Mandatory Steps for Basic Healthcare Reform

W After ten years of driving healthcare reform with healthcare systems, medical device OEMs, and thought leaders, I have an opinion on how we can get it done. I posted this on social media recently:  “There are 2 parts to driving #healthcarereform of reducing cost and improving outcomes: 1) Who gets care and 2) How care is delivered. Both need a radical overhaul.”

Someone replied, “Can you provide more detail around those points? How do you envision rationing who gets care? How would you go about innovating the delivery [for] that care?”

This article is meant to hit the highlights for each of those three questions. To keep it short, I’m not going to include all of the statistics so you will have to research them yourselves.

Who Gets Care

With the discussion of Obamacare and its repeal, the topic of “medically uninsured” is top of mind for many people. Some argue that healthcare is a right and that inequality and disparity of outcomes is unacceptable. Maybe it is, maybe it isn’t. I will leave that to the politicians and social reform.

There is much we can do regardless of where we stand on that topic. There’s a significant amount of healthcare spend and poor outcomes with births, untreated chronic diseases, and end of life.

Babies and their moms

Our babies need to come healthy into the world. Costs can be driven up for their entire life if someone has a poor start in life. Many infant mortalities and complications can be avoided with simple, prenatal care that is unavailable or unused for or by too many people.

The Chronic Diseased

With 45% of Americans having at least one chronic disease, healthcare reform must address this. We have to care for people with chronic diseases before exacerbations. Ultimately, we would like to drive down the rates of diabetes, hypertension, asthma, and others, but we can make a significant improvement in healthcare by offering easier treatment and education plans that are non-hospital, non-clinic based with minimal physician involvement.

Those Dying

We need to start talking about end-of-life sooner. When a loved one is in the hospital, it’s too late. I have seen far too many instances of family members trying to extend the life of their loved one for weeks days or even hours however possible. Not only is it uncomfortable for the person dying, it’s outrageously expensive and ultimately ends in death anyway. We should move to having 100% of advance directives in place prior to hospitalization. We should also talk about death with dignity in a non-hospital environment.

How Care is Delivered

Any industry is going to protect the status quo and tradition. It’s easier because it doesn’t require the players to change. Healthcare is no exception. Its employees are the most educated in the world. They have significant incomes and tremendous power. They accept change when legally mandated or when it could negatively impact revenue or personal income. Healthcare reform demands a change in how care is delivered.

Location

Last week, two major academic institutions announced hospital projects. Total spend for two facilities is expected to be $8 billion! Both were claiming to advance medicine and offer the absolute highest level of care for patients. They used fancy words like artificial intelligence and precision medicine. With healthcare spend in the U.S. at nearly 20% of GDP, projects like this are fiscally irresponsible.

Hospitals should only be used for the highest acuity issues, academia should conduct research but everything else should be treated somewhere else. The smaller and more distributed treatment places are, the better. The centralized hospital model continues to drive unprecedented levels of inconvenience, cost, and societal impact. They increase traffic, have poor or expensive parking, require long patient commutes, have acquired infections and more. It also puts people in the worst healing environment: a hospital room.

Licensure

We have overqualified medical professionals treating patients with simple issues. For many health issues, we don’t need to see an actual doctor. A nurse, nurse practitioner or physician’s assistant is more than sufficient. For other issues, our primary care physician isn’t the best and we should talk to a specialist. We can’t overutilize the high-priced experts, though.

We must use specialists, subspecialists, and super subspecialists only when necessary to return a patient’s health to “normal.”

Method

We can’t continue to require a patient to schedule an appointment at a doctor’s office. It’s overkill. A significant number of appointments don’t require “hands-on” presence of a physician and they can be done via phone call, video conference, email or text. We must kill the office visit unless absolutely necessary.

Convenience

Having open hours when the majority of dual-income families are working is ridiculous. Opening at 9 AM and closing at 4 PM doesn’t work. Non-acute healthcare, especially primary care, needs to be available before normal working hours and after normal working hours. Finally, we can no longer have providers that reject evidence-based medicine and instead rely solely on their own experience. Too many physicians and offices are clogging their schedules with appointments that are medically unnecessary. This includes everything from annual physicals to how often and how early a woman should get a mammogram.

Innovating Care Delivery

We have to innovate our patient care model to achieve healthcare reform. As much as I would like to think that an existing healthcare system can do this, there is little evidence that they can. There are very few systems that even have an innovation center in place and even fewer that focus on the patient care model. Most want to be a tech incubator for new ideas from the surgeons or physicians. While I applaud those efforts, we can have a significantly higher impact by investing equivalent time and resources into care model changes.

This requires a systematic approach with a dedicated team. A hospital or healthcare system must invest in the minimal number of resources required to develop new care models. It is a skill set not possessed, taught or practiced in any healthcare environment yet we must establish and expand this skill set, everywhere.

We can’t expect corporate mega-conglomerates to come up with the best way to care for patients. They are focused on selling technology and solutions at a high-profit margin. They rarely understand the customer, the entire healthcare process or the people delivering it. You must have an immersive, ethnographic process, such as design thinking, coupled with technology development and change management. It must be internal- healthcare systems know their patients and market best.

Create Healthcare Reform

Now, when I say it only takes two things to impact healthcare reform, they are big things. However, I have personally led and experienced organizations that are taking the right steps. There are companies like CVS which are redefining care delivery.

Reform will happen. Time will determine the winners and the losers. It can’t be the patients. Check out my article on Population Health for a deeper dive.

Value Proposition Sells, Not Technology

Here’s My Marketing Plan

I met with the marketing lead of a tech startup recently. He was developing his 2018 marketing plan and wanted my feedback. The company’s business model was B2B with a focus on “industry distributors” as the sales force to the end customer, employers. My first question was, “What is your value proposition?”

He had a great timeline that included the appropriate different campaigns, content, and targeting. He told me the areas he would be focusing on. It was all good stuff but with a limited budget, it would not maximize the results. He was highly underselling the value of their disruptive offering by promoting the wrong elements.

What Problems Does It Fix

The most important of all marketing dimensions is your actual value proposition. What is it that your product or service does better than anyone else? Why would someone want to buy what you have over what they are currently using? If you can answer those, without listing features, you have your value proposition. As innovation guru, Clayton Christianson would ask, “What job does it do?”

This should answer questions such as: Does it make my work easier? My life better? Is it cheaper? Can I expect higher performance levels using it? Particularly with B2B models, you are displacing an incumbent and must show a significant improvement to be worth the extra hassle of dealing with a new vendor.

Technology for technology’s sake is not good.

Although people may be wowed by it, your technology is not the value proposition, it simply enables it. Technology for technology’s sake is not good. It must solve a problem. The more widespread the problem, the higher the potential for success. The better it solves the problem the more people will be willing to spend.

If you can clearly articulate the one to three customer “pain points” solved by your solution, you can get a buyer and you can easily enable your salesforce. The harder it is to articulate a value proposition, the more difficult it will be to sell your product.

The Value Proposition Sells Itself

As you can see, your go-to-market strategy should be a natural extension of your product development. Even if your salespeople can sell ice to an Eskimo, it’s better to give them messaging that makes their job easier and you will sell much more. It can be as simple as a clever rewording of the information you uncovered during the early design thinking stage. You will have an excellent message.

With everything in development, it should be tested. It’s very easy to get early feedback by meeting face-to-face with the sales members and key customers. Do this at least once prior to campaign launch to ensure success.

Lead with what your solution can do, not what makes it do it. 

Passionate People Can’t Wait

“I just want to succeed in life.” Then you better be passionate about something.

There are few things that satisfy more than doing what you think you were built for. Without getting into life purpose and that challenging exercise, I just want to address passion. Those with it achieve far more than those without it.

I have a pretty high standard for those on my teams, especially for leaders. In addition to subject matter expertise, they must have creativity and be hardworking. Above all though, I favor the passionate. If there is alignment to values, they become unstoppable. It starts early in one’s career.

Don’t Be Boring

When I look at a new grad’s resume, I don’t care about the college portion: the school, the GPA, the classes. It’s easy enough to find people who check those boxes. I want to know what else they did in college. Where did they spend their free time? What projects did they work on? What are the interesting activities and why did they do them?

The same goes for an experienced professional’s resume. Positions and descriptions bore me. Show me the cool stuff they did. Was there something they almost got fired doing. What impossible project succeeded? What do they do outside of work? I want to see what really gets them going. The intersection of passion and talent is incredible.

A Burning Within

The passionate can’t help it. It’s a fire inside of them screaming to do something. The passionate have an unfair advantage. They possess an unrivaled internal engine. You don’t have to get the passionate started for what they believe they’re to do. They figure out a way and do it. They don’t wait for education, job training or permission. They do it because they’re curious and courageous. The passionate change their world.

Passion minimizes the negative by focusing on the possibilities. Obstacles get smaller. Problems are simply issues that have to be solved. Failures are lessons learned.

What do people care about? What do they enjoy doing? What would they do if they didn’t get paid to do it? That’s where the passionate become obvious. Everyone has something. If you don’t see it in someone, there is probably something deeper: it could be job misalignment, troubles in another area of life, current work assignment, competency frustration or depression.

You

If you’ve lost your passion, consider your career trajectory. Change it if you need to. I’m serious. If you don’t have a hobby, get one. Find something that makes you passionate and do that thing. Do it really well. Life will be better and you will feel like you are succeeding.

Population Health and What it Really Means

State of the Union

It’s hard to discuss population health or the topic of healthcare in the United States and not hear about how expensive it is. In the United States, we spend about $10,000 per person per year on healthcare. That amount is approaching 20% of our country’s gross domestic product. The Peterson Foundation tells us, that second place for highest per capita healthcare spending is Switzerland, at about $7000. Sweden and Germany spend about $5000. France is at $4500, while the UK, Australia, and Japan spend about $4000.1

Despite the high spend, both media and healthcare reform advocates point to the fact that the United States is behind many industrialized nations in quality of care. The current WHO ranking for the U.S. healthcare system is 37th.2 Many wonder how we spend so much and seem to have the best at everything, yet still have such a low health score. If you are an American, white male who is wealthy and educated, you have access to the best healthcare in the world, period. Change any of those variables, and your access to that “best healthcare“ is diminished. Period.

The factor of wealth alone lead to a thirteen-year difference in age of death.3 Some would say your zip code is the primary indicator of longevity. In greater Philadelphia there is a twenty-year difference in lifespan between the best and worst zip codes. Spend varies wildly too. In America, 20% of our population accounts for 90% of our spend.

There are multiple factors to our ranking but the biggest impact is the discrepancy between the people with the worst health in the U.S. and those with the best. It depends how you define health or what factors you consider lead to a healthy environment whether your country is ranked high or low. In fact, there were 100 indicators in use by WHO in 2015.4 For example, our alcohol usage, sexuality, suicide and obesity negatively impact our numbers compared to other nations although we rarely deal with other issues like tuberculosis or amount of spending on healthcare.

Population Health Panacea

Most medical literature today mentions population health. Healthcare systems are promoting it across the country. Universities are beginning to offer certification and advanced degrees in it. Hospitals and health systems are hiring executives to run it. A countless host of medical vendors are offering solutions that deliver it. What is it?

In 2003, Dr. David Kindig, Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin-Madison, proposed that population health was “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”5 Three terms should jump out: outcomes, group and distribution.

Outcomes

The World Health Organization defines an outcome as a “change in the health of an individual, group of people, or population that is attributable to an intervention or series of interventions.” It is the resulting change in health after a specific effort. WHO includes things like malaria and access to clean water in its world health ratings. We simply don’t worry much about those in the U.S. However, our culture of sexual freedom does care about the incidence of HIV and access to family planning, two other outcomes used by the WHO.

The problem with outcomes is the variation. They could be macro-measurements like national infant mortality rate or expected lifespan; or they could be very targeted measures such as uncontrolled diabetes in rural areas or hypertension of people living in economically depressed regions.

You have to determine what outcomes you are trying to move. They must be defined and measured. They must be tracked. It could be the percent of women over 50 with a biennial, breast cancer screening. It could be the blood pressure for all adults in a county. The combinations of outcomes are infinite. You must decide which are important and which aren’t. Once known, an action plan can be created and deployed. Outcomes should improve over time. This will define whether your interventions are working or not. You can’t use the same outcomes for different groups. Each group must use their own customized outcomes.

Group

There is the “population” part of population health. Kindig calls it a “group of individuals.” What defines a group? Like outcomes, there are an infinite number of ways to define a group. Using the previous example, the group could be all women over 50. It could be the entire state of Ohio. Health systems, however, like to define populations by disease state or condition.

Several tech firms offer software to “identify all individuals” with a high-risk condition that will eventually lead to an exacerbation and hospitalization if left untreated. Popular ones include all patients with a blood pressure greater than 140 over 90 (hypertension) or all patients with a hemoglobin A1c over 7.0 (uncontrolled Type 2 diabetes).

For this reason, many healthcare systems have been forced by insurance companies to hire nursing care coordinators (CCs). These CCs specifically target rising-risk and high-risk patients to lower the cost of future care. Therefore, they define populations as the ones “on these lists.”

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease. There population includes anyone approved for participation in the program.6

Medicaid is a state program (funded jointly by states and the federal government) that provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities.7  There are fifty different populations for Medicaid.

Depending on your interest, the population varies. Often people are overlooked until there is a known problem. There is very little interest in healthy or low-utilization groups of individuals.

Distribution

The term “health inequities” is used when negatively defining distribution. The WHO defines health inequalities as “differences in health status or in the distribution of health determinants between different population groups.” 8 For instance, what are the individual BMIs for a group of people and why do they vary. Is it due to lack of access to healthy food or regular exercise or is it something else?

Some believe the distribution of outcomes should be equitable across the entire population. Zero variance is best. There shouldn’t be spikes, dips and huge variances. Your view on how equitable variation should be likely determines your political alignment and what the government should be doing for poor performers. Regardless, everyone is placed in the healthcare system. It is complex.

Healthcare Players

Healthcare providers, federal and state government, employers, and insurers are the major institutions in healthcare. Supporting these are a host of other entities such as medical device makers, pharmaceuticals, IT firms and more.

Healthcare Systems

According to Becker’s Hospital Review, just over 20% of United States hospitals are run as a for-profit business. That leaves almost 80% that are either not for profit or government funded. Provided they achieve annual profitability to continue operating, their primary focus is providing care.9 Healthcare systems provide the actual care for the patient in outpatient, inpatient or virtual settings. They own the physicians, clinical staff and administrators that run hospitals and clinics. They bill a third party for your services. This is the government or your insurance agency.

Government

The government creates policy that impacts all players in the healthcare arena, including all of the aforementioned entities. It is their responsibility to look after the health of its citizens. Historically, government’s view on health changes based on which party controls it.

The U.S. government pays for about half of all medical expenses today. Medicare and Medicaid make up nearly forty percent of spend and other government programs are an additional twelve percent. (Private insurance is over forty percent and the balance of the total spend is out-of-pocket.) The government became a significant player in the healthcare market when most insurance was running through employers, leaving out the elderly and poor. The Medicare bill that included Medicaid was signed in 1965. This led to the formation of Centers for Medicare and Medicaid Services (CMS).10

Although there are nuances, the federal or state government sets the amount they are willing to pay healthcare providers for services provided to Medicare or Medicaid patients. Some suggest that the healthcare reform CMS is pushing is pop health. Initiatives like Accountable Care Organization (ACOs), Merit-based Incentive Payment System (MIPS) and other APMs (alternative payment methods) are mentioned in these discussions. I would call this hint-of-pop-health-flavored healthcare. It’s the government’s way of controlling costs and telling healthcare what they will and won’t pay for. It’s not population health.

Healthcare providers are stuck in between the patient and those paying for it, trying to figure out outcomes and populations and interventions. Eager, publicly-traded mega-corporations stand on the sideline, ready to fill the performance gap with solutions. The government defines the reimbursed amount clearly. The healthcare systems have to comply. The amount owed by non-CMS patients varies wildly. Primarily, insurance companies negotiate with health systems on behalf of employers’ health plans.

Insurance Companies

There is no altruism among healthcare insurance companies. They simply want profit. They want a greater share of the insurance dollar. Your health only helps their revenue. The more they collect (from you or your employer) and the less they pay out (for your visits and meds) the more money they make. Costs are controlled by increasing premiums and deductibles. Rates are negotiated with employers on an annual basis. They won’t lose money. That is why many are not on the healthcare.gov exchange in many states.

Less than a century ago, there were no health insurance companies. Health insurance started when a Baptist hospital was looking to keep the bills paid. The hospital worked with a group of public school teachers in Texas. For fifty cents per teacher per month, the hospital would pick up any medical expenses for the teachers. This employer-based plan gained popularity during the Great Depression and eventually got a name: Blue Cross.11  When funneled through the employer, the benefit was tax-free. Eventually, if you were employed, your employer would cover a large portion of your health insurance. The unemployed had to find insurance elsewhere.

Employers

For the foreseeable future, employers continue to foot the bulk of the medical insurance spend. Most will send you a statement of benefits showing what you used the prior year. This is useful to decide during “open enrollment” for the following year. Costs are going up the cost of care increases and as the health of our nation decreases. At some point, we must fix the direction of both. This is accomplished by addressing health determinants.

Determinants of Health

You health is determined by five areas. These areas are called the determinants of health. They are biology and genetics, socio-economical, individual behavior, clinical care, and the environment. Each contribute to your overall health. Although 88% of our spend is on clinical care, only 14% of our health is impacted by it. The vast majority of our individual health (79%) is determined by our genetics (30%), socio-economics (28%) and behavior (21%). The remaining 7% is due to our environment.

These determinants impact our health. They create health inequities. They impact the distribution of health across a population. They determine who will get sick, from what, and why. Some we can control. Some we can’t. Some are easy. Some are difficult. Everyday, we make a voluntary or involuntary deposit to our future health. At some point, we will have to pay for a lack of health. 

It is the area of socio-economics that most pop health thought leaders want to target, hoping to improve the lives of those suffering from health inequalities. However, this means a greater invasion into our lives.

Healthcare’s Blurry Lines

Based on a 2015 research study with a client in eastern Massachusetts, a vast majority of patients do not want more interaction with healthcare, they want less. Healthcare is intrusive to their life, not complementary.

They consider health as the ability to do life. There chronic conditions and acute incidents are annoyances in the way of doing life. Their last resort is to enter the healthcare system with all of its cost, complexities, and inconveniences.

Population health advocates want more involvement in the lives of people. They want to push healthcare up the value chain and be even more proactive in people’s lives. They want it to include community meetings, school involvement and rigorous legislation. They want to expand it beyond clinical care. Maybe you agree. Maybe you don’t.

When there is a breakdown in our health, we want it fixed. There are two sides to fixing it: providing healthcare and paying for it. Anyone can find a doctor. Who should pay for it? Does age matter? Race? Level of wealth? There is currently no one responsible for the health of an individual over their entire life. Therefore, population health is a glimpse at a group of people’s health at a specific point in time, either good or bad. It is a snapshot that tells part of the story.

Our determinants impact our need for healthcare and thus our spend. Fairness means we should each pay for our personal predispositions and lifestyle choices along the full continuum of our life. If we are more prone to certain diseases, use tobacco products, eat poorly, fail to exercise or are sexually promiscuous, we should pay more for health. People must be personally responsible for their impact to lifetime healthcare costs.

Conclusion

In my humble opinion, we need a party that is vested in an individual’s full-longitudinal lifespan of health across the entire population. This could be solved with a universal insurer. Our base healthcare would be covered by this insurer and our premium would be accounted for by our top three determinants. Extras such as non-elective procedures would require an additional premium. We would have a full lifetime view and responsibility.

Is population health the future? Some say yes. Others disagree. Truly doing population health would require a massive overhaul that would make the Affordable Care Act seem insignificant. Is it right? Probably. I wrote another article that shares how we can fix health care without waiting for the government. As for me, I’ll keep working on my own health and its contribution to our country’s health.

#StopEatingFries #Exercise #NoTobacco

References:

1 https://www.pgpf.org/chart-archive/0006_health-care-oecd

2 https://www.nytimes.com/2016/02/13/health/disparity-in-life-spans-of-the-rich-and-the-poor-is-growing.html

3 http://thepatientfactor.com/canadian-health-care-information/world-health-organizations-ranking-of-the-worlds-health-systems/

4http://www.who.int/healthinfo/indicators/2015/100CoreHealthIndicators_2015_infographic.pdf?ua=1

5http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.93.3.380

6https://www.medicare.gov/sign-up-change-plans/decide-how-to-get-medicare/whats-medicare/what-is-medicare.html

7 https://www.medicaid.gov/medicaid/index.html

8http://www.who.int/hia/about/glos/en/index1.html

9https://www.cms.gov/About-CMS/Agency-information/History/

10https://www.beckershospitalreview.com/hospital-management-administration/50-things-to-know-about-the-hospital-industry-2017.html

11http://www.npr.org/templates/story/story.php?storyId=114045132

Um, that’s not an MVP

One of the questions I get frequently when I am speaking at conferences or training clients on how to improve their new product/service development process is this, “what about the minimum viable product?” This article is to help managers and executives understand today’s implications and limitations of a minimum viable product. 

Defining MVP

The minimum viable product (MVP) was popularized by Eric Ries’ book The Lean Startup. Eric states that “the goal of the MVP is to test fundamental business processes.” He goes on to say “Any additional work beyond what is needed to start learning is waste.” Technopedia defines MVP as “a development technique in which a new product or website is developed with sufficient features to satisfy early adopters. The final, complete set of features is only designed and developed after considering feedback from the product’s initial users.”

Technopedia defines MVP as “a development technique in which a new product or website is developed with sufficient features to satisfy early adopters. The final, complete set of features is only designed and developed after considering feedback from the product’s initial users.”

Since its introduction, the concept of MVP has been abused by software and hardware designers alike. Unfortunately, most MVPs I see serve the impatient and undisciplined as a way to justify their rushed approach to launch a scaled-down product with plans to add additional features in the future.

In classic Silicon Valley style, proponents push the MVP model just like entrepreneurs push unicorn valuations for software companies that have no sustainable business model: it’s not ready for prime time yet. In the valley, something that hasn’t been updated in a week is “old” and if a month goes by without an update, a product is knocking on death’s door. Heaven forbid you update a product quarterly. Despite “real time” updates, this method is fraught with problems.

No Quality

One of the things I hate the most are poor quality products. To me, it is a sign of poor engineering. Although it could be that the product or service was produced or manufactured poorly, it is most likely a failing product was due to a bad design and insufficient testing during development. The damage due to a poor quality product can be long-lasting. Dodge Dart’s initial quality problems & Sling TV’s poor streaming issues are great recent examples of not delivering a quality product. People tell more people about poor experiences than good ones. One lost customer due to a poor experience can lead to many others never trying it. I’m not the only one that feels this way.

According to EY, a global leader in knowledge management, Australian businesses are losing more than $720 for every negative customer experience. That’s a lot of money to lose and a number MVP practitioners likely don’t share with the CFO when pitching a new product. Your product has to be high quality from the start. You can add new, valuable features in the future to differentiate it from the competition, making sure each product or service release is successful from the start. 

In software, the rush to release a revenue-producing MVP leads to many issues from their poor workflow, missing features or annoying bugs. These software issues are then addressed and updated on a continual basis. This is one of my biggest frustrations in software. The number of updates that companies are pushing to their smartphone apps is unacceptable. I have my app auto update settings turned off because I don’t want my phone to automatically download the latest version. Consumers should know what changes have been made before they update an app.

Because of this, I often have dozens of apps that are always in need of an update. I scan the description of every update before I make my decision to update or leave as is. If it says bug fixes or minor improvements, I am passing on the update. I will usually only update when there is an interesting new feature being introduced. Many times, I have seen apps change their user interface, just to be different. I think this is confusing and causes the end-user to relearn the app, leaving her in frustration. 

Excuse to Appease Sales

I can’t tell you how many software teams I’ve seen say “We’ll add it or fix it in a future release, we’re working on the MVP.” This is simply the sign of a poor development capability and leadership. If the marketing team has identified a pain point the customer has now, it needs to be developed now. If there are known bugs or workflow issues, they need to be fixed before release. MVP is not permission to release a substandard product. 

Although many companies are now pushing for MVPs, an MVP is not an excuse to throw a poor quality product or service into the market faster. 
There can be a great harm done if the next iteration of the product occurs fairly quickly after the original. In B2B applications, the software must be pushed out to the whole enterprise again and an entire workforce needs to be retrained on new features or capabilities.

Companies that sell software as a service (SaaS) rely on subscriptions. Poorly done MVPs may result in cancellation. A customer won’t spring for the next period of subscription or wonders why fixes weren’t included in the first release. 

Hardware is NOT the Same

In hardware, the implications are much more significant. The investment is not simply a software engineer’s salary for writing lines of code but instead huge investments in tooling, manufacturing and service readiness. Going from an initially released MVP to an updated can be extremely expensive. 

MVP was never meant to be developer lingo for “release something to the market as soon as you can.”

An MVP is a prototype to validate your hypotheses. (read this again)

Prior to creating the prototype, you need to understand the major pain points you’re trying to solve. Fixing these is what will create differentiation for your product. The software or hardware development team, its capacity, and their agile-epic-train-sprint-release protocol is not the determining factor for what a successful release needs. 

Development teams need to focus on creating what the product’s owner has defined as what is required to win. The MVP is the first attempt at delivering that solution. After validating with a subset of the customer base, the company can then make the final changes prior to release.

You don’t release an MVP as a formal product. You don’t rush something out the door hoping to fix it later. An MVP is a chance to test a prototype with your future customer base. Period. Use it for such and benefit from the learnings prior to release. Then, you will experience success.

Work – Balance Your Week For a More Meaningful Life

Dear Work Professional

How many hours a week are you willing to work to seem valued by your employer: 60…80…100+?

Unfortunately, for many, long hours at work is worn as a badge of honor. It’s a rite of passage. Long hours demonstrate the highest level of commitment. It is used as a tool to compare employees. It is one of the most treasured of unspoken corporate awards: The Long Hours Award. My career has benefitted from the Long Hours Award and I’ve been a victim of others winning the Long Hours Award. I have had many bosses that mistakenly held “hours work” as the benchmark for performance. I have had many that haven’t.

This is what I have learned.

Long hours equals long hours.

Nothing else. 

Long hours does not mean hard work. Long hours does not mean high value. 

Not Hard Work

There are countless examples from my past about people who were “on the clock” but were effectively useless for many hours of the day. They were there to show they were there; they weren’t working hard; and they took long breaks, long lunches, and long desk chats. They got less done in 60 hours than I did in 40. But when the weekly overtime report came out, they were champions. 

Not High Value Work

Ok, you’re burning the midnight oil. Every night. You’ve built in the expectations to your employer that your job is 1 FTE when it clearly isn’t. You can’t back down now. You agreed to the role. The thing is, when those hours tick by, you become less and less effective at your work. Every hour on the clock become mere minutes of productive effort if any. You aren’t fooling those who work under you, even if your work is still impressing those above you.

Loss of Life Balance

We aren’t built to work the hours we do. Our relationships weren’t either. Unless we’re married to our job and our best friend is someone at the water cooler. Here’s what you lose when you put too many hours in–personal health, family relations, volunteerism and personal breadth.

“But,” you say, “If I stop, I’ll lose.”

Who are you competing against? Where is the finish line?

You’ve already lost. Your company won.

Your Health

Long hours in the office can wreak havoc on your health. The minimal amount of cardio exercise recommended is 2 1/2 hours every week. Include prep and clean up and that number can balloon to double that. And that’s the minimum. Your heart and health can hold for a while. You certainly can pack weight on through your 20s and 30s without really feeling it. At some point, it starts to catch up with you. Your blood pressure is suddenly high. You become diabetic. Your joints are aching all the time. You can’t catch your breath. Maybe it becomes a major medical event. Perhaps your quality of life suffers. 

Maybe you are squeezing in workouts, at the expense of your family.

Work Family or Real Family

Do you think your spouse cares about your career as much as you do? Even if you think they do, how long will they think that before they change their mind? It’ll be sooner than you think. You’ll drift. Unofficially two separate lives until it becomes officially two. Your kids certainly don’t understand it. Eventually, they will become teens, teens you are or aren’t connected with. Those teens will make decisions that impact them as they enter adulthood. But I had to provide for them, for college. Then it’s too late for your to get off of the hamster wheel. You’ll get back what little time you invested.

Volunteer Work

So the school/church/neighborhood needs help. They know they can’t ask you. You’re too busy. Your spouse/child/friend is always embarrassed by the suggestion they ask you to help. You’ve already made your decision. Your career. Your work. You. YOU. All of those teachers, parents, coaches, helpers, and the army of people that helped you grow up, learn and become who you are today…

So you write a check instead. Bravo!

Work Breadth

If narcissism is the trend from long hours, then here is where you lose. You gain tremendous expertise in one, infinitesimally-small slice of the professional world. Your expertise is limited to one industry, one company, one series of roles. If that company folds or downsizes or offshores your role, you may be looking at relocation or unemployment.

You running under the misassumption that all of your time is for your personal consumption.

Choosing to play the game of long hours at work will always catch up to you. Always. You may seem invincible. It may seem like you have everything under control. You may think people don’t know what’s percolating behind the scenes. Spoiler alert: you can’t win. I’m trying to head off your regrets before it’s too late for you.

Win the Award that Matters: Your Legacy

Start with working forty hours, not fifty, not eighty.

  1. Do a great, focused job while you’re working 
  2. Give a little extra time on occasion when needed
  3. Balance the rest of your life and give time for others

It’s worth it.

Never Fail

There is a phrase that is being misinterpreted. “Fail fast and fail often” should never be the mantra of a development team with regards to projects.

Not a project badge of honor

“We want to fail fast, fail often.” I hear clients say all the time. This is no doubt repeating what they have interpreted from popular innovation books, when discussing their product pipeline. 

I disagree completely. 

Every product idea requires development team effort. Teams consume more resources as they go through the development process. Development resources are among the most precious of all corporate resources. They are extremely finite, have a long gestation for their work and create the soul source of future revenue for the company. One bad bet could sink the company. A project failure means you have wasted time. There is certainly no room for failing often. 

Instead, your mantra should be “Never Fail” with the tagline: “…with projects, but fail regularly with options.” Approach every project with the mentality to succeed. However, this assumes that the team will not pursue a singular solution option from the start 

Fail on Options

At every decision point on a project, consider a minimum of three options. In addition to this, the team should never jump ahead more than one critical decision at a time. Teams can’t focus on a singular solution or jump ahead to a defined solution. Doing so increases the likelihood that a product will eventually fail.

It is the options at every decision point that fail fast and fail often. Therefore, the amount of failure should exponentially increase in proportion to the number of people working on the project. Every designer should be studying a myriad of options for all of the solutions they are responsible for at every decision point. 

Let’s take buying a house as an example. One of the first decisions you’re going to make when buying a house is where you want it. Unless somebody gave you some property or you have your mind set on an exact lot, there are a myriad of options for exactly where your next house could be. Multiple factors impact the location: proximity to work, distance to amenities, closeness of relatives and so on. For every home location option, each one of those factors have a better “rating.” Over time, you will narrow down to the city and  neighborhoods that are options. 

The process will proceed when one chooses a location. Every other location “failed,” but the home buying project did not. However, if you blindly chose the house without regards to location and then discover after closing that it was too far from many destinations, the project failed. You are regretfully stuck in a home would rather not be in. 

Shoot for success with EVERY project
Your Project House

Every decision about the project should have multiple options that are studied, feasibility conducted and alternative solutions partially developed. Only one option makes it to the next step of project maturity. The next decision should also have multiple options. 

If a project fails, it usually means that due diligence was not done on a previous decision or that the development team took to long to introduce the product to the market. Never take the approach that you want to project to fail. You certainly don’t want to fail often. Instead, you want to kill a near infinite number of options on your way to project success. 

Healthcare Fix Despite Government-Media Vitriol

Healthcare Targeted

Like our nation at large, I live in a politically divided state. We are equally Republicans and Democrats. This was demonstrated in the ‘16 election and evident by our two Senators being in separate parties. Everyone is hotly debating healthcare. In the lead up to the BRCA vote after the AHCA passed the House, I emailed both of them. Eventually, I received carefully crafted responses, likely sent by a staffer. Neither were focused on the real issues, instead they were filled with the same partisan lines we’ve seen in the news.

The healthcare debate is dividing our nation for no reason.
I thank my senators for their responses but neither had a true grasp on the real problems occurring within healthcare. We should not have acted like either
ACA or BRCA is better for the country. There are pros and cons to each bill. It would behoove lawmakers and citizens alike to investigate the facts before offering a canned assessment of healthcare. However, I believe we can unite and fix healthcare despite the circus in Washington.

I See Something Different

Virtually every week of my life I am helping healthcare organizations transform themselves through the IHI Triple Aim–better outcomes, lower cost and patient satisfaction through innovation practices. I have helped many of these organizations make enormous progress toward this goal, despite regulatory constraints. We could easily improve Triple Aim metrics by a factor of two through the adoption of a fraction of the best practices I have seen. With or without ACA, if we don’t act, insurance premiums will continue to increase. The trend is staggering. Premiums will not begin to match inflation until four things are done:

Healthcare providers must: streamline their operations, maximize licensure usage, apply the most effective technology,  and focus on treating the person, not the disease.

Addressing the Four

Operations

Healthcare operations are among the most clunky of any industry. Streamlining through the use of operational excellence principles is critical. Every person in America could be meaningfully insured and treated without a government mandate or a single payer system; however, we have to lower the cost to deliver care. It’s actually easier than the industry would like you to believe. I have audited thousands of appointments across multiple healthcare systems: many do not require an actual office/hospital visit, a large percentage do not require a physician, and many are not required by evidence based practices. These appointments fill the schedules, restricting access for higher acuity patients.

In addition, there is excessive waste in clinical and administrative processes. These add zero value yet are repeated constantly. I have seen major waste removed time and time again by expert practitioners working with health systems to modernize their operations to these best practices.

Licensure

Staffing in healthcare is not unlimited. It takes half a generation to train many of them. We need to take advantage of every level of licensure. For example, in many states Advanced Practice Clinicians (APCs – Physician Assistants and Nurse Practitioners) can see many of the cases that currently go to a physician. In primary care, there needs to be an about face. High acuity, complex patients are the ones who should be using physician’s time the most. There is a perception that the patient only wants to see their doctor.

In the thousands of patients I have surveyed and interviewed, I have found this to be the case only about one third of the time when the patient is facing an appointment delay. Doctors need to see only the patients and cases that other clinicians cannot handle. APCs, RNs, LPNs and others can all focus more of their daily activity to match what their state allows them to do.

Technology

Next is technology. I’ve seen repeated installations of technology for technology’s sake. Only a handful of healthcare delivery organizations have the capability to determine the needs for a technology from both the clinician and patient viewpoint, research options and make purchase decisions. What I typically see is a radiography department leader being courted by an imaging firm or an EMR vendor singing praises of the latest module to a CIO. You can’t fix a broken process with a shiny new object.

This recipe is simple: fix the process and then add technology to advance the process toward the Triple Aim. Don’t let the medical device companies push what they think is best for clinicians and the patient. They’re not close enough to really know. The best innovations are ones created in the hospital or clinic, not the R&D center of a multinational conglomerate.

Treating The Patient

Finally, we have to treat the person. Unfortunately, many people who need care are not entering the system until it’s too late for an optimal outcome. A variety of social determinants impact a person’s health and their ability to get appropriate care. Areas that desperately need attention are behavioral health and patient education. The break-fix treatment model doesn’t work anymore. We can’t afford it so it’s time to be proactive. There aren’t enough physicians entering the workforce or enough dollars allocated to treat the future issues as we are now. We have to address poor health choices sooner in life.

Take Type 2 Diabetes Mellitus (DM) as an example. Diabetes plagues almost 10% of our population. This condition skews toward impoverished, minority communities. It is the 7th leading cause of death yet understanding and adherence to best practice care by patients remains elusive.2 Untreated, DM leads to vascular damage which then leads to more serious issues like nerve damage, amputations, blindness and eventually death, significantly raising the cost of care for that patient while simultaneously having a profound negative impact on their life. Patients following a proper treatment protocol significantly reduce or eliminate those expensive, life-altering exacerbations. This is true many conditions including congestive heart failure, hypertension or asthma.

Escape the Noise

I attended multiple, so-called healthcare innovation conferences last year. I listened to dozens of speakers. There were zero presentations on reducing cost. Instead, every organization, whether it was a payer, a medical device maker, software provider or provider, was looking to get a bigger chunk of the existing insurance premium dollar from another company for their own organization. This doesn’t save money, it merely shifts it around.

If lawmakers truly cared about health, we would ban smoking, the number one contributor to health issues and costs. Close to smoking is obesity. We have allowed our restaurants and grocery shelves to be full of low-cost, high-sugar and high-fat foods, practically begging for obesity. A myriad of health issues arise later in life due to obesity. These issues are expensive to treat, significantly more than the healthier, lean population.

Focusing on the number of insured won’t fix healthcare nor will it break it. Patients are empowered to cooperate when we focus on getting the proper treatment to them using a method they prefer. Reimbursements must reward outcomes achieved, not actions taken. Healthcare providers that continue to force patients to high-cost facilities (hospitals) by overqualified medical staff (MD/DOs) with a protocol that doesn’t follow the latest evidence based medicine (EBM) can no longer be tolerated. Patient behavior must be guided by insurers, including Medicaid, by pushing EBM practices. Allowing these things to continue is kicking the proverbial can down the road until we hit a healthcare version of the 2008 subprime market collapse.

Leading the Charge

Institutions like Jefferson Health, UPMC and Kaiser Permanente are leading the way in true healthcare reform with thought leadership practices like population health, innovation centers and vertical integration.

We cannot allow partisan politics continue to slow true transformation of our healthcare system for those it impacts most, patients. We don’t need regulations to deliver the right care. I’ve seen it. However, I’ve more frequently seen the opposite.

Worse, the division, angst and spectacle Congress has created and the media has fueled has paralyzed and misled those inside and outside healthcare. Regardless of government direction, hospital administration must take the reigns. We need strong leadership cooperating and developing a real solution; our country’s and citizens’ health depend on it.

Adam Ward is an Innovation Consultant for Simpler, an IBM Company. Initially trained as an engineer, he designed cars for 12 years before switching to improving processes, products and services in healthcare, where he has worked as a consultant for several large healthcare systems, public and private in the 10 years since. His passion is radical performance improvement while delighting the customer–patients and clinicians. He started his personal health transformation in 2009 and has finished multiple Ironman triathlons.

 

Longevity Doesn’t Reward The Innovator

Creative professions that innovate like coding, engineering, and design need career turnover to stay fresh. When I see innovator work anniversaries over ten years I feel sad. Over twenty, and I genuinely feel bad for them. If the number of years is thirty or more, I feel sincerely depressed. Note, I am impressed by their loyalty and perseverance but not their creative drive. Longevity is only good when it stays full with learning and growth.

Years ago, people worked for one business their whole life and then retired, frequently with a good, employer-provided pension. Years ago, people used home phones. Years ago, people read newspapers. Years ago, you had to shop in an actual store to buy hobbist gear. Today, there is precious little left of any of those. Innovator corporate monogamy should go the way of the dodo as well.

Here is the truth: big businesses don’t care about their employees. There is no reward or honor for a lifetime of loyalty to a company. The employees are “curmudgeons” or “stuck-in-the-past” or “old-timers” who “just don’t get it.” Although, I hear some version of “people are our biggest asset” all the time, I rarely see evidence of this. I have actually been asked to manage out people near the end of their career.

If a business doesn’t care about you, why do you stay with them? My hypothesis: because you’ve settled. You’re most creative and innovative years are done. You’ve stopped learning. You saw your world as the size of your department or the size of your business. You stopped trying new things because the business didn’t like it. You stopped being a true innovator.

You matter to a business as long as you’re boosting revenue or cutting costs and are getting along with your boss. There is still some humanity and mistakes are occasionally forgiven, but rarely without career impact. Few are the “Jack Welch blows up lab and eventually ends up as GE’s CEO” stories today. Innovators must experiment and be risky.

As an innovator, I am constantly looking for improvements: little to big, incremental to disruptive. An innovator never settles. They never accept the status quo. They never “get used to it.” An innovator pushes. Rules aren’t there to be followed, they’re there to be challenged as opportunity shows itself. Their internal drive frequently forces them to try stuff that gets them in trouble as they push the boundaries. Innovators never settle.

So, when I see an R&D employee celebrating 16 years (like I did on LinkedIn this week), I have to wonder how effective they still are at innovating. One thing is for certain, it’s not as much as it used to be. To me, that’s not something to celebrate, that’s something to mourn.

Don’t get stuck in the rut. If you’re in an innovator role and you’re approaching or past the ten year mark at your current employer, you may need to move on, or find yourself obsolete.

Margin Creates More In Life

margin
Full speed will drain you.

I have been fortunate to be a highly productive individual. I define productivity as output per unit. I can squeeze the maximum output for a given level input from many areas: time, effort, and money. I have had my hand in multiple things simultaneously as well as a few things. In a society where busyness is not just expected but celebrated, productivity, despite technological advances, has dropped. Sure, we can do more now then we could a few years ago, but what we could do relative to what we have is getting worse and worse. Reflecting on my 30 year work career, I have found that margin is crucial to productivity. 

Margin has several definitions. Margin in business is measured as the difference between revenue and expenses and less frequently referred to as profit or net income. Margin is also the amount of white space around the text on the page. The dictionary calls margin a border. In this article, I define margin as the difference between capacity and usage. 

Time and money are the two most abused areas regarding margin. People rarely have extra in either. When margins disappear, problems arise. The slimmer the margin, the less variation is acceptable. Any hiccups get magnified when margins disappear. 

trafficTake traffic as an example. As road capacity is reached, almost anything can drastically slow traffic: roadkill on the side of the road, a car tapping the brakes, bad weather, or an emergency vehicle on the side of the road. Worst case is an accident in the middle the road. Traffic can be stopped for hours! However, as space increases between vehicles, hiccups cause no problems at all. That’s is the power of margin. 

That’s the same in life. The less margin, the more potential for a massive slow down or a complete stop. I am a big advocate for thinking time. You can call it solitude, meditation or whatever; but it’s time where you can process information mentally. What I’ve discovered in the past two years is unprecedented. 

Unlike my high energy, overbooked past, I took a radical turn to huge margin. It has given me a freedom unlike anything I’ve experienced. The two areas were money and time. I took major steps in each to cut the spend/activity in half. 

It was tough at first, of course. It felt highly restrictive and like I was doing anything. However, like the highway at rush hour, my mind–as creative as it is–was being held captive. I didn’t even realize it. Cutting back paid dividends. The added capacity supercharged my life. 

It allowed me to invest time and money not just in the now, but more critically for the future. My innovation productivity took a major leap upward. I thought at a higher and more strategic level than ever before. 

It’s not popular and people think it’s counter-intuitive but margin can help you before more productive than you’ve ever been. We don’t need to continue to advance to get less and less productive. We need to advance and be more productive. We should be able to get the most out of life, not have life take the most out of us. 

Margin. Make some.