American Healthcare

American healthcare has lately been in the news quite often. Why? Well, for one, people are feeling the pinch of rising costs of healthcare. For those with insurance, co-pay and deductibles are going up while the insurance rates are also going up. Many employers are no longer provideing free health insurance, expecting the employees to pony up anywhere from 10% to 50% of the premium. For those without insurance, life is full of stress because of the amazingly high costs of medicines and doctor visits, not to mention surgical procedures. Employers too are feeling the heat from insurance companies as they attempt to trim costs, especially towards retiree healthcare.

Many Americans are coming up with clever methods to reduce their costs. Many in the northern states are visiting Canada for a weekend of fun and a bagful of medication for their chronic conditions, from diabetes supplies to heart pills. Many others are going on medical-tourism, getting elective and not-so-elective surgeries done in Poland, India, China, Thailand and Mexico. All these developments beg the question - Is our system broken?

Critics of the American system of healthcare often point out that Americans spend far more money than any other developed nation without the commensurate benefit in the form of higher life expectancy and better quality of health. Is it a fair statistic? As tempting as these statistics might be, I don't think that they are fair. Life expectancy is a complex measure derived from a lifetime of choices and decisions. We Americans lead, by and large, sedentary lives and are exposed to far more mental stresses than most other people. While medicine definitely has a role to play, life expectancy is more about lifestyle choices than medicine.

The supporters of our system of healthcare are quick to point out that Americans lead in innovations in medicine, surgery, therapy and if you were to be involved in a major accident, your survival is best in the US. All of this might be true but it still does not answer the fundamental question - Is our mechanism for healthcare delivery broken?

The American system has evolved over many decades, with many features and nuances that are unique to this country. The American psyche is quite allergic to government-run and government-mandated systems even though we interact with them on a daily, even hourly basis. Our electricity, gas, water, cable-TV, sewage, garbage collection and roads are all either supplied directly by the federal, state or local government or through government-sanctioned monopolies. The healthcare system also has a veneer of private enterprise even though many of the hospitals are funded by state or local governments and most hospitals are run with federal monies. In addition, many millions get health insurance from Medicare or Medicaid, both federal government programs.

My personal frustration with the healthcare system is the un-needed complexity and disincentives built into the system. For example, each health insurance company (and there are hundreds of them) has their own codes and forms for the doctor to fill out for reimbursement. Because of this lack of uniformity, errors in billing are common and require quite a bit of extra work on part of the doctors, nurses and ancillary staff. In addition, each health insurance plan has its own list of covered services which is another minefield that the medical staff, not to mention the patient, has to negotiate. The upshot is that payments take a long time, require many iterations of attention from the insurance company, the provider and the patient and in general waste a lot of productive hours, which get paid out of the higher medical costs.

The disincentives are even worse. Most insurance plans allocate a fixed amount of money for each patient to pay the providers for regular care. As the providers have an incentive to do the least amount of tests and spend the least amount of time and thus save money, the real loser is the patient and his/her health! Insurance companies pay large sums for treating diseases such as cancer but prevention takes a backseat. Many insurance plans don't even cover vaccinations!

What can we do to improve the situation?

Well, there are a lot of things that we can do. We can definitely try to compel the health insurance companies to get together and unify their codes and forms. This would reduce inadvertant billing errors which eat up a lot of time, effort, money and energy.

But, a bigger issue is, what is the society's response to the healthcare situation in the big picture? General Motors has been in the news lately for its very high healthcare costs that are helping it shrink. Toyota overtook GM as the world's largest automaker. Are the American companies and the American society going to go that way?

So, dear reader, ponder on the questions while I try to formulate how a single-payer system can be to our benefit.


Laws and loopholes

Let me tell you a story. Long time back in India, there was a king who was a devout follower of Brahma (one of the original Gods in Hinduism, along with Vishnu and Shiva; rest are avatars of these three). The king once prayed to Brahma for such a long time that Brahma appeared in front of him and asked him what he wanted. The king said "I want to be immortal". Brahma said "Sorry, but that is not possible. Only Gods can be immortal. You are a human being. I can grant you long life but not immortality". Hearing this, the king though long and hard and said "Okay. I would like that neither man nor beast can kill me". Brahma said "Ok".
"I cannot be killed during the day or night."
"I cannot be killed indoors or outdoors."
"Neither on ground nor in the air." (As you can see, he was anticipating air travel)
"Neither by missile nor by melee weapon." (In Sanskrit, there are two words for weapons - astra and shastra - differentiated by whether they are held while in use, such as a dagger, or thrown to use, such as darts)

The king was happy. But soon, he became cruel and started abusing his populace. And given the boon of near-immortality, he was simply unbeatable. When things came to a boil, Vishnu decided that he had to do something (Vishnu's role in Hindu mythology is quite central. His job is to keep the world in order by periodically restoring the balance between good and evil).

So, Vishnu came on earth in the avatar of Narasimha, a man-lion hybrid (Nara = man + Simha/Singha = lion). He grabbed the king and went and sat in the courtyard and lay the king on his lap such that no part of the king was touching the ground and at dusk, ripped the king apart with his long fingernails. Thus the king was killed by neither man nor beast, neither indoors nor outdoors, neither on ground nor in the air, neither during the day nor during the night and finally neither by held nor thrown weapon.

So, as you can see, the king might have figured out a loophole to become immortal, but Vishnu figured out a loophole within that.

The take-home lesson that I see in this story is that the more complicated the law, the easier it is to find loopholes. Therefore, I would like to see laws written in simple language. Our tax laws are as clear as mud and often we see people take advantage of loopholes. Then there are other laws that are so complicated that people don't even know when they are violating them. We should make laws simple to read and understand.

Something to ponder...


5 major mistakes in software projects and how to avoid them

1. Feature Creep
As any software project manager knows, customers cannot stop asking for more. At the same time, most customers don't think of software as "concrete" so they think that all changes are possible, unlike houses or machinery. Therefore, they don't think that the deadline needs to change when adding scope so it is imperative to communicate the cost of extra features, either in time or manpower. Of course, it is important not to confuse clarification of features (very useful) with new features.

2. Buzz in the trenches
It is human nature to be optimistic. People dwell on the positive more than on the negative. When facing a roadblock, it is common for leaders and managers to hope that everything would work out quickly and hence project only the rosiest of scenarios. It is fairly common for managers to assign a fixed number of hours to solving a roadblock when the source of the error hasn't been ascertained! But for the overall manager, this is usually a prelude to disaster. The overall manager must keep an eye and an ear on the people in the trenches to make sure that deep-seated problems are not being sugarcoated till it is too late.

3. Tools
Vendors will happily sell you tools that you never use. On the other hand, really good tools can dramatically improve the return on effort. Therefore, a good manager pays attention to the tools being used and helps in the adoption of tools that make a positive difference. Go for tools that you can play with and test out not with some toy scenarios but with the actual problems that you are facing. The best tools are those that get worked to death. Shelfware is your enemy, eating up your budget and your people's time.

4. Consultants
Consultants can be godsent in a lot of projects. Unfortunately, they are rarely used well. That is why consultants and contractors have such a bad reputation. Remember, the onus is on the client to make the best use of a consultant. There should be a clear start condition, a clear end condition and what exactly the consultant is expected to do. Measuring progress via daily updates, preferably in writing, helps clients ensure that the consultants are worth the money being spent on them. I have often seen contractors working for the same client for years and getting paid a lot more than the employees. Such environments can breed resentments of epic proportions. Also, often the client is left in a lurch when the contractor moves on to some other project. Therefore, knowledge transfer should not be an afterthought, it should be an ongoing process.

5. Stability
A successful software project ends with the customer getting what (s)he needed and wanted. Usually, this requires frequent feedback from the customer, thus risking feature creep. However, it also means that the customer's expectations are grounded in reality. The single most important mechanism for eliciting feedback is to show the customer the software built so far. This is only possible if there is a stable and usable build from the recent past. But the collaborative nature of software development goes beyond just the customer. Developers, quality assurance people, technical writers and other such members of the team are also needed to provide feedback. If every build is usable, it is easier to provide feedback and improve the software. Thus, in my opinion, a daily stable build is necessary for project success.

I have been in software all my professional life so I don't know how much these pointers would help non-software people but you are welcome to it...


Difference between education and wisdom

Here is a story that I heard long time back:

There once was a king who had a very able advisor. This advisor was well educated in all matters, both earthly and spiritual. The king relied heavily on the priest in running the kingdom. Once, the king noticed that the advisor was quite unhappy. The king asked him why. The advisor replied with a deep sigh "Dear Sir, my son is a very well educated man. He is an excellent student and has excelled me in all aspects of education. But he is an idiot and an utter fool."

The king was completely shocked! He couldn't imagine someone beating his advisor in all educational aspects and yet not be the smartest man on eath! So, he said to his advisor "Sir, you have been invaluable in the matters of my kingdom for many years. Perhaps your son is not as dumb as you are fearing. Why don't you tell him to meet me tomorrow and perhaps I can find him a good position in my administration." The advisor was happy to hear such a remark and promised that he would send his son the next day.

The next day, as the son was entering the throne room, the king removed a ring from his finger and hid it in his fist and said "What do I have in my fist?" The son was very well educated in the arts of prediction and said "It is round in shape". The king said "Yes".

"It is made of gold."

"It has a circular hole in the middle."

The advisor's son thought hard and said "Dear Sir, you have a millstone in your fist."

Sadly, the ranks of our "leaders" is full of "millstone-in-the-fist" wisdom...


5 Republican Myths

1. Republicans are against taxes
Yes, it is true that Republicans like to cut taxes. It goes hand-in-hand with their theory that a smaller government is a better government. However, their targets for tax cuts are interesting. They are keener to cut taxes on multi-million dollar inheritances than on wages. Ordinary Americans, whose income is primarily derived from wages, do not benefit from cuts in taxes on capital gains and dividends. Accounts that allow Americans to save money tax-free, such as 401(k) and Roth IRA have curious limits on them, such as phasing out Roth IRA contributions once you start making $100,000. Social Security taxes have gone from 4% in 1967 to 15% today. Just imagine, dividend income of millions is taxed at 15% but wage income of $80,000 is first taxed at 15.4% for Social Security and Medicare taxes and then taxed at income tax rates that can go upto 31%. Reality: Republican are against taxes only if they impact the rich.

2. Republicans are for states’ rights
For years, many Republicans have supported conservative initiatives in state legislatures as a strike for states’ rights. But when 9 states, including Arizona and California made medicinal use of marijuana legal, these same Republicans rushed to ensure that these changes in state statutes were ineffective. The current administration is looking for ways to penalize doctors who, in their considered opinion, find medicinal marijuana to be useful. John Ashcroft, the ex-Attorney General, battled Oregon over Oregon’s assisted suicide law that has been passed by the citizenry twice and once by the Oregon legislature. Reality: Republicans support states’ rights only if they are conservative.

3. Republicans are for smaller governments
Ronald Reagan, a president who was elected in 1980 under the banner of smaller government, left the presidency in 1989 with one more department, Department of Veteran Affairs, than when he arrived. Budgets had ballooned during his tenure and his successor, George Bush Sr., did not stem the tide. Now, George Bush Jr. has managed to create yet another department, Department of Homeland Security, and has increased the federal government payroll by literally hundreds of thousands of employees. The proposed 2007 budget comes in at a staggering $2.77 Trillion! Reality: Republicans like large governments just as everyone else.

4. Republicans have strong moral values
Let us see, Ronald Reagan was on his second wife (divorced from the first), Bob Dole is on his second wife (divorced from the first), Newt Gingrich is divorced from two wives, as is Rush Limbaugh, G. Gordon Liddy is a convicted felon and Oliver North sold weapons to Iran. Bob Livingston had to resign his seat in the House of Representatives after it became clear that he had affairs for the last 33 years! Bill Bennett has run up gambling losses of $8 million. Dan Quayle got to serve in Indiana National Guard while less well-connected boys of his age died in Vietnam. Jack Abramoff scandal is ensnaring lots of Republicans. Today's news headlines talks about how mine safety has been abandoned by the Bush government while putting on the ole' somber poker face when miners have died in Pennsylvania and West Virginia. Reality: Republicans are as fallible as the rest of us.

5. Republicans are fiscally responsible
When Ronald Reagan got elected in 1980, the annual budget deficit was $90 Billion and the debt ceiling (the total amount of money the federal government could borrow) was less than $1 Trillion. In the 12 years under Reagan and Bush Sr., deficits ballooned, reaching $300 Billion and the debt ceiling was raised again and again. Luckily, Clinton’s presidency saw not only a reduction in deficit but for the first time since the Eisenhower administration, the US government actually bought back the debt. But Bush Jr., after inheriting a budget surplus, has put us back in financial quagmire. Debt ceiling is now at $7 Trillion. Reality: Republicans are fiscally irresponsible.

These 5 myths have been bandied about again and again to beat up on the Democrats. Now, the Democrats are not any better than the Republicans but the holier-than-thou of the Republicans gets on my nerves...