Professor Porter tackles health care finance

Michael E. Porter is one of 15 current University Professors at Harvard and one of America’s foremost business theorists. This Boston Globe article reports on Professor Porter’s latest research project — America’s dysfunctional health care finance system.

In a long essay in the June edition of Harvard Business Review, the 57-year-old Porter argues for redefining healthcare competition on the level of specific diseases and treatments, rather than on the level of health plans, networks, or hospital groups. ”The wrong kinds of competition have made a mess of the American healthcare system,” contend Porter and his coauthor, Elizabeth Olmsted Teisberg of the University of Virginia. ”The right kind of competition can straighten it out.”

The article notes that the health care finance problem is the type of particularly knarly issue that Professor Porter enjoys taking on:

What attracted Porter to the healthcare sector, in fact, was its standing as a competitive industry that seemed to defy the laws of competition. In properly functioning businesses, from personal computers to mobile phones, product and process improvements drive down prices and costs, quality rises, markets expand, and uncompetitive players go out of business. In healthcare, costs are forever climbing, services are restricted or rationed, many patients receive poor care, preventable medical errors persist, and there are wide discrepancies in costs and quality among providers and across geographic areas.

Professor Porter and his collegue, Elizabeth Olmsted Teisberg of the University of Virginia, note that the antidote to what ails the health care finance industry is simple:

Porter and Teisberg have a deceptively simple diagnosis: Healthcare competition today works on the wrong level. The players — health plans, payers, providers, and doctors — engage in what the authors call ”zero-sum competition,” dividing value rather than creating it. They seek to transfer costs onto one another, limit access to care, hoard information, and stifle innovation, all to the detriment of patients.

The right kind of competition should occur at the level of preventing, identifying, and treating patients’ conditions and diseases, Porter and Teisberg assert. They call for collecting and disseminating information about the outcome of medical procedures, so patients can make intelligent choices about physicians and hospitals. They also recommend transparency in billing and pricing to reduce cost shifting, discrimination, and other inefficiencies. And they propose increased specialization by healthcare providers, resulting in more centers of excellence in conditions and treatments that compete for patients.

”There’s only one kind of competition that’s directly connected to healthcare value,” Porter maintained in an interview. ”And that’s the competition about who can do the best job of your prostate surgery, with the least complications and the best recovery records. That’s where the competition needs to be. Yet that kind of competition has been all but eliminated in the system, in a misguided effort to save costs.”

Although the Porter-Teisberg model reduces the government’s role in the health care finance system, the government would nevertheless have an important policing role:

Government would have a role, not as a ”single payer” or an insurer of last resort, but by blocking network restrictions, hospital consolidation, and multiple hospitalization bills, and helping to set a framework for reform through its Medicare program. The role of health plans, meanwhile, would be more akin to that of coaches and advisers, helping their members navigate the system and find the best care.

And what does Professor Porter think about the current level of debate over health care finance reform in the Presidential campaign?:

”The debate now is totally about cost shifting and not value creation” in healthcare. Could his proposal influence that debate?
”I hope so,” Porter said. ”I would love to challenge both candidates to see what they’re going to do to engage these issues.”

The type of innovative approach that the Porter-Treisberg model advocates –along with such concepts as the Health Savings Accounts described in this earlier post — is what is necessary to overhaul the increasingly obsolescent American health care finance system. Inasmuch as that system already accounts for almost 20% of federal expenditures and those expenditures are increasing rapidly, my sense is that we all would be better advised to require our Presidential candidates to address these tough issues rather than the relatively unimportant but trendier business issues such as “outsourcing” and “energy independence.”
Hat tip to Tom Mayo’s HealthLawBlog for the link to the article on the Porter-Teisberg study.

William Buckley interviewed about Ronald Reagan

In this interview, William Buckley reminisces about his old friend, Ronald Reagan. The entire interview is well worth reading, and includes the following anecdotes:

Q: How was it when there was disagreement?
A: It was sometimes vigorous, but never sundering. For instance, he was opposed to ratifying the Panama Canal treaty, and we debated the subject for two hours on television, each of us with illustrious assistants. We punched each other pretty hard. A couple of months later I was scheduled for dinner at his home in Bel Air. He got me on the telephone: “Drive slowly up the drive, real slow.” I did — and came upon, every 20 yards, huge hand-drawn signs: “WE BUILT IT.” “WE PAID FOR IT.” “IT’S OURS!”
Q: Did he offer you a job when he became president?
A: Yes/No. I had written him during the campaign that I didn’t want a job. He answered back that he was disappointed: “I’ve had it in mind to appoint you ambassador to Afghanistan.” Big joke, the Soviet Union having just taken over there. But in correspondence thereafter he always referred to me as “Mr. Ambassador,” and the week before leaving the White House he wrote to commend me on the Soviet withdrawal — “and you did it,” he wrote, “without leaving Kabul for a minute.” Good-humored fantasies played long with Ronald Reagan.

Reaganomics in context

In this Tech Central Station op-ed, Arnold Kling places Ronald Reagan’s economic policies into the context of his presidency, and corrects several misconceptions regarding those policies. First, Mr. Kling puts the economic problems that confronted Reagen into the context from which they arose:

Richard Nixon, like Ronald Reagan, inherited an economy that needed a dose of tight money in order to bring inflation under control. However, Nixon took office at a time when liberal economists had been arguing for more than a decade that inflation could be contained without a recession by using “incomes policies,” a euphemism for government interference in wage and price setting. In the fall of 1971, over the objections of his conservative economic advisers, Nixon decided to give “incomes policies” a try. The result, over the next several years, was that the cure was worse than the disease: “incomes policies” made inflation and unemployment higher, not lower.
In addition, as part of his 1972 re-election campaign, President Nixon undertook a large expansion of Social Security. Along with wage-price controls, this enlargement of the welfare state makes Nixon’s economic policies worse than those of any subsequent President, . . .

Mr. Kling then points out the vagaries of attributing relative economic progress to a particular President when that success is primarily attibutable to policies that his predecessor implemented:

When Ronald Reagan defeated Carter’s re-election bid, “incomes policies” were a proven failure. . . . [B]y 1980 it took a lot less courage to stand by a monetary approach to disinflation than it did a decade earlier. I believe that Carter would also have stuck with Volcker through the recession, and if that is the case, then the behavior of the economy in the 1980s would have been about the same regardless of who had been President. Of course, I generally believe that the business cycle follows its own course, and that giving credit or blame to a President is an attribution error. Thus, Presidents who enjoy strong economic performance, like Clinton, are over-rated . . . , while Carter, who suffered from the policy errors of previous Administrations and had began to undo those errors, is under-rated on economics. (I have plenty of issues with Carter on foreign policy, but that is another subject.)
I believe that President Reagan made a positive difference for the economy. However, unlike most analysts, I do not focus on his tax cuts. Instead, I think that Reagan’s main contributions were on energy policy, tax reform, and resisting government expansion.

Mr. Kling concludes with an ominous observation regarding the Bush Administration’s economic policies:

Finally, the government’s size ultimately will depend not on the tax rates that we set today but on the role that we choose for government long term in education, health care, and retirement security. If we continue to give government a large role in these fast-growing sectors, then spending and taxes as a share of GDP will inevitably increase. I call this “The Great Race,” and so far under President Bush it is a race that we are losing.

Stros edge M’s

The Rocket won his ninth game without a loss this season as the Stros made a Morgan Ensberg sac fly in the seventh hold up for a 1-0 win over the Mariners.
As usual, Clemens was brilliant and battled like a classic gamer. He did not have his best control as he walked five in six and two thirds innings, but he gave up only three hits and struck out seven. For the second straight night, the Stros languid hitters made another pedestrian Seattle pitcher — this time Joel Pineiro — look like a stopper as they scratched out only three hits. Astros manager Jimy Williams contributed to that offensive inefficiency by playing ineffectual Jose Vizcaino for the third straight game.
By the way, Lidge and Dotel made things interesting in the last two innings before nailing this one down. In the eighth, Lidge gave up a lead off triple when Bidg misplayed a fly ball (he was not given an error, but he really botched the play). Lidge proceeded to bail his teammate out by getting the next three batters on a pop up and two whiffs. Then, in the ninth, Dotel appeared to be dominant and got two quick outs before giving up back to back singles to put runners at first and second. Certainly fearing the prospect of having to face Clemens in the clubhouse after blowing another save, Dotel struck out the next batter to secure the victory.
Underachieving Wade Miller pitches for the Stros in the Wednesday night game against Mariner and former Astro farm hand, Freddy Garcia. The Stros get an off day on Thursday as they move on to Milwaukee for a weekend series with the Brew Crew on the last leg of this marathon two week, 12 game roadie.

Telegraph Reagan obituary

The London Telegraph’s thorough obituary on Ronald Reagan is here.
Also, Lou Cannon, Mr. Reagan’s biographer, wrote this measured Washington Post obituary.

Milton Friedman interview

This Fox News interview with Milton Friedman provides the usual dose of Professor Friedman’s provocative thoughts about economic freedom and the costs of governmental interference in markets, but also provides the following common sense analysis on why shifting health care and education finance from markets to the government is intrinsically inefficient:

There are four ways in which you can spend money. You can spend your own money on yourself. When you do that, why then you really watch out what you’re doing, and you try to get the most for your money.
Then you can spend your own money on somebody else. For example, I buy a birthday present for someone. Well, then I’m not so careful about the content of the present, but I’m very careful about the cost.
Then, I can spend somebody else’s money on myself. And if I spend somebody else’s money on myself, then I’m sure going to have a good lunch!
Finally, I can spend somebody else’s money on somebody else. And if I spend somebody else’s money on somebody else, I’m not concerned about how much it is, and I’m not concerned about what I get. And that’s government. And that’s close to 40% of our national income.

By the way, Professor Friedman is 92 years old and still as sharp as a tack! Hat tip to Arnold Kling for the link to this interesting interview.

Ronald Reagan’s economic legacy

Jane Galt over at Asymmetrical Information has an intriguing post regarding Ronald Reagan’s economic legacy. First, Ms. Galt dispels the myth that Reagan’s policies were solely responsible for improving America’s economic malaise of the late 1970’s:

I think it was Grover Norquist, saying that Reagan was great because when he took office, unemployment was 10% and interest rates were sky-high, and when he left office everything was boom-a-riffic.
This is every bit as fine a bit of data mining as Democrats who make similar claims for Clinton — the economy sucked when he took office, and was booming when he left. When Clinton took office, the economy was already recovering from a recession; when he left, it was sliding into another one. That’s luck, not talent. (Rubinomics buffs, peace out. I’ll deal with you later.)
Similarly, high unemployment and interest rates under Reagan were not because Democrats Had Been Driving the Economy Into the Ground Until the Grownups Took Over. High inflation was the result of a dozen years of bad fiscal and monetary policy under two Republicans — Nixon and Ford — and two Democrats — Johnson and Carter — that was brought under control only when Paul Volcker, the Carter-appointed head of the Federal Reserve, jammed interest rates up to national-heart-attack levels and left them there until inflationary expectations were well and truly tamed. Reagan had nothing to do with unemployment and interest rates falling; that was the inevitable result of a drastic monetary tightening finally working its way through the economy.

Ms. Galt also debunks the supply-side economics myth that budget deficits have no effect on interest rates:

While we’re here, can we put to bed the oft-quoted supply side factoid that you can tell budget deficits have no effect on interest rates because interest rates fell under Reagan, even though the budget deficit expanded? Interest rates fell because once inflationary expectations were overcome, the natural interest rate for the US was well below the 20% it reached at the start of Reagan’s presidency. But they might have fallen even farther without the budget deficits.
Then again, they might not. As far as I can tell, there’s no evidence that budget deficits have a significant effect on interest rates. One can theorize that it should, and indeed the theories make a great deal of sense. It’s just that you can’t find any actual good data to support them in the Real World. This is one of the major sources of my skepticism about Rubinomics.

Ms. Galt goes on to opine that the single greatest economic achievement of Reagan’s presidency was tax reform, and not so much marginal rate reduction as the simplification of the tax code that was enacted in the Tax Reform Act of 1986. Then, Ms. Galt views Reagan’s overall legacy:

Oh, it was not a perfect legacy. It wasn’t as sweeping as some people, like, say, me, would have liked; there were a lot of silly deductions left in, like the home mortgage interest deduction. And the Clinton administration and their accomplices in congress did their best to undo his good work, by introducing thousands of new loopholes. Though, recognizing that loopholes are damaging to the economy and the cohesion of civil society, they did at least try to mitigate the damage: they stopped calling them “loopholes” and instead referred to them as “targeted tax cuts”.
By forcing a showdown with the air traffic controllers union, Reagan helped forestall the sorts of public employee quiet riots common in Europe whenever the government suggests that maybe eight weeks vacation and retirement at 55 are quite generous enough already.
He advanced the deregulation begun under Carter, which wasn’t always good for the regulated companies, but was great for those of us who remember the rotary telephones and extortionate long distance rates of Ma Bell.
He helped bring down the Soviet Union. Oh, I agree with liberals that he didn’t do it singlehandedly, but hey, Communism and Soviet imperialism really sucked, so isn’t advancing its demise by fifteen years a pretty damn worthy accomplishment? Plus he had the guts to tell Gorbachev to tear down the Berlin wall, which was more than any of his predecessors had done.
And he pulled us out of the doldrums of the 1970’s. He got the country to stop taking Europe’s word for it that we were a bunch of rubes and know-nothings, fit for nothing except Continental security guard.
Plus, he made a bunch of movies. All in all, I think it likely that he’ll be remembered alongside Roosevelt as one of the two greatest president’s in the twentieth century. And they’ll be remembered that way not because of the events they presided over, but because they recognized an evil empire when they saw it, and they led the country into battle against it.
We should all be able to claim so much.

Amen!

Ronald Reagan’s leadership

Franklin L. Lavin is the U.S. ambassador to Singapore and previously served on President Reagan’s White House and National Security Council staff. In this Wall Street Journal ($) Manager’s Journal column, Ambassador Lavin provides an interesting insight about President Reagan’s leadership skills and tells an even better story about Reagan. First, Mr. Lavin outlines the basis of Reagan’s leadership skills:

Don’t be afraid of friction. Friction, or even unpopularity, can be the price for trying to change the status quo. If elected leaders view their job as simply finding the center of gravity on every issue, they might retain their popularity — but all they will have done is encapsulate public opinion, not lead it. On the other hand, if political leaders want to shape a new consensus, they have to risk alienating those who support the current status quo. Reagan knew that his job was not to make everybody like him, but to help move America in the right direction.
Focus on a few key goals. For Reagan, his goals were to confront Soviet expansionism, reduce the tax burden and place limits on the size of government. He proved to be highly successful on the first two goals, and only abstractly successful on the latter. The federal government expanded substantially during Reagan’s presidency, even if we allow for military growth. But let’s not confuse an inability to implement goals with the desirability of the goals. Reagan did change the debate about the nature of government and the open-ended expansion of the welfare state.
Don’t confuse expertise with leadership. As a political leader, Reagan was masterful. He combined a clear sense of purpose with natural stagecraft and the charming occasional idiosyncrasy. He also understood that as president, you didn’t need to be an expert, you could hire experts, and he did.
Be upbeat. People want to believe in their leadership, believe in their country, and believe in themselves. A president has to paint a picture of a better country and come up with the program to help get us there. There is an old saying in politics. “People don’t care what you know until they know that you care.”

And then Ambassador Lavin passes along a story that provides a glimpse of Reagan’s humanity that helped make him a great leader:

Reagan was in Alabama once and visited a special school for handicapped kids. He offered a few minutes of remarks and took questions from the kids. It was a terrific — dare I say Reaganesque — moment, because simply by spending time with these kids he was endowing their experience with a bit more worth.
Then came a moment of terror. One of the kids had a severe speech impediment. He asked his question, and no one in the room could understand it. The president asked him if he could repeat it and again no one could understand what was said. The staff froze. The teachers froze. What was to have been an upbeat day was turning into a disaster. Instead of allowing these wonderful kids to forget about their handicap, this kid was going to be reminded of it.
Reagan to the rescue:
“I’m sorry,” he said with a smile, “but you know I’ve got this hearing aid in my ear. Every once in a while the darn thing just conks out on me. And it’s just gone dead. Sorry to put you through this again, but I’m going to ask one of my staff people to go over to you so you can tell him directly what your question is. Then he can pass the question back to me.”
Rather than make the kid feel small, Reagan brought his own handicap to the forefront.

Market reacts to Landry’s management shakeup

Shares of Houston-based Landry’s Restaurants fell about 7% during Monday trading after the company announced on this past Friday that Chief Financial Officer Paul S. West had resigned “to pursue other interests.” Shares of Landry’s stock closed Monday at $27.66 per share, down $2.04.
Mr. West’s departure follows by a month Landry’s dismissal of Ernst & Young LLP as its outside auditors, for undisclosed reasons. Landry’s named Grant Thornton LLP to succeed Ernst & Young.
The Houston Chronicle story on Mr. West’s resignation is here. Incredibly, the Chronicle article neglects to mention that Landry’s had replaced its auditor last month.
Needless to say, keep a wary eye on Landry’s.

Stros continue their big fade

The Stros opened their first interleague series of the season in particularly unimpressive style as they made Seattle Mariner rookie Clint Nageotte look like the Rocket in losing to the Mariners on Monday evening, 5-0.
Brandon Duckworth was the worst he has been in an awful season for him, exiting after giving up three runs and getting only one out in the first inning. Given Duckworth’s incompetence, one can only imagine what it takes to get released from the Stros’ generally underperforming pitching staff this season. Probably the only thing that has saved Duckworth is that the Stros’ AAA club does not really have a good replacement for him at this stage of the season. Newly-acquired Pete Munro relieved Duckworth and at least battled over the next five innings, giving up the other two runs.
Meanwhile, the Stros’ hitters took a powder against Nageotte and his reliever, Julio Mateo, slapping out seven impotent singles and a double. At least the Stros’ Propoganda Department will be happy as Jeff Kent‘s single extended his hitting streak to 22.
Even Jimy Williams continued his dubious managerial moves. Playing in Seattle allows Williams to use the designated hitter in the Stros’ lineup. So, does he use one of the team’s best hitters to date, Mike Lamb? Or underutilized potential slugger, Jason Lane? No, Jimy uses one of “his guys,” Jose Vizcaino, who continues to be — along with another one of Jimy’s “guys”, Brad Ausmus — one of the most unproductive hitters in baseball.
Finally, consistent with the sense of doom around the Stros right now, Andy Pettitte will miss at least another start and probably more as a result of his recent “forearm” (psst – it’s really his elbow) injury.
The Stros are now 10-15 in their last 25 games, three and a half games behind the Reds in the NL Central, and sinking slowly into oblivion. This team needs a serious jolt, and perhaps Clemens can give it to them this evening as he takes the hill against the Mariners’ forgettable Joel Pineiro (negative 14 RSAA).