healthcarereimagined

July 16, 2019
Officials outlined plans to drive innovation, streamline IT acquisitions and build a more agile and resilient cyber posture.

By Jack Corrigan, Staff Correspondent

Pentagon officials vowed to improve oversight of their IT investments as part of a multi-year push to upgrade the Defense Department’s tech for the 21st century.

Officials on Friday released their Digital Modernization Strategy, offering insight on how the Pentagon plans to prioritize its roughly $46 billion annual IT budget over the next five years. Cloud adoption, artificial intelligence and cybersecurity will all factor in heavily to the department’s technological future, according to the strategy, but those capabilities won’t be possible unless officials do a better job coordinating their efforts.

“More effective oversight of IT investments is necessary due to the decentralized nature of [Defense Department] operations and spending,” officials wrote in the strategy.

In January, Congress passed a law giving the Pentagon’s chief information officer more authority over IT budget requests and spending plans, and officials said the new measures “will enable continual, comprehensive department-wide IT modernization in a common, coordinated way.”
In the strategy, officials outlined four overarching goals that will guide the department’s tech efforts in the years ahead: innovate for competitive advantage; optimize for efficiencies and improved capability; evolve cybersecurity for an agile and resilient defense posture; and cultivate talent for a ready digital workforce.

Under the first goal, officials pointed to a number of areas where the Pentagon should focus its investments in the years ahead, including cloud computing, artificial intelligence and command, control and communications systems. While each new capability will be critical to maintaining the nation’s technological edge, the department sees cloud adoption as “the foundation” for many of the others, officials said.

Today, the Pentagon is in the process of bidding out two massive cloud computing contracts—Defense Enterprise Office Solutions and Joint Enterprise Defense Infrastructure—worth billions. The platforms are intended to help the department make better use of data and pave the way for emerging technologies like artificial intelligence, and if they’re not up and running soon, Defense leaders fear national security could suffer.

Officials are also ramping up operations at the Joint Artificial Intelligence Center, which will serve as the hub for AI research across the department. In the years ahead, officials plan to focus on building more partnerships between the JAIC, industry and academia, and building a pipeline to scale up the technologies developed at the center.

The second goal—optimize for efficiencies and improved capability—will focus largely on the department accelerating IT procurements and adopting more enterprisewide solutions, as opposed to component-specific systems. Officials plan to accomplish the goal in part by improving category management and technology deployment process, as well as optimizing migrating applications that can’t run in the cloud to optimized, enterprise data centers.

The third goal, agile and resilient cybersecurity, will involve prioritizing security in each step of the acquisition process for “every network, system, application and enterprise service,” they said. Other steps include restructuring the department’s cyber architecture to bolster defenses and digital awareness, deploying an “end-to-end” identity, credential and access management infrastructure, and securing information held by Defense contractors, they said.

Lastly, maintaining the country’s technological capabilities will require the department to build a similarly capable tech workforce, officials said. To that end, the department plans to improve its internal workforce management processes, increase training opportunities for IT procurement specialists and expand programs to recruit and retain cyber specialists.

The government faces a continuous struggle to recruit and retain talented technologists, though the Pentagon has historically fared better than civilian agencies.

Article link: https://www.nextgov.com/it-modernization/2019/07/pentagon-releases-its-5-year-digital-modernization-strategy/158460/

In Beyond Performance 2.0 (John Wiley & Sons, 2019), McKinsey senior partners Scott Keller and Bill Schaninger draw on their 40-plus years of combined experience, and on the most comprehensive research effort of its kind, to provide a practical and proven “how to” guide for leading successful large-scale change. This article, drawn from the book’s opening chapter, provides an overview of this approach and explains why it works. Future articles will deal with specific topics such as uncovering and shifting limiting mind-sets during change efforts, as well as how to create the ownership and energy needed to succeed.

Neville Isdell took the helm as CEO of Coca-Cola during troubled times. In his words, “These were dark days. Coke was losing market share. Nothing, it seemed—even thousands of layoffs—had been enough to get the company back on track.”¹ Its total shareholder returns stood at minus 26 percent, while its great rival, PepsiCo, delivered a handsome 46 percent. Isdell was clear eyed about the challenge ahead; as he put it, “There were so many problems at Coke, a turnaround was risky at best.”²

Isdell had a clear sense of what the company needed: to capture the full potential of the trademark Coca-Cola brand, develop other core brands in noncarbonated soft drinks, build wellness platforms, and create adjacent businesses. These weren’t new ideas, and Isdell’s predecessors had failed to make change happen at scale. No matter which direction he set, the company couldn’t make progress until it improved its declining morale, deficient capabilities, strained partnerships with bottlers, divisive politics, and flagging performance culture.

Just a hundred days into the new role, Isdell announced that the company would fall short of its meager earnings-growth target: 3 percent. Later that year, Coca-Cola announced that its third-quarter earnings had tanked by 24 percent. However, Isdell plowed onward, launching what he called “Coca-Cola’s Manifesto for Growth.” The goal was to outline a path that showed not just where the company aimed to go—its strategy—but also what it would do to get there and how people would work together differently along the way.

Isdell launched what he called “Coca-Cola’s Manifesto for Growth.” The goal was to outline a path that showed not just where the company aimed to go—its strategy—but also what it would do to get there and how people would work together differently along the way.

Working teams tackled performance-related issues, such as the company’s new targets and objectives, as well as the capabilities they would require. Other teams addressed organizational effectiveness: how people could work together as a global team; how to improve planning, metrics, rewards, and people development; and how once again to “live our values.” The manifesto was created using a collaborative process to ensure that the organization’s leaders would feel deep ownership and authorship of the program. As Isdell explained, “The magic of the manifesto is that it was written in detail by the top 150 managers and had input from the top 400. Therefore, it was their program for implementation.”³

Soon, the benefits of Isdell’s approach became apparent. Within three years, shareholder value jumped from negative territory to a 20 percent positive return. Volume growth in units sold increased by almost 10 percent, to 21.4 billion. Coca-Cola had amassed 13 billion-dollar brands—30 percent more than Pepsi. Of the 16 market analysts who followed the company, 13 rated it as outperforming.

Quantifiable improvements in people-related measures matched these impressive performance gains. Staff turnover at US operations fell by almost 25 percent. Employee-engagement scores jumped so high that researchers at the external company that conducted the survey hailed what it called an “unprecedented improvement.” Employees’ views of the company’s leadership improved by 19 percent. Communication and awareness of goals rose to 76 percent, from 17 percent. According to Isdell, however, the biggest change was qualitative. Three years into the role, Isdell noted that “when I first arrived, about 80 percent of the people would cast their eyes to the ground. Now, I would say it’s about 10 percent. Employees are engaged.”⁴ When he retired as CEO, he handed over a healthy, well-performing company.

Isdell explained the turnaround’s success by pointing out that he had “taken the ‘how’ as seriously as the ‘what.’”⁵ Another way to explain it is that he put equal emphasis on the hard and the soft stuff: performance and health. Performance is what an enterprise does to deliver improved financial and operational results for its stakeholders. Companies evaluate their performance through financial and operational metrics such as net operating profit, returns on capital employed, total shareholder returns, net operating costs, and stock turn (and the relevant equivalents in not-for-profit and service industries). By contrast, health describes how effectively people work together to pursue a common goal. It is evaluated by an organization’s levels of internal alignment, quality of execution, and capacity to renew itself to sustain high performance in an ever-changing external environment. To deliver successful change at scale, leaders should emphasize performance- and health-related efforts equally.

How do we know? In 2010, we wrote Beyond Performance,⁶ which laid out a methodology we called the “five frames of performance and health,” a change-leadership approach that emphasized performance and health equally. The book included the finding (from our 2010 survey of 2,314 global business executives) that only a third of those who had experienced a large-scale change program during the previous five years reported that it had been “mostly” or “completely” successful. This was consistent with findings from previous research that we had conducted and others in the field had reported.⁷ By 2015, we felt enough time had passed to test how well the five-frames approach worked. A global survey of 1,713 executives who had taken part in at least one large-scale change program during the previous five years showed that 79 percent of those organizations fully implementing the five-frames methodology reported success.

The value of health

Quotes about the importance of organizational health could fill a whole article, if not a whole book. Yet many leaders think that however well this wisdom works elsewhere, it won’t for their companies. Still others argue that they must improve performance first or that the people-oriented aspects of change don’t have a proven return on investment. Our research, over many years, has therefore focused on determining—through hard facts—how much value organizational health creates. When we wrote Beyond Performance, we had accumulated 600,000 data points across 500 organizations from our Organizational Health Index survey tool since its development in 2002, which meant that we had the data required to answer the question once and for all.

When we tested for correlations between performance and health on a broad range of business metrics, we found a strong positive one in every case. Companies in the top quartile of organizational health were 2.2 times more likely than lower-quartile companies to have above-median EBITDA⁸ margins, twice as likely to have above-median growth in enterprise value to book value, and 1.5 times more likely to have above-median growth in net income to sales.

Now, almost ten years later, with more than five million data points across 2,000 organizations, the analytics tell the same story. Companies in the top quartile of organizational health had total shareholder returns three times greater than bottom-quartile companies, and their returns on invested capital were two times higher (Exhibit 1). Companies in the bottom quartile for health didn’t experience any growth in sales; top-quartile ones averaged 24 percent sales growth.⁹

The correlation between health and performance doesn’t necessarily mean that the relationship is causal. Education and income are highly correlated, for example, but it is just as logical to argue that a higher income creates opportunities for a higher education as that a higher education creates opportunities for a higher income. This is why we haven’t rested our case on correlations alone. We’ve also tested the relationship over time. First, we looked at regression coefficients between comparable units within organizations—for example, the performance and health of branches in bank networks, hospitals in healthcare networks, stores in retail networks, and oil refineries in oil companies (Exhibit 2). We’ve found, in every case, that health explains more than 50 percent of the variation in performance across locations.

We’ve also tested causality by conducting extensive research comparing experimental and control groups over multiyear time frames. One group embarked on change in a traditional, relatively performance-oriented way, the other used our five-frames approach. After running five longitudinal tests in industries as diverse as telecommunications, mining, financial services, and retailing, we found that the experimental groups applying the balanced performance-and-health approach delivered results that, on average, were 1.8 times higher than those of groups using the traditional one (Exhibit 3).

For example, at a large financial-services institution, we studied two experimental groups and a control group, which were comparable and representative of the wider organization across a range of criteria, including net profit before taxes, branch-staff characteristics, and customer economics (average income per customer in retail banking and industry composition in business banking). Over an 18-month period, each experimental group pursued a sales-stimulation program, one using a more traditional, performance-heavy approach, the other emphasizing performance and health equally. During the trial, we took care to minimize distortions (corporate initiatives such as operational restructuring, leadership changes, and significant staff turnover) that might disproportionately affect any one group.

The results of the study were compelling. In business banking, the traditional approach generated 8 percent more value than the control group did, but the performance-and-health approach generated 19 percent more value than the control group. In retail banking, the respective figures were 7 and 12 percent. With findings like these across multiple industries, we felt that the case for causation was well and truly closed. This proof that health is a significant causal driver of performance is great news for leaders. Unlike many factors that affect performance—changes in customer behavior, competitors’ moves, government actions—your organization’s health is something you can control.

The perils of performance

Emphasizing performance and health equally isn’t simple. When your company requires large-scale change, for example, spending time on health may seem counterintuitive. In fact, companies can and often do make short-term gains without improving their health, but these are unlikely to last.

Perhaps the starkest example of the perils of pursuing performance at the expense of health is the story of Albert J. Dunlap—“Chainsaw Al”—famous for taking over struggling companies, ruthlessly downsizing them, and selling them at a profit. When he took over the US appliance-maker Sunbeam, he sold two-thirds of its plants and fired half of its 12,000 employees. Ironically, the stock price of Sunbeam then rose so high that he couldn’t sell it quickly. Having compromised its health, Dunlap now needed to sustain its performance for the foreseeable future. But the damage was too great. Two years later, the company faced quarterly losses as high as $60 million, and Dunlap was fired.

By contrast, when Louis Gerstner became CEO of IBM, he decided—in the face of pressure from Wall Street—not to focus exclusively on improving its performance but instead to devote considerable effort and resources to lifting its health as well. Under Gerstner, the company strived to act as “one IBM” across its businesses: it became more externally oriented and less arrogant, trimmed its bureaucracy, and adopted a continuous-learning mind-set. By the time Gerstner retired, nine years later, IBM’s stock had increased in value by 800 percent, and the company had regained its leadership in parts of the computer, technology, and IT-consulting sectors.

Perversely, the greatest obstacle to emphasizing health in an appropriate way isn’t an urgent performance imperative but rather its absence.

Gerstner was courageous to work on IBM’s culture despite the threat that the company would fail. Yet, perversely, the greatest obstacle to emphasizing health in an appropriate way isn’t an urgent performance imperative but rather its absence. When organizations are thriving financially, a certain complacency may set in, so that their health declines. That in turn leads, in the least-bad case, to a slow decline in performance and, in the worst, to an existential crisis.

Consider the cautionary tale of Atari. Founded in 1972 to develop electronic games, which were then just a figment of a designer’s imagination, the company sold $40 million worth of them and earned profits of $3 million in 1973. Not long afterward, deep-pocketed owners who invested heavily in R&D bought Atari. By 1980, it had posted revenues of $415 million and was hailed as the fastest-growing business in US history.
Yet Atari soon began to crumble from inside: teamwork declined, communication broke down, a risk-avoidance culture set in, investment in R&D fell, and the quality of products was sacrificed to push them into the market more quickly. The result was some of the biggest duds in video-gaming history. Alienated engineers departed, many to found or join rival companies. By 1983, Atari had lost $536 million and resorted to massive layoffs. It never recovered. The shell of the company—little more than a brand name—was sold in 1998 for only $5 million. Atari was so focused on performance that it was unaware of its deteriorating health.

By way of contrast, consider the case of Pixar, the computer-generated-animation studio. Pixar has 15 offerings that rank among the 50 highest-grossing animated films, and it has earned 19 Academy Awards, eight Golden Globes, and 11 Grammys. Its president, Ed Catmull, who had no business experience before cofounding the company, says that its development process is unusual: “Our development team doesn’t look for stories. Their job is to create teams of people that work well together.”10

That isn’t the company’s only distinctive feature. An average Hollywood studio produces six to 12 films a year. Pixar produces just one—a risky bet, since an animated film costs about $180 million to make. “We have realized that having lower standards for something is bad for your soul,” Catmull explained. Taking the right risks and accepting the reality that bold, innovative ideas demand a tolerance for uncertainty are central to the culture. As Catmull says, “Talent is rare. Management’s job is not to prevent risk but to build the capability to recover when failures occur.”11

Pixar focused on health to build a strong organization from the start. Other companies have learned over time the importance of pursuing performance and health in equal measure. In 2009, for instance, General Motors (GM)—once the world’s dominant carmaker—filed for bankruptcy and accepted a $50 billion US government bailout. The company then underwent an 18-month turnaround that enabled it to pay back a significant portion of that money and to reenter the stock market in 2010. Many observers suggested that GM was on track, but though performance was on the upswing, underlying health issues remained.

Soon enough, in 2014, the devastating ignition-switch problems of GM cars left at least 124 people dead and 275 injured. An internal investigation attributed this disaster to organizational-health-related factors.12 Mary Barra, who took over as CEO in 2014, vowed to improve not only the company’s performance but also its health by focusing on accountability, teamwork, results, candor, transparency, and customers. 13 Her efforts seem to be paying off, with three profitable years and a strong balance sheet. As GM’s experience shows, when organizations tend to their health, it really does improve—and so does performance.

The five frames of performance and health

How can change leaders emphasize performance and health equally in practice? There are no simple guiding principles or rules of thumb—if there were, success rates would no doubt be much higher than 30 percent. However, we can offer a structured, careful, and proven methodology that has now been battle tested and further refined for almost ten years: the five frames of performance and health.

This approach divides the overall change journey into smaller, more manageable stages. Each stage has a basic question companies must answer through their work at that point in the journey. It’s easy to know when to advance from one stage to the next—if you have the answer, move forward. These five stages are collectively called the “5As”:

• Aspire. Where do we want to go?
• Assess. How ready are we to go there?
• Architect. What must we do to get there?
• Act. How do we manage the journey?
• Advance. How do we continue to improve?

For each of these five stages, we offer explicit, practical guidance for addressing performance and health. It takes the form of five frameworks for performance (one for each stage) and five for health (ditto). These are the frameworks for performance:

• Strategic objectives (aspire). Create a compelling long-term change vision, set midterm aspirations along the path, and guard against biases in the process.
• Skill-set requirements (assess). Forecast demand for skills and understand their supply dynamics; then decide how to close gaps.
• Bankable plan (architect). Define the portfolio of initiatives that will realize your strategic objectives and meet your skill requirements; then sequence your actions and reallocate resources accordingly.
• Ownership model (act). Establish strong governance, decide how to scale your change initiatives, monitor their progress, and dynamically adjust them throughout implementation.
• Learning infrastructure (advance). Institutionalize processes and expertise so that the organization shares knowledge, constantly improves, and continually learns how to do new things.

Here are the five frameworks for health:

• Health goals (aspire). Objectively check your organization’s health, choose where to be exceptional, and target areas that need immediate improvement.
• Mind-set shifts (assess). Pinpoint helping and hindering behaviors for priority health areas, explore the underlying mind-set drivers, and prioritize a critical few “from–to” mind-set shifts.
• Influence levers (architect). Use four levers to reshape the work environment: role modeling, understanding and conviction, reinforcement mechanisms, and confidence-building efforts. Then ensure that performance initiatives are engineered to promote the necessary mind-set and behavioral shifts.
• Generation of energy (act). Mobilize influence leaders, make the change personal for employees, and maintain high-impact, two-way communication.
• Leadership placement (advance). Prioritize ongoing roles by their potential to create value, match the most important ones to the best talent, and make the talent-match process business as usual.

The advance stage prepares the way for another five-frames cycle, starting once again with aspire. This approach helps organizations to drive multiple S-curves of change: an intensive period of activity and radical improvement, followed by a period of consolidation and incremental improvement, eventually followed by another ramp-up in intensity, and so on. If both performance and health improve during each cycle, the organization over time “learns to learn” and changes continually.

This approach helps organizations to drive multiple S-curves of change: an intensive period of activity and radical improvement, followed by a period of consolidation and incremental improvement, eventually followed by another ramp-up in intensity, and so on.

To apply this approach, it’s important to understand how the elements work together horizontally and vertically. Let’s start with the horizontal elements.

In practice, the performance and health elements of each stage are far more integrated than the previous discussion implies. Early on (for example, in the aspire stage), the work related to each element of performance and health is relatively self-contained. Later, as the work moves from planning to action, efforts to boost performance increasingly reinforce health, and vice versa. By the act stage, employees experience a single, integrated change program—the distinction between performance and health is semantics. Unfortunately, however, some leaders grasp the concepts of performance and health but not the need for integrated activity to promote them. They therefore tell their business heads to “do the performance stuff” and HR to “do the health stuff.” That approach is doomed to fail.

Now let’s consider the vertical relationship between the elements of performance and health. Although we lay out the 5A change process in a linear way, from aspire to advance, in practice it must be applied far more dynamically. In the assess stage, for example, an organization may discover that its readiness to change is so doubtful that the aspiration it set earlier isn’t realistic. If so, the next step is to move backward. That must also happen if new discoveries or unexpected events in the act stage invalidate assumptions in the architect stage.

Mastering irrationality

The Nobel Prize–winning physicist and Santa Fe Institute cofounder Murray Gell-Mann once asked people to consider “how hard physics would be if particles could think.”¹⁴ The “particles” in the physics of change—employees—can not only think but often do so in seemingly irrational ways. As the change journey unfolds, smart leaders must therefore understand the social science of “predictable irrationality.”¹⁵ When people are in a hurry to park, for example, how many circle around a parking lot to find the most convenient space when it would be much quicker to take the first one they see? Why take home pencils from the office without guilt if the idea of raiding the petty cash to buy pencils would shock you? As these examples show, we are all susceptible to irrationality in decision making.

The social, cognitive, and emotional biases that promote seemingly irrational decisions are well understood by the field of behavioral economics. That isn’t true for change management and organizational leadership, but it should be. In each stage of the 5A process, leaders ought to consider important lessons about human irrationality and how to work with it constructively. We call this part of the effort the change leader’s “masterstrokes”: building buy-in by involving the people who will execute a solution in its development; paying as much attention to what’s going well (and trying to get more of that) as to finding and fixing problems; thoughtfully describing the “why?” of change to tap into five sources of motivation; signaling a long-term, reciprocal relationship with employees rather than a transactional one; and putting equal effort into ensuring a fair process and a fair outcome.

Exhibit 4 shows the specific steps within each of the five frames of performance and health, as well as the relevant masterstrokes.

Many workplaces are characterized by competing agendas and conflict (no alignment on direction), by politics and bureaucracy (low quality of execution), and by the corrosive idea that work is “just a job” (a low sense of renewal). These aren’t just unhealthy for companies that want to deliver sustainable bottom-line results—they are unhealthy for the human soul. As the Japanese proverb goes, “Vision without action is a daydream. Action without vision is a nightmare.”

Healthy organizations, by contrast, unleash our potential and uplift our spirit. They inspire (aligning on a big, important goal), create a sense of belonging (executing as one team), and foster creativity and innovation (through a sense of renewal). To paraphrase motivational speaker Joel Barker’s riff on the aforementioned Japanese proverb, healthy organizations connect vision with action to change the world.

In this way, putting equal emphasis on the performance and health elements of leading organizational change doesn’t just improve the odds of success; it improves the lives of employees, builds an organization’s resilience, and creates a pro-change mind-set.

About the author(s)

Scott Keller is a senior partner in McKinsey’s Southern California office, and Bill Schaninger is a senior partner in the Philadelphia office.

Article link: https://www.mckinsey.com/business-functions/organization/our-insights/a-better-way-to-lead-large-scale-change

March 22, 2019
Roosa Tikkanen

Toplines
“Medicare for All” has captured a lot of attention, but there is a wide range of approaches to universal health coverage, as other countries show

Countries that have universal health coverage achieve it in different ways, with some relying more on public insurance and others on regulated competition among private plans

Last week, the Commonwealth Fund released an interactive tool to help people compare recent congressional bills aimed at expanding health insurance coverage and lowering the cost of health care in the United States. Using the tool allows you to see how much each bill would expand the nation’s public health insurance system, or those aspects regulated or run by state and federal government.

While “Medicare for All” has captured the most attention, a comparison of the reform proposals reveals that their approaches to achieving universal coverage are far more nuanced than this term would suggest. “Single payer,” meanwhile, is generally used to describe how other wealthy countries organize their health systems. But a closer look similarly shows a wider variety of approaches than this catchall term implies. Other high-income nations manage to insure all their residents and spend less per capita than the U.S. But some of them do that by covering everyone through a regulated system of health plans, while others truly have a single public plan for everyone.

Countries also diverge in their approaches to financing health care — relying on different combinations of taxes, premium contributions, and cost-sharing — and in how they control growth in overall costs. Finally, while nearly all the health systems feature a role for private insurance — a fact that might surprise many in the U.S. — its size varies considerably.

Let’s take a closer look at how eight of our peer countries get to universal coverage, how much they pay for their health care, and what role private insurance plays in each.

A Regulated System of Health Plans

One way to achieve universal coverage is through a system of competing private health insurance carriers. In the Netherlands and Switzerland, people are legally required to buy private insurance or else pay a fine. The Dutch choose between plans offered on a national marketplace, while the Swiss shop on regional marketplaces. These systems resemble the marketplaces introduced in the U.S. by the Affordable Care Act (ACA).1
But there are key differences. In the Netherlands, financing is shared between individuals and their employers, and insurance plans also cover dependents. But the Swiss pay the entirety of their plan costs, and children require the purchase of separate plans.

The Dutch also pay lower premiums, averaging around $115 to $150 per month, compared to $385 per month in Switzerland. In comparison, average employee premiums in the U.S. in 2017 were $118 for single-person plans and $435 for family plans. Approximately 40 percent of the Dutch, moreover, receive tax subsidies to purchase insurance, similar to the subsidies introduced by the ACA.

Cost-sharing is also lower in the Netherlands: there is none for primary care and preventive services, while copayments for other services are capped at $475 per year, after which they are free. By contrast, the Swiss face copayments for all services up to a deductible of their choosing, between $248 and $2,065. After this, 10 percent to 20 percent coinsurance applies on all services, capped at $579 per year for adults. All told, average annual out-of-pocket costs in Switzerland are nearly four times higher than those in the Netherlands ($2,313 vs. $605).

A Single Public Plan

In countries that have public insurance systems, also known as “single payer” systems, national, regional, or local governments are the main payer of health care. In the United Kingdom, the National Health Service is funded by national taxes, while other systems are decentralized, with revenues raised through regional taxes (Canada) or local taxes (Sweden). In Norway, funding is split: primary care is funded through municipal taxes, while national taxes pay for hospital and specialty care.

The House and Senate bills that would introduce a single public plan for the U.S., however, differ from the approaches taken in other countries in two important ways.
First, many of these proposals would impose no patient cost-sharing. This is in contrast to Scandinavia, where patients pay copayments for most services. Norwegians pay $17 (U.S.) for primary care visit, $39 for specialist visits, and up to $51 for prescription drugs. At the same time, total annual out-of-pocket spending is capped at $221 per year (as of 2017), after which services are free; also, vulnerable populations such as children and pregnant women are exempt from most cost-sharing. Even in countries where physician and hospital services are free, such as the U.K. and Canada, patients pay some portion of prescription drug costs.

Second, the single public plans that have been proposed in the U.S. so far would provide everyone with a wide range of benefits, including vision, dental, and long-term care. Most countries with universal coverage, however, cover vision and dental benefits only for targeted populations such as children and low-income adults. Similarly, long-term care is not typically covered. Instead, these services are financed separately, whether through national long-term care insurance or local taxes.

Private Coverage: A Bit Part or a Featured Role?

In all countries with universal coverage, at least some portion of the population has secondary private insurance, either to help pay for noncovered services like dental and vision care or physiotherapy or to provide quicker access to elective care or private providers.

While less common in England and Norway — where only one in 10 has private coverage — private insurance plays a large role in several other countries. In Canada, the majority of residents have private insurance for prescription drugs — which the national program doesn’t cover — and other benefits, paid mostly through employers.2

In Australia, the federal government has introduced strong financial incentives for adults to purchase private hospital insurance, such as premium discounts for younger adults, financial penalties for high-income earners who don’t purchase coverage, and rebates on premiums. As a result, approximately half of Australians have purchased such coverage.

One country allows its residents a choice between two systems. In Germany, everyone is mandated to have coverage, and the majority choose among 110 nonprofit insurers known as “sickness funds.” This type of coverage is financed by individuals and their employers through payroll contributions (cost-sharing is relatively low). But the government allows people to opt out of this system entirely.

About one in 10 Germans choose instead to get private coverage from for-profit and nonprofit carriers; they pay for it entirely themselves through contributions. This option is particularly attractive to higher earners and to younger adults, to whom insurers typically offer generous benefit packages and lower premiums.

Weighing Options

Several members of Congress have proposed — or plan to propose — ways to cover the remaining 28 million uninsured Americans, reduce the number who are underinsured, and lower the overall rate of cost growth. The health systems described here all get to universal coverage while paying less for health care — and often with better health outcomes — than the United States. If we as a nation aim to achieve similar results, it will be informative for lawmakers to carefully consider the full range of options these other systems represent.

1. Their insurance requirement also resembles the ACA’s individual mandate, although the penalty for not having coverage was eliminated by the Trump administration and Congress beginning January 2019.

2. Most Canadian provinces and territories also operate public prescription drug plans for targeted populations such as children, the elderly, or people receiving social assistance.

Article link: https://www.commonwealthfund.org/blog/2019/universal-health-coverage-eight-countries

The Department of Defense’s program to transfer management of its medical treatment facilities from individual military departments to the Defense Health Agency is helping to improve military patient access to care.

By Fred Donovan on July 08, 2019

The Department of Defense’s program to transfer management of its medical treatment facilities (MTFs) from individual military departments to the Defense Health Agency (DHA) is helping to improve military patient access to care.

Under the transfer program, which was mandated by the 2017 National Defense Authorization Act, DHA will be responsible for all MTFs with respect to budget, information technology, healthcare administration and management, administrative policy and procedures, and military medical construction.

The DoD’s MTFs include 51 hospitals, 381 ambulatory care and occupational health clinics, and 247 dental clinics.

As an example of the benefits of the transfer, Womack Army Medical Center has been helping out Seymour Johnson Air Force Base, which was understaffed in its radiology department, the Fayetteville Observer reported recently.

“We had some staff challenges that usually would take at least six months to resolve,” said Air Force Tech. Sgt. John Perez, the noncommissioned officer in charge of the radiology clinic.

Womack sent a radiology technician, Spc. Zachary Bevington, to help with the understaffing situation at Seymour.

“I have been performing diagnostic radiology because doctors constantly come in wanting to see what’s going on inside of their patients,” Bevington said. “I’m very happy to be able to come here and help. I love being a part of the patient healing process.”
Womack and other MTFs in the Carolinas are in the processes of transitioning administrative policies and processes to DHA.

“It’s great to have more people across the services that work in the same specialty care,” Perez said. “It’s very appropriate to have a standard across the board regarding military medicine.”

Womack Army Medical Center, Seymour Johnson Air Force Base, Pope Army Airfield, and other MTFs in the region have been assigned to the Coastal Carolina Market. They are included in the first phase of the transfer.

Other MTFs in phase 1 of the transition include Fort Bragg, NC; Naval Air Station Jacksonville, FL; Keesler Air Force Base, MS; Joint Base Charleston, SC; Walter Reed National Military Medical Center, MD; Ft. Belvoir Community Hospital, VA; and associated clinics.

Phase 2 of the transition is scheduled to be completed this October. Phase 3 will include remaining U.S. MTFs and will be completed in October 2020, while phase 4 will include overseas MTFs and will be completed in October 2021.

Add link: https://hitinfrastructure.com/news/amp/dods-transfer-of-mtfs-to-dha-designed-to-improve-patient-access

By Olga Khazan, The Atlantic  June 25, 2019

Americans waste time and money filling out paperwork and repeating tests in the doctor’s office. A small Baltic nation has found a better way.

The scene: a doctors’ office. You: frustrated, on lunch break from work, just wanting to get in and get out. It’s probably not your first visit to that provider. It might not even be your second or third. And yet, there you are, filling out byzantine papers attached to a clipboard, promising to pay if your insurance doesn’t, providing your Social Security number for the kajillionth time, and trying to remember your insurance-group number, which is not the same as the ID number.

“Every time I go to the doctor, I spend the first half hour filling out pages of information. Why isn’t that traveling with me?” asked a cancer survivor in the audience of a recent talk by Eric Topol, the chair of innovative medicine at Scripps Research, at Aspen Ideas: Health, which is co-hosted by the Aspen Institute and The Atlantic.

“It’s so real that you have to fill out the same forms all the time,” Topol responded. The American medical system is atrocious at keeping track of the stuff it does. According to Topol, 10 percent of all scans in the United States are repeated unnecessarily simply because patients can’t get ahold of their past records and scans. It amounts to billions of wasted dollars.

Instead of this current system, Topol recommended the U.S take a page from Estonia, the Baltic nation in which health records are digitized and travel with the patient. “You wouldn’t be filling out all these forms, because you could send your data [to the doctor],” Topol said.

Under the wonderfully named “E-Stonia Project,” much of the data behind Estonians’ lives, from doctors’ appointments to taxes, have migrated from dead trees to the cloud. Almost every person in Estonia has an electronic ID card that contains their entire health record. Doctors can see each others’ notes, as well as past scans and X-rays the person has had. “In an emergency situation, a doctor can use a patient’s ID code to read time-critical information, such as blood type, allergies, recent treatments, on-going medication or pregnancy,” the E-stonia site explains. Patients own their own health information; they can access it at any time. The health data is kept secure through blockchain technology, which takes note each time something in the record is changed. Even the country’s ambulances get downloads of the health data of the people they are rushing off to help.

The disparity between the United States and Estonia when it comes to electronic health records came to the attention of Estonia’s former president, Toomas Hendrik Ilves, during a trip to Northern California. “If you have to prove that you live where you live or get your child to be registered for school, you have to come in with a paper copy of your electricity bill,” Ives told PRI’s The World in 2017. “The reality of your sort of life dealing with bureaucracy, it is not touched by the digital revolution.”

Article link: https://www.nextgov.com/it-modernization/2019/06/what-us-medical-system-can-learn-estonia/157984/

The U.S. Coast Guard wasted $60 million and seven years developing a health IT system that resulted in no equipment or software that could be used and a return to paper medical records.

July 01, 2019 – The U.S. Coast Guard wasted $60 million and seven years developing a health IT system that resulted in no equipment or software that could be used, according to the Government Accountability Office (GAO).

This health IT system project and other federal IT projects have suffered from a lack of disciplined and effective management, such as project planning, requirements definition, and program oversight and governance, the GAO judged.

“Executive-level governance and oversight across the government has often been ineffective, specifically from CIOs. For example, we have reported that some CIOs’ roles were limited because they did not have the authority to review and approve the entire agency IT portfolio,” the GAO commented in its report.

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The Coast Guard ended up canceling the health IT system project, called the Integrated Health Information System (IHiS), in 2015 after decommissioning two legacy electronic health record (EHR) systems.

The head of the Health, Safety and Work-Life (HSWL) Directorate at the Coast Guard identified several financial, technical, schedule, and personnel risks with the IHiS project that led to its termination. Some of the risks with the IHiS project identified by HSWL director included:

Lack of testing: IHiS lacked an independent security assessment to verify that the system’s security infrastructure was adequate. In addition, full interface testing with systems such as the Defense Eligibility Enrollment Reporting System had yet to be completed to ensure security and data integrity.

Limited system functionality: The system that was to provide user verification and IHiS role management services had yet to be completed. In addition, Coast Guard workstations could not yet access IHiS from the network, and the patient portal lacked two-factor authentication. Further, the service that was to register new IHiS users in the system had yet to be completed.

Delays in the implementation timeline: The Defense Health Agency team projected the timeline for the first clinic implementation of IHiS would be approximately one year later than originally estimated. DHA said that the timeline was delayed, in part, because critical IHiS interfaces and workflows were not complete or operational.

As a result of the decision to cancel the IHiS project and shutting down the legacy EHR systems, Coast Guard clinics had to revert to using paper medical records for their 50,000 military members, the GAO said.

The challenges presented by the paper-based system included incomplete records, bad penmanship, problems tracking medications, amount of time needed to manage records, and limited ability to search within records.

The Coast Guard subsequently joined the DoD MHS GENESIS contract to deploy a Cerner-based EHR system. To incorporate the Coast Guard into the EHR implementation and to establish a standardized EHR baseline with the Coast Guard and the Department of Veterans Affairs, the DoD asked for a $1.2 billion increase in funding for MHS GENESIS based on the Cerner platform.

The standardized EHR baseline will include common off-the-shelf software, clinical application services, and interfaces, as well as shared infrastructure.

The MHS GENESIS system will replace legacy DoD EHR systems, such as the Armed Forces Health Longitudinal Technology Application, the Composite Health Care System, and components of the Theater Medical Information Program-Joint.

The new EHR system will provide two-way communication and integrated medical and dental records. It will monitor members’ health through better population health data, tracking, and alerts; improve the ability to track patient safety, outcomes, and readiness; expand access to and sharing of health data across military operations and veteran and civilian healthcare organizations; and increase accessibility of integrated, evidence-based healthcare delivery and decision making.

Article link: https://hitinfrastructure.com/news/gao-coast-guard-wasted-60m-on-unusable-health-IT-system