Karen, a good friend, dropped by this weekend.  She brought croissants and her Scottish terrier, I guess thinking we would eat one of the two.  The dog bared its teeth and growled at me, which made me divert my gaze to the croissant.  Fortunately for me, on the danger scale, terriers fall somewhere between guppies and sunflower seeds.  Karen has the fashion sense of an accordionist in a polka band.  One might argue, as she did, that I didn’t have the right to criticize her sartorial spender as I was dressed in bellbottom pants and was sporting a Puka shell necklace.

We talked politics.  When we do, it is a veritable Tennessee Williams play, akin to playing Twister on the edge of a cliff.  Our time together would have been more enjoyable had we simply agreed to listen to an eight-track tape of Abba. Ours was not a conversation for the junior varsity.  With or without the use of automatic weapons, to hold my own I had to step up my game with her.  Karen has always had a mind of her own—it’s how she uses it that keeps me awake at night.  Sometimes I feel as though our combined intellect could not solve the TV Guide crossword puzzle.

She was a Hillary acolyte and someone whose mission in life was wondering why Gilligan never left the island.  I however, was from the dark side and content to solve the world’s problems from the comfort of my Barcalounger.  I launched into defending my political position with as much trepidation as a middle school geography teacher trying to find Burma on a dated classroom map.  I would have had an easier time defending my position had I been trying to squeeze a hippo through a clarinet.

I tend to stand out even in a crowd of one.  Some people who know me think that I am the type of guy who might just walk into a Seven-Eleven and lose it just because the Slurpee machine wasn’t working.  That’s not true, unless, of course it was the blue Slurpee pump that was on the fritz.

Trump supporters.  When I speak of this, I speak in parenthesis to ensure I am not overheard.  Wondering what to do, I looked it up online. WWTDD—what would Tyler Durden Do? (The Fight Club).   The first rule of the Fight Club is that you don’t talk about the Fight Club.  The first rule of post-election politics is that you don’t tell anyone for whom you voted. I was disappointed to learn that there were no links on Google about anyone offering asylum to Trump supporters.

Being a Trump supporter is analogous to having a dirty secret.  While my friends and neighbors shared their political opinions incessantly prior to the election, everyone who had opined has gone into seclusion.  People get that way when the conservatism cat gets out of the bag; but I’m a dog person.

I grew up in Baltimore—70 miles from where I live as the crow flies; 90 miles if the crow were driving a pickup. My wife and I were supposed to be on our way to Baltimore but we were running late because one of us takes too long to put on our makeup and the other one of us gets impatient and threatens to leave.  This is when one of us decides to send the other one of us to a reeducation camp.  As someone who prides himself in knowing which way the wind is blowing, I changed out of my Brooks Brothers suit and dressed in rags and Birkenstocks.

So now you know how I spent the holiday.  I don’t have a segue, so let’s dive into this post and then you can get back to whatever it was you were doing.

The Wall Street Journal had an article about a drug that helps reduce the urge to smoke—Chantix.  The article wasn’t really about Chantix.  Rather, it focused on the fact that payers do not cover prescriptions for Chantix.

Healthcare just gets curiouser and curiouser.  If you’ve never smoked, smoke a pack a day for a month, try to quit, and then return to reading this post. Literature suggests it is easier to quit using heroin than to quit smoking.  I used to smoke.  I tried everything imaginable to quit. I even went to a hypnotist hoping that would help me quit smoking.  And the hypnosis worked.  Until I got in my car and immediately lit a cigarette.  (However, now, every time I hear my trigger word, “consumerism”, I stop whatever I’m doing and I launch into my version of Rosalind Russell singing Everything’s Coming Up Roses from the Broadway musical Gypsy.  It could have been worse. I could have been hypnotized to say the line from Silence of the Lambs, “It rubs the lotion on its skin; it does whatever it’s told.”)

I digressed.  So, I took Chantix, and I stopped smoking.

The WSJ article about why payers would not cover the cost of Chantix confused me.  After all, not smoking is a good thing.  Right?  Because not smoking would prevent several other illnesses.  A, implies B.  but that is not how payers look at the issue.  While they may be interested in preventing members from smoking, they have no financial interest in the fact that A leads to B for smokers.

When payers do the math, they know that some percentage of smokers are well on their way to B—contracting smoking-related diseases.  Smoking-related diseases that are expensive to treat.  Smoking-related diseases that do not count as pre-existing conditions.

Their logic makes financial sense to them.  We know smokers will cost us more in the long run.  So, if we cover Chantix, we are still stuck with paying for the diseases those smokers will incur once they quit smoking.  If we don’t cover smokers, we pay out less.

The payer care model for smokers seems to parallel Dickens’s line from A Christmas Carol—“Let them die and decrease the surplus population.”

Payers’ advertising buries that fact.  Their advertising continues to show healthy people picnicking and hang-gliding.  To be accurate, their commercials should depict a black and white clip of Alistair Sims explaining to the two men collecting charitable contributions, let them die and decease the surplus population.  Chantix only stops a percentage of smokers from smoking.  The let them die model is much more effective if your firm is responsible for paying smokers’ medical claims.

Once smokers die, the payers’ out-of-pocket costs are zero.

The gimlet-eyed woman sitting next to me on the flight looked like she probably knew ten ways to kill me using sesame seeds. She had precisely aligned, glimmering white teeth that indicated either magnificent genetic breeding or a wonderfully talented family dentist.

She asked. “What makes consultants different from the rest of the world?” I winked at her and said, “My one great accomplishment is that I once got elected treasurer of my third-grade class.  Unfortunately, my triumph was short-lived, since the election got overturned by the principal as soon as he learned I had a D in recess.  I don’t mention the second part to too many people. I just let them keep thinking that I served out my term with honor and distinction.”

Consultants, I told her, are the people in the movie theaters rooting for the iceberg instead of the Titanic.  “It helps if you know how to make rocks cry and can teach a dog to meow,” I said.  She gave me a look that seemed to indicate that if it were up to her, she’d save a special place for me in the guillotine line when the revolution went down.

In addition to all of our presumed flaws, some consultants are sycophantic enough to suck the bark off of a tree. Consulting even lets in a few Republicans now. Not in great numbers, certainly, but the odd token here and there.

Junior consultants can be a little paranoid.  The problem with paranoia is that it sneaks up on you. You start by wondering why the guy next door didn’t invite you to his barbecue.  Then you’re convinced the whole neighborhood’s in on the conspiracy.  Then you’re passing out literature about the Trilateral Commission.  Then before you know it, that same neighbor is telling a CNN reporter that there’s a guy on a rooftop with a high-powered rifle.

Some people dream of having Bill Gates’s money, not just his looks.  Consulting firms dream of making that kind of money.  A lot of them make money working with payers.  Big money.

One way they make all of that money is by helping providers save money.  The way they do that is by helping payers not pay a nickel more that they are obligated to pay their members.  Members like you and me.

It is easy to sell consulting if what you are offering is a way to save your clients money.  For payers, claims show up on their balance sheets as liabilities, the same way deposits show up as liabilities for banks.  If you are a payer, anything you can do to minimize your liabilities sounds like it ought to be a good thing.  Pay less, earn more.

It’s simple math, unless of course paying less causes members to leave, then the simple math gets very expensive.  The value of payers, like many other services firms, can be calculated based on the average value of its members times the number of its members plus free cash flow.

Reduce the number of members, and the cash flow (premiums) contributed by those members and their value decreases.

What if instead of a strategy that minimized payments of claims, payers decided to maximize them?  That would yield more members and more members paying their premiums.

It’s a simple strategy and a strategy not used by any of the firms.

I don’t play well in public.

Contrary to what you may believe, I do not have special powers of perception. Like you, I’m just a customer and a patient. However, I have a very short fuse when it comes to confronting stupidity.

Most people walk into a store, do what they need to do, and leave. I walk into a store and the consultant in me wants to start fixing things. I want to speak to the manager and ask him or her why they do some of the things they do.

Why have fifteen cash registers at Wegmans and only have three cashiers? Why does TSA have different security procedures at every airport?

I bought gas today. I parked my car between two pumping stations that were set ten feet apart. A built-in receptacle for depositing lit cigarettes stood a few feet from me. A structural metal pole stood midway between the two pumps. Attached to the pole was a metal box. Inside the box was a fire extinguisher. The box required a key in order to get to the fire extinguisher. (Do you see where this is headed?)

I’ve never worked at a gas station, nor have I been a fireman. Nonetheless, the stupidity wheels in my head started screaming at me. In an effort to temper myself, I looked around the complex and thought, if a fire was to break out, where would it happen? After a millisecond of thinking, I was able to eliminate all of the other places except for where I was standing. The minimart seemed pretty fireproof. The place where people pumped air into their tires looked like there was nothing to cause a conflagration.

And then it hit me. I was standing at ground zero. A very large tank below the ground held thousands of gallons of gasoline. That tank was connected to hoses whose only purpose is to move gasoline from the tank and out of those hoses as quickly as possible. Gasoline burns. Then bad things happen.

So, what would happen if there were a fire at one of the two gas pumps? There would be flames. Big flames. And it would be the job of Mr. Minimart, let’s call him Skippy, to put out the fire. Skippy, seated behind the minimart’s counter, would put down his copy of his Cliff Notes magazine, How to be an International Diplomat, and he would say to himself, I must do something. I should get the fire extinguisher and put out the fire.

And if Skippy is not a mouth breather—one of the fish NPR claims walked from the ocean, Skippy would remember that he locked fire extinguisher in the box—say it with me—that is located smack dab in the middle of the inferno. Skippy is out of options. From the minimart, Skippy calls the fire department and starts eating a Slim-Jim.

Stupid ideas have consequences. Every business is chocked full of stupid ideas that yield dumb processes that were made by people who never considered the consequences of their ideas.

Healthcare is not immune to dumb ideas.

“People call us. So, let’s build a big room and buy a bunch of phones so we can talk to them. If too many people have to be placed on hold, tell our people to talk less, and then they can talk to more people. And let’s buy some philodendrons and place them in the big room.”

“Should we give our people free coffee?” Asked the assistant vice president.

“I just gave them plants,” she replied. “Come to think of it, get them plastic plants. That way we can market ourselves as ‘going green’, by not having to water them.”

Dumb ideas.

Many health systems and payers have executives whose singular responsibility is to drive innovation. The results of the recent election should have a lot of healthcare executives wishing that they had written their strategic plan on an Etch-A-Sketch. Make healthcare great again is going to change the dogma of every aspect of healthcare. It is certainly going to shake up the Veterans Administration.

To be effective, the chief innovation officer should set aside a day and talk to patients and caregivers and family members of patients and referring physicians and prospective patients and ask them two questions:

• What can we do to help people manage their health
• What can we do to help people do business with us

And then he or she should go back to his or her office—I used both pronouns to try to be politically correct—and that person should rethink the definition of innovation. It is not about providing valet parking. It does not include serving Starbucks in the hospital’s fifty million dollar lobby. And innovation does not include free Internet.

What it requires is upping your game. It requires letting people do what they want, every time they want to do it, whenever they want to do it and using whatever device they want to use. And the vast majority of them want to do it without having to call you.

If that makes you uncomfortable, grab a Slim-Jim, and watch what your competitors are doing.