ObamaCare:  Math So Simple That My Dog Understood It!

The is a scene in the movie City Slickers in which one man on horseback is trying to explain to his friend how to program a VCR.  A friend joins the discussion and says, “He doesn’t get it. He’s never going to get it!”

I may have mentioned that I have degrees in math and economics and an MBA in finance.  The good news is that you do not need any of those degrees to understand the numbers behind the failure of O-Care.  However, an advanced understanding of prestidigitation or legerdemain–I had to look that one up–would be helpful.

I was watching the Clinton News Network (CNN) anchor as he tried to explain to his audience, “Pay no attention to the announcement that the average healthcare premiums in 2017 are estimated to increase according to the following formula:

Increased monthly premium amount per individual = your (weight x height)/IQ x (the number of letters in the name of your state + plus the number of the cable channel for CNN).  If you don’t want to do the math, suffice it to say that it is a BIG number.”

The anchor went on to say, and this is the really funny part, “This will not impact the average family because almost eighty percent of those rate increases will be subsidized.”  He then sat down with two of his colleagues, Jane and Dick, who were seated at a table with the Monopoly game board opened before them.  “It will work like this,” he said.  “Suppose that Jane owns the Baltic Avenue property, and she has one house on that property.  If I land on Baltic Avenue, I have to pay Jane rent of $16.  However, if instead of a house, Jane had a hotel on Baltic Avenue, and I landed there, I would owe her rent of $450.”

So in simple terms, you are playing ObamaCare Monolpoly.  Let’s assume that Obama has hotels on all of his properties, If you have ObamaCare you are going to land on one of his properties every month.  So you ask, “What about the subsidies?”  It works like this.  You land on Jane’s property, the one with the hotel, and Jane shouts, “Rent! You owe me $450.”

You pay her the $450, and you say, “But now I don’t have enough money to buy a Stronger Together t-shirt.”

And here is what Jane does when the third Monopoly player, Dick, had his back turned.  Jane stole $400 of Dick’s money and gave it to you.  So the way the math sorts itself out is that instead of paying $450 of rent, you actually only pay $50, and Dick pays the other $400 that you owe.  Jane is happy. You are happy. And Dick has been taken to the cleaners.

And that, boys and girls, is how ObamaCare claims to be solvent.

Let’s address one other topic before class ends today.  Let’s say that the US collects $1,000,000 of taxes this year to pay for  its spending.  (I used a really small number because the actual figure makes my head hurt.)  However, the US actually spends $1,300,000; $300,000 more than it collects–deficit spending.  (And you thought I did not learn anything in my Econ classes.).  So, if the US says it is going to spend another $200,000 to subsidize ObamaCare, where does it get that money?  It gets it in one of two ways.  Either it taxes all of us more to make up for the additional $200,000 (including the person who thinks they just received an ObamaCare subsidy), or it borrows the money.

So we, you and me, either fund the subsidy–like Dick did for Jane, or the government does a little accounting, and adds the $200,000 to the deficit by spending money it doesn’t have.  And that, boys and girls, will make the $19,000,000,000,000 US debt even greater.

If I was playing Monopoly against Dick and Jane, and I saw what Jane did to Dick, I would tell Dick, and then I would make Jane take a time-out. 

So when the television anchor tells you that the increased rates for ObamaCare will be affordable because of the subsidy, you should yell, “Not so fast, Skippy!” And then you should make the ObamaCare acolytes take a long time out.

Make healthcare great again.

Customer Experience, Elephants & Winki-Leaks

Three chairs were spaced evenly about my client’s round conference table.

A smallish elephant entered the room and sat in the third chair. The elephant wore a tightly fitted t-shirt printed with the phrase, “Stronger Together.”

“Why is he in my room?” My client asked me, nonplussed. The elephant looked at me and gave me a wink—he and I had already been in several meetings together. By he, I assumed she was asking about the elephant since I already knew I was a he. (The pay me for my broad powers of deductive reasoning.)

“You should know,” I told her, and I returned the elephant’s wink. “He’s your elephant. Besides, your other two elephants are busy meeting with your colleagues.” I removed a bag of roasted peanuts from my backpack. The elephant reached across the table with his trunk and grabbed the bag.

“What’s with his t-shirt?”

“He wore it to annoy me.” I showed her my baseball cap with the words, “Make Healthcare Great Again” embroidered on the front.

“Why are you feeding him?”

“If I don’t feed him he will talk during the entire meeting.”

“He talks?” The elephant cleared his throat and winked at her. “And what’s with the winking?”

“He winks because his eye leaks. The veterinarian says he suffers from winki-leaks. All elephants talk, but very few people listen to what they have to say. You and I have been working together for four months and this is the first time you’ve even mentioned the elephant.”

“Do you mean he’s been here before?”

“As I said, he is your elephant, not mine. He was here before you and I met the first time.”

“Can’t you make him leave?” She asked me.

“Now that you have acknowledged that he exists I can.”

Dear readers, the next time you are in a meeting and you see an empty chair ask yourself this question, “Is the chair really empty, or are you just not seeing your elephant?”

(And if you do see the elephant, tell him to take off that stupid t-shirt.)

Why Is Healthcare Like Watching Black & White TV?


I am amazed at the speed at which most of the world changes.

When I was young, drinking-water was free, and our rotary phone was attached to the kitchen wall.

We used to get two newspapers a day; the Baltimore Morning Sun and the Baltimore Evening Sun. As a result, we knew everything that had happened in the world before ABC, CBS, and NBC televised the evening news at 7 p.m.

Our television set was a piece of furniture the size of a dishwasher. To watch the television we had to adjust the rabbit ears to try to get the picture to stabilize. During storms, sometimes we had to attach a piece of aluminum foil to the antenna to stop the picture from fading. If we wanted to watch one of the other two channels, someone had to walk to the television and turn the selector knob. To be fair, rumor had it that there was also a UHF channel. That channel came with its own non-functioning antenna, but I never met anyone who was able to get the picture clear enough to watch.

Even so, we also watched the news, and when Walter Cronkite went from black and white to color, I knew technology had just about peaked. And then came portable television—television on wheels. Instead of something the size and weight of a chifforobe, televisions were so miniaturized that they could fit on a wheeled cart and could be moved from room to room. Naturally, we did not have to worry about connecting it to the cable outlet because there was no cable.

Next to the portable television, on the end table, was a spiral-bound, paper AAA map with the directions to get me from Baltimore to Vanderbilt in Nashville—stone age GPS.

As an aside, it occurred to me that the practice of healthcare and the practice of law have a lot of similarities—however, people don’t call having a thousand doctors on the bottom of the ocean a good step. The greatest commonality is that nobody wants to engage either a doctor or a lawyer until it’s already too late. I guess though that telling a lawyer that you were thinking of robbing a bank would garner about the same reaction as telling a doctor that you were thinking of taking up smoking.

So, back to the fact that many years ago what we thought of innovation as consisting of tap water, a morning and evening newspaper, color television, and a TV on wheels.

Almost everything has changed since then because of the rate of change of technology.

Almost everything.

I went to the hospital to get an MRI on my knee.  The clerk inserted a three-part carbon firm into her IBM Selectric typewriter and typed my admissions data.  I was instructed to go to the waiting room. A woman dressed like June Cleaver rolled a black and white television into the room and turned on the Get Smart. She told me there was bottled water in the avocado-colored refrigerator and that if I wanted to make a call, the phone was on the wall next to it.

The song from the Archies, “My Heart Went Bang-Shang-A-Lang” was playing on my transistor radio. I reached down and retied my Converse Jack Purcell sneakers. And folded neatly next to me, on the end table, was a copy of this morning’s newspaper and a spiral-bound map from AAA.

The business model of healthcare never left the 70’s.

The 23 Reasons Healthcare Marketing Needs A Makeover


Since nobody wants to sit through having to read twenty-three of anything, I’m going to try to make this each for each of us.

These are a few of Roemer’s Healthcare Axioms:

  • Axiom 1: Nobody knows what it costs to acquire a patient
  • Axiom 2: Nobody knows what it costs to retain a patient
  • Axiom 3: Nobody knows what it costs to prevent leakage—heck, nobody even knows if someone leaked; before treatment, after treatment. Leakage is one of life’s great mysteries
  • Axiom 4: Patients and members, both new and existing, will tell you that healthcare marketing has zero impact on who they choose as their provider and payer
  • Axiom 5: Providers and payers will continue to play a zero-sum game, spending money on marketing campaigns that do not resonate with anyone outside of marketing

So, here’s how I got to the number ’23.’ (You can come up with your own number using this same approach.)

I started thumbing through this month’s issue of Philadelphia Magazine, and I was gobsmacked by the number of full-page healthcare ads, so much so that I felt the need to count them. By the time I reached page sixty-six I had counted twenty-three ads.

Four providers and two payers paid for those twenty-three ads. Doing the math—four plus two, divided into twenty-three—indicates that each organization marketed to the magazine’s readers about four times in the first sixty-six pages.

I took some time to reach each ad, and to ask myself if there was anything in any of those ads that would compel me to take action. There wasn’t.

It is worth noting that all of the ads had the same look and feel. It was almost as though all of the marketing departments, independent of their firm, operated from the same marketing omnibus—it means compilation—of acceptable healthcare marketing strategies.

The only difference among the ads was the name of the institution doing the advertising. The ads each pictured one or two animated and healthy people having the time of their lives. The people were frolicking, picnicking, biking and jogging. They were carefree.

I suppose the ideas behind the ads were that even if you had cancer, that if you brought your cancer to one of these organizations, you could be frolicking by the time you finished reading the magazine. The ads do not show someone with any hair connected to an IV dispensing cisplatin. Perhaps the thinking is that ads about frolicking are preferable to ads about cisplatin.

The same kinds of ads are on billboards and on television. They are in your mailboxes and mine. If every healthcare organization is pitching the same message, is the effect on consumers the same as if they had pitched no message? I think it is. I think consumers think the same thing.

I am willing to bet my neighbor’s BMW that not a single reader of the October issue of Philadelphia Magazine will be influenced one iota about who to choose as their provider or payer based on a magazine ad, a billboard, or a television commercial.

If you want to get my attention, tell me that you designed a tool that will help me manage my care and wellness. Don’t give me frolicking. Give me care and then I will care.

Healthcare’s Favorite Meaningless Numbers For Managing Its Business

I was a mathematician for six months.  That long enough for me to discover that real mathematicians were a lot smarter than me.  I had no more chance of being successful  than a Detroit auto worker who did not speak Spansih.

One of the things I remember is that it’s pretty easy to convince yourself that you can get the numbers to tell you whatever you wanted them to say. I learned how to prove that one plus one did not equal two, a fact that led me not to trust numbers.

That fact was especially true with statistics.

Last night we attended the ice hockey game at the Rochester Institute of Technology.  The scoreboard overhead displayed to sets of numbers; the score, and the number of shots on goal–the SOG.  The game ended in a 1–1 tie.  I told my son that hockey would be more fun if they doubled the size of the net and used two pucks simultaneously.  Americans don’t like ties.

The SOG showed that RIT had thirty-six shots on goal.  U-Conn had twenty-one SOGs.  As you can see, the SOG is a meaningless stat; lipstick on a pig.  It is meaningless because the only stat that matters is the score.  RIT was not awarded an extra goal simply because they had missed fifteen more shots than their opponent.  But the total lack of value of the stat does not stop them from tabulating it.

As I’ve written previously, the business of healthcare–how it’s managed–is mired in a 0.2 business model.  While all other industries have taken flight with business models that employ design-thinking, interactive, cognitive, and mobile-first technologies, healthcare–providers and payers–continue to debate the color of the carpeting to install in their call centers.  And they manage their business based on meaningless data they collect to measure access and engagement.

Healthcare could fill a book with its meaningless stats.  It’s even likely that many healthcare organizations paid someone a lot of money to create a dashboard so that their management could get up-to-the-minute updates on those stats.  “Joe-Bob, come over here and take a look at these numbers!  I’m showing that we have a .2% improvement on stat 7 from the same quarter last year.”

“What does that mean in terms of patient engagement?”  Asked Joe-Bob.

“I don’t’ know.  But I do know that better is always a good thing.  Isn’t it?”

Below are but a few of the most meaningless statistics that are collected and reviewed by executives whose jobs are to improve patient and member access and engagement.  Access and engagement, if they are measured at all, are measured using data collected online and from call centers.

  • Number of people who access their website each month
  • Average minutes spent viewing each web page–this statistic should tell the webmaster that they have hundreds of pages that nobody ever views
  • Total number of Facebook ‘likes’
  • Average wait-time per caller (Some callers have enough time on their hands to buy green bananas.)
  • Average number of callers in the queue
  • Average talk-time
  • Average handle-time

There would be no negative impact on their businesses if providers and payers stopped tracking those numbers tomorrow.

If you want to measure the success of access and engagement, track these statistics:

  • Number of people who accomplish a single task by visiting your website.  Note: tracking the number of people who went to your site to learn at what hour the gift shop opened is meaningless.  Equally meaningless is those who viewed ‘Find a Doctor.’
  • Number of people who scheduled an appointment online
  • Number of visitors who used online chat
  • Number of visitors inputting information in the ‘Contact us” box who received a real-time reply
  • Number of one-time visitors (leakage)
  • Number of callers who called because they could not accomplish what they needed on your website
  • Number of callers who wanted to speak with someone helpful  on weekends and after 6 p.m.
  • Number of callers who called your scheduling center for a reason other than scheduling an appointment (this number is usually around 80%
  • Number of abandoned calls (leakage)
  • Average number of calls per person to resolve a single issue
  • Number of frustrated callers who do not call back (leakage)

If you track theses numbers and understand their impact, you should be depressed.

If you want to know what to do to improve access and engagement, develop innovation teams to figure out how to manage each of those statistics.  The targets for some of those numbers should be one hundred percent, and the targets for the others should be zero.  I will leave it to you to determine which are which.

If that option is not attractive to you, you could sign up for a match.com account and write your profile; “Fond of unicorns and long walks on the beach.”

Is This Why Payers Can’t Spell Consumerism?

People think healthcare’s least understood concept is the relationship between payers and members (customers and patients). I believe the opposite to be true. People clearly understand the relationship, and it is that understanding that has such a negative impact on almost everything related to a person’s health.

The member/payer relationship not only discourages access, engagement, population health, accountable care, and wellness, it seems to do so in a particularly purposeful way. In fact, to members, it seems like payers are either guilty of designing it to be that way, or they are guilty of neglecting the member/payer relationship.

To give us a starting point for exploring this topic, I searched Google for the following: “t-shirt” and “I love Humana.”

I could have searched on any number of payers and received similar results. My search returned zero hits. (You get the same number of hits if you search for the phrase, “French military victories”.) If Google were more advanced, I think the number of hits for my search would have been negative. I also searched the phrase, “Why do people hate their insurance company?” That search returned 1,750,000 hits, and my laptop started laughing at me.

The relationship between members and their payers is a topic that is only mentioned behind closed doors. I wish I could state that both parties are culpable, but that is not the case.

Everyone who has ever called his or her payer to dispute a claim thinks the term ‘payer’ is an oxymoron. Their payment strategy for dispute resolution seems to be based on the premise that if they can get you to call them seven times, they know you will not bother to call and eighth time.

Wreck your car; your insurance company gives you a new one. Have a heart attack while driving, one company gives you a new car, the other company, your payer, tells you what is not covered—page seventy-two, section eleven, sub-paragraph six.

To be fair, payers do offer a number of other free benefits to offset the fact that they may deny some portion of or your entire claim. Someone in your HR department probably skimmed through those free benefits on January 2 when they were explaining your new and improved and more expensive health insurance. Very few of you or anyone else could probably list, or as ever made use of those benefits.

Stating that your firm wants its members to have a good experience, and delivering that good experience, is vastly different. Most payers only interact with twenty percent of their members on a regular basis. They either pay the members’ claims, or they do not pay their members’ claims. The one thing they do not know about those claims is whether the services their members claimed made them better.

I learned today that I have a torn meniscus and a stress fracture of my tibia. My orthopedist wants me to be on crutches for a month. Just for fun, I Googled the cost to repair the tear and to fix the stress fracture. The estimated cost to repair the tear is $5,000 and the cost to repair the stress fracture is around $16,000. Knees are expensive.

Crutches cost $40. I called my payer—let’s call them Hartford-Anthem-TIAA-Esurance (HATE), to find out if it will pay for repairing my meniscus tear and my stress fracture. The person with whom I spoke said HATE covers those procedures.

That was the good news.

Then I asked if HATE would cover the cost of crutches. Crutches, I was told, are not covered. Up until that moment I had considered buying an “I Love HATE t-shirt.” I asked to speak with a supervisor. No supervisors were available to speak with me—were they out buying their own crutches?  I asked.

An hour later I received an email from HATE. In their email was my Case Number, #38756. I replied to HATE’s email and told them that their Case Number was #00001. I received a new email from HATE telling me that my Case Number was #93852. I replied and told them that their new Case Number was #00002. I don’t know how long HATE’s patient engagement with me will continue, but I am prepared to play their game for as long as it takes.

HATE will pay about $20,000 for the two surgeries, but they will not pay $40 for crutches.

Payers spend tens of millions of dollars on data and they spend equal amounts on advertising. Their data, were they to look at it, would tell them that the outcomes from two surgeries and from using crutches are identical. Their data may tell them that someone with of my age and weight, who exercises six days a week, may have a higher probability of having a stress fracture and torn meniscus than, say someone who wears skinny jeans and who drinks lattes. The one thing their millions of dollars of data will not tell them is that you or I will injure our knee.

Payers spend almost nothing on my wellness or yours. They do not know how to lower their costs, engage members, improve member experience, and promote their wellness.

Patient Care 101: Thank God It’s Monday

This is a true story. The names of the actors have been changed for literary purposes. It goes something like this.

In 1983, Jim lived in Dallas, Texas. He was working in Amarillo. Monday evening, Jim saw a news report about testicular cancer on the local news. Jim knew immediately that he had cancer. He knew he had because he had discovered a lump a few months ago. Jim did not know what to do because he had never had a lump. He went to his hotel room, opened the Yellow Pages, and started calling doctors until he found one that would speak with him at 8 p.m.

The doctor agreed with Jim’s diagnosis and agreed to see Jim in the morning.

Tuesday morning, the doctor made a few calls and referred Jim to MD Anderson. Jim called his parents. They called him back and told their son that they had scheduled an appointment for him at Johns Hopkins on Thursday. Jim flew back to Dallas.

Because Jim was twenty-seven and knew he was going to live forever, Jim did not have a primary care physician. Early Wednesday morning, Jim walked into Medical City Dallas. The only thing Jim knew about Medical City was that it was the hospital closest to his apartment.

He went to the front desk and told the receptionist he had cancer and he needed to see a cancer doctor. He would have said he needed to see and oncologist, but he did not know cancer doctors were called oncologists. That was because, as we already learned, Jim was twenty-seven, and Jim was going to live forever.

Late Wednesday afternoon, the cancer doctor examined Jim. Jim was scheduled for an MRI on Thursday. Jim, thinking he might have cancer, was a little nervous. He received an MRI and told the radiologist that he wanted to wait until the doctor told him if he had cancer. The radiologist told him that that was not possible. Jim was very worried.

The doctor told Jim to return on Thursday for a small needle aspiration because the MRI showed there was an abnormality in his right lung.  Jim again told the oncologist that he wanted to wait to learn if he had cancer. Again, the doctor told Jim that was not possible.

Jim called the doctor several times on Friday, and all day Saturday. Jim was very worried. Somebody whom Jim did not know told him there wasn’t anyone who could help him. On Sunday Jim went to Medical City and asked to see a doctor. Any doctor. The gift shop was open.  He was told that maybe somebody could help him on Monday.

He drove home, disappointed and worried.

Jim had waited seven days. By day seven, Jim was no longer certain he would live forever. On Monday, the cancer doctor told him to come to his office. Jim met with the doctor and he was told he had testicular cancer.

Jim would have preferred not to have spent his weekend wondering if he was going to live or die. In case you did not figure it out, I am Jim.

Thank God it was Monday, thought Jim.  For the 99% of the US population who will not be sleeping tonight in the hospital, healthcare is closed after five p.m. on weekdays, and all day on Saturday and Sunday–unless, of course, you go to CVS.