Author Archive

The Doctor Conundrum

Saturday, December 1st, 2007

Health care in America is a $2 trillion, high-growth industry. Doctors are in short supply just about anywhere you go in the country. Many, if not most, family practice doctors are not accepting new patients. Even upper-class, well-insured patients have to wait a couple of weeks or more for a regular appointment with a specialist.

Doctors seem to be busy. Indeed, the surveys show that they are spending as much time or more on patient care activities than they did 10 years ago – and the volume of procedures per physician is way up.

The stock of new physicians (new graduates minus retirees) is growing no faster than the population, but health care costs have been consistently growing at 6 percent to 10 percent per annum over the last decade or more. We are also smartening up as a nation and starting to reward physicians for quality improvement through pay-for-performance schemes. And here is the big one: Given that baby boomers have started to hit the early stages of total body breakdown, the demand for almost every medical specialty is poised to explode.

Reasons to Be Cranky

It would seem to be a brilliant time to be a doctor. You have market power, a demographic bonanza, lots of new technology to use that liberates you from the clutches of hospitals, patients who want to spend time with you, and an American society that appears to grant health care an ever-expanding share of the economy. What’s not to like?

How then can you explain the fact that in Harris Interactive/Harvard surveys of physicians conducted for Strategic Health Perspectives, my colleagues found physician satisfaction at its lowest ebb since we started measuring it in the early 1990s? A full 43 percent are saying they are dissatisfied with their practice. Are these people nuts?

Well, I don’t think they are crazy. Physicians are frustrated by administrative complexity, both public and private. They are angry at the constant threat of Medicare price cuts. They feel they are losing autonomy to faceless bureaucrats in Washington, the state capitals and Hartford, Conn. They see their patients as having to jump through mindless financial hoops that impair their compliance. They are happy about expanding science and knowledge and want to deliver good care, but the economic and administrative circumstances overwhelm the positives and put them in a black mood. Doctors are just cranky.

But what really pisses them off is the gap between their incomes and those of the rest of the high-end college graduates of America. The Center for Health Systems Change analysis of average physician income adjusted for inflation between 1995 and 2003 showed that income for all physicians declined by 7.1 percent over the period; for primary care doctors, by 10.2 percent; for medical specialists, by 2.1 percent; and for surgical specialists, by 8.2 percent. This is in sharp contrast to the 6.9 percent gain that all professional and technical workers made in the same period.

Put in stark local terms, my surgeon neighbors at Stanford drive Chryslers, my software neighbors drive Mercedes, my lawyer neighbors drive multiple BMWs (they are good at multitasking) and my venture capitalist neighbors have off-site garages to store their many exotic cars. If I were a doctor, the smartest kid in my high school class, the top 2 percent of my college class, and magna cum laude at Stanford, I would be pissed off, too. It is pretty bad when the lazy geography graduates like me make more than the surgeons.

Compensation Discrimination

While many like to point to the fact that doctors make more money in America than in any other country – which is true – they miss the big point. There are way more undeserving, highly compensated pigs at the health care trough than doctors.

Let’s start at home. Consultants and futurists are paid four to five times what they would be in other countries; hospital CEOs, three to four times; administrators of all types, two to three times; and so on. CEOs of health plans who rack up $100 million-plus in compensation over the course of a career are well ahead of the cumulative earnings of all the ministers of health in the developed world.

And then there are the sales men and women of America. I want my son to be a salesman because America rewards sales more than almost any other profession. There are armies of sales people in American health care, many of whom are making much higher incomes than the doctors they are calling on. These are just estimates: I urge someone with access to all these numbers (such as the compensation consultants) to publish them. Just wait and see how angry the doctors will be then.

The solution is not just to pay doctors more through fee-for-service upgrades or to tweak their incentives through petty pay-for-performance schemes. We need to imagine reimbursement systems that reward clinical excellence and professionalism and that provide incentives to do the right thing for patients, at the right time, in the right place and by the right people (which may mean less expensive and more reliable auxiliary health professionals). We also need to look long and hard at whether we are rewarding acts of commercialism in health care more than the health care services that patients and society really want.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. This article 1st appeared on December 11, 2007 in HHN Magazine online site.

Conversations on The Changing Face Of Managed Care: Insights From the 2006-2007 Podcast Series

Thursday, September 6th, 2007

Conversations on the Changing Face of Managed Care: Insights from the 2006-2007 Podcast Series


Saturday, September 1st, 2007

Most policy wonks, consultants, CEOs and venture capitalists live a bicoastal existence, jetting between San Francisco, New York, Boston and Washington, D.C., and occasionally touching down at O’Hare. They fly over the rest of Amurrica, often believing, mistakenly, that nothing new or interesting happens there.

Regarding health care, they are wrong. Many of the more innovative health care organizations, including regional coalitions, health plans, hospitals and health systems, can be found in the middle of America. I have had the opportunity to work with many of those organizations over the years, but I would draw attention to Ohio as a good example of quiet innovation where institutions are making a difference without all the fanfare and self-promotion of California and Massachusetts.

Midwest Successes

Ohio is the nation’s seventh most populous state, with more than 11 million residents, and has proven to be a critical swing state in national elections. It’s a state with several significant cities, including Cleveland, Columbus, Cincinnati, Dayton, Toledo and the Akron/Canton metropolitan area (if people share an airport name, I figure they don’t mind being lumped together). I have had an opportunity to visit several institutions in the state and have been impressed at many innovations and health care successes.

Cleveland. If you are going to have a heart attack, have it on the doorstep of the Cleveland Clinic. Under the leadership of pioneering heart surgeon Dr. Toby Cosgrove, Cleveland Clinic continues to earn its reputation as a global leader in high-quality care and as a key generator of medical innovation. Much less heralded, though equally impressive, is the story of University Hospitals Health System (UHHS) in Cleveland, which has undergone a massive financial turnaround in the last four or five years under CEO Tom Zenty’s leadership. UHHS is on its way to Vision 2010, investing over a billion dollars in new development.

Dayton. At the nationally recognized Kettering Health Network, CEO Frank Perez is leading the system in rapidly implementing personal health records, not just for his own hospitals’ patients, but for the community at large. This ambitious, patient-centric initiative will help patients manage their own health and provide information to local physicians, improving the timeliness and quality of patient care.

Canton. Aultman Health System, providing nationally ranked quality in its facilities, has a long history of delivering high quality at low cost. Since 1985, Aultman has built its own health plan, Aultcare, which serves 500,000 members in the local area (mostly through PPO products). Aultman Hospital doesn’t need any other managed care contracts, as its value proposition to local employers is that it can deliver care better and more cheaply by taking the insurance dollar out of the community. This is a rare and high-performance example of virtual integration. CEO Ed Roth quietly builds on the Aultman legacy to provide the value proposition for the Canton community.

Cincinnati. The Greater Cincinnati Health Council celebrated its 50th anniversary recently. The council has been a pioneer in many areas of regional cooperation among hospitals and other stakeholders. Its pioneering work under current CEO Colleen O’Toole and her predecessor Lynn Olman has included path-breaking innovation in transparency of cost and quality measurement and reporting, in quality improvement, and in regional health information networks. These and other initiatives have won accolades and awards from the Joint Commission and from the Robert Wood Johnson Foundation. The council spawned a long-standing regional health information organization (RHIO), Healthbridge, which remains one of the few successful and self-sustaining RHIO business models in the country, and is a tremendous platform for communitywide health management and disease management initiatives. Somehow Healthbridge has overcome the difficulties of infrastructure, privacy, complexity, standards setting and lack of organizational commitment that have dogged so many of the RHIO efforts nationally.

Dublin. Ohio Health is building a brand-new hospital, Dublin Methodist, to serve the expanding local community in the Columbus suburbs. CEO Cheryl Herbert and her team have created, and are about to open, a new, evidence-based-designed facility that promises to be one of the highest state-of-the-art health care facilities in the country. Dublin Methodist is a living laboratory of how organizational culture and design can be melded to deliver a superior health care experience.

Three Lessons from Ohio

I am sure if I looked, I would find similar good work in other parts of the state. So to any Ohioans I’ve left out, please don’t take offense. But my general point is this: While Ohio is not at the top of the pile in being one of the high-quality/low-utilizing states, like Oregon and Minnesota, it has significant innovations in finance and delivery that are worthy of attention. I would make three observations about those innovations:

Leadership matters. In all cases, the institutions I ran into were blessed with good leaders—in many cases, two and three generations of such leaders. Leaders make a difference; it’s not just a bumper sticker.

Local is good. Sometimes it’s easier to get people around a table to act locally than to make plans and policy globally. This is not always the case: “All politics is local” they say, and my observation is that the more local it gets, the more vicious it gets. But somehow these local leaders have found a way to bring stakeholders together.

Look everywhere. The nation’s business and policy elites need to stop flying over the middle of America and actually touch down, watch and listen to what is going on. You all might learn something.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN OnLine. This article 1st appeared on September 4, 2007 in HHN Magazine online site.

Aussie, Aussie, Aussie

Sunday, July 1st, 2007

Well, it’s health reform season again. Every 10 years or so we get geared up to reform health care. We never actually do anything, but we have a great old time talking about it at conferences.

At some point in the debate, maybe soon, we start casting around for solutions from abroad. Somebody must be doing it right, we start to think. Well, actually, every system around the world is an ugly compromise among cost, quality, access and security of benefits, and almost all systems are in crisis according to the local news media. We in the United States have a bad bargain, maybe the worst: high costs, uneven quality, poor access and no security of benefits except for those over age 65.

Looking around the world, there are lots of things to learn from the United Kingdom, France, Germany, Canada and others. The place that has my attention these days is Australia. I like Australia for the people, the wine and the weather-but it has a lot to teach us about health care, too.

Australia is a big country (bigger than the continental United States), but it has only 20 million people. Aussies are a no-nonsense, sarcastic, fun-loving and friendly people who have a very low tolerance for pretentiousness-my kind of people. On a recent visit, I had a chance to meet with the nation’s top CEOs of health plans and learn a little about what Australia is doing. Australia can teach us some important lessons to fuel the U.S. health reform debate.

The Aussie Health Plan

All health care systems are difficult to describe, and all reflect the culture and values of the country. Here is a very brief and simplistic overview of Australia’s health care system.

Imagine the Canadian system as a base (a national health system funded through taxes that provides all ambulatory care and has public hospitals where care is effectively free to residents, although their choice of specialists and amenities in the hospital would be somewhat limited). This is what Australians call Medicare.

Add to that a private insurance system that supports hospital care in private hospitals and in higher-amenity environments in public hospitals for people with private health insurance. The private system is not dissimilar to the United Kingdom’s. The big difference is that, while less than 10 percent of Brits have private insurance, nearly 50 percent of Australians have some form of private coverage that was purchased directly by families and individuals. And unlike the United Kingdom, where the private sector has historically been characterized as queue jumping for minor procedures like varicose vein removal, the Australian private system covers about half or more of chemotherapy, joint replacement and other high-tech care.

Private insurance in Australia is relatively cheap by our standards, with cost depending on the type of coverage purchased from a few hundred dollars a year up to about $3,000 (Australian) for “Rolls Royce” coverage. Experiments are under way to fund health services through private insurance “outside the hospital gate,” as they say down under, meaning in the ambulatory environment.

Overall, the nation spends about 10 percent of its GDP on health, compared with 16 percent in the United States. The people seem as happy as anyone else, based on international surveys, and they live longer and seemingly better than we do. I think it’s the beer, the beaches and the barbie that does it, not the health care, but that’s another story.


How do Australians manage to get people signed up for a two-tiered system and deliver what seems a pretty decent value to all Australians? Here are some clues that we might learn from:

An explicit choice/cost trade-off. Australians face a clear and seemingly socially acceptable choice: You can have free care, paid by you and your fellow taxpayers, but you will have no choice of provider for specialty hospital-based care, and you will not get the fancy private room unless you are devastatingly ill. Or you can buy a private insurance policy and have complete choice of provider, no waiting and higher amenities. If you buy the private insurance (as in the United Kingdom), you still have to pay your taxes to the Australian Medicare system, and all Australians get pretty much the same primary care and ambulatory public services. Private patients care about the public system because they are subsidized by the public system while in the hospital, in that Medicare is paying for a significant portion of the private patient’s stay. That is one reason the private insurance system accounts for only 11 percent of overall funding for health, despite its 50 percent penetration of the population. Overall, Australia is a very interesting example of what the Europeans call social solidarity, blended with and supplemented by private insurance. It will be interesting to see as the private sector grows outside the hospital gate whether the solidarity remains so solid, but to date, the Aussies seem to have broad buy-in for the system, with the exception perhaps of trade unions and the political left.

A simple tax subsidy. In the last decade, Australia has experimented with tax-based inducements for individuals to purchase insurance. They tried means-tested subsidies, but those did not seem to work, and Aussies have now hit on a 30 percent flat rebate as a way to stimulate growth in the private system. It seems to be working like a charm. Since the introduction in 1999 of the rebate and lifetime health coverage guarantees (I’ll say more about the latter below), enrollment in private insurance, which was dwindling at around a third of the Australian population prior to the reform, jumped dramatically to now almost exactly half of all Australians being covered by some form of private insurance (with 43 percent having coverage for hospital care). It’s not just the richest half who signs up. A quarter of those with private insurance have annual household incomes of less than $33,000 Australian (about $27,000 in U.S. dollars), and half of all privately insured Australians have household incomes of less than $70,000 (Australian), which is about $58,000 U.S. and pretty close to the U.S. median household income. My impression from the Sydney news media and local ads for coverage is that buying health insurance is viewed as a no-brainer for the middle class, largely because of the tax subsidy.

Incentives to sign up young and stay in. Critics of private insurance point to the classic sources of market failure: cream skimming, adverse selection and moral hazard. True, Australia has to be wary of all of these. But it has developed a sensible inducement to sign up when you are young and healthy and stay in for life. Most importantly, private health insurance in Australia is community rated, and a reinsurance pool handles the risk adjustment that could face insurers who get disproportionate enrollment from the elderly or the sick. (What a radical idea! I am still mystified that we in the United States abandoned community rating over the last 20 years with seemingly no public or political debate about the consequences of the shift.) In addition, as part of the 1999 reform, Australians 30 years old or under who sign up for private insurance pay a lower premium throughout their lifetime than those who postpone enrollment. People over the age of 30 will face a 2 percent increase in premium over the base rate for every year they postpone joining an insurance plan. Brilliant. (Recent legislative changes remove this penalty after people have paid the increased premiums for 10 years because research showed that it was a reason people abandoned private health insurance. Again, this latest move is targeted to keep the younger people enrolled.)

The employer has no role. The Australian system is about government, private insurers and consumers figuring out how to get along. Employers are out of the picture. There is almost no group insurance, and almost no employer sponsorship of health insurance. Who needs it if you have community rating and risk adjustment? Australian businessmen do not have to fret about how health care costs are eating their earnings per share. They just have to pay their taxes and let their employees figure out on their own if they like the value proposition of private health insurance.

Marketing and administration costs are low. The traditional rap against individual insurance markets is that they have astonishingly high administrative costs to pay brokers, do underwriting and so forth. It appears that this is not the case in Australia. Total administrative costs of private insurance (including profit) are around 9.5 percent, way less than in the United States. This is partly because the products seem to sell themselves as a result of the tax subsidy, partly because they are simple and not overly expensive products, and partly because the industry is efficient and seems to operate in a form of collegial competition through regional oligopolies rather than through an advertising and marketing arms race.

Containing costs through the pharmacy benefit scheme. The private sector CEOs of health plans in Australia love the nation’s pharmacy benefit scheme, a universal system of coverage paid by the Commonwealth (the federal government), which covers most medications through a very tight price-controlled, reference-price-based system. It is a system that is detested by every global drug company, but is enthusiastically embraced by the health plans (or health funds, as the Aussies call them).

Where do they go from here? I gave a little talk in Sydney to a group of health fund leaders about what we are doing in America about value purchasing, transparency, pay for performance and so on, and the Aussies seem interested in embarking on many of these initiatives. Indeed, my mate Dr. Michael Armitage, a former health minister of South Australia and current CEO of the Australian Health Insurance Association, is pursuing many of these initiatives with his members. In other areas, like health IT, the Aussies are way ahead of us.

There is no such thing as a perfect health care system. But Australia has wrestled, I think successfully, with big issues such as the balance between public and private coverage, the role of employers, the value of tax subsidy, simplicity of insurance product design and coordination of public and private controls for new technology. Australia is worth a visit for a whole host of reasons, including some ideas about health care. So as the Australian tourist board ad says: “Where the bloody hell are you?”

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. This article first appeared on July 9, 2007 in HHN Magazine online site.

Time Out

Friday, May 4th, 2007

Everywhere I go in health care as a patient, a family member of a patient or a futurist, I see that people in health care are really busy. Actually, frenetic is a better term. Doctors are frantically pedaling to keep up with medical innovation; declining reimbursement; and waiting rooms full of patients who get older, fatter, crankier and more demanding every day. This is the hamster care I have described elsewhere: Doctors are like hamsters on a treadmill of discounted fee-for-service, scurrying faster and faster to make their target income as real reimbursement per unit of service declines.

But nurses and other caregivers are even more harried. They live in a world of hyper-documentation, of HIPAA compliance, of measurement of everything, of endless meetings and exhortations for performance improvement, all enabled by information systems that are feeble, disconnected or nonexistent.

Health care delivery is like Jet Blue on a bad day, trying hard to be cheery when it is overwhelmed.

High-Tech Chaos

As my wife was being cared for recently in a prestigious teaching hospital with magnet status, fabulous doctors and nurses and shiny new buildings, I watched the nurses scribbling on Post-it Notes that they placed on top of the keyboards of expensive mobile workstations that seemed to be permanently disabled. There were signs about infection control processes, warnings about name duplication of patients and exhortations to wash hands everywhere you looked–a disorienting blizzard of quality improvement information.

My wife was surrounded by, and plugged into, an assortment of expensive-looking machines that we Americans love so much. “Machines that go ping” Monty Python once called them. No one seemed to pay much attention to them or the alarms that went off. The very expensive bed moved itself periodically, whether you wanted it to or not, making it virtually impossible for the patient to get comfortable.

Every few hours a whole new cast of characters became my wife’s caregivers. Everyone did a great job, but I was struck that no one in their right mind would actually design work processes that way. Health care delivery really is Pimp My Ride writ large, with layers of gadgets and technological excess on a tired, old, and beaten-up chassis.

More recently, as a nation we experienced shock and awe that our brave military folk who have been wounded in Iraq are not receiving seamlessly coordinated care, that health care information systems for veterans don’t talk to one another and that there are significant failures in integrating sophisticated acute care with the rehabilitation and management of chronic conditions and serious mental illness so epidemic in Iraq veterans. But that’s no different from the rest of us.

A Stop to the Madness

I do not blame the valiant doctors and nurses who are trying their best. I think they are overwhelmed. So I am proposing a mammoth time out for health care. Here is how it would work:

Declare a technology moratorium. No new drugs or devices would be approved for two years until we learn how to properly use the ones we have. I would suggest we pay the manufacturers exactly what we are paying them right now, but instead of selling new stuff, they send all their smart people into the hospitals and doctors offices to apply their sophisticated business acumen in redesigning care processes so that they are efficient and effective. The technology vendors could still do R&D on new products, but the rules would be different when the moratorium ends: We won’t buy anything unless it is better, faster and cheaper than existing methods, otherwise it’s not happening.

Ban the consultants. Futurists and health care consultants would be banished for two years unless they were prepared to do bedside management engineering, helping doctors and nurses design care processes that really work. There would be no conferences about the future of health care, PowerPoint presentations would be outlawed and there would be no national meetings, unless they were authorized by Don Berwick.

Freeze the insurers. All insurers would be required to keep all the members they currently have. There would be no marketing or dropping of coverage, and all the money saved from their marketing budget would be sent to the Time Out Czar, who would use the money to build a new delivery system from scratch for the uninsured.

Shut up the politicians. Politicians would not be allowed to talk about health care unless they specified how it was going to be made more affordable. Promising Magic Kingdom entry passes to a dysfunctional health care delivery system would be banned.

Furlough the doctors. All doctors would be furloughed at a salary of $500,000 a year for a specialist and $200,000 a year for a primary care doctor. They would be called back to staff a redesigned delivery system as needed. This suggestion actually might save a lot of money, because physicians’ net income is only about 10 percent of health care costs. It is the economic havoc they wreak trying to get that income in a fee-for-service system that causes all the problems.

Zero-base the delivery system. Starting with the uninsured, the Time Out Czar would design a rational delivery system. I started my health care career doing zero-based budgeting in Canadian health care. It was made fashionable in the late 1970s by Jimmy Carter, but the premise was simple: What would you do with your first dollar of expenditure, then with the next layer of spending, and so on, all to reach the optimum outcome?

At a recent meeting of emerging global health care leaders from Africa, Asia, North America and Europe, I suggested that if you took the zero-based approach to health globally, you would start with spending your first health care dollar on clean water and condoms, then add lady health workers (as they do in Pakistan, where local women, not nurses, are empowered to give basic prenatal care, dramatically reducing infant mortality), then add immunization and hydration therapy for infants, then capitated primary care (as they do in Chile), then free generic drugs (as in South Africa), then basic outpatient surgical services. All of this could be done for probably less than $1,000 per capita, even in the United States. You would have to spend much more before you ever built hospitals or bought MRIs, but even developing countries fall into the trap of building fancy Western hospitals as a symbol of a great health care system.

Obviously, this is not a serious proposal. But if we do not pause and reflect; if we do not start to set priorities based on cost-effectiveness criteria; if we do not change the reimbursement system for providers to reward outcomes, not volume of marginally effective services; if we do not become more judicious in our introduction of new technology, we will bankrupt ourselves. We will create millions more uninsured and underinsured, and we will have no policy options left.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN OnLine. This article 1st appeared on May 1, 2007 in HHN Magazine online site.

Care, Not Coverage

Thursday, March 1st, 2007

We should cover the uninsured. You hear that a lot. We have been saying it for 40 years. Hasn’t happened.

Even in the roaring ’90s when the economy was rocking and rolling, when really rich Americans earned a lot and paid a lot in taxes, when we had a popular Democratic president and when we had a government surplus, we did not cover the uninsured. Maybe we don’t want to. Maybe it is just too expensive now. Maybe we can’t be bothered, what with Iraq and the war on terrorism and global warming and all.

Nevertheless, you are going to hear a lot about covering the uninsured in 2007. It is becoming fashionable again. Politicians, from governors to mayors to maybe even presidential candidates, are going to speechify about covering the uninsured. Some may even go further than that and pass some legislation through their elected bodies.

Massachusetts offers an interesting state-level experiment in which everyone, both employer and individual, is compelled to participate. In Massachusetts, health care insurance is both a right and an obligation: You have the right to expect health insurance coverage, but you have an obligation to pay something for it. (Note that it doesn’t seem providers have to sacrifice anything–they just get more insured patients.)

We will all watch Massachusetts very closely, but can we learn from the experiment and apply it elsewhere? As I point out to my Boston buddies, we have more uninsured in California than they have people in Massachusetts, so the problem is of a different scale in California or Texas.

California Coverage

Speaking of California, the residents of that state have a wave of initiatives coming at them over the next couple of years. They have universal coverage in San Francisco. (Actually it is not coverage, because according to the mayor it is not insurance, because insurance would be challenged on ERISA pre-emption grounds and challenging ERISA is like challenging big tobacco: You don’t go there. So it may look like insurance–you pay a premium and you get covered services–but it is not insurance, OK?)

At least in San Francisco the bureaucrats have run the numbers past actuaries and come up with a very rich benefits package for only $201 per month. How can they do it? They’re presuming that all providers will spontaneously accept Medicaid rates. Other plans have been floated in California, including everything from single-payer alternatives to employee mandates (the so-called SB2 ballot initiative that was shot down recently, but may well resurface).

Again in California, Kaiser Permanente has developed an ambitious and logical proposal to cover the state’s uninsured by requiring all taxpayers to participate in some form of coverage. Those who are ineligible for existing public and private programs or cannot afford them (below 300 percent of the federal poverty level) would be funded through a mix of payroll and provider taxes at a total additional cost of $7.5 billion.

And Gov. Arnold Schwarzenegger has declared that universal health care coverage is his top priority. The governor’s plan is to be commended for the “shared sacrifice” that it requires. Government (especially the federal government) has to give some, and state taxpayers have to give some. Businesses with more than 10 employees have to “pay or play” (provide insurance or pay into a state pool). Other individuals, including those who work for small businesses, have to buy at least a catastrophic coverage plan. And most interestingly, providers are taxed (4 percent for hospitals and 2 percent for doctors) in recognition that their uncompensated care burden would be reduced by expanded coverage and improved Medicaid reimbursement. All oxen are gored in the process, which is a good thing.

This and all plans say very little about how health care will become more affordable or how costs will be contained in the long run. But overall, it represents an emerging consensus that health care is both a right and an obligation. You have the right to expect some access to health care, and you have the obligation to participate in paying for it. It’s easy to say, but the hard part is figuring out who pays for what.

Focusing on Care

We can expect more proposals as politicians see an opportunity to focus on an issue that has political traction, even though the potential solutions are complex, messy and difficult to communicate–and end up costing payers, employers, providers, patients or taxpayers much more. That’s why we may find that all these schemes go nowhere, and the number of uninsured continues to rise, particularly if we see double-digit increases in the cost of care (the single biggest driver of the uninsured) or, even worse, a downturn in the economy. Because if you cannot cover the uninsured when you are at full employment and a budget surplus, as in 1999, when can you?

Maybe we need to change the focus from coverage to care. For example, giving people an insurance card helps only if a provider accepts both them and the card. Try, for example, finding an OB/GYN in California if you are on Medi-Cal. We might be better off training a whole cadre of nurse practitioners to create universal prenatal and well-baby care as a government-funded service, like K-12 education. People can always buy additional insurance if they want more than the basic program.

A further benefit of focusing on care delivery, not coverage, would be reducing the absolutely staggering costs of administering the eligibility requirements for complex, means-tested programs involving moms and kids in poverty. My favorite statistic is that there are 1,900 people employed in Los Angeles County who do nothing but fill out Medi-Cal eligibility forms for county residents at a union-mandated productivity target of two such forms per day! We should give these employees white coats and have them go to schools to immunize kids and teach them about the perils of a fast-food diet. Oh, and if we extended the universal care system to all kids, eligibility would be easy; if you are a kid, you get care: no coverage, no forms, no questions.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. He is also a regular contributor to H&HN OnLine. This article 1st appeared on March 6, 2007 in HHN Magazine online site.

With Mayo

Monday, January 1st, 2007

Last fall I was with Mayo. Not in the sandwich sense, but in the Rochester, Minn., folks at the Mayo Clinic sense. It was my second visit, this time to meet with the leaders of the Mayo Health System.

Mayo Health System is not the Rochester clinic but the network of 16 affiliated hospitals and clinics with 720 physicians spread over 250 miles where Minnesota, Wisconsin and Iowa meet. Mayo Health System is part of the consolidated financials of the Mayo Clinic (which in total has some $6 billion in revenue from all its sites). But from a governance perspective, Mayo Health System reports to the board of trustees of the Mayo Clinic Rochester. Got it?

Once-independent community hospitals and clinics have been absorbed into this network over the last 14 years. The progressive integration that has occurred under the able leadership of Dr. Peter Carryer, chair of the Mayo Health System board, and his colleagues has created a network that gets progressively more Mayo over time, exhibiting ever-more characteristics of the mission, values and behavior of the mother ship in Rochester. Actually, mother ship is the wrong term, more like mother fleet, because the whole of Rochester, with the exception of the giant Libby’s corn-on-the-cob water tower, seems to be part of the Mayo Clinic–from the myriad hospitals and clinic buildings to the fact that everyone on the regional jets flying into Rochester is going to the clinic to get treatment, to get training or to give a talk.

I came away, once again, from Mayo even more firmly of the belief that we all deserve to have the Mayo Clinic: not to all fly to Rochester, please understand–there isn’t room on the planes or in the Marriott next door–but to have our local health system deliver the Mayo.

Lessons from Mayo

What makes Mayo? My friend Len Berry, Ph.D., distinguished business professor at Texas A&M and an internationally recognized expert in service industries, spent a lengthy sabbatical studying Mayo in Scottsdale, Ariz., and Rochester, and I cannot even begin to do justice to his scholarly review of what makes Mayo so good. (You should it read for yourself. See, for example, “Clueing in Customers,” by Leonard L. Berry and Neeli Bendapudi, Harvard Business Review, 2003, Reprint R0302H.) But here are a few personal observations I would add to Len’s work about what factors distinguish Mayo from the pack.

Global brand. The Mayo Clinic is synonymous with quality. No, really, it is. It has a global brand that speaks of medical excellence in solving difficult diagnostic problems, of providing desperately sick patients with hope and offering path-breaking medical advances in research and treatment. That’s why patients come from all over the world to get care and why Mayo has more than 1,700 clinical fellows receiving training in graduate medical education. “I trained at Mayo” is a proud boast of many of the world’s greatest clinicians and medical scientists.

Saudi princes and a lot of locals. Despite Mayo’s globally recognized brand, it is important to know that only 3.5 percent of patients come from afar. I am sure these patients represent a bigger share of the bottom line, maybe 10 to 15 percent, but it always comes as a bit of a surprise to find that Mayo is a regional and local health system at its core. Mayo remains financially healthy because the local Blues plans pay a fairly high share of reasonable and customary charges. If these plans started to get difficult, Mayo might have a problem, but I can’t imagine why a payer would take them on; what’s not to like about getting the right care the first time around?

So, even at Mayo, health care is primarily a local good. Actually, this local-versus-national focus isn’t that much different from any of the national flagships like the Cleveland Clinic, M.D. Anderson, Stanford, Hopkins, Cedars-Sinai, Mass General and on and on. While these great institutions attract patients from all over the world and these (generally affluent) patients contribute a disproportionate share of the bottom line, they tend to account for less than 5 percent of volume. Funnily enough, just the other day, I landed in Cleveland and as we pulled into the gate, across the way was an Airbus emblazoned with the government of Kuwait colors. At first, I was shocked that there was a direct flight from Kuwait to Cleveland, and then I realized it was probably some ailing emir who commandeered the government jet to come and get a bypass at the Cleveland Clinic.

Values-based culture. In the early days of Mayo, one of the clinic’s founders, William J. Mayo, M.D., stated, “The best interest of the patient is the only interest to be considered.” Mayo is built on this simple premise that the founding Mayo brothers hammered into the DNA of the organization: “Put the patient first.” This is not a slogan. It is the credo that guides the organization and the people who work there. Len Berry’s research reveals a staff at Mayo Clinic highly committed to serving patients. From volunteers to world-class surgeons to the more than 70,000 individual benefactors, the people at Mayo are focused on the best interests of the patient.

Minnesota nice meets medical excellence. As Berry and Bendapudi’s research shows, Mayo carefully captures this will to serve and reinforces it through training, selection of staff and a structure of compensation (salaried physicians in particular) that rewards integration and teamwork to serve patients’ needs. It doesn’t hurt that Mayo is in the “nice” state of Minnesota, but these values and practices apparently extend to the Scottsdale and Jacksonville, Fla., campuses as well.

No jerks. In my limited exposure to Mayo, I would argue that one of the hallmarks is that they don’t hire jerks. This is not a place for brilliant but difficult prima donnas. The folks at Mayo say they may have the odd jerk, but they are the exception rather than the rule. When physicians and staff are recruited, they get the no-jerks-allowed message, so the people who are attracted to Mayo tend to be self-selected to this culture of getting along to serve patients.

Team is everything. Integrated, team-based care is the hallmark of the Mayo delivery model. If your doctor can’t figure out the problem, he or she will bring in colleagues to help, and there is no shame in drawing on others’ expertise. While this is how medicine is supposed to work, it doesn’t always turn out that way in many large, internally competitive, clinical settings that operate more like Survivor.

No empire building. Unlike many big, prestigious academic medical centers, there is remarkably little sense of departmental empire building at Mayo. Partly this is reinforced by the fact that important physician leadership roles (such as chairman of the board of trustees of the Mayo Clinic at Rochester) are for four-year terms, and while in some cases an exceptional incumbent may serve two terms, it is anticipated that they will return to full-time clinical practice or some other combination of duties after their leadership service concludes. (In the interests of full disclosure, my wife’s first cousin, Dr. Hugh C. Smith, a distinguished cardiologist, recently concluded two such terms as Rochester Clinic board chair and has now returned to a combination of clinical practice and development work on behalf of the clinic. So if my column seems uncharacteristically positive, you skeptics might attribute it to family-oriented bias.)

No expansion beyond two satellites. While Mayo has successful satellites in Arizona and Florida, it seems they have settled on the formula that they don’t have to be everywhere in America to serve patients. Indeed, by focusing locally they can sustain and enhance the model without having the values and vision corrupted by the pressures of competition in a whole bunch of different geographic markets with very different medical mind-sets.

Leading health and health care. Mayo has been a pioneer in public education on health and wellness; they play a key role in health promotion nationally; and it is no accident that Olmsted County, where Rochester is located, is among the healthiest in the nation. Thankfully, the Mayo Clinic is also committed to becoming more of a voice in the national health policy debate, as evidenced by the Mayo Clinic CEO, Dr. Denny Cortes, leading a National Health Policy Summit at Mayo Clinic earlier this year. We need their help.

We all deserve the Mayo Clinic. We all need truly integrated care, where the patient is put first; where the care is done right the first time; where the payer pays for value and outcomes, not low-cost units of service; and where staff are proud and happy to work, on behalf of patients. If that doesn’t sound like the frenetic zoo where you work, or where you get health care, then maybe you should get your care with Mayo.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. He is also a regular contributor to H&HN OnLine. This article 1st appeared on January 2, 2007 in HHN Magazine online site.

First Class

Friday, October 6th, 2006

We have a first class healthcare system. It works pretty well for people in first class but if you are in coach you might not be so happy. Class (by this I mean socio-economic status) is increasingly the predictor of healthcare outcomes, service, and satisfaction, and here’s the really good part, if you are in first class you pay less of your income for healthcare than if you are in coach. So what’s not to like?

The Role of Class in Health

A number of recent studies are reinforcing a point that we have known for a very long time that socio-economic class is a powerful predictor of disparities in health care treatment and outcome, even adjusted for access. Here are two recent examples, quoted directly from the news feeds or the study abstract:

  • Study of Disability rates in the US. “U.S. residents ages 55 and older with annual incomes less than the federal poverty level are more likely to have disabilities that limit routine physical activities than those with higher incomes, according to a study published in the New England Journal of Medicine on August 17, 2006. According to the study, respondents ages 55 to 64 with annual incomes less than the federal poverty level -at the time, $8,259 for an individual – were six times more likely to have disabilities that limited activities such as walking, climbing stairs and lifting objects than those in the same age group with incomes of $60,000 or more. The study also found that the rate of disabilities continued to decrease among respondents ages 55 to 64 as annual incomes increased higher than $60,000. Study authors said the disparity did not result only because of more limited access to health care among respondents with lower annual incomes. Meredith Minkler, a professor of health and social behavior at UC-Berkeley and lead author of the study, said, “Social class is a tremendously important risk factor for disability,” adding, “If policy makers are concerned about improving health status, they need to focus not only on medical coverage, which only accounts for 10% to 15% of health status, they need to look at how to improve social class.”
  • US and England Comparisons. “The US population in late middle age is less healthy than the equivalent British population for diabetes, hypertension, heart disease, myocardial infarction, stroke, lung disease, and cancer. Within each country, there exists a pronounced negative socioeconomic status (SES) gradient with self-reported disease so that health disparities are largest at the bottom of the education or income variants of the SES hierarchy. This conclusion is generally robust to control for a standard set of behavioral risk factors, including smoking, overweight, obesity, and alcohol drinking, which explain very little of these health differences. These differences between countries or across SES groups within each country are not due to biases in self-reported disease because biological markers of disease exhibit exactly the same patterns. To illustrate, among those aged 55 to 64 years, diabetes prevalence is twice as high in the United States and only one fifth of this difference can be explained by a common set of risk factors. Similarly, among middle-aged adults, mean levels of C-reactive protein are 20% higher in the United States compared with England and mean high-density lipoprotein cholesterol levels are 14% lower. These differences are not solely driven by the bottom of the SES distribution. In many diseases, the top of the SES distribution is less healthy in the United States as well.”

These dramatic differences across socio-economic class are not just about access to healthcare or insurance coverage. They point to the fundamental role of class as a determinant of health. But obviously, these results are further compounded by the well-documented effects on health of both health insurance status and race and ethnicity. For example, analysis by the Commonwealth Fund has shown that among working people, the rate of uninsured is only 5% for those in the top income quintile (roughly $90,000 plus in household income) whereas it is 52% in the lowest income quintile (households earning less than $20,000). The most dramatic recent increase in uninsured rates is among those households earning between $20-35,000 (the second and third quintile of income). All of these effects are even worse when race and ethnicity are added to the mix, as the IOM’s report “Unequal Treatment” carefully documents. (By the way, the UK/England study focused solely on the white population, partially I believe to head off the old canard of international comparison studies, namely that the US is different because of our more heterogeneous population).

The bottom line of these studies is that socio-economic status matters a great deal and there are real smart scientists that believe there are neuro-physiological processes at work affecting human biology that have to do with stress and degree of control. In reviewing the US/UK study with a British journalist from the Financial Times of London, I speculated that we all work too hard in the US, and the poorer you are and the less educational opportunities you have, the harder you have to work. Maybe we should all put down our brooms or our Blackberries and go to the pub and we might be a lot healthier.

Class and Payment

But, I want to link the concept of class to the broader question of who pays for healthcare, because we have a unique set of circumstances in the US, where the income distribution is getting ever more extreme (the very rich getting very much richer) at the same time that we have healthcare financing policies that are regressive in their funding. High deductible health plans, in general and HSAs in particular are regressive forms of payment (rich people pay a smaller share of income to health care than poor people). As I have estimated in this column before, a million dollar a year earner in Canada would pay $150,000 in taxes toward healthcare, a million dollar earner in the US would pay about $58,000 in taxes and premiums toward healthcare. That is why single payer schemes such as the one passed in late August by the California Assembly is an assault to the status quo. The proposed legislation would be paid by an 8% payroll tax and a 3% individual income tax, probably doubling the overall healthcare bill for those million dollar earners. Obviously, only a few hundred thousand folk in America make over a million a year, but we all think we will, if we can’t go the Princeton, Stanford, venture capital route we are betting on the NBA, hip-hop, or No Limit Texas Hold’em to get us to the bling.

The battle that will ensue in the next round of national and state health policy debates will center on whether the middle class associates itself politically with the top or the bottom of the income distribution. Bear in mind that only slim majorities of national or California voters are willing to pay any more in taxes for healthcare and that the support evaporates after about $200 per year in additional taxes. It will be interesting to watch.

A Modest Proposal

Here’s my little idea. What if we took the best of the right and left. High Deductible Health Plans (HDHPs) are cheaper, because they don’t cover everything and when people have to pay out of pocket they use less (which may be good, bad or ugly depending on what care is foregone, but many of us believe it is generally bad or ugly, for example causing people to postpone needed preventive services or not comply with treatment, particularly for low-income people). The reason HDHPs are cheaper is not because of the tax advantage of HSAs but because of the high deductible. We should cover preventive services and chronic care medications on a comprehensive basis. We should have incentives for patients to be mindful of cost (not just drugs) and we should make the financing system a bit more progressive than regressive if we want to mitigate some of the worst effects of class. So here goes: everyone gets a basic preventive package covered on a first dollar basis, everyone gets a $10,000 per household deductible catastrophic health plan (premium sharing would be based on income), everything in the middle (the $10,000 in patient spending) is on a sliding co-insurance scale where the lowest income folk pay zero co-insurance and the top income folk pay a 100% co-insurance rate. According to the latest data from the Census Bureau for 2005, 19.7 million households (some 17%) earn over $100,000 in household income, 2 million households make over $250,000. Those top 1 or 2% earners would pay a larger share of premium, the taxes necessary to cover the premium subsidy to the poor, and up to $10,000 out of pocket making hospitals, doctor visits, and elective surgery a bit more of a retail experience. Oh and we probably should be using after tax dollars, not pre-tax dollars in a Health Savings Account. By making the affluent, well educated, savvy consumers pay more for first class we might even get the effects promised by the consumer-directed advocates, such as more questioning of the prices charged by providers. Enlightened employers like the University of California have some elements that point in this direction such as income-based premium sharing: janitors pay less toward healthcare than tenured professors, but that is a small step toward addressing the disparities created by socio-economic class.

Before the rich readers go up in arms about socialism and income re-distribution being dangerous and seditious, let me point out it is better for you than the single-payer alternative which is, by its nature, an even more massive transfer of income from rich to poor.

While this or other redistributive schemes is unlikely to be enacted as legislation it is important for all of us in healthcare to remember that class matters. It is always good to be in first class, but way too many of us never get the upgrade.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California.

Choice, Security and Stuff

Sunday, August 6th, 2006

All economies and all health systems struggle with trade-offs among three key elements: choice, security and stuff.


Choice is a manifestation of freedom. Americans love freedom and the choice that goes with it. We like choice of doctors, maybe even health plans, and we certainly don’t want our choices limited by government fiat or managed care bureaucrats. When choice is constrained we get very cranky. We hate gatekeeper physicians, we detest pre-authorization, we can’t stand limits on our use of expensive technology, even when it does more harm than good, and we go crazy when we are told we can’t get what we want.

But sometimes we have too much choice for our health. We have a plethora of cheeseburger options (including a cheeseburger embedded in a Krispy Kreme doughnut–I am not making this up). Seniors have 45 or more baffling Prescription Drug Plan choices in the new Medicare Part D world. Doctors are free to perform any procedure they want if a consumer with cash asks for it. Sure there is a wee thing called professional ethics, but the variation literature says there is a lot of excessive care based on provider preferences compared with best practices.

We have codified the health plan of the future as “you can have anything you want as long as you pay for it out of pocket.” Certainly, we have some annoying bureaucratic hurdles, but generally you can get anything you want in health care, if your insurer–or more often now, you–are willing to pay for it.

All this choice comes at a cost. Not only are we being asked to pay more for choice in the form of premium sharing, copayments and deductibles, but because we have so much choice, and we are unwilling to put limits either individually or collectively on our choices, health care is becoming increasingly unaffordable. Our freedom to choose in the short run may limit our choices in the long run. It’s a bit like global warming.

Choice and Security

Unfettered choice is fueling cost escalation, and in the long run it will limit our ability to choose and undermine our health security. We see it in the growing numbers of uninsured: In the last five years there has been a dramatic rise in the percentage of lower and middle-income people without health insurance, largely due to the fact that small businesses and individuals increasingly can’t afford health insurance.

We see it in the dire forecasts of how much money it takes to retire at 65 to pay for out-of-pocket medical costs (currently estimated to be more than $200,000). We see it in the rising number of medical-related bankruptcies. We see it most acutely in the rust-belt industries where retired auto workers have to gamble between health security and income security: For example, GM has offered a $140,000 buyout to workers with at least 10 years on the job who are willing to walk away without continuing benefits.

We may see it in the public sector and local government, in particular, as the GASB (Governmental Accounting Standards Board) Statement #45 provisions begin to take effect starting at the end of the year. (I am no accountant, but in a nutshell these provisions require state and local governments to make their unfunded retiree health benefit costs explicit on their balance sheets, starting with largest entities on December 2006 and phasing in over the following three years.)

A senior financial services executive told me the effect would be to make every municipal bond in America a junk bond. He may be overstating the case, but these provisions will surely put pressure on state and local governments to cut the generous retirement health benefits that schoolteachers, firefighters and folks at the DMV have enjoyed. The private sector has already cut the obligations to future retirees; the public sector will likely follow. Many people chose the public sector for health and retirement security over income security–they may be disappointed in their choice.

Choice, Security and Stuff

To date rising health care costs and the looming threat of a retirement with inadequate or expensive benefits has not really limited our consumption of stuff. Low interest rates and high house prices have buoyed American’s net worth (albeit on paper). We take out home equity lines to buy SUVs and other stuff. We consumers keep the American economy humming by borrowing money and getting bigger houses to store our stuff, as George Carlin so famously pointed out.

Health care may give us cause for concern in the future, but it has not seemed to cramp our style in the consumption of stuff in the present. And we don’t seem that upset about it. This mystifies me. Economists will tell you that health benefits are part of total compensation (albeit tax-advantaged). Yet the lucky folks with health insurance think they get it free, or for the modest premium sharing. The reality is that working people with health insurance haven’t had a wage increase in a decade because it all went to health benefits. Health care has limited their consumption of stuff, yet they blame rising gas prices, not health care for the problem.

Looking Ahead

The trade-off among choice, security and stuff may come to a head in the next presidential election cycle. Voters may seek security over choice. Watch for politicians who will preach about the need for health security for an aging and excessively cheeseburgered middle class. In the Social Security debate we elected for the security part over the choice and the prospect of more stuff that came with the private accounts.

In addition, consumers will be forced to select between a wide choice of providers and having more stuff as health care goes retail, making these trade-offs even more dramatic. In health care we may start to value security over everything else, even if it means limiting our choices and getting a little less stuff.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California.

Five Books

Thursday, July 6th, 2006

The greatest compliment you can give another author is to tell them that you so admire their work that you wish you had written it yourself. Now, there may be a wee bit of jealousy that they sold a million copies and you sold only a few hundred to assorted friends and family, but it is still a mark of respect. Being a bestseller is not always the mark of greatness, but it does send a signal that the message has touched many in a way that is accessible and clear. That is why short little books about cheese being moved seem to do very well.

I keep a running list of books that I wish I had written, all of them are non-fiction. Interestingly, there are no books on healthcare on my short list but everyone in healthcare should read them. Here they are, in approximate rank order:

Good To Great by Jim Collins (2001). As a genre, business books are easy to write: you develop a half-baked theory, provide some cute phrases to describe the obvious, and then you add a few anecdotes. Well that’s how I’ve done it. But, Jim Collins, has a rare combination of deep research skills and the ability to synthesize and communicate the essential truth. An award winning teacher, writer, scholar, and consultant, Collins has given us brilliant insight into what makes some companies capable of greatness compared to similarly situated peers. His latest monograph on Good to Great in the Non-Profit Sector should be required reading for every hospital, foundation, and non-profit in healthcare. Collins does not just guess at answers to difficult management questions, he bases his recommendations on rigorous research. And often, he surprises himself because he lets facts and findings drive conclusions not just biases and hunches.

The Tipping Point by Malcolm Gladwell (2002). It is unusual for a phrase to become an enduring part of our vocabulary. Cute one-liners come and go, fads and trends and the language that accompanies them may pass. For example, some day the Blueberry Green Tea Frappacino may be a distant memory. But on occasion, a book, a concept, a phrase, so captures a phenomenon that it becomes a permanent feature of the lexicon. Malcolm Gladwell’s Tipping Point is such a book. It distilled and explained the magic of exponential social change that academic diffusion theorists, marketers, and culture watchers had waffled about for years. Gladwell’s contribution to the language has helped us think more clearly about change, in all areas of life, including healthcare.

Freakonomics by Steven Levitt and Stephen Dubner (2005). Born from the unlikely liaison of a nerdy, obscure behavioral economist and a financial journalist, Freakonomics is a fun, mildly disconnected ride through a whole series of social and economic pheneomena, like why crime rates and abortion are connected, why drug dealers live with their mothers, and why real estate agents rip you off. But, the overarching message to me was that people respond to information and incentives in ways that might not be as obvious through the conventional lenses of micro-economics or psychology. I believe I have been a practitioner of Healthcare Freakonomics for years without knowing it, trying to combine analysis of stakeholder motives, missions, and methods with the usual analysis of who gets the money. Now I feel there is a spiritual home for all us random social scientists that try and make sense of the freaky healthcare world.

The Art of the Long View by Peter Schwartz (1996). If you had told me that you could write an engaging book about futures methodology, I would have said you were nuts. There are many yawners in this genre, most of which never saw the light of day beyond obscure academic publishers. Peter Schwartz, founder of the Global Business Network is the world’s leading scenario planner. From his early days at SRI and Shell Oil to his most recent writing, research, and consulting, Schwartz has provoked us to think about radically different futures in a world that is increasingly and perhaps permanently dangerous and uncertain. But, Schwartz’s greatest gift was The Art of the Long View, because he gave away the recipe to the secret sauce. He confirmed for fellow practitioners, like my old colleagues and I at the Institute for the Future, that what we were doing was about right and helped us do it better. But most importantly he laid out for anyone in an organization a basic road map for writing and using scenarios as a strategic planning tool. Although it was written ten years ago, you can use the methods today. Scenario planning isn’t hard to do, but it is hard to do well. Schwartz’s book can help.

How the Scots Invented the Modern World by Arthur Herman (2001). I am a proud Global Scot, a network of expatriate Scots who provide the Scottish Executive with a conduit for promoting trade and investment with Scotland. It’s kind of like the Scottish mafia without the violence. Arthur Herman’s book is required reading for Global Scots and it should be required reading for all Americans. Herman, an American, is a professor of history at the Smithsonian and his brilliantly researched and wonderfully written book tells the tale of how Scotland evolved from a bunch of Braveheart, claymore-wielding maniacs to being the crucible of the industrial revolution and the Age of Enlightenment. The ideas, philosophies, and people of late 18th century Scotland had a profound effect on the Founding Fathers, and on those that followed. As Andrew Carnegie (of Dunfermline, Fife) famously said: “America would have been a poor show had it not been for the Scotch.” I believe he was referring to the people and not the drink. But it is a history we Scottish-Canadian-Californians are proud of, I just wish I had written it.

I learned a lot from these book and from these authors. I am thrilled that two of these authors Jim Collins and Malcolm Gladwell will be keynote participants at the Health Forum Leadership Summit in San Francisco. I can’t wait to learn some more.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California.