Redefining Health Care: Creating Value-Based Competition on Results

Book Description

The U.S. health care system is in crisis. At stake are the quality of care for millions of Americans and the financial well-being of individuals and employers squeezed by skyrocketing costs--not to mention the stability of state and federal government budgets.

In Redefining Health Care, internationally renowned strategy expert Michael E. Porter and innovation expert Elizabeth Olmsted Teisberg reveal the underlying and largely overlooked causes of the problem and provide a powerful prescription for change. The authors argue that participants in the health care system have competed to shift costs, accumulate bargaining power, and restrict services rather than create value for patients. This zero-sum competition takes place at the wrong level--among health plans, networks, and hospitals--rather than where it matters most: in the diagnosis, treatment, and prevention of specific health conditions.

In spite of competition among these systems, the patient care cycle is poorly coordinated. The fractured system undermines both efficiency and quality of outcomes.

Redefining Health Care lays out a breakthrough framework for redefining health care competition based on patient value over the full cycle of care—from prevention and diagnosis through recovery or long-term disease management. With specific recommendations for hospitals, doctors, health plans, employers, and policy makers, this book shows how to move to value-based competition on results that will unleash stunning improvements in quality and efficiency.

Customer Reviews:

How sick is US Healthcare.......2007-10-17

Interesting view on the actual US healthcare and a challenging way to solve the mailaise

Excellent analysis with some weak points.......2007-09-01

This book has received probably disproportionate attention due to Prof. Porter's notoriety as a strategic thinking theorist. There are better overall books on healthcare policy available. In particular I recommend the Bodenheimer/Grumbach books, one on healthcare policy and one on primary care, Dr. Arnold Relman's book, A Second Opinion, Strained Mercy, an outstanding and thorough analysis of healthcare economics with particular regard to Canada's healthcare system, among others.

I find the analysis of the USA healthcare system by Profs. Porter and Teisberg to generally be excellent, although I find it wanting in regard to their disparagement of a single-payer/single-insurer system and to their description and analysis of healthcare systems outside the USA. From my perspective private health plans play only a net negative role in the system. The authors' analysis of how the health insurance market works is quite good. However their recommendation that a system of private insurers should persist is refuted by their own analysis! A single payer/insurer system will not cure the problems of the US system, as they clearly point out, but it does remove the inherently dysfunctional characteristics of private insurance, not least of which is its failure to meet the needs of the uninsured - a very large number - and its inherent propensity to exclude the very people who need coverage and care. The authors rightly point out that mandatory health insurance along with risk-pooling among insurers to spread the costs of those insured individuals who generate the highest costs is a "solution" to the current non-functioning system, but the same result, at lower cost and with much greater simplicity, can be achieved through a single payer/insurer.

The other key aspect of healthcare - how it is delivered - is ultimately more important than the financing/insurance side. The authors provide excellent analysis and recommendations in this regard. They correctly address the aspects of the healthcare market that prevent its functioning as a "competitive" market, specifically the abysmal lack of patient information on prices for services, on outcomes of actions by providers, comparative statistics on provider performance and similar. They also provide an interesting report by the Cleveland Clinic on outcomes, i.e. results, of the Clinic's heart surgery activity. They appropriately use this as an example of the kind of reporting that is needed.

The authors' analysis of healthcare systems outside the USA is skimpy and inaccurate in my opinion. The authors underplay the demonstrated efficacy of government-funded systems that outperform the USA system almost across the board in gross measures of outcomes (infant mortality and longevity) and vastly outperform the US system in regard to cost. They gloss over the fact that per capita costs in the USA are 2.5 times! the average of other OECD countries. It is not as though the costs are say 10% above the average with comparable outcomes. They are 150% higher with worse outcomes. Instead of noting this and analyzing it thoroughly, the authors assert that waiting times and rationing of care are significant problems in those countries, assertions which are simply not borne out by a closer examination of the facts. Also the fact that (mostly) single-payer/insurer systems function well universally does not fit the authors' main thesis, so rather than revise the thesis based on this evidence they choose to ignore the evidence.

As a consequence of these limitations I rate the book with 4 stars rather than 5. Too bad, because most of the book is excellent.

Redefining Health Care.......2007-05-23

Book Review
Redefining Health Care by Michael Porter

I am writing this review to help share some excellent ideas on the availability and quality of medical treatment in the United States and on the U.S. economy which is being dragged down by ever-increasing medical costs. The economic impact is not just on corporate profits and stock prices but also on U.S. employment because everything that raises costs makes it harder for U.S. manufacturers to compete with foreign suppliers and makes it harder for U.S. manufacturers to sell in foreign markets.
Unfortunately, the book is long, turgid, and full of details, which help to substantiate his conclusions and also provide guidance on implementing improved policies. I am afraid the book does not appeal to executives, politicians, or doctors. It also proposes radical changes in all aspects of the medical system and its financing and operation. Dr. Porter proposes major changes on the part of all parties involved in delivering and paying for health care.
The book begins with a review of health indexes and health care throughout the world and shows, while the U.S. has the greatest expenditures by any set of measurements, it does not have the best results.
Then, Dr. Porter introduces his most important concept: that any medical treatment should be measured by its results; how much lost time and discomfort did the patient have, is he or she completely cured, or how much disability measured over the entire span of the illness or even the life of the patient. We tend to think of an operation as being successful if the patient left the hospital in good condition. But how much additional recovery time, disability, or reoccurrence was there? If the patient doesn't come back to see him, a doctor doesn't know whether he was cured by the treatment or if the patient was so dissatisfied he went to another doctor or simply gave up on a series of treatments. The goal is to develop a scoring system for each group of illnesses that can be compared with the cost of each individual's treatment and their results to determine what is the best set of procedures and the best doctor or group of doctors to do the work can be used to guide providers and treatments. Porter has some reason to believe that the best treatments are generally less costly even though the individual item costs may be more, the greater effectiveness and the less chance of complications reduces overall cost. Included in the overall cost should be lost wages, which is a reasonable proxy for the patient's time.
The goal is to develop a health plan that pays for results not for treatments. In many cases, that would be a single payment to the provider for a whole series of treatments from diagnosis on through operations, post-operative care, and follow ups which could extend over a long period of time. This is a radical change from the present system which pays for treatments and tends to produce more treatments and does not have any effective means for either the insurers, or the employers, or the patients even to compare one treatment option with another. This is an extreme, radical change and would take a long time to implement, but there are pieces of the program in operation. A number of these are explained at length. Health insurance companies could hire these firms for their specialized expertise and would not have to do the work on their own. An example of what is done is how the firm studies the history of heart transplant patients and will give an insurance company a single payment for the entire course of treatment providing it is done in the manner and by people they specify. They would particularly focus on caregivers who have an outstanding record of success. It appears that for most illnesses, there are organizations that are substantially better than others and this program could be extended broadly.
Another area of development would be to have counselors which would be part of the function of the insurer to advise a company's employees with a list of particularly well qualified doctors and suggest treatment elements.
Government would seem to be poorly adapted to facilitating these changes because they are radically different from Medicare. Medicare seems to promote cheap, but not necessarily effective treatments and set arbitrary pay scales which do not allow the better providers to charge more for their services and thus encourage more providers to be in the high performance category. Companies that pay for the insurance are the ones that have to put pressure on the insurers to implement the above changes. This could not be done over a short period of time but would eliminate a lot of the wasted time that is now involved in the payments for each little step of the process and for each treatment step.
Chapter 8 is a detailed discussion of how to implement the aforementioned concepts using modifications of Medicare and other laws. This is too complex to summarize here but it appears doable if Congress and the Executive are sufficiently motivated. It is likely that few people would understand what is happening, but the benefits to cost ratio is sufficiently great that the changes would probably be supported and accepted. On the other hand, the situation is so complex, it is questionable whether lawmakers and administrators would be willing to undertake the many complex tasks required. On the other hand, the downside risk appears quite small.
Porter approaches the whole subject from the points of view of business strategy and the problems of decisions with very imperfect information. While the government frequently acts with very imperfect information, its strategy for doing so is not well developed and poorly applied.

Redefining Health Care: Creating Value-Based Competition on Results

A new look.......2007-05-20

Though a little dry, and at times repetitive, this book offers practical information. In a mess of books describing the massive problems in healthcare today, this book was at once motivating and up-lifting. I bought it for a class, but it is one of the books I'll be keeping instead of passing along at the end of the quarter.

Disappointed but Some Might Find Value.......2007-04-05

I'm a big fan of Porter, but I was somewhat disappointed by this book. Let me be frank. The first problem I have with the book is that the authors try to capture as large of an audience as possible, being careful not to place blame on certain providers within the health care system. That approach might get better reviews and sell more copies, but it is not delivering real value. One cannot escape mention of the realities of corruption and fraud by every player in health care and expect to address the problems.

The second problem I have is that Porter fails to recognize that health care is distinct from any other industry in America because it is highly politically influenced. Much of the health care system is public (government funded). This is a main reason why competition in this industry is highly ineffective. How can you have a pure competitive environment when poor performing providers continue to receive government-funded contracts? How can you have full competition when Washington merely fines providers for fraud with no jail time? How can you have competition that creates value when Washington places the burden of increasing costs upon taxpayers, letting the industry charge what it needs to deliver earnings that Wall Street expects?

Overall, by failing to address the harsh realities of politics and big money within America's health care industry, Porter's book is too idealistic and therefore falls short of offering a real solution. Regardless, it is a quality book and at least does what no other has in trying to approach the problems from a reasonable standpoint. I expected more from him, but clearly this book is a view from academia and is far detached from many realities of big industry in America. There are many good points in the book, but without addressing the main problems of a system whereby lobbyist groups who control health care policy, very little will change.

Evaluation: An Integrated Framework for Understanding, Guiding, and Improving Policies and Programs

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A Primer for sorting out conceptual muddles in the field
Aimed at both practitioners and academics
Aimed at both practitioners and academics

Evaluation: An Integrated Framework for Understanding, Guiding, and Improving Policies and Programs
Melvin M. Mark , Gary T. Henry , George Julnes , Gary Henry , and Melvin Mark
Manufacturer: Jossey-Bass
ProductGroup: Book
Binding: Hardcover

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Teaching Evaluation Using the Case Method: New Directions for Evaluation (J-B PE Single Issue (Program) Evaluation)

ASIN: 0787948020

Book Description

"This is one of the most coherent and comprehensive theories of evaluation yet formulated and one that makes a most valuable contribution. The authors are pioneering in important new directions."
--Ernest R. House, author of Professional Evaluation and Evaluating with Validity

"This book is the best I've ever read detailing a practical theory of evaluation. It is comprehensive, beautifully written, and makes sense of the evaluation enterprise. It does so by emphasizing the major function of evaluation as sense-making about policies and programs."
--Thomas D. Cook, professor, sociology, psychology, education, and public policy, Northwestern University

Programs that serve the needs of the public continually face changes brought by social, political, and economic forces. To survive these changes, organizations must evaluate their programs wisely and realistically. This book offers a new approach to evaluation, one that will encourage all kinds of organizations and agencies to improve their contributions to social betterment. The authors draw from three decades of evaluation practice and theory to present their own framework for conceptualizing evaluation and for pragmatically assessing social policies and programs.

They analyze four purposes of evaluation:

To review the merit of programs and their value to society

To improve the organization and its services

To ensure program compliance with mandates

To build knowledge and expertise for future programs

For the practitioner, these purposes help define the approach and methods for an evaluation. The authors also enrich their discussion with four possible modes of inquiry: description, classification, causal analysis, and values inquiry. Filled with tables, charts, and figures, this resource invites organizations to make the most appropriate programming decisions based on thoughtful and systematic methods. Evaluation: An Integrated Framework for Understanding, Guiding, and Improving Policies and Programs is a tool that scholars can use to rejuvenate their view of evaluation and that practitioners can use to integrate the best techniques with a contemporary understanding of social policy and change.

Customer Reviews:

A Primer for sorting out conceptual muddles in the field.......2004-01-22

Amidst a burgeoning growth industry in policy evaluation, characterized by a plethora of approaches and non-standard language usage, editors of two prominent evaluation journals join forces with a third colleague to provide an overview and an inclusive framework that differentiates in simple language, major approaches taken to policy and program evaluation to date.

Beginning with a core definition of evaluation as assisted sense-making whose ultimate objective is social betterment, the authors distinguish four purposes of evaluation: (1) assessment of merit and worth (2) program and organizational improvement, (3) oversight and compliance, and (4) knowledge development. Conceptual clarity over purpose(s) helps avoid muddles encountered in everyday arenas of evaluation and is directly pertinent to modes of inquiry appropriate to those purposes. In the second section of the book the authors distinguish four types of evaluative inquiry and discuss how to plan corresponding evaluative methods appropriate to the purpose(s) at hand. With a view toward conceptual coherence, they spend a chapter grounding their conception of evaluation as assisted sense-making in a philosophy of common sense realism. The third and final section of the book then considers closely, uses and challenges for each of these four modes of evaluative inquiry and devotes one chapter to each: (1) "Description," (2) "Classification," (3) "Causal Analysis," and (4) "Values Inquiry." In so doing, the authors contribute toward enhanced clarity in the "evaluation jungle" at significant levels of analysis and deliver what they promise in simple common sense language: an integrated framework for understanding, guiding, and improving public and nonprofit policies and programs.

My only reservation is related to what in content is also a strength. Rich in academic references, with an adaptation in format, these references could have better been placed in endnotes rather than parentheses. This would have facilitated reading flow. The decision to keep a format that is probably more useful in journals than books accounts for a one star deduction and four star rating.

A solid well-grounded theoretical analysis that will help those engaged in policy/program evaluation sort out a lot of muddles ahead of time rather than unnecessarily being caught in the mire. Another indication that, while good theory will never get as far as accounting for all the exigencies in a complex world, good theory is helpful in avoiding unnecessary confusions and many commonplace and wholly predictable errors in advance. Highly recommended.

Aimed at both practitioners and academics.......2003-08-23

This book serves two purposes. It is a comprehensive text on evaluation aimed at both practitioners and academics, but most importantly, it is a treatise aimed at introducing a new evaluation framework. It is a textbook with a point of view. The authors begin with the premise that the fundamental purpose of evaluation is social betterment, which is "...the reduction or prevention of social problems, the improvement of social conditions, and the alleviation of human suffering." From these roots, they build a new `realistic' evaluation framework. Although aimed primarily at public and non-profit organizations, many of the lessons can be applied in the private sector as well.

Part one examines why one would want to do an evaluation in the first place. The authors purport that evaluation is a fundamental part of the democratic process because it is crucial in informing policy and decision makers about the effectiveness of public policy and programs. The book reviews the four purposes of evaluation (assessment of merit and worth, program and organizational improvement, oversight and compliance, and knowledge development) and introduces the four inquiry modes (description, classification, causal analysis and values inquiry). The authors provide extensive coverage and a critique of the academic debates concerning purposes, modes and methodology. This leads to the proposal of a realistic philosophy, which aims to move beyond traditional paradigm silos. The authors argue that by focusing on the ultimate goal of social betterment and by seeking to surface underlying values, it is possible to follow a path that tailors methodology to intended purpose.

Part two covers evaluation planning and begins the practical application part of the book. Different evaluation purposes become paramount and are more aptly suited, depending on the environment (stable, competitive, shifts in funding or new policy/program). Choosing appropriate methodology and evaluation extensiveness (i.e. quality) is aided by an understanding of primary and secondary evaluation purposes; the book provides decision-making matrices as well as many examples and references. The authors expand on their notion of a `common-sense realistic' philosophy and provide an extensive overview of the supporting principles. It is a philosophy underlined by the notion of evaluation as `assisted sensemaking' that aims to build upon and extend natural human perceptual processes. In practice, it is flexible, antiformalist and rejects the fact-value and qualitative-quantitative dichotomies. In short, it aims to do what works in a given situation and contributes the most to social betterment.

Part three provides extensive detail on the four inquiry modes (description, classification, causal analysis and values inquiry). Each chapter provides a complete overview: detailed arguments about how the selected mode can be used to support the four evaluation purposes, examples of specific evaluation methodology, interactions, notable caveats and pitfalls and an overview of critical opinion. The sections on classification and causal analysis are especially extensive, full of detailed methodology and references to external sources. The authors expand on the notion of how values inquiry can be critical in a complementary role with other modes.

The authors conclude with a statement that the field of evaluation is "...moving towards yet another rite of passage." They argue that evaluators need "...to take their proper place in the policy community" and they must become "...shameless in broadly spreading their findings...." They make a final argument in support of their realistic philosophy.

Aimed at both practitioners and academics.......2003-08-23

Book Description

This acidly funny account of the battle over an offshore wind farm is both a fascinating window on the business and politics of energy and a scathing portrait of the ruling class.

When Jim Gordon set out to build a wind farm off the coast of Cape Cod, he knew some people might object. But there was a lot of merit in creating a privately funded, clean energy source for energy-starved New England, and he felt sure most people would recognize it eventually. Instead, all Hell broke loose. Gordon had unwittingly challenged the privileges of some of America's richest and most politically connected people, and they would fight him tooth and nail, no matter what it cost, and even when it made no sense.

Cape Wind is a rollicking tale of democracy in action and plutocracy in the raw as played out among colorful and glamorous characters on one of our country's most historic and renowned pieces of coastline. As steeped in American history and local color as The Prince of Providence; as biting, revealing and fun as Philistines at the Hedgerow, it is also a cautionary tale about how money can hijack democracy while America lags behind the rest of the developed world in adopting clean energy.

Customer Reviews:

The hijacking of democracy by a powerful elite.......2007-10-20

Ironic is the only way I can describe the situation regarding the Cape Wind project. You'd think that politicians who have been at the forefront of environmental issues would jump to the head of the bandwagon to approve this project, yet instead they are doing everything they can to oppose it. I'm talking about powerful people like Ted Kennedy, Robert F. Kennedy, Jr., and Mitt Romney.

In the case of the Kennedys, I can understand that they are trying to protect their view of Nantucket Sound for themselves and for their wealthy neighbors, but in Romney's case, his decision to subvert democracy to appease a powerful elite could cost him a run at the White House. I can't put a URL in a review but you can find more in my blog about this book by searching for my name and 'Cape Wind' on Google.

This book is entertaining, full of interesting facts, and is fun to read. I highly recommend it.

Outrageous Hypocrisy Revealed.......2007-09-07

Well researched and written. This book should be read by everyone who is really concerned about the reduction in use of fossil fuels. The outrageous hypocrisy of politicians of both parties as well as some of the beautiful people who claim to support the development of alternative energy sources is laid out for all to see.

A must read for any energy entrepreneur.......2007-09-03

It would be shame for an energy entrepreneur to be tripped up by the obfuscation described in this great book without its warning. Extensively researched, masterfully written, a lesson of the times. Read it and learn! Bet you won't be able to put it down,

Cutting edge history in the making.......2007-08-21

Cape Wind is a brilliant account of a project that has the potential to revolutionize the energy future of the US. It couldn't be more timely, given the current energy crisis, the need for serious and concrete solutions and the fact that the controversy over the project is happening at this very moment.

The authors provide a powerful experience - the opportunity to gain a thorough understanding of the politics and history of this project as it unfolds every day. The presentation of the facts and players is fascinating; their delivery of the story is incredibly entertaining.

Read it now and stay tuned to the project - History is being made!

Amazing... We need a documentary on this!!!.......2007-08-21

There's too much happening here to not have a well executed and informative documentary on this. It may seem like a small issue to those outside of it, but it's implications reach much further than the Cape.

Read this easy to follow and well written account of this project and engage yourself into todays questions about our planet and our political stratosphere.

Risk and Reason: Safety, Law, and the Environment

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A short review of 'Risk and Reason'
Political
Insights Into Rational Risk Management for IT Professionals
Huge Helping of Reason, Needs Salt

Risk and Reason: Safety, Law, and the Environment
Cass R. Sunstein
Manufacturer: Cambridge University Press
ProductGroup: Book
Binding: Paperback

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ASIN: 0521016258

Book Description

What should be done about airplane safety and terrorism, global warming, polluted water, nuclear power, and genetically engineered food? Decision-makers often respond to temporary fears, and the result is a situation of hysteria and neglect--and unnecessary illness and death. Risk and Reason explains the sources of these problems and explores what can be done about them. It shows how individual thinking and social interactions lead us in foolish directions. Offering sound proposals for social reform, it explains how a more sensible system of risk regulation, embodied in the idea of a "cost-benefit state," could save many thousands of lives and many billions of dollars too--and protect the environment in the process. Cass R. Sunstein is the Karl N. Llewellyn Distinguished Service Professor at the University of Chicago. Appointed by President Clinton to serve on the Advisory Committee on the Public Interest Obligations of Television Broadcasters. His many books include Republic.com (Princeton, 2001) and Designing Democracy (Oxford, 2001). He has worked in the United States Department of Justice and advised on law reform and constitution-making in many nations.

Customer Reviews:

A short review of 'Risk and Reason'.......2004-08-08

It is sometimes referred to as "emotional decision making", when after accidents which cause loss of life, government authorities decide to spend irrational huge budgets to try to prevent these accidental risks from happening again. This 2002-book of Prof. Sunstein from the U of Chicago explains the sources of such irrational behaviour and comes up with novel ideas what can be done about it. This book contains a great deal of new material, but it also draws on Sunstein's publications in the J of Risk and Uncertainty, Stan L Rev., and his 2001-book 'The cost-benefit state', amongst others.

The book gives the reader a lot of recent case studies, such as the sniper murders in the Washington DC area in fall 2002, the SARS epidemic, the Love Canal controversy in the 80s, as illustrations of people's unjustified fear, which in the same time neglects the real hazards, such as obesity, indoor air pollution, sun exposure, etc.

Risk and Reason advocates the government to produce cost benefit analyses (CBA) before choosing an emotional course of action. Sunstein argues in his book to see CBA as a pragmatic tool, designed to promote a better appreciation of the consequences of a certain regulation, rather than a form of unethical, barely human calculation, treating health and life as variables for some kind of huge maximising objective function. The author succeeds in delivering this message to the reader very well.

Sunstein urges toward four alternative strategies in optimal cost-saving risk regulation: disclosure of information to the public, economic incentives, risk reduction contracts and free market environmentalism. With the economic incentives he means financial penalties for harm producing behaviour, and tradable emission rights (similar as the Kyoto protocol is designed to reduce global warming. The alleged fact that risk creators might be given a right to create harm is shown to be false.

Political.......2003-08-14

Sunstein is a lawyer. He is neither a scientist nor an economist. His advocacy of (what he calls) "rational" and "scientific" models of risk evaluation appears to be motivated by politics, not good science or economics. Be wary of his methodology and his rigor.

Insights Into Rational Risk Management for IT Professionals.......2003-01-18

While this book focuses on government regulation of health and environmental risks (regulation is government-speak for risk management), IT risk managers can learn a lot about IT risk management from the book. For example, Chapter Three is entitled "Are Experts Wrong?", which will tell you why you need to be cautious about adopting "Best Practices." Chapter Five is entitled "Reducing Risks Rationally," just what every risk manager should be striving to do. Sunstein makes a very convincing case for the value of cost benefit analysis in managing risks. If you are responsible for risk management, get this book and read it.

Huge Helping of Reason, Needs Salt.......2002-12-02

The bottom line on this book is clear: our governance of risk to the public tends to be managed by political gut reaction rather than informed investigation; there is no clear doctrine for studying and articulating risk (for example, distinguishing between high risks to a few and low but sustained risks to the many, or between three levels of cost-benefit analysis so that choices can be made); and the best form of risk management may be through the effective communication of risk information to the public rather than imposed costs on private sector enterprises.

As reasoned as the book is, it also constitutes a direct attack on all those who expouse the "precautionary principle." While I do not agree completely with the author, who seems to feel that rational study allows for the discounting of any risk to the point where it can be economically and politically managed at an affordable cost, he certainly take the debate to an entirely new level and his book is--quite literally--worth tens of billions of dollars in potential regulatory risk savings.

Most compelling is his methodical aggregation of data from several sources to show that the cost of saving one life (he notes that we fail to distinguish adequately between a life saved for a few years and a life saved for many years, or between young lives saved for a lifetime and old lives saved for a brief span of time). Table 2.1 on page 30 is quite astonishing--of 45 major regulated risks, one (drinking water) costs over $92 billion per premature death averted; eight including asbestos cost between $50 million and $4 billion; seven including arsenic and copper cost between $13 million and $45 million; 14 including various electrical standards cost between $1 million and $10 million per death averted; and 15 cost less than $1 million per death averted.

What cost human life? Even on this there is no standard, and even within a single regulatory agency (e.g. the Environmental Protection Agency) there are different calculations used in relation to different risks being regulated. The author does a really fine job of comparing the public perception of the value of a life saved ($1.3 million for automobile-related risks, $103 million for aviation-related risks) with the values used by the government and the courts, which vary widely (into the billions) but seem to hover between $10 million and $30 million per life saved and without regard the the number of life-years actually involved.

The heart of the book is in its conclusion, where the author proposes a four-part strategy for dramatically reducing the cost of regulatory risk management, suggesting that we focus on 1) disclosure of information to the public; 2) economic incentives; 3) risk reduction contracts; and 4) free market environmentalism. With respect to the latter, he is strongly supportive of allowing the "sale" of pollution privileges between nations and industries and companies.

For additional observations on reducing risk to the future of life see my reviews of Joe Thorton on "Pandora's Poison," Raffensperger and Tickner on "Protecting Public Health & The Environment," Novacek on "The Biodiversity Crisis," Czech on "Shoveling Fuel for a Runaway Train," Lomberg on "The Skeptical Environmentalist," Helvarg on "Blue Frontier," and Wilson's "The Future of Life."

Cass Sunstein and Lawrence Lessig join Jerry Berman and Marc Rotenberg and Mike Godwin as America's "top guns" in responsible law-making. This book makes a great deal of sense, is worth a great deal of money, and should guide the future evolution of regulatory and information-driven risk management.

Market-Driven Healthcare: Who Wins, Who Loses in the Tansformation of America's Largest Service Industry
Average customer rating:

OVER THE EDGE

market s in healthcare?

So she's no Tolstoy, but the ideas are great.

There is no "market" in American medical care, period.

Admirable goals,solutions ignore some regulatory constraints

Market-Driven Healthcare: Who Wins, Who Loses in the Tansformation of America's Largest Service Industry
Regina Herzlinger
Manufacturer: PERSEUS PUBLISHING
ProductGroup: Book
Binding: Paperback

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Saving Lives & Saving Money

ASIN: 0738201367

Customer Reviews:

OVER THE EDGE.......2007-04-14

THE IDEA THAT " THE MARKET " CAN FIX ANYTHING HAS BEEN AROUND A LONG TIME.
AND IT CAN IF YOU ARE ON THE RECEIVING END OF THE PAYMENT SYSTEM. IT'S GREAT! HOWEVER IF YOU ARE THE " PAYER " I.E. WORKING FOR LITTLE OR NOTHING, PAYING TAXES, BUYING THREE DOLLAR GAS, GETTING YOUR RATTLE TRAP CAR FIXED SO YOU CAN GO TO YOUR EIGHT DOLLAR AN HOUR JOB...YOU REALLY CAN'T FIX ANYTHING.
VOTING DOES NO GOOD WHAT-SO-EVER AS EVERY POLITICIAN WHO HAS EVER LIVED IS ON BOARD FOR ALL THE MONEY THEY CAN GET. THE ONLY THING THAT WILL WORK, REALLY WORK IS IF THE PEOPLE OF THE USA TAKE THEIR GOVERNMENT BACK AND MAKE IT WORK IN THE BEST INTERESTS OF ALL. THIS IS NOT LIKELY TO HAPPEN SOON BECAUSE 99%
OF PEOPLE IN THIS COUNTRY ARE BRAIN-WASHED DAILY INTO BELIEVING THEY HAVE NO POWER.
GET READY FOR MORE "MARKET" DRIVEN "SOLUTIONS" FOR YOUR EVER MOUNTING PROBLEMS. AND IF YOU HAVE YOUR HEAD IN THE SAND YOU DESERVE WHAT YOU GET IN THE END...

market s in healthcare? .......2005-07-30

Herzlinger is a card-carrying member of the club that believes that markets can cure all social ills, and like all members of this club, she plays fast and loose with reality. For instance, she tries to present the vision market as an exemplar of how market forces can work in healthcare. Vision is one of the few areas of medicine where patients can appraise the value of the service, the quality of the provider, and make decisions about how much they are willing to pay. That is simply not the case when a patient is really sick with heart failure, and needs multiple medications, multiple doctors, and is probably going to be hospitalized repeatedly.

In trying to argue that all aspects of medicine can follow market rules the way vision services do, Herzlinger conveniently ignores one critical fact: there is no true market in the healthcare industry, and there can't be. Kenneth J. Arrow, Nobel Prize winning economist pointed this out 30 years ago, and his observations are still true today. Providers (doctors and hospitals, and increasingly the drug and device industries) drive demand for their services. They are the ones who decide what patients need. The notion that patients can have suffient information to be able to determine what they need is probably only true for the 80 percent of people who consume 20 percent of healthcare costs. The 20 percent who eat up 80 percent of costs are sick with multiple conditions. Imagine your grandmother is in the hospital, sick with diabetes, and pneumonia, scared, having a hard time breathing, and she's supposed to sort through whether or not she should pay the $600 to call in the pulmonologist? The patients with chronic, multiple, debilitating disorders actually need the exerpertise of medical professionals.

Her focused factories have come to pass: they are called specialty, or even super-specialty, hospitals, which focus on one procedure, or one category of specialty. There are cardiac hospitals, for instance, that only perform by-pass surgery, cardiac catheterization,angioplasty, and stenting. Are they good at what they do? Sure, because they focus on a narrow range of procedures, they only take insured patients, and they don't take anybody with comorbidities. Of course, the really expensive patients tend to have comorbidies. The effect of the specialty hospitals on local healthcare markets? They do not bring down costs, they simply drain profit from full-spectrum community hospitals, which still have to care for all those patients with pneumonia and who don't have health insurance.

The imbalance of information between physician and patient is simply insurmoutable, and without that kind of balance, markets don't work very well.

So she's no Tolstoy, but the ideas are great........2004-03-15

No one will accuse Ms. Herzlinger of being a great writer, but her conversational style is easy to read and she does have some good ideas for how the healthcare industry should be. Ideas that still haven't been implemented even now, 8 years after it was written. She does make a fairly convincing argument for how focused factories could reduce costs. In addition, suggestions that everybody should have health insurance, that healthcare providers should not be insulated from market forces, that consumers are the ones with the real power to stop the soaring healthcare costs, and that they'll only curtail spending when given incentive to do so are good points that can't be made often enough. Points that seem even more relevant today given the continued increase in healthcare costs, the inability of the HMO system to manage them, and the spiraling problem the growing uninsured population is creating (the more uninsured people there are, the more insurance costs, which increases the number of uninsured, etc.). She has good ideas, I think it's time people listened. It's of vital importance that the healthcare system incorporate what's great about America, what has made America a leader in every other industry: innovation and sensibly regulated free markets. Ms. Herzlinger gives us a good way to get it done.

I also have to ask if some of the other reviewers actually read the book. The author gives a pretty good analysis of how focused factories would reduce costs, using that 20% of the people produce 80% of the costs as a cornerstone of her argument. Also, she cites physicians' inability to deal with market forces as a cause of the problem and gives suggestions for how to deal with it.

There is no "market" in American medical care, period........2003-12-13

Market forces cannot solve the medical crisis. No market exists. Knowledge of what is sold is inequivalent: if patients knew the difference between colonoscopy and colposcopy, they would not know the fair market value of either procedure. Unlike buying a car, where the dealer knows you can walk off, patients cannot negotiate, and can't determine the quantity of medical services needed. Eyeglasses constitute a misleading example. Physicians are the principal drivers of all expenditure on medical care. Without a medical license, nothing can be ordered or prescribed. This fact must be faced squarely: the supplier of services regulates the level of demand for medical services. Annual outlays have now reached $1.6 trillion with no end in sight to the physician-driven escalation in expenditures. This is not COST inflation, but relentless EXPENDITURE INCREASE driven chiefly by an oversupply of medical doctors. If this system is ever to be fixed, these stubborn realities must be faced. This author evidently has no clue that there is not a "market" operating in the world of medical care delivery, thus her analysis is unhelpful.

Admirable goals,solutions ignore some regulatory constraints.......1999-03-01

The author accurately identifies a subpopulation of patients who are middle class,time constrained, and annoyed with the difficulty of obtaining quick evaluation and therapy for a variety of health problems of varying complexity. After examining a number of systems for health care delivery, she gives the nod to highly specialized and focused units such as the Shouldice Clinic for hernia surgery in Canada. There are several problems with the soultions she proposes: 1) Goverment regulatory agencies and third party payers currently refuse to pay multiple consultants for seeing a patient on the same day. 2)Patients with complex multisystem problems may be ill served in such a focused system- eg. the patient who has congestive heart failure and a hernia. 3)There would monumental problems with education of medical students and residents in such a system. While this is a secondary consideration in a market driven system in which there is a physician surplus, if we fail to adequately educate physicians for future generations the law of supply and demand will ultimately come back to haunt us.

Megaprojects and Risk: An Anatomy of Ambition

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Packed with Knowledge!
A fool, his money and the bridge that parted them.......

Megaprojects and Risk: An Anatomy of Ambition
Bent Flyvbjerg , Nils Bruzelius , and Werner Rothengatter
Manufacturer: Cambridge University Press
ProductGroup: Book
Binding: Paperback

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Mega-Projects: The Changing Politics of Urban Public Investment
The Strategic Management of Large Engineering Projects: Shaping Institutions, Risks, and Governance
Rationality and Power: Democracy in Practice (Morality and Society Series)
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Mobility

ASIN: 0521009464

Book Description

Promoters of multi-billion dollar land-use development megaprojects systematically misinform parliaments, the public and the media in order to get them approved and built. This book not only explores these issues, but suggests practical solutions drawing on theory and scientific evidence from the several hundred projects in twenty nations and five continents. It is of interest to students, scholars, planners, economists, auditors, politicians and concerned citizens.

Customer Reviews:

Packed with Knowledge!.......2004-03-02

Every once in a while a little book comes along that, while small in size, carries sufficient intellectual weight to strike the body politic between the eyes, thereby getting its collective attention. This may be one such book. It offers a realistic look at megaprojects - those major infrastructure endeavors that span vast bodies of water, dam natural resources to generate energy and extend rail lines to previously unreachable regions - and compares the promises of these projects to what they actually deliver. The report card isn't very good. Cost overruns are typically 25% to 100%, and sometimes 200% or more. Worse yet, studies show that the public tends to use megaprojects - be they airports or subway systems - only a fraction of the amount predicted. We strongly recommends this book to politicians, legislators and anyone who wants to know the truth behind these huge infrastructure projects, as well as to CEOs, CFOs, project managers and risk officers in the private sector - this applies to your projects, even if there is a difference of scale.

A fool, his money and the bridge that parted them..............2003-09-13

I am the first amazon.com reviewer of this short, but important book. It concerns me that this might reflect a diminished U.S. readership. That would be unfortunate. Professor Bent Flyvbjerg and his colleagues have written a book of significance to taxpayers everywhere. It's apparent that they have written this book largely for the policy-maker; yet, make no mistake about it: the ordinary taxpayer has a major stake in this book's message. The central characters in Megaprojects and Risk are three large-scale, European transportation projects: the Chunnel, the Great Belt and the Oresund. American readers unfamilar with these names (the chunnel connecting London and Paris is perhaps the most recognizable to American readers) will nonetheless recognize familiar features. Specifically, they will find project costs that exceed estimates, and revenue inflows that are below projections. The traits are not unique to these projects. In fact, cost over-runs and revenue disappointments are a familiar global refrain, according to these authors. In spite of this, the number and scale of infrastructure projects continues to grow, forming what they call the megaproject paradox. The book is stronger on documenting problems, including the lack of project post-audits, than on providing solutions. I think they have correctly identified the problem -- the lack of accountability throughout the project life-cycle -- but their solution, which largely involves ensuring a healthy segment of private capital not supported by state guarantees, together with more attention to genuine risk assessment, falls short of the mark. The risk assessment tools are firmly established and largely well-understood (Monte Carlo simulation packages are increasingly available). So is the "moral hazard" problem that rears its ugly head when projects (in this case) are "over-insured." The difficulty, which they acknowledge, is that the political interplay between state, private interests and NGOs are decisive in determining whether and to what extent the appropriate risk assessment and risk management tools are used.

This problem is inherent in the beast. Policy-makers would love for the private sector to shoulder the risk, but may not be willing to permit a commensurate return. Private players, just as understandably, are apt to seek insurance of one kind or another on the downside. The best medicine, and one that this book delivers admirably, is simply to raise our awareness of the track record from the start.

Book Description

Written by an international panel of distinguished global health experts, this book distills valuable lessons from a wide variety of successful health programs that have been implemented around the world. Global Health Leadership and Management gives practical suggestions for enhancing and developing the essential skills of leadership, management, communication, and project planning for health care leaders. The book will assist health leaders to work well within their communities and effectively plan, direct, implement, and evaluate effective programs and activities. Global Health Leadership and Management outlines and describes such core competencies as

Identifying challenges and developing and managing policy
Developing strategies, pathways, and solutions
Creating networks and partnerships and planning for change
Learning from experience to build a generation of leaders
Leading and managing teams by recognizing and celebrating success

Download Description

"Written by an international panel of distinguished global health experts, this book distills valuable lessons from a wide variety of successful health programs that have been implemented around the world. Global Health Leadership and Management gives practical suggestions for enhancing and developing the essential skills of leadership, management, communication, and project planning for health care leaders. The book will assist health leaders to work well within their communities and effectively plan, direct, implement, and evaluate effective programs and activities. Global Health Leadership and Management outlines and describes such core competencies as

Identifying challenges and developing and managing policy
Developing strategies, pathways, and solutions
Creating networks and partnerships and planning for change
Learning from experience to build a generation of leaders
Leading and managing teams by recognizing and celebrating success

Book Description

Public Information Technology: Policy and Management Issues constitutes a survey of many of the most important dimensions of managing information technology in the public sector. Written by noted academics and public administration practitioners, this book addresses general policy and administrative issues in this arena as well as the information technology skills needed by public managers.

Customer Reviews:

strictly school.......2005-07-25

Very boring. I like the easy wayit reads. I wouldn't have bought it unless it wasn't necessary for school.

Changing the U.S. Health Care System: Key Issues in Health Services Policy and Management (Jossey Bass/Aha Press Series)

Average customer rating:

Many questions and issues, few answers...

Changing the U.S. Health Care System: Key Issues in Health Services Policy and Management (Jossey Bass/Aha Press Series)
Ronald M. Andersen , Thomas H. Rice , and Gerald F. Kominski
Manufacturer: Jossey-Bass
ProductGroup: Book
Binding: Hardcover

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ASIN: 0787954047

Book Description

Explore in-depth the possibilities for public health and policy reform. The second edition of Changing the U.S. Health Care System is a thoroughly revised and updated compendium of the most current thought on three key components of health care policy-improving access, controlling costs, and ensuring quality. Written by a stellar panel of experts in the field of health care policy, this second edition highlights the most recent research relevant to health policy issues. This valuable resource also includes analyses of current health care policy challenges and presents a wide-range of viable solutions. In addition, the book contains an overview of the opportunities in the growing fields of public health and health policy.

Customer Reviews:

Many questions and issues, few answers..........2007-05-03

As I work for a health insurance company, I felt that I would benefit from reading Changing the U.S. Health Care System: Key Issues in Health Services Policy and Management by Ronald M. Andersen, Thomas H. Rice, and Gerald F. Kominski. Unfortunately, it was not what I was expecting. I was hoping for opinions and options on reforming health care. What I found was numerous stats, a lot of issues, and not too many answers.

Contents:
Part 1 - Access To Health Care: Improving Access to Care in America - Individual and Contextual Indicators; Ethnic Disparities in Health Status; Disparities in Health Care; Public Policies to Extend Health Care Coverage
Part 2 - Costs of Health Care: Measuring Health Care Costs and Trends; Containing Health Care Costs; Controlling Pharmaceutical Prices and Expenditures
Part 3 - Quality Of Health Care: Measuring Outcomes and Health-Related Quality of Life; Evaluating the Quality of Care; Public Release of Information on Quality; Health Care Information Systems; Performance Measurement of Nursing Care
Part 4 - Special Populations: Long-Term Care and the Elderly Population; AIDS in the Twenty-First Century - Challenges for Health Services and Public Health; Health Reform for Children and Families; Mental Health Services and Policy Issues; Women's Health - Key Issues in Access to Health Insurance Coverage and to Services Among Nonelderly Women; Homeless Persons
Part 5 - Directions for Change: Managed Care and the Growth of Competition; Medicare Reform; Public Health and Personal Health Services; The Continuing Issue of Medical Malpractice Liability; Ethical Issues in Public Health and Health Services
Index

I believe that most people would agree that the health care system in America is broken. Changes have to be made, as rising rates are making it harder for people to find affordable health care coverage. What I was hoping for in this book was a number of serious discussions on different approaches such as universal care, single-payer systems, etc. The chapters in the book are all written by a number of different people, making it a compilation of sorts. Nearly all the chapters go deeply into statistics and numbers, showing how population group x is affected by disease y in z percentages. From the standpoint of policymakers or actuarials, these numbers are necessary to know the extent of the problem. But I felt as if most of the discussion stopped there. Many issues were raised, and nearly any hint of a solution was watered down with all the reasons why it might not work or have the opposite effect of what was intended. Some of the sections were more informational than others, such as the chapter on Medicare reform. Learning the history of how Medicare came about, as well as under what assumptions, makes it easier to understand why the system functions as it does. But again, everything ended on a note of "things need to change", but not much was offered as an alternative...

Readers who need a heavy statistical or academic look at health care issues will find it here. People like myself who are more practical in nature will find the material rather plodding and dry. My overall conclusion after reading this was that there are no easy answers, and any solution will significantly hurt some portion of the current system. There's not enough money and resources for everyone to have unlimited access to the best health care available. And for a society that's used to immediate gratification, that'll be a hard sell...

Transportation and Sustainable Campus Communities: Issues, Examples, Solutions

Average customer rating:

Getting to school

Transportation and Sustainable Campus Communities: Issues, Examples, Solutions
Will Toor , and Spenser Havlick
Manufacturer: Island Press
ProductGroup: Book
Binding: Paperback

General | Transportation | Nonfiction | Subjects | Books

Mass Transit | Transportation | Nonfiction | Subjects | Books

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ASIN: 1559636564

Customer Reviews:

Getting to school.......2006-02-01

Of the many problems Americans frequently complain about, one has been lurking under the radar over the last several decades, and has occasionally surfaced in nasty fights at the state and local government level. This problem is that of transportation to and from college campuses. As the US population grows, the availability of open land goes down, and the number of college students increase, physical access to colleges has become a perennial issue in many states. I came to discover this in the past decade. First as a student, and now as a staff scientist at Arizona State University, I have been at ASU since 1994. In that time, I have watched parking at ASU go from great, to downright horrible.

Dr. Michael Crow became ASU's president in 2002, and since then, he has proceeded to enact numerous changes at ASU. One of them is the transformation of ASU from a commuter campus to a residential campus, and the associated loss of parking spaces inherent in such a change. As part of this, Dr. Crow had asked the students of ASU to form a task force to address transportation needs. I joined this task force, and as part of my duties, read a lot of books on transportation issues of college campuses. This is one of the books I read. I am glad I read this book. It examines transportation management at universities across the US, from large public schools, to small private schools, from schools in the countryside to schools in downtown. This book looks at the various aspects of transportation management, such as public transit, carpooling, greener forms of transit, correlating the demand and supply of parking on campuses, how to get schools and other government agencies to work together, etc, etc...

The book provides detailed case studies of how specific schools have handled their transportation needs for both their employees and students. Successes and failures are highlighted, and how both came to be. Details are given, such as costs, timelines, maps showing how transit plans were developed, charts correlating bus usage with ticket prices, etc... The primary conclusion reached by the book are similar to those I reached while working on the task force at ASU: reduce demand for car parking instead increasing supply. All in all, a great book that should be required reading for anyone who intends to work in the administration of a university or college. I do not give it five stars because it lacks examples from other countries, where cars are used less frequently than here in America.

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