Patient satisfaction ≠ Quality of care

Health care quality is a huge issue in the US; despite claims that we have the best healthcare in the world, reality is far different.

Why?  I’d argue its because healthcare consumer behavior drives our for-profit system.

What makes patients happy is completely unrelated to the actual quality of medical care they receive – or how likely they are to die.

Research article is here.

the horizontal axis indicates hospital performance by deciles for each category…note patient satisfaction doesn’t vary by hospital mortality and varies just a little by medical quality, but varies a LOT by nurse communication.

The effect of nurse communication on patient satisfaction is four times larger than the effect of the hospital’s mortality rate. Yup, as long as the nurse smiles, is responsive and nice, we’re satisfied. Never mind if we’re a lot more likely to die.

Another oft-measured factor, the quietness of the rooms, has a 40% larger effect on patient satisfaction than medical quality.

This is because hospitals provide two separate and distinct kinds of services  – the technical delivery of medical care and “room and board-related” services. Patients are much better at observing and rating the “hospitality” part of their hospital stay than the medical care they get.

To quote the authors;

Hospitality is the fast track to customer satisfaction in medicine. 

What does this mean for you?

Customer satisfaction is the fast track to profits… not to good medical care.


Wildly off-topic…F-16s

Russian general when he learned about F-16s heading to Ukraine…

Вот чёрт!!

From Phillips O’Brien…

Its impossible to exaggerate the intensity with which Ukrainians from all walks of life, from the top of the state and military to civil society, were focussed on getting F-16s for the Ukrainian Air Force.

Why F-16s are critical…

  • Ukraine’s Air Force is woefully behind the times, their main fighter – the Mig-29 – has been around for 40 years and is beyond obsolete. 
  • Getting spare parts for the UAF’s Migs is getting harder and harder.
  • F-16s are very, very capable – military-speak for they can do lots of things well.
    • shoot down other planes
    • support ground operations
    • launch missiles to hit targets hundreds of miles away
    • shoot down incoming rockets and missiles
  • Unlike the Mig-29, F-16s have constantly upgraded
  • Unlike many other planes, they are relatively simple to maintain and there is a huge stockpile of spare parts

The net is there is no other single airplane that fits the bill as well as the F-16.

Okay, it’s gonna take a very long time to train Ukrainian pilots on the F-16…

Well, no.

An internal US Air Force document indicates Ukrainian pilots  – with almost no training – could execute complicated maneuvers albeit it in an F-16 simulator. Multiple sources indicate Ukrainian pilots can be flying the F-16s in combat a few months.


It’s unlikely the F-16s will have much of an impact on the already-started/upcoming Ukrainian offensive, but they will play a major role in Ukraine’s likely long war.

What does this mean for you?

More good news for Ukraine, and bad days for Russian butchers.


What business are you in?

Hint – if you are a specialty network, you are NOT in the specialty network business…

Over the  last few weeks I’ve been talking with Rita Wilson of Tower MSA: Rita’s been attempting to educate me about the MSA world, a Herculean task to be sure.

What struck me about our conversation is Rita kept referring back to Tower’s purpose, which is claim settlement. From Tower’s website…

Tower focuses on the settlement of claims as we deliver measurably better Medicare Secondary Payer (MSP) compliance. We identify cost drivers and other barriers to closing claims, recommend and implement clinical interventions, and benchmark our performance against CMS responses [emphasis added]

Tower is not in the MSA business…it is in the claim settlement business.

Work comp payers don’t care about MSAs, they care about settling claims – once and for all.

By clearly defining Tower’s focus, the company speaks directly to the problem its clients and prospects are facing, demonstrating Tower knows what payers want and need.

Back to a specialty network…


What buyers care about is their combined ratio (if an insurer) or controlling costs and return to work (if a self-insured employer).

If you can directly show how your PT/imaging/DME/whatever network reduces combined ratios, controls costs and improves RTW, then AND ONLY THEN should you talk about HOW you do that.

What does this mean for you?

Be like Rita.


Wildly off topic #15 – Leaks and the coming offensive

There’s much rending of clothes and gnashing of teeth in the mass media about how Jack Teixeira’s criminal stupidity will:

  • help Russian generals defeat Ukraine’s pending attacks by identifying attacking units and eliminating surprise
  • really tick off our allies
  • reveal key shortages of materiel (military-speak for ammunition, spare parts, supplies and weapons systems)

Uh, no. Let’s take these in order. (much more detail at Phillips O’Brien’s excellent substack postings.)

The upcoming offensive

Is the worst-kept secret since Trump’s sexual antics with porn stars.

Ukrainian officials, military leaders, Allied intelligence, Russian military bloggers have all talked about this. Heck, they even know the military units that will do the attacking. What we don’t know is when and where…and Teixeira’s documents don’t give a date or location..

Angry allies

What? An ally is spying on us? How…common.

Reality is everyone spies on everyone else all the time. There will be outrage and histrionics from politicians from Israel to Norway, all furious at such conduct.

All will be for public consumption, this will die down pretty quickly, and really…does anyone think allies will abandon the US or Ukraine over this?

Materiel shortages and impact thereof

This is perhaps the most ridiculous “disclosure.” There have been hundreds of public reports, news articles, blog posts and stories about this over the last few months.

Lastly, among the “revelations” in Teixeira’s documents is that our intelligence community has doubts about whether Ukraine’s upcoming offensive will achieve much.

Hardly.  With some notable exceptions (e.g.the timing of Russia’s initial attack) US intel has a rather poor record of predicting what’s going to happen in Ukraine. And that is being kind.

What does this mean for you?

Top Secret…isn’t.

More than 1.3 million individuals have Top Secret clearances.

You can bet your house the Russians knew everything in Teixeira’s documents long before they hit Discord.



Benchmarks and outcomes

So what exactly are “benchmarks”?

Yesterday we dove into outcomes vs process metrics, and why focusing on process measures (e.g. call abandonment rate, three-point contact timeliness, savings below fee schedule) instead of outcomes can result in the classic…

Benchmarks are standards by which outcomes can be measured or judged. Outcomes drive process improvements, financial results, and most importantly, healthy, fully functional patients.

In work comp, you’ll most often see vendors or payers comparing their results to ACOEM and/or ODG...while that can be somewhat useful, it’s important to recognize several issues/potential limitations…

(beware of comparison’s to the vendors’ clients…while that can be helpful and illustrative, it’s usually a very small sample set, and begs the question – “just how good are the vendor’s overall results?)

  • median values are typically used…but they reflect average, run-of-the-mill performance, which is NOT the standard we should be aiming for.
  • data comes from a limited number of payers and other sources and may not reflect your injured worker population’s demographics, locations, injury types and other factors
  • case-mix adjustment tools can be very helpful – IF the tools are:
    • used with robust data sets that reflect your patient population,
    • specific to the time frames you are evaluating,
    • relevant to payer type, and
    • straightforward, with limitations explicitly acknowledged and explained.

This can get pretty complicated, as in migraine-inducing complicated. Don’t obsess…and unless you are a statistical whiz, Do NOT get caught up in the minutiae, it is up to the vendor to help you understand, not to baffle you with BS.

(very helpful to have a statistically literate person on your team to clarify, help explain, and when necessary call BS…there’s a LOT of it out there)

Rather, challenge the vendor to explain in layperson’s terms specifically and in detail why and how these benchmarks are relevant to your population, their limitations and strengths, and where you fall on the spectrum from worst to best. Also, get written documentation of their analyses and the methodology you can share internally and with your customers as necessary.

Vendors who cite benchmarks must be able to explain all of this...just don’t expect them to do this the first time around, as it is likely they’ve never been challenged.

What does this mean for you?

Know your outcomes.


Vendors – read this.

B2B sales is NOT about “value”, RoI, relationships, or anything else you think it is.

It is about meeting the emotional/psychological needs of the key buyers.

You may have sensed this, or interpreted it as “relationships” that make deals happen  – but that is a misread. The reason relationships work is they reflect the sales person’s deep investment in getting to know the buyer(s), understanding what drives them (outside of obvious business goals), and mitigating their fears.

A terrific piece in Harvard Business Review speaks directly to this…(quotes from the article)

  • findings indicate that B2B customers prefer interactions that fuel their psychological needs — even if they require more time or cost more money.
  • Among vendors who provide “poor” service, only 33% of respondents reported that the vendor knows them personally. In contrast, among vendors who provide “good” service, respondents indicated the vendor knows them personally more than twice as often (70%).
  • Even when you have an effective solution in mind, provide your clients with options so they’re reminded that they’re in control.

  • (this is directly supported by our most recent survey of prescription drug management in workers’ comp…respondents overwhelmingly want PBMs to provide them insight so they can fix problems collaboratively)
  • Our study also included some interesting findings around empathy. Expressing empathy, a common way of increasing connection with our friends and family, can backfire if customers perceive it to be disingenuous. Too often, service providers script empathy into customer interaction, assuming it’s what customers want to hear. That’s a mistake. Our research indicates that customers far prefer a service provider who responds knowledgeably over one who “feels their pain.”

What does this mean for you?

be genuine.

ask questions, don’t present.

don’t schmooze.


Regulations – the good and the bad

Work comp and healthcare are probably the two most highly regulated sectors of the economy – and yes I’m including the financial sector.

Over the last 25 years I’ve spent a ton of time with regulators, legislators, lobbyists and the government folks tasked with implementing those laws and regulations.

Here are my learnings…

  • < 5 state legislators know anything about workers’ comp, and only a smidge more about healthcare.
  • what legislators DO know is from mass media (healthcare) or lobbyists (work comp, because there’s never any mass media coverage of work comp)
  • the laws that pass (with some exceptions) leave much to the regulators
  • Regulators are mostly thoughtful, diligent, attempt to do the right thing and generally open to input.
    • There are some glaring exceptions – Florida being the most problematic.
  • That said they rarely – and understandably – fully understand the potential impacts of their rulings, with big consequence for injured workers, employers, and taxpayers.

According to sources that know a lot about financial regulation, the collapse of Silicon Valley Bank was due in large part to laws passed by Congress (with mostly R and some D support) that loosened capital and other requirements for a lot of banks.

Incompetence added fuel to the dumpster fire. Now staunchly-Libertarian Silicon Valley investors and business owners have suddenly become huge fans of central government intrusion into private business (what a bunch of %$#(*&># hypocrites).

credit New Statesman

From the LATimes:

venture investment firms…actually launched the run on SVB on Thursday, when they suddenly urged their companies to pull their deposits from the bank, triggering the $42-billion outflow. “And they now want the Taxpayer to bailout their investments…?! Capitalism, Silicon Valley-style.”

Tellingly, SVB dropped a half-million dollars lobbying to get those laws passed…and their CEO – a huge champion of de-regulation was the biggest champion.

Now we have what just might become a global financial problem that – with better US banking legislation and regulations – would never have happened.

What does this mean for you?

If you are a state legislator, find and talk with objective and informed people in each area you’ll be voting on.

If you are a regulator, do what you can with what the legislature gives you, but be realistic…work comp is <1% of US medical spend, so do NOT expect healthcare providers to do anything different for their work comp patients – even if your regulations require them to.

If you are a Federal legislator, think a lot more about some massive effort to shrink the government.

Those Silicon Valley Libertarians sure wish they did.



Lessons from Ukraine

A recent report from Phillips O’Brien and podcast from War on the Rocks got me thinking about parallels between Ukraine’s military and the workers’ compensation industry.

The net is the military units that allow front-line forces to be creative, adapt, and make key decisions about tactics, weapons used and allocation of resources are much more effective than those units which must follow strict plans from distant leaders.


  • In less successful organizations senior leadership tends to be hidebound, sets plans in concrete, allows subordinate units and leaders little freedom or flexibility in carrying out those plans, and measures “success” with metrics that are usually more process (we fired XX artillery rounds and killed YY enemy) than outcome (we took X hectares of land at the cost of YY munitions and casualties)
    Or in work comp terms, process (we answered Y calls in Z seconds, filled out XXX forms, cut medical bills by XXX dollars…) instead of outcome (our medical cost per claim was YYY, claim duration on closed claims was AAA and our closure rate was ZZZ).
  • In more successful organizations (those with better outcomes) senior leadership listens hard to front-line staff, develops back-channel as well as formal reporting processes, sets clear objectives and asks local leaders what resources they need to accomplish those objectives, and uses that information – and local leaders’ insights – to help determine which objectives will be pursued.
    In workers’ comp terms, a really effective organization would provide front-line staff with intel on which providers are most effective, which are profiteering dirtbags, what hospitals have the highest clinical outcome and patient safety ratings and are most cost-efficient…educate front line staff on the importance of these metrics, and enable adjusters and case managers to figure out how to best use that information when talking with patients, providers, employers and families.

Until relatively recently Ukraine’s military was pretty much a carbon copy of Russia’s. Recall Ukraine was a Soviet client state and its military’s structure, leadership model, training, and equipment was identical to the USSR’s. The result was very much a top-down military with even platoon-level 40 soldiers) and squad-level (12 soldiers) leaders required to follow strict plans on:

  • where to go,
  • what path to take to the objective or when retreating,
  • what weapons to use,
  • when to attack and withdraw,
  • how to assault or defend an objective, and myriad other details.

That’s how Russia is fighting in Vuheldar – where it is failing miserably in large part due to stupid tactics.

Some Ukrainian units have evolved to a less-dictatorial leadership model; Ukraine is by no means immune from Russian-style leadership, but it appears to suffer somewhat less from it. Bakhmut is an example; (my layperson’s guess is) leadership sees the battle as a key to the upcoming Ukrainian offensive; Russia is suffering huge and unsustainable losses in personnel and equipment due to human wave attacks and massive shelling. Ukraine is losing hundreds of soldiers as well, but it appears to be delegating authority on local tactics to local unit leaders, likely reducing casualties.

That means fewer Russian soldiers, shells, cannons and vehicles to resist Ukraine’s spring offensive, and more Ukrainian assets to attack.

Alas leaders at many workers’ comp payers – and most insurers – focus way too much on “the plan” and way too little on the planning process and figuring out how to enable local leaders to achieve objectives,

For an excellent discussions of where Russia is doing smart and dumb things due mostly to leadership click here.

What does this mean for you?

Planning and setting objectives is critical, as is delegation and enabling local leaders to figure out how best to accomplish those objectives.


Two COVID things

It’s been a blissful few months as COVIDF has retreated into the background, likely to remain with us forever but hopefully as a nuisance not the million+ killer it was for the last couple of years.

So, two new items.

First, in what can only be described as a huge waste of taxpayer money, a very large and very scientific study found ivermectin does not reduce COVID symptoms. 

Shocking, right?


  • double-blind, randomized, placebo-controlled platform trial
  • 1206 US adults with COVID-19
  • median time to sustained recovery was 11 days in the ivermectin group and 11 days in the placebo group.

Hucksters, charlatans, former US presidents and other of the willfully-ignorant will undoubtedly parse, lie, misstate, ignore, or otherwise continue to claim that a veterinary medicine for treating bacterial infections is actually a cure for a viral infection.

to quote a T-shirt recently spotted…

Lab leak, nefarious plot, or animal-to-human transmission?

Last week the new broke that the US Department of Energy thinks  – albeit with “low confidence” – that COVID leaked out of a Chinese lab.

This is sort of like saying “Tom Brady is going to sign with the Yankees as a pitcher…heard this from a guy I know who was on a plane sitting next to a woman who looked like a reporter and saw her writing that Brady’s heading to spring training in Tampa…”

This is NOT to disparage the scientists at DoE, rather to remedy what seems to be a serious lack of reading ability on the part of too many who can’t seem to grasp – or rather refuse to accept – that things are rarely black-and-white, or as friend and colleague Pier Rousmaniere notes in his signature line;

Doubt is not a pleasant condition, but certainty is absurd. – Voltaire

[Unless, of course, one has completed a rigorous 1200 person RDB – CT study]

Nine Federal intelligence agencies have completed their research on the “where did COVID come from?” question…Two of those concluded a likely lab leak, five said natural causes and two said they don’t know.

Given the really lousy record these state-of-the-art labs have when it come to keeping deadly viruses contained, it is certainly possible it leaked.

Reality is  – it is unlikely we will ever know – for certain.

What does this mean for you?

Read carefully before posting.


Wildly off-topic # 14 – the Russian “offense”

Last time we talked tanks

This time we’ll focus on Russia’s winter offensive. If you don’t have time, just skip to the takeaways at the bottom of this post.

credit Institute for the Study of War; I highly recommend ISW’s briefings

Quick take – the offensive isn’t going well. While Russia is making advances, they are measured in meters not miles, and are coming at horrendous cost in dead, injured, and captured Russian troops. The Russians did capture Soledar and have make barely measurable progress around Bakhmut and a couple other places but none of those are – in any way – changing the reality on the ground.

Which is Russia is screwed.

As we discussed in WOT #10, you need troops and equipment to fight a war.

The Russians lost a huge amount of equipment last year – hundreds of tanks, armored fighting vehicles, cannons, trucks, trains – equipment it cannot readily replace, if at all. If you want to attack, as Russia is trying to do in its winter offensive, you really need armored vehicles to penetrate opponents’ lines and break out into less well-defended territory. Dug-in defenses  – usually several lines deep – are very, very hard to defeat unless you can blow a really big hole in them and exploit the opening with fast-moving vehicles.

So, in what is eerily reminiscent of World War One, Putin the Butcher is throwing thousands of untrained men at Ukraine’s front lines. (If you want a taste of that, I highly recommend the book and film “All Quiet on the Western Front“.) Trigger alert – it is really awful and disturbing, and the German general is a bald version of Putin the Butcher.

PtB’s tactics are pretty awful…

  • untrained ex-prisoners and recruits from Russia’s far east are forced to attack Ukrainians positions.
  • they are slaughtered – because they have no idea what they are doing, have minimal weapons and ammunition, and are going up against entrenched, battle-hardened and well-supplied Ukrainians, but
  • in so doing, the Ukrainians reveal their positions, which are then bombarded with rockets and artillery and attacked by much more capable Russian troops.

That is NOT to say Russia’s “real” soldiers are invulnerable. Reports from the front indicate Putin’s “elite” units lost dozens of armored vehicles and hundreds of soldiers over the last few days…equipment and men which Russia cannot afford to lose.

Putin the Butcher has a seemingly inexhaustible supply of poor young men but they are a very poor substitute for modern military vehicles and artillery.


While others much more knowledgeable than I see this war grinding on for years, I’m hard pressed to agree.


  • cannot replace most lost equipment,
  • is losing more and more of its irreplaceable, experienced and well-trained troops,
  • has not demonstrated its generals have any idea what to do,
  • is facing an increasingly better-equipped and far more motivated enemy, and
  • is losing the information and intel dimensions.

Like we saw late last spring, all is well until it is not, and then it goes really, really badly for Putin the Butcher.

all previous posts on this topic are here.