Public Health Leadership-Evaluation

What is one of the problems with using competencies as a means of evaluating leadership?

The main problem with competency frameworks is that the competencies are not defined with sufficient specificity to permit their measurement. Competencies need to be broken down into specific components that can be measured. There must be an applied research strategy to evaluate the necessary leadership competencies on a regular basis and the competencies should be updated based on organizational objectives. The process of defining the framework for competency based assessment has only recently been developed and it will take some time for a complete performance standards system to be capable of evaluating leadership outcomes.

What are the pros and cons of credentialing leaders?

The supporters of credentialing argue that credentialing increases the credibility of public health professionals both with members of the public as well as with politicians. Furthermore, they argue that credentialing will enable the development of professional standards. Supporters of credentialing want to link credentialing to licensure. The proponents argue that the process of evaluating professional knowledge helps develop standards for professional performance. The critics argue that no credentialing system is possible because of the multidisciplinary background of public health professionals. Furthermore, they point out that schools of public health are accredited and so a degree from an accredited body should be sufficient evidence of competence.

                I understand both sides of this debate. Before I started graduate school it seemed like such a monumental undertaking that is seemed that graduates must have a special level of expertise. However, as I have neared the end of my course work and gotten to know graduates of this program as well as employees of HHS that have masters degrees, I have come to the conclusion that a person of only ordinary intelligence and character can graduate from a MPH program, and the fact of obtaining this degree may or may not indicate their competence to practice public health. Therefore, I can understand the argument that credentialing may serve to raise the bar and establish readiness to practice. In a sense, the argument that graduating is good enough is akin to arguing that doctors, by virtue of graduating from medical school, are prepared to perform as physicians.  

A report from the association of schools of Public Health discusses the factors that need to be addressed in a sound credentialing program. First role delineation that distinguishes between professionals who have different skills and levels of knowledge is a requisite. Second, the credentialing system must specify the knowledge and skills required to carry out the duties of a credentialed public health leader. Third, the system must determine the education, training, or experience necessary to generate the required competencies. Fourth, a testing procedure or other form of assessment must be devised to determine when a practitioner has achieved entry level competency. Lastly, the system must allow for a process for recertification or maintenance of certification through ongoing professional education.

What are five personal leadership lessons you have learned in the last year?

I have learned that it is important to cultivate emotional intelligence and stay in touch with your feelings. I have also learned that self-care is essential. I have the tendency to want to help everyone else around me and forget to care for myself. It is important for leaders to invest sufficient time in self-renewal and rest. Furthermore the issue of work life-balance is important for public health leaders. In a field where there is so much to be done, and where the workforce is committed to principals of social justice, it is easy for public health leaders to become overly invested in the work they do. I think it is important for leaders to manage their time from an integral perspective, making sure that they preserve work-life balance. Another leadership challenge I have grappled with in the past year is how to inspire a strong work ethic in subordinates. Finally, I have learned to work more effectively with partner agencies by clarifying our respective agendas and better defining our roles in campaigns.

What is a 360 degree assessment?

The 360 degree assessment process involves a multilevel evaluation that focuses on whether the leader’s style of leadership supports or obstructs achievement of the mission and goals of the organization. In a comprehensive 360 degree assessment, all key stakeholders have a voice in evaluating the leader and assessing the direction in which the organization is headed. In order for a 360 degree assessment to be carried out, the leaders of the organization must determine whether sufficient enthusiasm for and commitment to the process exists in the organization and whether they are willing to institute changes based on the results of the assessment. Secondly, they must collect high-quality data. Lastly, they must identify possible responses to the results, such as the development of new training programs and initiatives. The 360-degree assessment utilizes the leadership practices inventory (LPI). The five practices in the LPI are 1) modeling the way, 2) inspiring a shared vision, 3) challenging the process, 4) enabling others to act, and 5) encouraging the heart.

What are some difficulties associated with performing a 360 degree assessment?

A 360 degree assessment is often expensive and time consuming. Measurement instruments must be bought and staff must be trained to interpret the results. Furthermore, leaders must be comfortable revealing their self-perceived weaknesses to their colleagues and subordinates must feel comfortable rating their leaders. The last issue is of special concern in smaller organizations, where animosity could occur between leaders and subordinates if negative feedback is given.  

The rating of leaders is further complicated if subordinates know that ratings will be tied to the compensation of the leader. Regardless of employee’s role (leaders and non-leaders alike) all employees are subject to the exterior phenomena of inflation and if annual salary increases are not provided, then the real compensation of the employee decreases over time. Arguably, one of the key factors that influence health and well-being in American society is SES, which is made up in part by household income. If people are not compensated in such a way as to maintain their household income, their personal well-being may decrease. A public health agency needs to grapple with the issue of fair market value of compensation and how performance and compensation will be linked, when deciding how employees will be evaluated.

A final consideration when an organization is deciding whether to perform a 360 degree assessment, is contemplating whether performing the assessment will make a difference. Perhaps the process for changing leadership is so cumbersome that there is no way a leader can be forced out even if he/she fails to perform at a minimum level. A leader may be protected by political or administrative mechanisms that prevent any punitive action from being taken. If this is the case, a 360 degree assessment could simply be a drain on the organization’s time and resources.

What is qualitative leadership assessment and what are some techniques for performing such an assessment?

A qualitative leadership assessment evaluates the leader based on personal traits and behaviors. There are a number of instruments that can be used to perform a qualitative assessment. These include the Myers-Briggs Type Indicator, The Leader Behavior Analysis II, the Team Leadership Practices Inventory, and the Leader Behavior Inventory.  The Myers-Briggs Type Indicator (MBTI) assessment is a psychometric questionnaire designed to measure psychological preferences in how people perceive the world and make decisions. The Leader Behavior Analysis II is a tool for understanding perceptions of one's style by revealing what direct reports actually experience. It presents leadership situations along with four possible responses. Managers' responses to these situations reveal their leadership style flexibility, their primary and secondary styles, their effectiveness in matching the choice of a leadership style to the situation, and their tendencies to misuse or overuse a particular style. The Leadership Practices Inventory (LPI) is a questionnaire with thirty behavioral statements. Leaders complete the LPI-Self, rating themselves on the frequency with which they think they engage in each of the thirty behaviors. Five to ten other people—typically selected by the leaders—complete the LPI-Observer questionnaire, rating the leaders on the frequency with which evaluators think leaders engage in each behavior. Respondents’ feedback is anonymous. The Leader Behavior Inventory is based on five behavioral factors: Visualizing Greatness, Empowering the “We,” Communicating for Meaning, Managing One’s Self, and Care and Recognition.

Regardless of which instrument is used, public health leaders need to develop the competencies to carry out performance monitoring. They need to ensure that performance measurement is accepted by the staff and that the information gained through the monitoring process is used to improve operations. Performance measures for evaluating the activities of public health leaders and their community partners utilizing a systems perspective and the essential public health services paradigm have been developed by the National Public Health Performance Standards Program.

Why is leadership program evaluation important?

Ongoing program evaluation creates an atmosphere in which effective leadership and organizational learning can flourish. Leaders need to show support for program evaluation and include evaluation as part of the mission and vision of their agency. They need to be involved in the evaluation process and work with other agency officials to ensure that the process is successful. No organization can achieve excellence without opportunities for continual learning provided by training and leadership development programs. There are four major standards for program evaluation: utility, feasibility, propriety, and accuracy.

One of the first steps in program evaluation is to determine whether the training program is really necessary.  Once the topic of the program has been determined to be needed, the programs objectives should be set and the program developed. The third step is to offer the training program itself. Measurements should be done before or at the start of the training program and at its conclusion to determine the scope of the changes that occurred. Research can be done on several measures, including the association between program elements and leadership change, the lessons learned from the training course, measurable leadership competencies, the differences between new leaders and established ones, and the differences between trainees and colleagues who have not been trained.

What is one difficulty in evaluating leadership programs?

Because leadership development is sometimes used as a reward for public health professionals, there is a danger that this reward will benefit the individual and not the public health system if the training opportunity is not relevant to the needs of the system. Another challenge is the fact that a leadership development may not show an immediate return on investment. The delay between leadership development and the development of strategic outcomes creates difficulties in determining the value of training programs.  Another challenge is the lack of funding in public health leadership development for the evaluation function. There is also a lack of understanding about what such evaluations are supposed to accomplish.

How do leadership programs differ from other training or education programs?

Leadership development programs are different from other types of training programs because they seek to influence behaviors beyond specific skill sets. Traditional training or education programs seek to impart skills to the participants- teach them Java Script, how to better deal with conflict, or how a clinical trial can best be designed, etc. Because leadership is multidimensional and dependant on the internalization and projection of the organization’s mission and values, leadership development is much more profound than just learning a series of steps to carry out a project or handle a particular situation. 

What leadership issues do you think should be the focus of research?

I think the biggest challenge that leaders face is inspiring their employees to perform at the level of their personal best 100% of the time. Therefore studying the mechanisms whereby leaders can either inspire employees to perform at their peak level or leave the organization should be the topic of leadership research.

What are some benefits that would be gained by keeping a leadership journal?

Leadership is a complex, multi-faceted form of performance. We cannot know leadership exists unless something happens. Therefore it may be useful for the leader to keep a log of the activities and decisions she/he makes and document the outcomes of those decisions. Documenting situations and decisions over time allows a leader to look back and evaluate her evolution over time. This written record would also serve to help the leader construct case studies which could be shared with fellow leaders.

Public Health Leadership and Communication

As a public health leader, how would you develop a health education program to increase the health literacy of the people in your service area?

In order for a health education program to be effective it should be based on a relevant theory and it should be created based on a needs assessment of the target population. Program creation requires that the relevant background information be reviewed, program objectives be identified, audience segments be determined for targeting; message concepts should be developed and pre-tested, communication channels should be identified, messages should be created and tested, an implementation plan must be created, implementation and process evaluation must occur, outcome and impact evaluation must be carried out, and finally feedback must be integrated to improve the program or effort.

What are the barriers to successful communication and how have you personally overcome them?

There are many barriers to successful communication. The intended recipient’s mental state and cultural frame of reference can be barriers to receiving the sender’s intended message.  Anger, apathy, anxiety, confusion, disinterest, and fatigue can all influence how the intended message is received. Additionally, thoughts and attitudes of the message sender can influence the sender’s body language and pitch and cause the intended conscious message the sender wishes to transmit to be distorted in meaning by subconscious projections. Negative feelings toward or judgment of the other party may cause both the sender and the receiver to negatively influence the communicative process.

There are also many cultural and linguistic barriers to communication that the book did not explore in this chapter. The words of health care providers who are attempting to communicate with people who speak another primary language may be misunderstood. Additionally, cultural beliefs may influence the conceptualization of a message. In Peace Corps, there was a volunteer who was working with a group of women in her village to help them understand their birth control options. In explaining how a condom should be used, she demonstrated how to unwrap and place the condom, by demonstrating with a broom handle. After several months women in the village began to contact her: they didn’t understand what was happening to them. They had put condoms on their brooms and placed them in the corner of their homes exactly as she had done, and yet they had gotten pregnant. The volunteer and the women both had culturally established beliefs that caused them to make leaps of logic and meaning. The village women had a magical-tribal worldview and their health belief system was based on tribal practices. The volunteer had a “western-scientific” world view that caused her to assume that the women would understand that the broom was only the symbol of a penis and that the condom would have to be placed on their partner’s penis.

One of the ways I have found to be most effective in overcoming cultural-linguistic communication barriers, (as well as message corruption with people of the same cultural/linguistic group) is to ask for message receiver teach-back. Asking the message receiver to tell me the message they have just been given can help determine if the message was transmitted effectively and if the meaning they received was my intended meaning.   

What would be a workable communications strategy to get more funds for an expanded childhood immunizations program?

The first step in creating an initiative is to build a coalition of equal partners for the purpose of planning, operationalizing, and evaluating the scope of the issue. The next step is to examine the barriers to effective functioning of the coalition and address how these barriers can be overcome. All partners should have a vested interest in the success of the initiative. After the responsibilities of the partners are defined, the next step is to establish a consensus on the initiative and develop action plans for implementing the initiative.

What strategies might you use to increase your interpersonal communication skills?

Continuous growth in emotional intelligence is imperative for all public health leaders, as they must be careful to avoid allowing hostile feelings to interfere with good judgment. Additionally, there are steps that the leader can take to ensure that their interpersonal communication skills are top notch. Leaders should converse with others in a meaningful way on meaningful topics, they should state their positions assertively (not aggressively), control their hostile feelings, allow people’s demonstrated expertise be the basis for evaluating the their suggestions, make judgments carefully, be open to new ideas, respect other people’s boundaries, and use understandable language that is accessible to the listener.

What are the advantages and disadvantages or oral as opposed to written communication?

One of the major advantages of the written word is that it creates a permanent tangible record, and thus allows verification of past activities and events. At times the written word may be clearer than the spoken word, as the message sender has time to fully develop her/his thoughts before transmitting them. On the negative side, written communication can at times lack tone and inflection, which in spoken word would evoke a different emotion in the message receiver. Another drawback is that written communication takes more time to create. While the spoken word can be created and exchanged instantly face to face, written communication requires the message sender and receiver to set down their thoughts. When writing is intended to convey facts or important research, the message sender must prepare the facts and organize them in a way that will allow the message receiver to understand the message.

What are the characteristics of active listening?

The characteristics of active listening include the intensity of the engagement on the part of the listener, the listeners empathy for the speaker, the listener acceptance of the speakers message without judgment or interjection until the speaker finishes talking, and the listener remains open to the information the speaker is sharing, even if the listener dislikes either the speaker or the speaker’s message.

What are Walton’s five rules of conversational etiquette?

Walton’s five rules of conversational etiquette include the following: 1) don’t hog the floor (the time), 2) don’t change the subject, 3) don’t step on the sentences of others, 4) do hold your tongue, and 5) don’t forget that there is always tomorrow. If you are enraged or confused, it may be well advised to wait until a later time when you have had a chance to cool down and reflect on your feelings.

What speaker’s aids can be used to enhance a public talk and what are their advantages and disadvantages?

Speakers have a number of aids and strategies available to them to help them capture the audience’s attention. Many times the audience may not wish to attend the event, and is present because attendance was mandatory. Especially in those cases, the speaker needs to find ways to engage the audience in order to be able to transmit the message. Depending on the setting, the speaker may be able to ask for volunteers to answer a question, allow members of the audience to put on an impromptu skit about the topic under consideration, or the speaker may tell a joke that leads into the important topic of discussion. In more formal settings, such jovial approaches may not be appropriate and the speaker may attempt to capture the audience’s attention by telling a story or sharing illustrations or key takeaway points with tools such as PowerPoint slides, overhead projector slides, handouts, videos, and product/example demonstrations.

In cultural settings such as that of the United States, listeners are often primed to believe that the most important part of the speech will come at the beginning of the speech. In the United States it is usually best to have the message be clear, remarks be short, and the key idea might be repeated several times to help the audience follow along. In other countries that practice indirect communication, it is more important to use stories to communicate the main point in a way that allow both the audience and the speaker to “save face”. Furthermore, it may be necessary to talk for a longer time than what would be customary in the U.S., because the audience is primed to hear the message at the end of the speech as the most important part, and/or to believe that if a speech wasn’t long, what was said was not important.

What are the guidelines for interviewing job candidates?

Interviewers should prepare a series of questions ahead of time, they should ask all the candidates all of the prepared questions, they should have an appropriate interview structure, they should arrange for an appropriate setting for the interview, they should learn different interview techniques and how to use them appropriately, and they should keep job candidates informed about the process of selection.

What are the differences between media advocacy and public education?

Media advocacy can be defined as a form of empowerment in which public health leaders galvanize community residents to fight for policies that will benefit them. In traditional health promotion programs, the individual is the target audience, and the goal is to alter the individual’s behavior. In media advocacy, the individual becomes empowered and becomes involved in the push for policy changes. Advocacy is aimed at policy makers, and the goal of advocacy is to get beneficial policies legislated and put into action.

What are the advantages of engaging in dialogue before engaging in discussion or debate?

Dialogue is a process whereby people can speak freely. Generally, when people feel free to say whatever is on their mind, their values and agendas will be revealed. Dialogue is a communication process where everyone can win; it encourages win-win thinking. (Win-win thinking seeks to find outcomes where both parties engaged in a discussion feel that they have “won” in the negotiation and everyone is better off).  In dialogue, participants can share information, identify areas of concern, assess causes of conflict, and find new ways to further personal and organizational development. When dialogue is used first, participants have a better chance of using discussion to develop and implement action plans because their different perspectives can be addressed. Discussion is the form of discourse in which attempts to come to an agreement are paramount; hence it is less useful for discovering new information and strategies.

What are the differences between health communication and social marketing?

In health communications the target audience is the community or population at risk, and the long-term goal is to help the population increase control over and improve their health. Social marketing is aimed at increasing the acceptance of an idea, social practice, or social cause among the target audience. The desired goal of public health social marketing is to induce the public and policy makers to support disease prevention and health promotion.

Why is storytelling important? Describe the different types of stories.

Stories are often more engaging that facts and statistics. There are basic stories about the life of the presenter. Such stories can demonstrate the speaker’s values and help her/him build the audience’s trust, either in him/herself or in the speaker’s organization. There are stories that help the speaker define her/his relationship with the audience. Some stories are said to follow a springboard narrative pattern- these stories help move the listener to action. Through stories the speaker is able to reach the audience on an emotional and practical level. There are also stories about the future that can help the audience conceptualize the message shared into future time. Some stories allow knowledge to be shared. There are also stories that help move people towards collaboration, while others create humor or inspire people with a shared vision.

Lean Thinking in Healthcare

Use these comments on Lean Management in Your Term Paper/ Final Paper

I found the topic of lean management to be really fascinating, and think that there are many areas where this sort of efficiency thinking could be put to work.

I think that while we sing the praises of the TPS it is important to remember the Toyota recall problem that occurred in 2009-2010. Ultimately, the NTHSA found that Toyota didn’t have a manufacturing issue with their electronic throttles, but rather Toyota had a problem with lack of transparency and admitting there was a problem with their floor mats and steering columns (You can read press release here http://www.nhtsa.gov/PR/DOT-216-10) While lean thinking and the TPS may produce manufacturing efficiencies, when we are pursuing quality we may sometimes miss the mark, and organizations need to be able to admit when they have failed.

I found that the application of lean thinking in the emergency department to be especially valuable. Patients that are already admitted to the hospital may be less focused on getting out, so trying to speed up the inpatient process may be more challenging. However, patients coming to the ER (in most cases) just want to be treated and released. I found a really interesting video about lean in Great Britain  http://www.youtube.com/watch?v=tOuIrRPI9Xw where they completely re-designed their flow by having the 85% of people that will probably be released see only the receptionist and a nurse practitioner. The receptionist acted as both patient greeter and patient registrar, and the nurse practitioner replaced the triage nurse, the nurse aid that comes out to take you back to the bed and re-check your vital signs, the RN that performs the nursing assessment, and the physician that performs the physical exam and orders tests. The nurse practitioner is able to fill all of those roles, and by having the patient only interact with the NP, wait time and time spent rehearsing the history of present illness to multiple parties is reduced. Only the patients that the NP believes need admission are seen by the ER attending, and the ER attending is primarily responsible for seeing myocardial infarctions and traumas (whose treatment needs are beyond the scope of practice of the NP). An issue that management would have to consider is whether the efficiencies created counterbalance the higher salary they will pay the NP to do some work for which the NP is overqualified

There are many challenges to implementing lean management in an organization. In the aforementioned example, what happened to the jobs of all of the registrars, unit clerks, nurse aids, EKG techs, phlebotomists, and RNs that previously took care of the ER patients?  How do you have a “No Layoff Policy” while reengineering processes and positions? Another challenge that leaders face is resistance to change and negative employee attitudes. Leadership may have previously used some sort of quality or productivity tool and employees may initially see lean as a fad that leadership will eventually outgrow and hence not see the need to realign attitudes and behaviors around lean thinking.  Resistance to change is deeply ingrained in many professionals working in the healthcare field and leadership has to work hard to create buy-in and overcome the “that’s how we did it when I was in medical/nursing school” mentality.

One of the main arguments in favor of lean is that the American healthcare system is full of waste. As a society, we need to re-engineer our medical system because we cannot afford to maintain our status quo. This actually takes the idea of resistance to change to the higher level of society. Is our system wasteful only because we rely on expensive imaging technologies? Or is it also wasteful because our patient’s health literacy and ability to self-manage is insufficient? Or is it wasteful because of concern over medical malpractice causes duplicity in testing? As a people, Americans need to be willing to “trim the fat” that exists in our system; lean thinking can help health systems do this by systematically examining the root causes of problems and engineering long term solutions to solve systemic problems. 

Performance Management- Baldrige Award Winners and the Balanced Scorecard Approach

The positive aspect of the Balanced Scorecard approach is that it looks past simple financial results to the overall big picture of what is going on in the organization overall. This is especially important in businesses that are publically traded since there is a perverse incentive to take actions that “improve performance” on financial statements in the short run but in the long run jeopardize the competitive advantage and growth of the company. An example of this would be a government contracting services firm that dumps employees to reduce their immediate short term cash obligation to pay salaries, but later finds itself unable to bid competitively on new service contracts because they lack the people with skill sets to fulfill the contracts. Under the balanced scorecard, leadership should consider the customers perspective, the financial perspective, the internal business perspective, and the innovation and learning perspective.

The customer’s perspective has to do with how the external public (customer) views the company. An example would be how people view their iPad in comparison to how people view their Dell Streak. If you are Apple, your relationship with iPad users is going well; if you are Dell, your relationship with Streak owners is pretty dispassionate. The status of the relationship with the customer is essential when considering the future of a business. Just as the current status of a marriage relationship can tell us about the future of that marriage relationship, the current status of the company’s relationship with their customer base can be useful in predicting the probable future status.

However, current reality is not 100% predictive of future reality. This is why it is important for companies to consider innovation and learning perspective. Just as people grow and change over time, products and services demanded by the market grow and change over time. To know if the relationship with the customer will last over time, companies must proactively seek out new knowledge and trends. In terms of competitive advantage, companies should strive to be a market leader instead of a market follower in order to achieve maximum financial results. An example of this is Apple. People didn’t know they needed the iPhone until after Apple shared this information with them. All the other companies that produced similar products after Apple could only compete on price, since their product was not considered innovative by the market.

Financial reality is still important, however. Only through adequate cash flow and profitability can the business continue to exist and respond to its internal and external publics. The internal business perspective is critical in evaluating overall business performance. A company such as Starbucks is selling a product, but it could also be argued that they are also selling an experience. Part of that experience is the customer’s interaction with the staff. If companies are not adequately investing in their employees through wages, benefits, training, and the creation of a positive work environment, it is probable that employees will become resentful over time and seek out alternant employment options. For a services or knowledge based company, it is ESSENTIAL that the internal perspective of employee relationship management is prioritized. If the company is more a manufacturing type of firm, the internal business perspective may emphasize productivity or manufacturing excellence.

Since the creation of the managed score card requires data, and data must be generated and organized, it would be good if healthcare entities had a way to integrate external quality measures (from Medicare and the Joint Commission National Patient Safety Goals) in their internal management and processes. I looked at Poudre Valley Health Systems, AlantiCare, and Mercy Health System’s performance measure on their Baldridge applications. One thing I found across the board was that they all commented on how they assure data integrity, security, and HIPPA compliance. The timeliness of the data collection and review are necessary in order for the information to be actionable. By reviewing performance on a frequent basis, health entities can take corrective action to address areas where they are not performing at an adequate level.

Graduate Level Health Economics Essay Final

Three question final- free term papers- free downloads-, health economics, Medicare Part D, moral hazard, market failure, health insurance

1. Drawing on the webinars, webcasts, class discussions, and the book chapters, describe the relationship between high deductible health plans and the concepts of consumer surplus, moral hazard, and welfare loss. (35 points)

Consumer directed health plans (or high deductable health plans) first emerged in the United States market at the end of the 1990’s. This health insurance instrument differs from traditional managed care in having higher annual deductibles, often being linked to health savings accounts, and allowing consumers to experience the costs of their heath care choices until they meet their high annual deductable. The obvious advantage to the consumer of such a high deductable plan is that it allows for lower premiums. Indeed, this is a much more attractive product for healthy individuals that are unlikely to face significant health care needs but who wish to insure against catastrophic losses- such as those that would occur from the sudden onset of a deadly disease. Proponents of high deductable plans argue that these plans incentivize more responsible consumer behavior, and that consumers/patients who face the full costs of their choices will make more intelligent, less wasteful decisions. Opponents argue that because consumers/patients face the full costs of their health care choices until their deductable is met, they may be disincentivized to seek proper preventive care, may be less compliant with prescribed medications, and may actually cost the system more because they will not seek care until their health situation requires aggressive interventions.

Understandably, these issues have significant societal welfare loss implications. Consumer surplus refers to the difference in price between the maximum price the consumer is willing to pay for a product and the actual price they pay for said product. Moral hazard refers to the change in behavior when the entity that is protected from risk by an insurance instrument behaves in a different way than they would if they did not have said policy in place to protect them from the cost affects of their behavior. Welfare loss occurs when there is an incorrect allocation of resources in which society does not reach its maximum utility. Welfare lost can be borne by consumers, society, or producers.

Theoretically, consumer driven health care plans decrease moral hazard because beneficiaries are less protected from the costs of medical care and therefore less likely to create exposure to the risk of high medical bills. By the same token, consumer driven health plans may create favorable selection as consumers with known health problems opt for higher cost, lower deductable plans. There is some possibility that consumer driven health plans could create a consumer surplus because consumers would be willing to pay higher premiums. On closer examination, this would not truly be considered a “consumer surplus” because the higher cost premiums would provide more coverage; a true consumer surplus is only created when market price is artificially less than the true market equilibrium price. Whether consumer driven health plans create a net welfare loss depends on whether they create net costs or benefits for society overall.

2. Harford identifies three key considerations that are important for markets to work and uses these to comment on how to improve our health system. What are those key considerations and how does he weave them into a strategy to fix our current health care system. (35 points)

In order to function efficiently, markets must operate in a state of perfect competition. Perfect competition assumes that there are proper outputs, outputs are produced efficiently, and that the right quantities of outputs are being produced. There are a number of reasons why the market for health insurance is not competitive in the United States, the primary one being an issue of asymmetrical information. Asymmetrical information promotes adverse selection and moral hazard. There are several activities that insurers can engage in to combat asymmetrical information from their side. These include offering different benefit packages that induce beneficiaries to reveal their information. Additionally, they may establish some sort of “signal” to serve as an indicator of likely beneficiary riskiness. Passing on most of the costs of health care is a way that insurers can reduce moral hazard. However, such products may have limited marketability, since the consumer is buying the insurance to protect themselves from the possibility of unacceptable losses.

The three areas of market failure that are addressed in the text are scarcity power, externalities and imperfect information. Mr. Harford also addresses the issue of fairness, which he argues any humane society would want to address. In the United States, in most urban areas, scarcity power in not a big concern among consumers because there are a number of health care providers who may serve as substitutes for each other. Externalities are an issue in health care because if everyone else’s child has been vaccinated for whooping cough, then it is not really necessary for me to have my child vaccinated because herd immunity will probably protect my child from the possibility of contracting this illness. Inside information is the largest obstacle to achieving a more competitive health care marketplace. The suggestion is that consumers should have information readily available in order to allow them to make better decisions. Patients should have the opportunity to utilize this information by choosing providers and treatments.

The ultimate goal of a well-functioning health insurance/health care market is to give consumers the responsibility and information necessary to make choices about their care, while also incentivizing through their own payments to consume health care wisely. The system described is basically a universally mandated (to eliminate adverse selection) consumer driven health plan with obligatory health savings accounts that roll over and allow savings to accumulate during the lifespan. Health care expenses are paid by the individual out of the HSA- this eliminates the problem of moral hazard. During all phases of life, the individual would only desire to spend the funds on treatments that they are convinced would be beneficial, essentially eliminating the problem of wasteful treatment. To address the problem of social justice, catastrophe insurance would step in at a certain point and pay for the expenses for which no reasonable and responsible person could pay for over the course of a lifetime. This would ensure that less lucrative but socially necessary goods such as burn units or transplants would still be available.

3. Medicare part D is the latest in a series of policy adjustments undertaken to deal with catastrophic expenses not covered under Medicare. Discuss the key economic considerations in this the historical case study of the interface between health policy and health economics.

(30 points)

Medicare parts A & B were introduced in 1965 to assist the aged- those 65 and up- in paying for their health care expenses. The benefit design of Parts A & B reflected the social values of the time which included achieving greater income equality and security in old age. Medicare part C was established in the 1980s but became more pronounced in1997 to respond to new care utilization trends in health care markets. Medicare part D was created by the Medicare Modernization Act of 2003 to cover medication expenses. As medical care has advanced since 1965, patients have been living longer and more advanced medications have improved both their quality of life and functioning. Medicare part D came into force in 2006 with premiums and benefits managed by private firms. However, the cost of the program is still heavily subsidized by federal funding. The design of the program reflects its bipartisan support and populist backing. The greater involvement of private firms allows for amore market based approach to managing benefits. Furthermore, the creation of the “doughnut hole” helped limit the expense of the program and theoretically should have incentivized seniors to manage this benefit efficiently.

In the 2003 benefit design, enrollees had to first meet a $250 deductable and they pay a 25% co-pay for expenses between $250 and $2,500. From $2,500 to $5,100 enrollees were responsible for 100% of the cost. After reaching the $5,100 annual cut-off, the government would resume cost sharing, picking up 95% of cost. However, since Medicare has some features of a wealth redistribution program, the impact of this “cost-limiting” mechanism had the biggest impact on those least able to bear the burden. In order to gain support from senior citizens (who tend to vote en masse), part of the Affordable Care Act included a voucher payment to people who “fell inside the doughnut hole” as well as phased in benefits that will help lessen the percentage of the cost of brand-name medications that is paid by the consumer.

Unfortunately, many experts agree that Medicare as it exists is unsustainable and lacks efficiency incentives. Medicare Parts A & B have reimbursed providers through a fee-for-service structure that has incentivized overtreatment and waste. The text offers several possibilities for extending the viability of Medicare. These include raising the age of eligibility, reducing the rate of increase in payments to Medicare providers, increasing the payroll tax that funds Medicare Part A, increasing Part B premiums, scaling the Part B premiums to beneficiaries incomes, transforming Medicare from a defined benefit to a defined contribution program, and changing Medicare to an income related program. Most of these options are unpopular with senior citizens who feel that they have paid into the system their entire lives and that they deserve the benefits they are receiving. Reforms are also unpopular with Baby Boomers who are approaching the age at which they will begin to benefit. Ultimately, the fate of Medicare may be decided by Generation Xers and Yers when the programs are on the brink of bankruptcy because only then might public will be strong enough to confront the gravity and complexity of the Medicare situation.

I Was a Fat Kid.....

Last night as I was getting in bed my husband said to me, “I think you gained 5 pounds but I think I gained 3 pounds.”

Is he an ass, or is he just being observant?

Body dysmorphic disorder is “a type of chronic mental illness in which you can't stop thinking about a flaw with your appearance — a flaw that is either minor or imagined. “ However, I think there is a different class of people- the formerly fat kids- who also suffer from a type of body image issue.

I was the fat kid. The kid no one would sit next to. The kid who was put on a diet and not allowed to have ice cream when her brothers got ice cream. Yet nothing my parents said or did helped me stop eating. I had a sweet tooth, and I ate endless amounts of candy. I knew I didn’t want to be fat. But my almost magnetic attraction towards candy overpowered any voice of reason that might have echoed in my head.

When I was 13 I got this book from the library, called “total girls wellness guide” or something like that, and it marked a turning point in my eating and weight issues. This book explained that how much you weighed depended on what you did over time. It also said that exercise could help you lose weight but that if you hadn’t been doing it at all, you should start slowly and build up.

This gentle, incremental approach was beneficial for me, but when I was 15 I became really obsessed with my weight and my body. I hated my body. I felt betrayed by my body. I wanted to be Barbie. Every calorie was counted. I started jogging long distances. I got down to 140 pounds (I’m 5’ 8” so that is a healthy weight for me). But I realized that I was so obsessed with food and exercise, that it had completely taken over my life.

When I started college and started working, my priorities changed. I worried less about not putting to many calories in my mouth and more about just having the money to buy food at all. My weight bounced around in college from a low of 155 to a high of 180. I never took up the obsessive diet or exercise again, but I was watchful. I made sure I didn’t get too big.

The problem is that the voice of criticism in my head was never really silenced. I still worry about getting explosively fat. I still eat things that I don’t necessarily like because I want to manage my weight. Come on, salad is not as much fun as nachos! Everyone knows it’s true! What about you? Have you struggled with your weight? Or do you constantly feel you have to battle negative self-talk about how you look? What have you found useful in improving your body image?

If you are looking for resources to help you improve your self-esteem and body image, womenshealth.gov has some great information about how to cultivate a positive image at this URL: http://www.womenshealth.gov/bodyimage/

To Wipe or not to Wipe?

I’ve been thinking for a while about hand sanitizers at the gym. I don’t believe in them. I’ve been getting the stink eye from the one remaining person in the gym. However, I possess an almost religious belief that antibacterial products are unnecessary and could possibly be harmful. Now while I am willing to possess such a belief in a supernatural being, faith isn’t really required when it comes to soap because science can tell us about soap.

So I went off in search of the “truth” about antibacterials. The first thing I found was a piece from the New York Times entitled “Be Sure Exercise is All You Get at the Gym.” The story discussed a position statement from the National Athletic Trainers’ Association that stated (among other things) that athletes should bathe with liquid antibacterial soap immediately after using gym facilities. Somehow, I distrusted this information and dug deeper. A 2007 literature review from the Journal of Clinical Infection Disease found that there was a “lack of an additional health benefit associated with the use of (antibacterial) soaps over regular soap.” Other studies have looked at people washing with regular vs. antibacterial soaps over long courses of time. The result: people who used antibacterial soaps had the same level of bacteria living on their hands as people who used “normal” soap.

However, my big concern- that I would be promoting antibiotic resistant bacteria by using antibacterial wipes- appears to be unfounded. Or at least there is limited evidence in the literature to support this notion. I guess we will have to add it to the long list of problems that merit further investigation.

Does Common Courtesy Demand?

Last night I made my way to the gym. Just as I had predicted, the gym scene has shrunk predictably. Hot guys I and II were there, running on the treadmill. Just like they were back in November. There are also two African-American ladies who are old timers and they were riding the stationary bikes. I hopped onto the elliptical, and was happily peddling away when a new guy walked in. Now this new guy was older, sort of balding, boring looking. He was wearing pleated pants and they didn’t really work for him. He went in to the locker room to change and came out and got onto the elliptical by me.

Isn’t there a rule somewhere? “Don’t wear too much cologne if you are going to the gym?” This guy reeked. The smell sort of made me nauseas. But I made it to the end of my 30 minutes on the elliptical and the smell wasn’t too bad once I went over to the mat to do my physical therapy exercises.

I’ve been doing pretty well on my fitness regimen. Last week I went to Dr Kim in Annandale and he straightened out my neck with his amazing acupuncture techniques. After that I was able to move all my extremities and get back on track with the cardio workouts. I have been slacking on my PT exercises and I can feel that I really have to work now when I lift my legs. Of course it’s even harder to do them when you have to deal with people wearing stinky cologne.

Questions Outside my Pay Grade

People stealing my ideas! I already had this idea! http://franciscojaviermosquera.jimdo.com/

Basically, the idea is, in countries that are net exporters of drugs, make it totally legal to produce drugs and make it a state owned enterprise. Then let the net importers of drugs figure out what to do. Do they want to diplomatically negotiate? Import the drugs as pharmaceuticals? The developed countries (net importers) can figure out what works for them, and the lesser developed countries (net exporters) will no longer be plagued with domestic insurgency and terrorism.

And now some guy in Colombia is sending me nasty-Tweets via Twitter to ask me why the United States government is ignoring him? That kind of question is WAY outside my pay grade.

Pain in the Neck

Have you seen the Celebrex ad? “Bodies in motion tend to stay in motion?” This week my body hit a bump in the road. With the fear of gym overcrowding hanging over my head, I had stopped going to the gym in the morning. I was going every day at 1:40 p.m. (no one there at that time!) and doing 45 or 50 minutes or intense cardio. My goal was to reach 5 miles every time I set foot in the gym. Because of the time constraints of leaving the office in the middle of the day, I had stopped doing my physical therapy and stretching routine. I don’t know if the lack of stretching or Murphy’s law is what set off this problem in my upper back and neck.

On Thursday, I ran into the bathroom just before we left to attend the Surgeon General’s “Call to Action on Breastfeeding”. I was pulling up my pants when I got a sudden stabbing, throbbing “don’t move” horrible pain in my neck. It felt as if it were some sort of muscular spasm. I took my Ultram but to no avail. The pain was still there an hour later as we rolled into the George Washington University auditorium. It must have been bad because all four of my colleagues said the same thing when I walked in: “Are you okay?”

Yes, I was okay…no I really wasn’t. I ran into and out of the auditorium. That Amanda Bookmark was right. There was no signal in the auditorium, which made Tweeting out the messages impossible. I had to go outside and Tweet what I was hearing on the webcast. After the event was over, we went back to the office but I couldn’t leave. Dr. M was supposed to come and give an in-service on the Affordable Care Act. Of course, since it was evident that this was just NOT MY DAY, she couldn’t find us and was half an hour late, which meant that she didn’t finish her presentation in time for me to go see Dr. Kim the acupuncture specialist.

That night, my Darling Spouse gave me a massage….and every night since then. I’ve been doing my stationary bike and physical therapy exercises slow…ly….. religious…ly I don’t want to sustain this sort of injury again.

Dark Clouds Hanging Over Our Heads

The dark is taking over his mood again. I never know if his dark brooding is meant to block me out, or if he feels so bad, that this is the only logical way to act.

They say that part of the process of recovery from love addiction is seeing your partner as he/she truly is. If I were to stop and observe what he does, what I could say is this. He does not seek out information for self study. He does not decide on one vocational goal and stick with it. His ideas seem to jump from one to the next, without predictability or logic. As far as I know he does not pray or meditate or try and get in touch with his higher power. He seems to really hate living in the United States.

What does this mean for me? What does it mean for us? I can’t fault him for wanting to have a job. Everyone wants to have a job. However, you can’t argue for Marx’s theory of work utility in his case because clearly he is unwilling to take any job that would be available, but rather insists that he wants a professional job. Who can blame him? Not me. He deserves a job where people treat each other with decency. But yet he seems to be unable or unwilling to do what he needs to do to achieve his desire: learn English. I have repeatedly suggested that he should not work, but rather dedicate himself to studying English. But his hatred of living in the United States seems to block this idea and he is overwhelmed with the fantasy of making a quick buck and moving back to Bolivia.

I don’t want to move back to Bolivia. There are pros and cons to anywhere you live. Sure, in Bolivia you can take naps everyday and no one seems to get too upset about work never getting done when it is supposed to be done. You can spend all day drinking with your friends and then stumble home and have a nurse come to your house and give you IV ativan when you wake up the next day with the worst hangover of your life. But I don’t want to live that way. I want to feel like my life matters, I want to be intellectually engaged, I want to keep learning for the rest of my life.

Maybe our desires and goals are incompatible. Certainly I can’t make him into someone he’s not just like he can’t make me someone I’m not. Nothing he could say or do would ever convince me that I want to spend my life drinking with my friends or even worse being home with a bunch of babies while he is out drinking with his friends. Does that make either one of us bad people? No, I don’t think it does. Does that mean we aren’t compatible? Only time will tell.

Battle of the Bulge

I had been pretty good about keeping my New Year’s resolution to not go to the gym because of my fear of overcrowding. Tonight I went in and there were mad people everywhere, so I came home and rode my bike and did my physical therapy exercises.

This past week I ran into a colleague in the kitchen and she and I struck up a conversation around overweight and weight loss. The Jenny Craig commercials are starting to drive me batty and we were discussing why people want a quick fix for their overweight and how we trick ourselves into thinking fad diets can work. She really is religious (it would seem) in her adherence to her diet. Every time I am in there with her she is mixing salad greens with non-fat cottage cheese and non-fat dressing. I, on the other hand stray from the path. This past Thursday night I made hamburgers and since that didn’t satisfy my craving I made a follow up visit Friday night to the local Five Guys. Ummmm, umm, umm! It was like I died and went to burger heaven! Every delicious bite with extra pickles bursting in my mouth. I heard that as you age, your metabolism slows down and let me tell you, I am not looking forward to that! Saturday, I made pancakes for breakfast and then we made roast leg of pork for dinner. Mr. J got out his marinade and “meat tools” and got his leg of pork worked up to garlicky perfection. I did force myself to bike for 30 minutes on Saturday, but I had taken of Friday and I also took off Sunday. Mr. J. loves watching television, so I have to fight that temptation.

“Come snuggle with me,” he says.

How can I resist that kind of temptation? Another 5 minutes on the bike? I’m not so sure I really care that much. The battle of the bulge, people. I keep fighting it day after day.

Start the New Year Right!

2011 is off and running and I am afraid of everyone else’s healthy intentions. I am afraid of gym overcrowding. I am looking forward to gym drop out.

Every year I see the same thing in my gym. January first there are more people there than I have ever seen before. The locker rooms are impossible to navigate, the lines for machines long. That state of affairs continues for the first two weeks of January, and then right around Martin Luther King Day, there is a drop off. Something about the three day weekend makes people’s spirits give out. They give up, back away, let go, throw in the towel. That is when I get my gym back.

So my New Year’s resolution is the following: stay away from the gym for the first 17 days of January. I have a stationary bike, a couple of workout DVDs, and a list of physical therapy exercises. I am gonna work on those for the time being. Having the gym all to myself makes me want to go more. I can count on solace, and on having an elliptical with my name on it the rest of the year.

Health expercts argue about what is the best way to adopt a healthier lifestyle. Today while I was pedaling on my bike someone was on CNN saying that it is better to make a “big” change so you get immediate feedback about your behavior. Still, the Centers for Disease Control have taken the approach of promoting “Small Steps” as the secret to lasting adoption of healthy habits. What works for you? What makes you tick? I am a creature of habit and I like being left alone when I am sweating. That’s why you won’t see me in the gym until Jan 18th :)