average consumer.  In fact most of the insurance policies sold in the United States are through brokers or independent agents hired by a business that receives compensation from the company whose product gets sold. Consequently, the construct of this industry has kept marketing innovation and ingenuity at bay. For years the basic message segmentation for B2B advertisements has been limited to industry and firm size.

Not all insurance companies suffer from this lack of consumer centric segmentation however. The car insurance industry is a perfect example of what the health insurance industry will aspire to be by 2014. Geckos and cave men, made up stores with humorous sales representatives, over the top actors representing natural disasters and unfortunate accidents, and catchy jingles all represent the car insurance industry’s push for market share catering to consumer preferences. Geico, Progressive, Allstate, and State Farm have all used innovative TV, internet, and other media ads recently to differentiate themselves. One main reason is because car insurance is largely purchased at the consumer level. As such, the industry caters solely to the wants, needs, and desires of the personal shopper. They have developed enhanced customer service levels, easy to use online tools, and a wide array of products and services all with a focus on consumer appeal. The consumer is essentially the center of the strategy. After all, it is the consumer who has the power to terminate the policy at any time; not the consumer’s employer.

Health insurance companies have a tough road ahead if they wish to compete at the same level. Moving from an employer-centric model to a consumer-centric model is more than just a mission and a vision. It really is a shift in corporate culture. It starts from the top down as much as it does from the bottom up. The CEO must believe in the change as well as the customer service representative answering the phone. There must be a commitment to innovation, ease of use, positive public perception, and consumer preference. The products offered must allow for customization and flexibility. The policies for grievances, appeals, and complaints must be customer friendly and aimed at pleasing the client. Such attributes have unfortunately been foreign to the health insurance industry and they have less than 2 years to quickly figure it all out.

Errol Pierre works at a large insurance company focused on business development, sales, and strategy for employee benefits. He is currently pursuing a degree in Health Policy and Management with a specializing in health finance. He can be reached at errol.pierre@nyu.edu


Sticky Notes & Pairs: Dial Up Staff Collaboration and Improved Solutions in your Performance Improvement Work!

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Posted by Paloma Medina

Situation: You have an organizational issue that would benefit from the use a team approach. Perhaps you need to update a work flow or improve organizational performance on a specific measure. However, during staff meetings you find that engagement is low, brainstorming lacks innovation, specific people dominate the meeting, and/or inter-departmental tensions impede collaboration.

Solution: Change your meeting structure! The following “Meeting Recipe” will dial up staff energy and lead to better performance improvement solutions!

What you’ll need:

Meeting time of 1 – 2 hours (epending on the depth of the problem or area you’re focusing on)

20 or more sticky notes and one pen per attendee

Dry erase board or flip charts

A volunteer to act as a high-energy facilitator & time keeper

Instructions:

  1. Assign attendees into random or strategic pairs
    Have them sit together in their pairs
    I highly recommend being strategic — think about how pairs might increase collaboration among departments or individuals. You could pair up nurses with providers, administrators with front-line workers, etc.
  2. Pass out sticky notes and pens to each attendee
  3. State the challenge and the goal. Be clear and concise
    For example, “We want to increase provider productivity by 20% in three months” or “We want to improve our patient check-in process to decrease patient and staff stress”
  4. Give individuals 5 minutes to brainstorm on their own ideas for how this could be done
    Rules:
    1. One idea per sticky note
    2. Each attendee must write down  4 – 10 ideas (yes – this is doable!)
    3. At least one idea must be crazy, really fun, or pie-in-the-sky big (I often award candy to craziest ideas — this greatly energizes and revs up divergent thinking)
  5. Have individuals now share ideas in their pairs
    Give them 2-3 minutes per person to share their ideas, call “time” when it’s time to switch and have the other person share
  6. Have pairs generate ideas
    Give them 10 minutes to come up with 10 more ideas with their partners. Ideas can be  completely new or building on each others. Again, one idea per sticky, at least 2 new crazy ideas.
  7. Call everyone back together and round-robin to report back ideas
    Rules:
    1. Have pairs come up and post their sticky notes as they explain their idea onto the dry erase board or flip charts
    2. Hold off on judgement – responses to ideas can only be praise or clarification questions
    3. Limit reporting to 60 seconds per idea – make it a fun but strict cut-off to assure pairs report concisely and energy stays high in the room
    4. If an idea was already presented, just have pairs say “ditto on ___ idea” rather than repeat it
    5. Spread out the area where you’re posting the stickies, the more spread out, the better
    6. Anyone at any point can “build” on an idea that is being presented and write down a new sticky note for it
  8. Everyone vote for their 5 favorite ideas
    Have everyone walk up at once and move around to review the ideas, then “vote” by marking the chosen sticky notes with a star. Give this just 5 minutes for this to assure people move fast and energy doesn’t drop – you’re almost there!
  9. Now re-vote to narrow it down
    Take down all but the top 10  voted-on ideas. Have everyone vote again but this time everyone gets one vote – this will lead you to your top 2-3 ideas to test out.
  10. Decide on next steps
    As a group decide what are the next steps to test out the chosen ideas, include time frames. Have pairs volunteer to take on the tasks. Pairs can them meet outside the meeting to plan how they’ll carry out their tasks. Have everyone report back in a meeting within a week.

After the meeting: Have someone transcribe all the ideas and note which were the highest rated. Refer back to these when you’re ready to try out a new test.

Real-life example:

A New York community health center faced this exact challenge — front-line staff were tasked with improving their productivity numbers but felt frustrated by leadership’s lack of support for their ideas. Months of meetings went by with little improvement in the situation and their numbers remained low.  The front-line workers requested to have a potluck lunch meeting with leadership to re-energize the group and used this “recipe”. They paired up management team members with frontline staff members to break down hierarchy walls. After the meeting both leadership and front line workers reported loving the voting structure and noted the high energy among everyone- a significant change from prior meetings! They now plan on using “pairs” for all of their performance improvement work.

Paloma Medina is an MPA HPAM 2012 candidate with a specialization in organizational coaching and development. Her background is in homeless health care, community development and design. In her spare time Paloma can be found tailoring her clothing, re-organizing her craft supplies or coming up with new toppings for hot dogs.


Must the creation of excellent data visualizations be solely relegated to UI and graphic designers?

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Posted by Paloma Medina

Just when I thought my obsession with data visualizations was over, I come across a new gem.  Up until this point, my fan-dom had been focused on admiring finished products, like Hans Rosling’s Gapminder or GE’s Healthymagination Stats of the Union. However, what next interested me was how to bring this tool to the masses. My question was, “Must the creation of excellent data visualizations be solely relegated to UI and graphic designers?” As it turns out, no, it does not. There is a tool that democratizes the creation of data visualization:

Many Eyes: An experiment based on IBM research.

Many Eyes is an online tool that democratizes data visualization by allowing anyone, regardless of design or coding background, to turn data into visual information that is so much more than bar graphs and pie charts.  In addition, the site includes a browsing function and discussion forum that fosters collaborative learning.

Created in 2007, the site features pre-loaded data sets as well as the ability to upload your own set. Once you’ve selected what data you want to work with, you have more than a dozen options for how to organize your data. This is where it gets interesting. The beauty of the site isn’t just that you can create these amazing visual representations, it’s that you can play around and see how the same data translates depending on which type of visualizing model you choose. This means that non-designers can learn by doing what makes some data visualizations work and others not, depending on the data you’re working with.

The exciting thing about all of this is that tools such as Many Eyes will allow us to move towards a day when data visualization can benefit from crowd sourcing the way other fields have. What if Many Eyes was to health data what Flickr is to photographs?

Explore the site, let me know what you think and what potential you think it could have in your own health work.

Paloma Medina is an MPA HPAM 2012 candidate with a specialization in organizational coaching and development. Her background is in homeless health care, community development and design.


The Power and Shortcomings of Healthcare Interventions

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Posted by Katie Magoon

I was living in rural Kenya the first time I really began to think critically about the power and shortcomings of healthcare interventions.  I stumbled upon this totally accidentally as I was studying the economic empowerment of females in the “informal sector” of Kenya’s rural economy.   Specifically, I was exploring the ways in which women create and distribute their wealth, and the how these decisions impact the communities in which they live.  As I looked more intimately into the lives of these women, I realized that one could not truly understand the role of a female in an economy without understanding a variety of aspects related to her health.

In talking with many women, it became clear that some of their economic concerns were in large part related to the number of children their husbands/communities expected them to have.  Some women secretly obtained birth control in order to shelter their families from the economic hardships that they would face with having more and more children.  In some cases, their husbands would begin to suspect this and abuse them or use it as an excuse to have extra-marital affairs with other women (often bringing home sexually transmitted infections or HIV).  In many settings, women bear the brunt of raising families.  As a result their individual health is extraordinarily important to the health of an individual female’s family as well as community.  Issues such as lack of access to birth control, “back-alley” abortions, the dangers of childbirth, lack of empowerment for sexual decision-making and boundary setting, and even post partum depression can have a tremendous impact on the economic health of a community.  Such issues were so pervasive in the lives of the women with whom I spoke that it quickly became clear that these women could not achieve economic security without accessible and effective healthcare that is responsive to their specific needs.

Many believe that these are problems that do not apply to women in the United States.  I have found this belief to be grossly inaccurate.  In my work as a nurse practitioner, I encounter young women every single day who are forced to have sex, pressured to leave school and have children, and struggle with depression and other mental health problems that can make employment and/or caring for children very difficult.  Often these women put faith in their “boyfriend” who quickly moves on when their belly starts to grow or times get tough.  A young woman may be left to support a family with very limited resources.  Further, she has already stopped school to have and begin to raise the child, leaving her even more vulnerable to economic hardship.  This has obvious implications for her family and community.

Health interventions can address a small portion of this problem by offering family planning to women.  Women that do not want or are not ready to have more children can use birth control.  If need be, they can do this without the knowledge of their partner.  However, a woman is more likely to be successful with the use of her birth control if her partner is supportive.  In my mind, this simultaneously points to a success and shortcoming of the health system.  In this example, birth control is simply addressing a symptom of a larger problem in society—gender inequality.  Birth control could be considered a single disparity-decreasing intervention that can help women, and in turn their communities.  However, in a world that often does not value women as it values men, I cannot help but to ask: Is birth control enough?  Internationally and domestically, when will women finally be empowered to make their own decisions about what happens to their bodies, and offered support for those decisions?

Katie Magoon is a North Canton, Ohio native who currently works as a nurse practitioner at an adolescent community center in Manhattan.  She is an HPAM student, specializing in policy.

 


A Design Oriented Approach to Presentations

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Posted by Paloma Medina

In our last voyage into data visualization and design, I posed that incorporating these tools into the health sector could vastly improve how we share information with providers and front-line staff. In this last entry I want to focus on how these tools can make an impact for health administrators and policy folks.  To be specific, I want to explore the role of a design-oriented approach in presentations and trainings that we create.

To start us off, let’s explore the work of Hans Rosling. A statistician, award-winning global health researcher and all-around genius, Rosling also has an appreciation for good design. Rosling has infused the health field with inspiring presentations that rely on impressive data visualizations to show health data in a brand new way.

His talk, “Let my dataset change your mindset” on Ted.com is one of my favorite examples of the impact created from the marriage of design and data. Rosling’s lectures showcase his award-winning Trendalyzer software, which transforms an intense amount of complicated data with multiple data points into an engaging, beautifully interactive narrative that walks the audience through a new perspective on global longevity — all in under 20 minutes!

It is the ability to turn data into a story that makes Rosling’s Trendalyzer software (available for public use at gapminder.com) effective. The human brain processes information easier and faster when it’s able to see it as part of a story. Both data comprehension and data retention increase dramatically when new information is presented as a narrative. This is why it’s quite difficult for some of us to remember all 8 of these random words:

DONKEY  GIRL  GREEN REINDEER POLISH SHED APPLE PETS
But why almost anyone can remember them when we present them as a story:

The girl will polish the green apple laying by the shed after she pets the donkey and reindeer.

It’s a silly but important example – as administrators, policy makers and analysts, turning our data into a story can make the difference between a snoring and an inspired audience. Effective visual design takes this concept a step forward and transforms that story into an visual narrative — a series of images that communicate data faster than the brain can read text.

Your question now may be: That’s all well and good for people like Rosling, with his fancy software, but how does this relate to the rest of us who don’t have these resources?

I’ll answer that with a personal example:
Four years ago I attended a federal training on new cervical health reporting guidelines for Federally Qualified Health Centers. The presentation was a series of 25 PowerPoint slides overflowing with text and tiny work flow charts outlining confusing and frustrating new guidelines that doubled our reporting work load. We left angry at the government and dragged our feet on complying, in large part because we were not sure how to — even after a three hour training.

A year later, I attended a refresher training on the same topic, this time there were a similar number of slides but all with large images, hardly any text on them, and a worksheet that was well-designed and listed the requirements on the left and an area for audience members to write down their own notes and ideas for how to operationalize each guideline. The series of images told a story, narrated by the presenter, of a woman with many years of untracked pap smear results and how she was able to catch cervical cancer in the early stages thanks to her clinic’s new ability to track and report on her results. It was the story of what our clinic could do if we implemented the new guidelines. The presentation ended with a beautiful infographic of how tracking, reporting and better health outcomes all fit together. We left feeling energized and armed with information we could easily pass on to our staff members.  The interactivity, story, captivating images and infographic punchline all contributed to the success of the training. It mirrored Rosling’s lectures even without fancy software.

I personally would love to see the Trendalyzer in more global health presentations I attend, or the elements that make it a successful tool incorporated into the next training I’m required to go to. Do you have examples of a great presentation that used design to engage a health care audience? I’d love to learn of others – email them to me and I’ll post them in future posts.

Paloma Medina is an MPA HPAM 2012 candidate with a specialization in organizational coaching and development. Her background is in homeless health care, community development and design.


The Curious Case of Kansas

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Posted by Errol Pierre

On April 28, 2009, Kathleen Sebelius joined the Obama Administration as the Secretary of the Department of Health and Human Services (HHS). It was one month and five days after the President signed his landmark healthcare legislation into law. Sebelius’ primary task would be to lead the massive implementation effort of a very complex bill with multiple phased in milestones that run through 2018. Throughout her first two and half years she has been vocal about her commitment to transparency and affordability for the American healthcare consumer. She is no stranger to the underlying issues in our system. In fact her dealings with healthcare started in America’s heartland way before this cabinet appointment. It started in Kansas; the Sunshine state. Ironically, the same state where President Obama’s mother grew up.

There’s No Place like Home

After receiving a Masters in Public Administration from the University of Kansas, Sebelius moved to Kansas and pursued politics. This led her to an eight year stint as the state’s Insurance Commission from 1995 to 2003. It was historic for Kansas. Sebelius was the first woman to ever hold the post. She was later profiled as a public official of the year in 2001 noted for her balance between tough regulations and her promotion of business. In full manifestation of her principles, she publically battled healthcare giant, BlueCross BlueShield of Kansas. She successfully blocked the sale of the company to an even larger out of state insurance conglomerate noting her determination to keep healthcare costs low for Kansans. The move was unprecedented and proved to be very timely. It happened one year before the Kansas gubernatorial election of 2002. Sebelius would win that election handedly with 53% of the vote.
Despite her victory, she was a Democrat governing in a bright red Republican state. Nonetheless she reached across the aisle and signed several bipartisan healthcare reform bills in her first two terms. Her work increased the number of health professionals in underserved areas, expanded health coverage for children, and relaxed Medicaid eligibility rules covering more Kansan families. She also established the Kansas Business Health Policy Committee which found ways to the lower the number of the uninsured and increase the number of businesses that offered health benefits to their employees. The committee’s most important work however was the creation of a program that provided health premium assistance to low and modest waged employees ensuring affordability.

We’re not in Kansas Anymore

The Governor’s work on healthcare quickly caught national attention. She also publically supported Obama’s healthcare legislation prior to her cabinet post noting benefits the bill would have on her state. 13% of Kansas lacked health coverage but she believed those 360,000 Kansans could be covered through Obama’s bill. So it made perfect sense for Obama to have Sebelius continue her work on healthcare but on a much larger stage. Rather than worrying about the coverage of 2.8 million Kansans, as head of HHS, she now worried about 49 of the 308 million Americans that lacked insurance and the 40 or so insurance companies across the country she now had the power to regulate.
Sebelius brought along her expertise. Kansas had the prelude to health exchanges – the staple of the healthcare reform legislation. Health exchanges create a marketplace where individuals and small businesses can shop for coverage similar to the way they purchase airplane tickets from online websites. Subsides are also made available through these exchanges to anyone who cannot afford coverage. Exchanges must be in place by 2014 and will be equipped with navigators and a toll-free support line to assist with enrollment questions. HHS recently launched a 50 state version of such a website on November 21st (www.HealthCare.gov). As a former Governor, Sebelius realized that execution of exchanges would be a huge undertaking for the states though. So to nudge tem along, her office provided grants to states that act early. More than $241 million was awarded to seven states that were called early innovators. Secretary Sebelius’ own home state of Kansas was one such recipient; winning a $31.5 million grant

Ding-Dong Reform is Dead

After Sebelius’ departure from Kansas though, things quickly began to change. Her successor, Mark Parkinson, indicated he would not run in 2010. Sam Brownback, a Kansas household name, won the election convincingly with 63% of the vote. As a Republican Senator for Kansas prior to winning, Brownback was one of the strongest challengers to federal healthcare reform not only voting against the bill but calling for its repeal.  One of his first acts as Governor was a very public and symbolic gesture. He returned the $31.5 million grant Kansas received from Sebelius’ office prior to his election.  It was a politicized move that reiterated his firm belief that healthcare reform placed a heavy financial burden on states just like Kansas. The reasons are surprising.

Mandates Are Costly - Kansas already requires thirty seven different health benefits be added to every health plan sold in the state regardless if the consumer wants it or will use it. Mandates like the coverage for Alzheimer’s disease regardless of a person’s age, or the coverage of child annual check up’s for policy holders without children, increase the cost of healthcare for everyone. Additionally, in 2014 when exchanges are implemented; Kansas will not receive federal funds for any mandated benefits that exceed the federal ones. This could potentially be a budget crisis for Kansas if not managed properly. Brownback would prefer to have consumers build their own health plans allowing the free market to dictate what sells and what does not.

Subsidies Shift Costs to the States – Brownback also fears that exchange subsidies will spur employer ‘dumping’. There are about 70,000 businesses in Kansas but the healthcare reform law only requires that roughly 7,800 of them offer health coverage because they are considered large employer. The remaining smaller employers representing close to half a million Kansas workers will not have to offer coverage even though their employees will face financial penalties if they are uninsured. Since these employees will receive lower prices through exchanges, the incentive for small employers to offer insurance in the state will naturally decline, a worry for the Governor. Kansas already has one of the lowest unemployment rates in the nation at 6.2%. Yet the uninsured rate in the state is more than double that.  Kansans are already working for employers that do not offer insurance and exchanges have the potential to widen that gap.

As a result of these issues, Brownback has yet to introduce a health exchange bill for his state; but he’s not alone. Only 14 states currently have legislation passed. However inaction by a state could prove to be costly. Kansas runs the risk of defaulting to federally facilitated exchange which would essentially give power to Sebelius to create an exchange in his state. Brownback acknowledges this ironic twist of events in a letter sent to Sebelius’ office with signatures from 19 other governors stating that unless he receives complete flexibility in handling healthcare reform, he vows to not to act at all.
Brownback has even questioned whether the healthcare bill infringes on the rights of the people of Kansas. In another letter signed by 27 other governors, Brownback strongly requested President Obama to speed up the ruling from the Supreme Court on the constitutionality of the healthcare reform law. The court is due to make its ruling by next summer, but in the meantime the Governor has has taken matters into his own hands. On May 26, 2011, he signed bill HB 2182 into law. The bill created the Kansas Health Care Freedom Act which sets out to protect the rights of Kansas citizens to either participate (or not participate) in any healthcare system freely. It is clearly a preemptive move attempting to block the portion of the healthcare reform law that would require citizens of his state to purchase health coverage from a private insurance company.  Despite all these actions, Kansas has made some progress with regard to healthcare reform. A sanctioned work group of leaders from government and the private sector discuss the implementation of several provisions of the reform bill monthly.  Their work thus far can be view at http://www.ksinsurance.org/consumers/healthreform/hcr.htm.

Errol Pierre works at a large insurance company focused on business development, sales, and strategy for employee benefits. He is currently pursuing a degree in Health Policy and Management with a specializing in health finance. He can be reached at errol.pierre@nyu.edu


How Healthcare Can Benefit from Good Design

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Posted by Paloma Medina

Good design can create the foundation for health professionals to be on the same page.

In my previous post, I delved into the use of infographics and data visualizations in healthcare, with an emphasis on the patient as the audience. In this segment, we’ll explore how design can help get health professionals on the same page and on the road to productive collaboration.

Good design captures their attention: The first step in having health teams that hold common goals and strategy is to first get everyone on the same page about facts. Information dissemination for front-line workers and providers is a difficult task however because they are largely a mobile work force whose main roles keep them away from personal computer stations. More so than other professions, they are less likely to have the time to read through informational emails and text memos. Enter good design: A well-designed poster in the elevator, for example, trumps an email in two ways:

1. It brings the message to the place where they staff have time to absorb it

2. It captures staff’s attention and holds on to it just long enough to deliver the message

Smart design can thus engage the mind even when the message would otherwise be  less-than-exciting.

Good design rallies and inspires: Well-designed infographics, posters, etc. stimulate more than just one part of our brain. Within seconds, a great design can make us smile, enrage us, make us feel sadness and empathy, or just fill us with wonder and inspiration. By evoking emotions in us, the right visual language has the ability to motivate us towards action — action that could be anything from re-thinking our work flows to something as simple as reading an entire poster about medication side affects. This type of motivation and emotional engagement is what we need to get staff talking and caring about key health care issues.  Once staff are emotionally engaged, the hard work of creating shared visions, goals and game plans is, well, a little less hard.

Examples of good design with health professionals in mind:

The Unknown Killer
Another in a series from GE’s Healthymagination, this time in partnership with the creative agency JESS3.  A poster of this kind is a perfect platform from which to build buy-in around a performance improvement initiative. The design is instantly engaging — it’s use of color is lively and the design is clean. The effect is a poster that makes hospital-acquired infections (HAIs) interesting to read about – quite an accomplishment indeed! An improvement to this poster might be to have icons or imagery that highlight the comparison between HAI deaths and breast and prostate cancer deaths – a powerful fact that could use an equally powerful graphic besides a bar graph.

Fosamax: Just the Facts

An excellent example of how a poster can pack a wallop of information without overwhelming the senses – this “Just the Facts” poster is aimed at updating providers on new information on a medication (in this case, it was for a medication that was in pre-recall stages).

Why this poster works:

- The color palette is calming and simple: Blues and beiges are the only colors used — shading and text size are instead used to bring key items forward and move secondary information to the back

- Icons are used to build empathy: The usual text heavy, small-font list of side-effects in medication ads and pamphlets dehumanizes the effect that these symptoms have on patients’ lives. Providers are more likely to consider the implications of side effects on their individual patients when imagery is used. A great example of the power of images is the simple but emotive “Stomach pain” icon.

What’s Happening on a Night Shift?

Arm nurses and health professionals with information, follow it up with empowering quality improvement infrastructure, and you have a recipe for targeted performance improvement. This night shift infographic uses three-dimensional illustration to “walk” the viewer through the dangers on the night shift.  There are some flaws in the poster design — some numbers are confusing as to what they relate to and the flow chart could be much clearer. That said, this is still a great example of how we can turn data into a story by contextualizing the information into a place or scenario. This results in increased engagement, information comprehension and retention for the viewer.


Relating back to our work: What information-rich message do we have that needs to be conveyed to providers? Would investing in a few poster prototypes result in something that busy staff members would be more likely to feel engaged with? As a side benefit, could a well-designed poster add color and contribute to a better aesthetic in staff areas, rather than the posting of drab memos?

We do not need to hire a designer or firm to create great materials — we can move away from text-only communication to a design approach by simply learning from this field (or collaborating with it) and incorporating the successful elements of good design into in-house created pamphlets, posters, and web pages.

Next Up: In my next post, I’ll share some example of health infographics and data visualizations that target health policy makers and analysts as the key audience.

Paloma Medina is an MPA HPAM 2012 candidate with a specialization in organizational coaching and development. Her background is in homeless health care, community development and design.