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The Overtautness of American Healthcare

04.29.20 // Medicine, Miscellany

Siddhartha Mukherjee, author of the excellent Pulitzer Prize-winning The Emperor of All Maladies, writing for The New Yorker (emphasis mine):

To what extent did the market-driven, efficiency-obsessed culture of hospital administration contribute to the crisis? Questions about “best practices” in management have become questions about best practices in public health. The numbers in the bean counter’s ledger are now body counts in a morgue.

Deep, deep burn.

We’ve been teaching these finance guys how to squeeze,” Willy Shih, an operations expert at Harvard Business School, told me, emphasizing the word. “Squeeze more efficiency, squeeze cost, squeeze more products out at the same cost, squeeze out storage costs, squeeze out inventory. We really need to educate them about the value of slack.”

Medicine is a business, but it shouldn’t be run as just another business.

Everyone loves analogies with Toyota. There’s even one in this story, though it’s one that doesn’t usually make it into your average managerial or quality training, where people just love their black belts in Six Sigma, Lean, and tossing around those Japanese terms like Kaizen and Kanban. As Mukherjee argues, there’s a wide gulf between actually helping professionals take care of human beings and the complex dance of people and parts that requires and just ordering the fewest and cheapest widgets sourced from a factory in China.

What you really want to measure, model, and establish is the capacity to build something when a crisis arises. And this involves human as well as physical capital. We need to measure talent, versatility, and flexibility. Overtaut strings inevitably break.

Not only have they broken, but they’ve been unraveling for years.

Private Equity and Healthcare, a Marriage in Crisis

04.23.20 // Finance, Medicine, Miscellany

“Is Private Equity Having Its Minsky Moment?” is another excellent article from Matt Stoller’s BIG newsletter, something that anyone who is interested in PE and corporate finance should be reading (I referenced a couple of his newsletters previously).

You’ve probably been hearing about salary cuts, furloughed employees, and big losses in health systems around the country. I myself am currently experiencing a sizable pay cut. You may have even heard about the possible impending bankruptcy of healthcare megacorp, Envision. Envision is now drowning because they grew to massive size by buying companies using tons of debt. Because of that massive leverage, if those businesses do poorly, they can’t meet their debt obligations. To give you an idea of how Envision operates, they have less than $500 million in deployable cash on hand to cover $7.5 billion of debt.

Stoller gives a nice summary of why these highly-leveraged private equity companies (and other companies using the same toolbox) are ripe for failure when credit markets collapse.

Private equity is undergoing what the great theorist Hyman Minsky pointed out is the Ponzi stage of the credit cycle financial systems. This is the final stage before a blow-up. As Minsky observed, a period of placidity starts with firms borrowing money but being able to cover their borrowing with cash flow. Eventually, there’s more risk-taking until there’s a speculative frenzy, and firms can’t cover their debts with cash flow. They keep rolling over loans, and just hope that their assets keep going up in value so that they can sell assets to cover loans if necessary. To give an analogy, in 2006, when people in Las Vegas were flipping homes with no income, assuming that home values always went up, that was the Ponzi stage.

Now, what happens with Ponzi financing is that at some point, nicknamed a “Minsky Moment,” the bubble pops, and there’s mass distress as asset values fall and credit is withdrawn. Selling assets isn’t enough to pay back loans, because asset prices have collapsed and there’s not enough cash flow to service the debt. Mass bankruptcies or bailouts, which are really both a restructuring of capital structures, are the result.

I think you can see where I’m going with this. PE portfolio companies are heavily indebted, and they aren’t generating enough cash to service debts. The steady increase in asset values since 2009 has enabled funds to make tremendous gains because of the use of borrowed money. But now they are exposed to tremendous losses should there be any sort of disruption. And oh has this ever been a disruption. The coronavirus has exposed the entire sector.

Everyone wants to make the easy money in a bull market. It makes finance professionals seem competent in running multiple businesses across multiple industries even though their performance often has more to do with the amount of money in the pot driving valuations up. Rolling up companies in high-growth industries by paying top dollar? Piece of cake. But what do you do when the hard times hit? How can your businesses survive when you’ve saddled them to barely function in the best of times?

The business model of the 1980s has been institutionalized in ways that are hard to conceptualize. Sycamore Partners’ takeover of Staples was a recent legendary leveraged buy-out that shows how PE really works. Sycamore Partners is a private equity firm that specializes in buying retailers. Sycamore bought Staples for roughly $1.6 billion in 2017, immediately had Staples take out $5.4 billion of loans, acquired another company, and then paid itself a $300 million payment and then a $1 billion special dividend. Then, Sycamore had Staples gift its $150 million headquarters in the suburbans of Boston for free, after which Staples signed a $135 million ten year lease with Sycamore to lease back its own building.

Healthcare is different because the biggest cost center of most healthcare practices is personnel. And those providers are also typically the only source of profit. This limits the shenanigans you can pull, limits how you can grow, limits the cost floor, and—because of Medicare and agreements with other insurers—limits your profit ceiling. Taking care of people is not a software company or a tech business that can achieve limitless scale at near-zero marginal cost. And what seemed like an easy positive cash flow business isn’t as simple as selling toner.

Tens of millions of people no longer have income, and even those who do are afraid to go back to their old lifestyles. The Fed can’t ultimately can’t print a functional economy. And at the end of the day, no matter how many games you play with debt loads and capital structures, firms have to have customers, and people can only be customers if they have income.

We’re currently in process of bailing out a lot of companies, and low-interest rates will let some of these folks continue borrowing money trying to bide time until they can raise more capital or potentially grow out of their debt. That may not be feasible for long enough to outlast this downturn, especially if the money spigots shut off.

But the issue with bailouts in situations like these is that in recent history they’ve perpetuated a private-profit public-loss business model where PE firms are rewarded for taking on absurd risk because that risk is really on the shoulders of the American people. And without meaningful regulation, this perpetuates the growth of the industry instead of reining in its excesses. Our historically “strong” economy crumbled within about two weeks of the shutdown. That’s overleverage at work.

The actual underlying businesses within these organizations are often still sound once you remove the onerous debt obligations, leasebacks, and other financial machinations. A tiny silver lining of this horrible scenario may be getting some of the rent-seekers out of polluting healthcare.

Coronavirus: The Hammer and the Dance

03.23.20 // Medicine

Another excellent follow-up from Tomas Pueyo about the need to stop doing half-assed mitigation measures.

On one side, countries can go the mitigation route: create a massive epidemic, overwhelm the healthcare system, drive the death of millions of people, and release new mutations of this virus in the wild.

On the other, countries can fight. They can lock down for a few weeks to buy us time, create an educated action plan, and control this virus until we have a vaccine [ed: or treatment].

Governments around the world today, including some such as the US, the UK or Switzerland have so far chosen the mitigation path.

That means they’re giving up without a fight. They see other countries having successfully fought this, but they say: “We can’t do that!”

We can do better together with decisive action and cohesive government intervention/support.

Humans are a communal species. While we need to be alone, right now, we should act together.

Maxims for Academic Medicine

03.17.20 // Medicine

Highlights from Joseph V. Simone’s “Understanding Academic Medical Centers,” published way back in 1999 (hat tip @RichDuszak):

  • Institutions Don’t Love You Back.

A wise colleague once told me that job security was the ability to move to another job (because of professional independence).

  • Institutions Have Infinite Time Horizons to Attain Goals, But an Individual Has a Relatively Short Productive Period.

There is little incentive for an institution to rapidly cut through the bureaucratic morass. An institution will always outlast a dissenting individual, regardless of the merit of the case.

  • Members of Most Institutional Committees Consist of About 30% Who Will Work at It, Despite Other Pressures, and 20% Who Are Idiots, Status Seekers, or Troublemakers.

Generous.

  • Institutional Incompetents and Troublemakers Are Often Transferred to Another Area, Where They Continue to Be Incompetent or Troublemakers.

They force others to pick up the slack or repair their mistakes, reducing everyone’s efficiency. If this continues for long, those who are consistently unproductive may become the majority because the competent learn that the institution sees no virtue in hard work and collaboration.

  • Leaders Are Often Chosen Primarily for Characteristics That Have Little or No Correlation with a Successful Tenure as Leader.

Examples of such criteria include a long bibliography, scientific eminence, institutional longevity, ready availability, a willingness to not rock the boat, or to accept inadequate resources. Choosing leaders is not a science, but it is surprising how often management skills, interpersonal skills, and experience are undervalued.

See: Academic Medicine & The Peter Principle.

  • In Recruiting, First-Class People Recruit First-Class People; Second-Class People Recruit Third-Class People.

Some hesitate to recruit a person who is smart enough and ambitious enough to compete with them. Others want a position filled at any cost because of “desperate” clinical need or other institutional pressures. If that approach continues for long, the third-class people will eventually dominate in numbers and influence and ultimately chase away any first-rate people that remain.

  • In Academic Institutions, Muck Flows Uphill.

Leaders often try to ignore or deflect the unpleasant mess, but the longer it incubates, the harder it will be to sanitize.

See: the dropped balls nationwide with current COVID-19 pandemic.

  • Personal Attitude and Team Compatibility Is Grossly Underrated in Faculty Recruiting.

A faculty member may be very productive personally but create an atmosphere that reduces the productivity of everyone else.

Annoying people are the black holes of camaraderie and joy.

Coronavirus & Distance

03.12.20 // Medicine

There have been lots of good articles about the novel Coronavirus and the embarrassing state of America’s public health response.

This one from Vox has some excellent charts.

This one on Medium breaks down some of the underlying relationship mechanics of social distancing measures and spread as well as how one estimates the number of hidden (but transmitting) cases in a population (which does require some assumptions).

Here’s what I’m going to cover in this article, with lots of charts, data and models with plenty of sources:
— How many cases of coronavirus will there be in your area?
— What will happen when these cases materialize?
— What should you do?
— When?

When you’re done reading the article, this is what you’ll take away:

The coronavirus is coming to you.
It’s coming at an exponential speed: gradually, and then suddenly.
It’s a matter of days. Maybe a week or two.
When it does, your healthcare system will be overwhelmed.
Your fellow citizens will be treated in the hallways.
Exhausted healthcare workers will break down. Some will die.
They will have to decide which patient gets the oxygen and which one dies.
The only way to prevent this is social distancing today. Not tomorrow. Today.
That means keeping as many people home as possible, starting now.

Important reading.

Fragmentation and the Family

02.25.20 // Finance, Medicine

Affluent conservatives often pat themselves on the back for having stable nuclear families. They preach that everybody else should build stable families too. But then they ignore one of the main reasons their own families are stable: They can afford to purchase the support that extended family used to provide—and that the people they preach at, further down the income scale, cannot.

[…]

For those who have the human capital to explore, fall down, and have their fall cushioned, that means great freedom and opportunity—and for those who lack those resources, it tends to mean great confusion, drift, and pain.

From conservative columnist David Brooks’ “The Nuclear Family Was a Mistake” in The Atlantic.

Even in medicine, we are seeing a disturbing trend. While the mean and median student debt are rapidly increasing due to high tuition rates, this is actually partially masked by the increasing percentage of medical students graduating with no debt. This suggests that a greater fraction of students come from means and have family support to cover medical school’s incredible cost. And those without that family support are either not getting in or are looking elsewhere.

It doesn’t stop at admission. These disparities and resource differences play out in specialty selection as well:

Over just a six-year period, the number of debt-free graduates almost doubled. And, overall, more competitive specialties like ophthalmology, ENT, urology, radiology have substantially more debt-free graduates than family medicine. Yet, we know we have a specialization problem in medicine. Free tuition at NYU isn’t going to change this massive headwind. The system needs retooling from far, far earlier.

Pass/Fail Step 1: Initial Thoughts

02.14.20 // Medicine

I was going to write a lengthy post, but then my medical education spirit animal Bryan Carmody did and said most of what I have time to say at the moment better than I would have anyway. Take the time to read it: USMLE Pass/Fail: A Brave New Day. He’s created an impressive collection of excellent writing about acronym fiends like the AAMC, NBME, and NRMP, and this is no exception.

This is a Brave New World. It will be a period of change, and it may very well be a rough transition. I know in this post-fact world we live in that people are cynical and want to cling to an objective measure. The system was flawed but in many ways predictable, and that comfort goes a long way. Students know what to expect. For those who put the time in and succeed, doors can be reliably opened.

Everyone’s concerns about shifting pressure to Step 2 CK, replacement by other likely useless metrics, elite schools, etc etc are all valid. A better future isn’t guaranteed, and Step 2 CK will certainly be the new default if it’s allowed to be (though even that would be an improvement since it’s a better test; I suspect it will become pass/fail within a few years as well).

But Step 1 is not good measure.

It doesn’t measure what matters, creates false distinctions across similar applicants, and may even select for some negative qualities. It’s turned medical school into an overpriced correspondence course and forced students to waste all of their energies spending more and more time mastering less and less useful material. None of our knowledge assessments from the MCAT to the USMLE to any of the board certification exams actually do what they are designed to do. And that’s a huge problem when we’ve absolved ourselves of meaningful holistic and true performative review and instead let a bunch of basically anonymous Angoff panels decide what it is a doctor is and does.

Arthur Jones of Proctor & Gamble once remarked that “all organizations are perfectly designed to get the results they get.” Well our system—from medical admission to MOC—is designed to get unsustainable negative results.

Schools and residency programs have a couple of years to figure out a more meaningful way to evaluate students and select residents. Pass/Fail Step 1 is a lit fire under everyone’s tushes. It’s not a solution; it just opens a door.

 

About those Letters of Recommendation

02.11.20 // Medicine

This study was from 2014 and titled, “What Aspects of Letters of Recommendation Predict Performance in Medical School? Findings From One Institution.”

Do you have a guess?

Being rated as “the best” among peers and having an employer or supervisor as the LOR author were associated with induction into AOA, whereas having nonpositive comments was associated with bottom of the class students.

Best = good

Nonpositive comments = a nice way of saying you don’t really know someone or think they were lame = bad

Now, this was in reference to medical student performance based on college LORs, but some parallels exist in any situation where the current evaluation and the future task are not substantially similar, and—most importantly—bias knows no bounds.

Almost all LORs are positive, even if most people will, by definition, end up somewhere closer to average.

And because most LORs are based on classroom performance, they’re useless. We have more objective measures of classroom performance. They’re called grades (and—blech—the MCAT), and even those aren’t very good at predicting outcomes. At least your boss, whether in the lab or at a paying job, actually knows if you can show up to work and get stuff done.

I’d almost completely forgotten about the LOR process in applying to medical school. I remember I had one from my lab PI/thesis advisor. And then…I honestly have no clue.

Match Fever, AAMC Apply Smart, and Oodles of Bias

01.28.20 // Medicine

Brian Carmody is a pediatric nephrologist, associate program director, and man after my heart. He’s been publishing an impressive series of excellent, well-researched, and well-argued articles about basically everything wrong with the current medical school-industrial complex and the biases of its major players that have resulted in the general crapifying of medical education.

And here is a great investigative video/podcast to boot.

It’s an excellent video that illustrates one way in which the people who should know better (the AAMC, who own ERAS) subtly encourage students to overapply to residency programs, wasting valuable time, money, and stress in the process (and under the guise of trying to fight against the growing cluster of application shotgunning that has proliferated in recent years no less!)

If you haven’t seen any of his articles, check out his site. It’s excellent and is a must-read for anyone involved in medical education or residency training.

The Resident to Midlevel Ratio

12.26.19 // Medicine

As a great bookend to my recent brief article about resident pay, here’s an interesting little data point from this article about the shutdown of UNM’s neurosurgery residency for ACGME violations:

In the immediate future, UNM plans to double the number of neurosurgeons on staff by March. They have also hired 23 advanced practice providers to the staff to handle the workload of the departing residents.

23! There are 10 residents total. Even ignoring the attending coverage (which could in part be needed to provide adequate supervision), 23:10 is an amazing ratio.

To be sure, neurosurgery is one of if not the most valuable residency fields for a hospital. And highly trained upper-level residents obviously are capable of providing high-level and highly-remunerative largely independent care. And, in this case, the workload was clearly too much for even the ten residents they did have. According to the NRMP match data from the past several years, UNM only offered 1 spot in the match (and has over the past decade offered 2 in some years), so I can imaging the call burden must have been absolutely insane.

But damn.

And, just for fun, here’s a back of the napkin cost analysis:

Here’s a breakdown of UNM resident salaries for 2019-2020:

  • PGY I $53,898
  • PGY II $55,646
  • PGY III $57,671
  • PGY IV $59,800
  • PGY V $62,396
  • PGY VI $64,692
  • PGY VII $67,343

So, on average: $60,206 (we know that two of the residents are graduating this year, so a simple average isn’t quite right, but it works for illustrative purposes).

According to “salary.com”, starting PA/NP salaries in the area average around $92,000.

So, as usual, a new midlevel outearns even an overtrained senior resident.

And, with 23 advanced practice providers to replace 10 residents, UNM can expect to spend around $1.5 million more per year to replace residents with nonphysician providers.

(That doesn’t include the residents’ salaries themselves, which UNM must also continue to pay while the residents continue training elsewhere as part of losing their ACGME accreditation. Assuming 8 residents evenly distributed, adding those back in would be in the neighborhood of another $2 million (though presumably that money really comes from CMS and represents a loss to the system of that sweet extra dough not eaten up by salary/benefits that helps pay for the “cost” of training a resident, so maybe an extra $ 1 million total).

A pretty costly mistake, to be sure. But given the bare-bones staffing UNM was presumably using for years, they probably still end up in the black.

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