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Saturday, April 14, 2012


So, yesterday, I happened across a news item pertaining to PPACA expenditures to date, as tabulated by the Kaiser Foundation's very nice "ACA Federal Funds Tracker" interactive website (e.g., do a mouse-over within the state by state map; pretty handy). You can also "export data" to an Excel sheet, which I did.

Below is my excerpted and annotated snip of one of the gems therein. I added in a column of census population data and one for percentages (click the image to enlarge).

What happens in DC stays in DC, per capita, anyway. I was originally just interested in the funding to date for Nevada (and, tangentially, our other two service areas, Utah and New Mexico).

So, PPACA per capita funding in DC is ~eleven times that of Nevada? Good work, Harry (but, then, we could be Florida). And, the DC proportion going to the "private sector"? 82.2%

Two words come to mind: Beltway Banditos.

That'll buy a lot of bowties.

This kind of stuff is red meat for right-wingers.

According to the Kaiser data, ~$12.06 billion has been disbursed to date spanning a breadth of initiatives authorized within PPACA (PDF table of the legislative sections here). Cynics would say they're shoveling money out the door pronto to get the funds obligated in advance of the SCOTUS ruling on the constitutional fate of PPACA in June. We've heard a similar thing with respect to "obligating" ARRA / HITECH funds because budget-cutting concerns more generally.

BTW, my cleaned-up and census-addended copy of the data export can be downloaded here (.xlsx).

$12.06 billion? Yeah, a lot of money.

But, it's also a month or so in Iraq and Afghanistan, where we spent ~$138.4 billion in 2011.


I went to a HIMSS "health care quality improvement" presentation this week after work. This was, well...

The topic was some stuff about the arguably useful nexus between "Management Engineering" (I guess "Ops Management" has become passe in the lexicon) and "IT" for heath care improvement. The presenter became a bit agitated and mildly irritated when I voiced a concern about "Six Sigma," after he'd extolled the standard schtick about "reducing defects to less than 3.4 per million" (you know, the whole 'area in the tails outside ± 6 standard deviations' thing).

Gotta love those smooth Guassian curves. But, beyond the Chebyshev caution, I am reminded of some of "Abelson's Laws"

I let it pass that I was sitting there observing a production sample error rate of ~2.4% (i.e., in terms of words, 1/42). Dunno, I'm just a bit Old School, I guess.

Again, from Toussaint and Gerard's "On The Mend"
"Lean transformation is all about Dr. Deming’s Plan Do Study Act (PDSA), otherwise known as the scientific method. There is no simple formula to copy and no quick path to success. Instead you must perform your own experiments— tailored to the mission and circumstances of your organization. And then you must honestly study the results and act on your findings, including sharing them with the healthcare community."

The late W. Edwards Deming, in his own words:
"[T]he aim of leadership should be to improve the performance of man and machine, to improve quality, to increase output, and simultaneously to bring pride of workmanship to people. Put in a negative way, the aim of leadership is not merely to find and record failures of men, but to remove the causes of failure: to help people to do a better job with less effort." Out of the Crisis, page 248.


It's a "Six Sigma" thing (above with my PDSA overlay).
  • Design
  • Measure
  • Analyze
  • Improve
  • Control
OK. Whatever works, in terms of being "scientific" about things.

So, related to this subject, as is my erratic episodic wont, I stepped in it the other day during a staff meeting, during which I voiced my skepticism regarding Six Sigma. Whereupon our HIE manager announced to the group that she was going to Six Sigma training next week. She took vocal issue with my opinion. There was discomort around the conference table. We Made Fairly Nice, neither really backing down, and dropped it, but, oops.

She's not my Sup, but, nonetheless, we're ostensibly One Big Happy Agile Entrepreneurial Family now. My Oak Ridge Octagon-bred epistemological irascibility doesn't help matters. Uhhh...

Some candid cautionary language from a Six Sigma proponent site:
As with everything there are some arguably negative sides to Six Sigma.

Critics say Six Sigma is really nothing new – it has existed long before the term was ever coined. The other controversial aspect is the over-hyped and over-priced consultants. Some argue that Six Sigma does not result in any new breakthroughs in the manufacturing process and thus it can only somewhat improve an existing process but not add anything new or revolutionary to it that could potentially have much higher impacts on the company’s bottom line.

Six Sigma is mainly applied to larger organizations. Preferably ones with more than five hundred employees. Smaller ones will not achieve any significant results from implementation of the methodology and could actually end up losing money on the initiative. This is due to the serious infrastructural requirements and since the improvement will result in relatively small effects. While a big corporation can save very huge amounts of profits. Take for example GE whose announcements in 1998 of $350 millions saved made a huge wave for implementing Six Sigma.
Laudable for the frankness. It speaks to my concern.

But, WAIT! There's MORE!

Yet another new "methodology" is launched (above, again, with my PDSA overlay). "The Lean Startup

Registered Trademark (Service Mark, actually), no less (do I owe him a royalty for citing the phrase here?).

This Bay Area 2.0.1 Wunderkind freely admits to having simply read up on and appropriated some Taylor, and Deming et al (PDSA, TQM -- but, he omitted Shewhart) and Toyota Production System (Lean) ideas and triangulated them with his own software entrepreneur experiences to come up with this new "methodology."
The first step in a lean transformation is learning to tell the difference between value-added activities and waste. That foundational idea, so clearly articulated in books like Lean Thinking, is what originally led me to start using the term lean startup. I admit that I haven't always done such a good job emphasizing this connection; after all, there's an awful lot to the lean startup theory, and I'm always struggling with how best to explain it fully.
 Yeah. I get it. From his USPTO application:
Business consulting services, namely, advising about and designing, developing and implementing business fundamentals, strategies, and solutions, and identifying and creating business models, for new and existing companies; Providing a website featuring information about business fundamentals, strategies, solutions, and models.
Educational services, namely, providing lectures, classes, seminars, workshops, webinars, and webcasts in the field of business fundamentals, strategies, solutions, and models for new and existing companies; Providing a blog featuring information, discussion, and forums about business fundamentals, strategies, solutions, and models.
From some "3's" amid his reviews:
He's built a whole brand around the name--including a video series, a conference, and now this book--and attracted press coverage that's described it as a "radical new theory" (Wired).

Mr. Ries must mention at least a dozen times throughout the book (and sometimes several times a chapter) something along the lines of "My experiences are now part of the entrepreneurship curriculum at several business schools, including Harvard Business School, where I serve as an entrepreneur in residence. I've also told these stories at countless workshops, lectures and conferences." It's one thing to tell stories in a book to demonstrate principles and tactics, it's another to constantly remind the reader about the great stories and advice he/she is getting by reading the book.
I tend to sample the effusive bandwagon-ish 5's and the 4's (given a sufficient volume of comments), and read all of the 3's, 2's, and 1's when considering new stuff to put in the Cognitive Crack Pipe that is my Kindle.

In his own words, from the Amazon "Look Inside" preview.

Well, that pretty much covers the territory.

Dubiety and snark aside, he indeed is a very astute young man (an"award winning careerist" to boot). If you have 1:11:45 to spend, check out his Lean Startup talk at the London School of Economics. I certainly found it worth my time.


I have read and cited a lot of Joe Flower's work on this blog. I call him "Sensei." I can't wait to get my hands on this book. apropos of "Lean" -
Cut waste. It is obvious that hospitals and health systems need to “go lean,” finding much more cost-effective ways to do every process. But in the Next Health Care, it is even more important to stop doing unnecessary procedures. Under a fee-for-service system, waste is not waste, it’s revenue. Put an implanted defibrillator in someone who does not need it, and you get paid. Under a risk-based contract like an AQC, waste is waste. Do something expensive, unnecessary and risky for the patient, and it costs your bottom line.

Move fiercely upstream. When you assume financial risk for the health of a population, everything headed your way is not a revenue stream, it’s a cost. There is no doubt that everything coming your way will be easier and cheaper to deal with if you can get to it sooner. You must become your customer’s friend, using real people (not just robo-nags and websites) and working through naturally trusted pathways in customers’ schools, workplaces, churches, bars, police athletic leagues and local hangouts. At the same time, you will need to become world class in tracking, characterizing and understanding your customers and potential customers. This is miles beyond marketing research. It’s population health management on steroids. The skill set is in its infancy, but it includes tracking on individual and aggregate levels; mining and understanding the now very deep literature on prevention, incentivized wellness and healthy communities; geographic information systems to “geocode” the data onto neighborhoods, workplaces, churches and other community connections; predictive modeling to suggest what interventions will have the best effect; and tracking the return on investment of particular interventions. The skill set will have to include the ability to create targeted, flexible responses, to “mass customize” interventions and resources to individuals and to micro-populations (such as the residents of a particular convalescent home, or employees on a particular site, or all of your customers who have a particular condition). All of this is new, and there will be an extraordinary premium on getting it right.

More to come...


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