Friday, August 28, 2015

Vaccine Injury Payouts

A very interesting article in the Wall Street Journal today discussed the increase in payouts for vaccine related injuries.  This is interesting for a number of reasons:

(1) The claims are paid from a no fault system
(2) The system was designed to avoid discouraging companies from making vaccines and individuals from getting vaccines
(3) The increase in payouts has been for injuries related to the administration of the vaccines

It seems like the risk that this was supposed to deal with was a risk faced by the manufacturers of their vaccines.  If what was in the vaccine caused harm to someone (even after all the appropriate testing had been done to get the vaccine approved) the company would not suffer economic consequences.  This seems to be in line with item #2 above.  And if patients feel confident that they will be compensated for harm and not have to go through a traditional court to do so, they may be less likely to be discouraged to get a vaccine.

However, the risk of causing an injury to a patient because the vaccine is administered too high in the shoulder and may cause damage to the musculoskeletal system, is not a risk that the manufacturer has anything to do with.  This is a risk created by the health care provider (and potentially the health care system for whom the provider works.)  Covering these shoulder injuries under the same claim system reduces the risk for a very different stakeholder.

And given the actual number of cases, the trajectory in the number of cases, and the size of the awards, it is easy to imagine that these injuries will could account for a very large proportion of the payout.

Policy makers should take stock of the situation and decide whether this removing the risk from the providers and the organizations for which they work is appropriate.  While there may be clinical risks from the vaccines that show up in 1 in 1,000,000 patients that would never be detected in a clinical trial for approval of the drug, appropriate administration of the vaccination is a medical practice that is completely under the control of the practitioner and for which there are clear best practices.  Placing the risk back on the provider and the organization for which a provider works would provide a very strong incentive to vaccinate appropriately.  Unless it is determined that there is so much uncertainty that the government should also bear this risk in order to avoid discouraging the providers and organizations from administering the vaccines.

This tradeoffs here are interesting.  But the level of risk and the control over the risk seem much different.  Public policy should not be "one size fits all" for solutions. 

Monday, July 13, 2015

Owning My Position

So, I have held my position of Vice Dean for Education at the Johns Hopkins Carey Business School for a little over two years now.  Today, I felt for the very first time, that I fully "owned" the position.  I think it is worth thinking about what it means and why it took me so long.

Today was the first day for the fourth cohort of the dual degree program in which students get an MBA from the Carey Business School and the MA in design thinking program at the Maryland Institute College of the Arts.  We call it the MAMBA program.  That is MA and MBA together.  As a business school we generally emphasize the MBA part over whatever dual degree program we work with, but the pronunciation is so much easier as MAMBA rather than MBAMA that we decided to go with what students were calling it.

In any case, I was the first speaker after an introduction by the Carey Business School program manager.  While I did not have any slides to present, the screen behind me had the Carey Business School home desktop that is found on all the classroom computers.  It says "Teaching Business with Humanity in Mind."  That is a key phrase that clearly reflects the value of the school.  I did not go so far as to say, "This is my idea of what it means," but I did not attribute it to the Dean today either.  Next time, I will tell students, "This is what I think it means."  And while I mentioned the Dean a bit in the presentation (for the difference that he has made in the school), for this day I simply presented that as a useful fact for students to be aware of.  For the first time, I really focused on my story of Carey.  My ideas about Carey.  Giving credit where credit is due to parts of the school like Career Development, Student Services, Academic Advisors, and program administrators but it was my story.  Not any "standard" story.  Not the Dean's story.  But my story.  And in the process of telling my story, I had the chance to introduce myself to each student individually before my welcoming statements, and I had a chance to speak with numerous students during the first break. That included one who was interested in fashion, one who worked for Cover Girl, one who works at Under Armour, and one who was involved in a large capital campaign for Everyman Theater.  And in the future, I will talk to each of them to get a better feel for their incredible sets of interests.  This is now a class that I will begin to get to know. I will come to understand. And I will represent myself to--particularly in a case study that we will discuss on August 4.  Thus, it really is becoming my position, my set of ideas, and my set of interactions with the students whom I will then be able to follow through the entire program.

In the meantime, I do wonder why it took so long.  I believe that part of it was really taking two years to settle in to understanding all that I need to know about the field. But it is also the case that I now feel like I have a set of connections that I could ad for the students.  What do I know about Hunt Valley in the area where the Cover Girl offices are located?  What do I know about local fashion?  How about Under Armour?  How about theater?  I mean, the student said I sounded like a local theater aficionado.  I don't think of my life that way, but I do realize that I have been to see local theater maybe a lot more than others and that it is a critical part of my life.  So, this year, I truly felt that I had something to add to these students' experiences and to these students' lives rather than just giving a cursory introduction.  I could not have said that a year ago.  But I can say it now.  

And that is a good thing for staking out my place in the school.  Contributing to the success of the school. Contribution to the future success of the students.

I find it interesting to hear others' stories of how long it took them to understand their organizations well enough to feel completely comfortable in their positions--particularly when representing their organization to outside or brand new customers.  

Sunday, June 21, 2015

It’s a Matter of Perspective

Sometimes, it is hard to remember that not everyone comes to the table with the same information, the same background, and the same ideas of cause and effect or automatically draws the same conclusions when presented with the same data.  Today, I had a fun example of that at the grocery store.  But it made me think—what are the assumptions that I have, what are the assumptions others bring to a discussion, and if I miss or fail to anticipate the differences what could be the impact.

As it is Father’s Day, I have three things that happen almost every Father’s Day: I run the 5K that benefits the NICU at GBMC (a local medical center at which my kids’ pediatrician is the Chair of Pediatrics); we take my middle son to his boychoir’s summer camp; and I wear my “World’s Greatest Dad” t-shirt, that really isn’t appropriate to wear any other day of the year. 

The day started off as usual.  A solid 5K run.  I was second in my age group to a guy I had been running with since the 0.5 mile mark but I couldn’t shake him and he had more than I did at the end.  My youngest son ran his best race ever by over 2 minutes and came in third among boys 10 and younger.  My good friend and training partner was second female overall.  And we won a team trophy for the second year in a row. 

And, after this entry, we will take my son to camp.

But this is a story about the shirt.  Walking to the milk/cheese/egg/yogurt aisle of the grocery store, I was greeted by an employee who mentioned that he had the same shirt (minus the foot and hand prints of my kids).  We got to chatting, and I pointed out that the shirt has only two sets of prints.  I now have three sons.  And the son whose baby or toddler feet are on the shirt now has his driver’s permit. 

I thought it was a comment about growth and long-term parenting goals and how long items of clothing that only get worn once a year last.  The employee said, “That’s a testament to you that it still fits so many years later.”  The employee was a little hefty.  I thanked him and moved on.

But I really thought about it.  I just take for granted my running and my fitness and my weight.  But there are plenty of guys my age who have put on a few pounds since their now 15 year olds were 2 or 3.  So, the fact that I have a shirt that still fits from when my kids were little makes a big impression.  Maybe he has had to replace his entire wardrobe.  His experience and assumptions are a lot different.

As an employee at the grocery store I may never see again, understanding his assumptions and impressions is not that important.  But when this happens in the workplace and people cut off conversation early and don’t explore that they may have drawn different conclusions about the same piece of data and then understand why—bad things can result. 


It’s a reminder to me to make sure that I always ask what conclusions my colleagues have drawn and if we’ve drawn different conclusions follow up with an effort to uncover what their beliefs and assumptions are and ask “Is there more” until we understand how differently we are approaching things. 

Tuesday, June 2, 2015

First Impressions are Key

Yesterday, I had the pleasure of meeting a member of the Department of Microbiology and Molecular Immunology for the first time.  He came to visit me in my office at the Johns Hopkins Carey Business School and was impressed by the view from the 12th floor of the building in which we rent space in the Harbor East area of the city.  He was visiting from the Johns Hopkins Bloomberg School of Public Health.  While we had been colleagues (in much different departments) for 7+ years in public health before I changed schools, we had never met.  It actually turned out that our commonalities went much further back--having graduated from the same College at Penn State in 1991.  That was how he started the meeting.

Then, I took my turn.  As an economist, I am not sure if he had any idea of what I brought to the table in terms of understanding the science and the underlying topics that he was about to discuss.  Or that I would have much room on my plate for new activities.

However, I shared with him all sorts of different projects I had worked on.  Pancreatic cysts.  Wegener's granulomatosis--studied by someone in the vasculitis center.  Surgical treatments for dysfunctional uterine bleeding and the different between ovulatory and anovulatory bleeding.  And my eye care work.  And I could speak about some of these with some degree of authority.

After I closed my 5 minutes of "isn't cost effectiveness with any type of condition fun?" I made the comment that I wasn't sure if I had told him more than he had ever wanted to know about my background.

He said, "No."  And he commented that it was actually good that I had worked on a lot of different things that obviously fascinated me and kept my attention.  It suggested to him that I might not shy away from yet another new topic.  He was coming to talk to me about genetically engineered mice.  That was new.  But it was exciting.

It was part of a two day period in which I heard about everything from mice to HPV to worrying about a student's dissertation to admissions issues to our online MBA to accreditation and many other topics. It is part of what I like about my job--so many different aspects constantly shifting.

Sometimes colleagues think I should be more focused.

But I learned (as I have many times before) that sometimes colleagues are looking for those who can be open to new ideas, think about new things, and expand their horizons.  First impressions are key.  

Sunday, May 31, 2015

Business with Humanity in Mind

I have both a personal blog and a professional blog.  It is usually pretty clear to me which blog an entry belongs in.  For this one, I debated.

I don't usually think of writing about the Roman Catholic mass at which my middle was confirmed as a professional blog topic.  So, let me share a few of the interesting personal details and then give three quick lessons that tie over professionally.

First, this was by far the most inspirational Confirmation mass I'd ever experienced.  That includes my own many, many years ago, and about five or six I played for at St. Pius X over the years including my oldest son's confirmation.  Why was it so inspirational?  My youngest son was involved in ushering and helping to make sure the mass ran smoothly.  My oldest son is--as I am--an alumnus of the musical group that plays and no longer plays with them at our church, but did come to see his brother get confirmed.  And a young woman whose singing I have heard off and on for almost a decade gave the most beautiful solo for a song Sacred Silence I'd ever heard.  Plus, the gentlemen who had led this group of youth getting confirmed at the start of their journey and who had passed away in December was remembered in a wonderful way.  All inspiring enough.

But then the three other things that link to professional experiences.

First, I received the wine as part of the Eucharistic celebration from a young woman whom I had taught in religious education years ago.  It is a sign of how long I have been part of the parish.  It is a sign that the kids I taught are not just "growing up" but truly maturing.  Coming into their own.  And seeing the process is amazing.  I have helped doctoral and masters students through their studies.  I have mentored undergraduates at my undergraduate alma mater.  But this has been a year to see one of my old religious education students first become a lector and then become a Eucharistic minister.  It shows how being a part of one organization for so long can give a perspective on the growth and development of the organizations and those within it that just can't be appreciated in a year or two.  And when I appreciate the long term perspective, it also makes me think of the range of stakeholders, and to being to practice what the Dean of the Johns Hopkins Carey Business School calls "business with humanity in mind."  I like to summarize it as realizing that there can be a lot of humanity that can be affected by business decisions other than the most immediate stakeholders, i.e. customers and owners.

Second, the idea of the sacrament of Confirmation in the Roman Catholic church is about making a big commitment.  And as I think about business and business with humanity in mind, I think about commitments.  Becoming an entrepreneur is a commitment.  Becoming any type of professional is a commitment.  Becoming a leader is a commitment.  Sharing idea--commitment.  Everything about being successful requires commitment.  And thinking about business as not just focusing on the bottom line but focusing on all the stakeholders including the customers, the employees, the community immediately around the business, and the entirety of humanity requires a commitment.

Third, my son got a "shout out" from the Bishop at mass.  He was one of at least two who in their letters to the Bishop mentioned the feeding the homeless service experience.  This service experience exposed the youth in our parish to problems in the city.  These are not exactly the same problems that led to the recent unrest in Baltimore, but the roots of at least some of the problems are the same.  The gentlemen who had started the journey toward Confirmation with this year's class but passed away half way through told the children after the service experience--you fed these people today, but who will feed them tomorrow, next week, next month, or next year?  In part, there is a service answer to this question.  But in part, there is a business with humanity in mind answer to this question.  Why are there not jobs?  Why are there not economic opportunities?  Why are opportunities lacking for these people?  And what is the meaning of business?  What is the role?  How can we who train future business leaders and the current and future leaders find ways to create economic opportunities in these areas?  How can business consider all the stakeholders and help everyone?  Is it ultimately business's responsibility?  No. There is charity and there is government.  But if business stays only at the sideline and does not figure out how to contribute, there will be something missing.  At least some of the solutions to the problems that we see in the world are, in fact, ones that business can solve if we have creative leaders who can find ways to convince others of the value of their ideas, secure resources, and move themselves and those working for their organizations ahead.  

So, this year's confirmation mass illustrated three important ideas for business with humanity in mind--seeing the long horizon that gives a different and more informed perspective on the full scope of stakeholders, making a commitment to something, and having business as part of the solution to the problems of society--not just a cause of problems in society.   

Friday, March 6, 2015

Affordable Care Act and Disparities in Access

A new research brief from the Commonwealth Fund focuses on the potential relationship between the Affordable Care Act and a variety of measures of disparities.  In short, the authors of the brief used data from the Behavioral Risk Factor Surveillance System to look at the relationship between insurance and several outcomes that may be expected to change after the affordable care act.  These outcomes were not having a usual source of care and foregoing care because of cost.  The Behavioral Risk Factor Surveillance System is a survey administered by the Centers for Disease Control in coordination with state departments of health to hundreds of thousands of respondents each year.

For the two outcomes of interest, the assumption is that having a usual source of care is better and that foregoing care because of cost is not a good thing.  Before we look at the implications of the Affordable Care Act it is worth thinking just a little more about those two issues.  

First, having a usual source of care is supposed to increase the provider's awareness of the conditions a patient has and, as a result, enable the provider to offer better care. That is important for chronic conditions.  It may not be as important for purely acute events. A key question is at what point it is useful/necessary to establish a relationship with a provider who will become a usual source of care, so that when a person has a chronic condition at some point they will get the best care possible.  Does one need to have a long-term and usual source of care before the incidence of the chronic condition or would it suffice to establish a usual source at the time of the incidence of the chronic condition.  In general, the expectation is that a longer relationship is better.  

As for going without care as a result of cost, that is an even more interesting question.  Specifically, as an economist, I would say that price is supposed to lead people to forego some services.  That is the role of price in a market economy.  Some people cannot afford some things and so they do not consume them.  The trick, of course, is whether the average person can ascertain whether the care that she went without was necessary care or was discretionary care.  We want people to think about the medical and health care resources they are using and to not assume that everything has zero opportunity cost.  But we don't want people to forego necessary care now that could potentially help to control costs later.  This is a tough question to address.  But, I am willing to accept that there is an issue if people feel they are not able to get care simply because of cost.  It is a signal of something important, although economists may debate just how important.

Not surprisingly people who have insurance are more likely to have a usual source of care and less likely to fail to get care because of cost.  Not only are the negative outcomes less likely but the disparity among individuals of different races and ethnicities decreases.  

There are also reports of the Affordable Care Act leading to more insurance--not surprisingly--and diminishing the racial disparities in insurance.

Thus, if the newly insured individuals behave and have success at accessing care that is similar to those who were already insured, we would expect to see the existing racial disparities diminish.  This would be a very positive outcome.  The key question is whether the rest of the system will adapt and evolve in ways to make finding a usual source of care and obtaining care as easy for the newly insured as for those who have historically had insurance.  Even the authors of the brief are careful to title their piece in a way that reflects that the past results may not reflect future outcomes. 

Saturday, February 28, 2015

Affordable Care Act and Changes in Uninsured

A press release about a Gallup poll that provides details about the number of uninsured individuals in the United States.  The number has gone down from 17.3 percent of the population to 13.8 percent of the population.  The article then provides information on several states that have had more substantial decreases in the percentage of the population that is uninsured.  In those states, hospitals have seen the proportion of patients in emergency departments or general admissions decrease.  In addition, Medicaid has increased coverage.  The hospitals have improved financially.  A key question is whether this is a causal relationship.  Even more importantly, if the law's implications are put into jeopardy by a current supreme court case and there is no contingency plan, then it is truly not clear what will happen to hospitals' financing positions.