So recommendations for President Obama for how to reign on costs abound: from the “let’s deregulate the private health insurance market and allow everybody to spend their health care dollars as they choose to” types (one wonders where these folks have been during the meltdown of the global financial system!), to the “consumer driven” types, who suggest shifting (yet more) costs to “consumers” – higher premiums, co-pays, or deductibles — to the “shared responsibility” types (well, who would dare oppose “shared responsibility”, even if it is hardly a meaningful health policy concept? Incidentally, the latest paper by Jacob Hacker, the “father” of the “shared responsibility” model,is the best defense of public financing and indictment of private health insurance I’ve read in a long time!), to the over 100 options-list of the Congressional Budget Office(CBO) – which, incidentally, has (correctly) challenged the enthusiasm for wellness programs, preventive medicine, or electronic medical records, at least as strategies to reign on costs (That’s right! it is not the broccoli that others eat and that we presumably don’t that explain why others spend so much less than what we do! And if you don’t believe me, ask the Brits!).
Remarkably, nobody close enough to the corridors of power, indeed, not even the CBO, seems to mention the “s” word (single payer!). Could it be that “single payer” is too close to “socialism”? (they both begin with an “s”, no?). Or is it that whoever has been organizing the meetings around health care reform under the blessings of Senator Edward Kennedy thought that single payer advocates were unworthy guests to the secret “talks to shape policy”?
Given this notable absence, let me fill this vacuum so that the president hears all the options (don’t you think he’s the type who can appreciate a good challenge?). Let me explain in a simplified way how every other industrialized economy in the world — and even more recently Taiwan — has managed to develop systems that guarantee a basic amount of health care to virtually 100% of their population, based on medical need and not ability to pay, spending no more than 60% of what we do, and yes, using a lot of government! I am quite confident that the president will like my proposal. After all, I remember him saying that the question is not too much or too little government, but government that works for ordinary Americans.
So how do others achieve the remarkable feat that has defied Americans for decades?
First, they’ve created systems that pool health risks widely, because they understand that money spent on dividing people up into different pools or plans — as we do, we spend over 30 cents of each health care dollar underwriting policies and adjusting claims, to make sure that the moneys collected from premiums suffice to pay generous CEO salaries and shareholders — is money not spent on health care, and therefore wasted. Wasted, of course, if the goal is to provide health care universally (as opposed to, for instance, create a “competitive illness market” just for the heck of it). So at any given moment, the healthy majority subsidizes the unhealthy minority, the young, who on average spend less, subsidize the old, who on average spend more, and so forth.
Let me point out that broad cross-subsidization minimizes the need for public subsidies, because it eliminates the category of “special populations” (the old, the poor, the disabled, the “other”) whose “special needs” must be paid by somebody (you guessed it, all taxpayers!) because private insurers don’t want them: after all, they are not “good customers”. Pooling also exempts health professionals from the time-consuming task of figuring out what is covered, under which conditions, and for whom, and from the expensive paperwork of the multiple payment schemes with the unpredictable rates of reimbursement characteristic of the private sector.
Third and last, they finance their health care systems collectively with compulsory contributions. One could say that they take shared responsibility seriously, rather than merely advocating for the sum of individual responsibilities, individual-mandate type! But because they understand that it is pointless to demand that people contribute what they cannot afford, in all cases contributions to the system are a predictableproportion of income, which makes contributions affordable to individuals and families, and adheres to the principle of financial fairness,as articulated by the World Health Organization.
Now, systems vary from country to country and no system is free of problems. Yet what matters is what they share:
They share a commitment to a goal: to eliminate financial barriers to health care.
They share an understanding of a best strategy: that insuring health care cooperatively is the way to go — cooperative financing is known as “social health insurance”, a type of insurance where everybody plays, where the ability to make a profit from connecting patients with providers is severely restricted if not altogether banned, and where contributions are a predictable proportion of income and entitlements a function of medical need.
And single payer is simply a type of social insurance: it is a hybrid system, a private-public partnership which combines public financing with private delivery of services. And it is the only mechanism that has the capacity to reign on costs while achieving the goal of universal health care. And I say care, not insurance coverage — they are not equivalent and should not be considered so.
Single payer can expand coverage while containing costs by maximizing purchasing power, minimizing administrative waste, and minimizing the need for subsidies, that ultimately have to be picked up by all of us, taxpayers. It embodies the pragmatism that President Obama is often credited with in that it builds upon well-tested, and anything but radical, models of financing, yet clearly in the pursuit of a goal: that of universal health care. And it is fiscally conservative in that it provides relief to states that, like California, among many others, spend enormous amounts of money on public programs and health insurance for employees, including retirees, and their families.
Moreover, under single payer, Americans would be able to choose, and keep, their doctors whatever happened to their financial or work lives. They would have meaningful choices — not choice of “health plans” where people are forced to select from within “preferred provider” lists or to second guess their present or future medical needs, but choice of doctors and whatever services they need, the sort of choice that people care about.
As an aside, the notion of social insurance is over 120 years old. Otto Von Bismarck, first chancellor of the German empire, sponsored the first social health insurance system in 1883, among other reasons to preventthe spread of socialism. And as history shows, he succeeded.
In closing, single payer shares with the health care systems of all developed nations, with the glaring exception of ours, the understanding that social health insurance is both good economics and good morals:
It is good economics because it yields the best bang for the health care dollar. And it is good morals because guaranteeing health care, a basic human need, is the mark of a society that cares about human dignity.
Will President Obama think that we can? I can only hope.
Dr. Dolan began by discussing the difference between traditional clinical genetics and the current field of genomics. Genetics was originally concerned with single gene defects, usually associated with rare diseases. These mutations were usually of high penetrance (i.e. having the genetic mutation usually caused you to be sick) and caused conditions (like Down’s syndrome) in which environment played a relatively minor role. Genomics, on the other hand, typically involves multiple (often interacting) genetic variants that are associated with common conditions. These genetic variants often confer only a modestly increased risk of the disease. The diseases in question are ones (such as lung cancer) in which the environment plays a large role. (For more on this distinction, see the article by Alan E. Guttmacher, M.D., and Francis S. Collins, M.D., Ph.D. in the November 7, 2002 issue of the New England Journal of Medicine entitled: Genomic Medicine: A Primer).
Genomic medicine promised to make genetics relevant to everyone. In a 1994 article in the American Journal of Human Genetics, Dr. Eric Hoffman predicted “[t]he day of the personal DNA profile provided at birth, complete with calculated risks of various cancers, heart disease, and many other conditions could be actuality by the time that current first-year medical students begin to practice medicine.” While this prediction proved premature, a few years later genomics entered the mass market with internet-based direct-to-consumer advertising.
Dr. Dolan expressed considerable skepticism regarding the value of many genetic tests. In order to assess their clinical validity she recommended use of the ACCE criteria developed by the Foundation for Blood Research for the CDC. These criteria evaluate:
Analytic validity: Does the test actually measure the genetic variation it is supposed to measure? (“ability to accurately and reliably measure the genotype of interest. “)
Clinical validity: Is the genetic variation actually predictive to the disorder of interest? (“ability to detect or predict the associated disorder (phenotype)”)
Clinical utility: What are the risks and benefits of introducing the test into clinical practice?
Ethical, Legal and Social Consequences of the Test
The ACCE criteria suggest 44 specific questions that should be answered in considering a given genetic test.
Several genetic tests have not lived up to their initial promise. For example, Roche’s AmpliChip CYP450 test was touted as a breakthrough that would allow individualized dosing, particularly of psychiatric medications. But the clinical utility of the test has been questioned (The Medical Letter, 47(1215/1216), August 15/29, 2005). In 2007 the Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Working Group writing in Genetics in Medicine concluded that: No evidence was available showing that the results of CYP450 testing influenced SSRI choice or dose and improved patient outcomes, or was useful in medical, personal, or public health decision-making.” [SSRI’s are a common class of anti-depressant drugs].
Similar concerns have been raised about pharmacogenetic testing for warfarin. Reviewing commercial tests for CYP450 polymorphisms associated with differences in warfarin metabolism, The Medical Letter concluded in May of 2008 that: “Currently available data are probably insufficient to recommend pharmacogenetic testing just yet for all patients taking warfarin, but these tests may be helpful, especially in selecting an initial dose and in some patients with unexpected therapeutic responses to the drug. Whether they improve clinical outcomes remains to be established.” (The Medical Letter, 50(1286), May 19, 2008)
Regardless of these cautions genomics has now entered the world of direct to consumer advertising and Dr. Dolan reviewed the major categories of this fascinating “brave new world”. [Please note, we are not endorsing the use of any of these websites.]
1. Determining Paternity. DNA Lab Centers features a smiling baby on the home page with the caption: “Does he really have your eyes?” Results can be used to “provide Maternity, Paternity, Immigration, Grandparent and Sibling Testing/Verification.” The use of DNA for immigration cases is, apparently, a growing field.
3. Dating and Social Networking: Sites like Gene Partner and Scientific Match claim to match people based on genetics. Gene Partner bases its system on HLA matching and the site provides references to 11 scientific publications. Four of these were non-human studies and three of the studies are listed twice (ouch!). Of the remaining four studies three relate to female preferences for different male odors and only one associates HLA types with romantic involvement, a study involving 48 couples. Not a particularly strong evidence base. Scientific Match seems also to use the HLA types, but the site is less explicit.
4. Sites looking for specific medical disorders: Sites like DNA Direct and 23 and me provide comprehensive genetic testing services include whole genome tests. Again, the clinical utility of most of these tests has yet to be demonstrated.
Maybe major histocompatibility genes truly explain romance. But in the market, let the buyer beware.
I prefer poetry and will close with the thoughts of Edmund Spenser:
Amoretti XXX: My Love is like to ice, and I to fire
My Love is like to ice, and I to fire:
How comes it then that this her cold so great
Is not dissolved through my so hot desire,
But harder grows the more I her entreat?
Or how comes it that my exceeding heat
Is not allayed by her heart-frozen cold,
But that I burn much more in boiling sweat,
And feel my flames augmented manifold?
What more miraculous thing may be told,
That fire, which all things melts, should harden ice,
And ice, which is congeal’d with senseless cold,
Should kindle fire by wonderful device?
Such is the power of love in gentle mind,
That it can alter all the course of kind.
A friend recently brought to our attention the film, A Right to Health, Neighborhood Health Centers in Profile, made by the Office of Health Affairs of the Office of Economic Opportunity (OEO) apparently in the early to mid-1970’s. This 33 minute film highlights the work of diverse Community Health Centers in the US, beginning with Montefiore’s Martin Luther King Health Center in the South Bronx.
We have also posted Out in the Rural, a film about one of the first two OEO community health centers, the Tufts-Delta Health Center of North Bolivar County, Mississippi. See our media page for a link to this film and the following link for an introduction to Out in the Rural.
A Right to Health is made in the overly somber, paternalistic style of old public service announcements. Nonetheless, the voice and feeling of the communities manages to emerge. Dr. Roger O. Egeberg, then Dean of USC School of Medicne, introduces the movie stating that it “describes new ways of providing health care for the poor.” But this is a bit deceptive. The film describes ways of organizing health care services – community care, comprehensive care, team care, the use of community health workers – that suggest a broader vision of clinical care than just “poor care.” In fact, the title “A Right to Health” expresses a universal ideal that we have yet to achieve in the US.
Last but not least, the Poor People’s Economic and Human Rights Campaign has developed a project to move homeless people into many of the foreclosed and vacant homes in Minneapolis’s North and South Side, and is seeking a moratorium on foreclosures and evictions.
Anyone who has driven across the Whitestone Bridge more than once or twice has probably noticed the large brick building located just east of the highway on the Bronx side. This is the home of the St. Joseph’s School for the Deaf, a school founded in 1869 and which moved to its 10-acre campus in the Bronx in 1913. St. Joseph’s is is one of eleven New York State 4201 schools which are supported by the state to provide educational services to children who are deaf, blind or physically challenged. Social Medicine Rounds last Tuesday (2/10/2009) took us to the School to learn something about deaf culture.
We were greeted by Patricia Martin, Noreen Collins and Roxana Aguilo who were gracious enough to spend nearly 90 minutes talking to us about the school and about the meaning of deafness. Dr. Martin is the Executive Director of St. Joseph’s and has been with the school for seventeen years. Ms. Collins in responsible for pupil personnel services and is the person to call (718.828.9000) for assistance with referrals . Ms. Aguilo is a former student at the school who works there now as a teacher’s assistant. Since she is deaf, she participated in the Rounds through the able translating abilities of Dr. Martin and Ms. Collins.
Dr. Martin began by distinguishing two definitions of deafness. Deafness can be seen as a pathology; this is what we could the “medical model.” In this model the important questions are why it occurred, how severe it is and how it can be fixed. But deafness can also be seen as a culture. From this perspective to have deafness is not to be dis-abled, but rather to be differently abled. To emphasize the reality of deaf culture, Dr. Martin read a poem entitled “Being Deaf” by Dianne Kinnee:
“What is it like to be deaf?”
People have asked me.
Deaf? Oh, hmm… how do I explain that?
Simple: I can’t hear.
No, wait… it is much more than that.
It is similar to a goldfish in a bowl,
Always observing things going on.
People talking at all times.
It is like a man on his own island
Isolation is no stranger to me.
Relatives say hi and bye
But I sit for 5 hours among them
Taking great pleasure at amusing babies
Or being amused by TV.
Reading books, resting, helping out with food.
Natural curiosity perks up
Upon seeing great laughter, crying, anger.
Inquiring only to meet with a “Never mind” or
“Oh, it’s not important”.
Getting a summarized statement
Of the whole day.
I’m supposed to smile to show my happiness.
Little do they know how truly miserable I am.
People are in control of language usage,
I am at loss and really uncomfortable!
Always feeling like an outsider
Among the hearing people,
Even though it was not their intention.
Always assuming that I am part of them
By my physical presence, not understanding
The importance of communication.
Facing the choice between Deaf Event weekend
or a family reunion.
Facing the choice between the family commitment
And Deaf friends.
I must make the choices constantly,
Any wonder why I choose Deaf friends???
I get such great pleasure at the Deaf clubs,
Before I realize it, it is already 2:00 am,
Whereas I anxiously look at the clock
Every few minutes at the Family Reunion.
With Deaf people, I feel so normal,
Our communication flows back and forth.
Catch up with little trivials, our daily life,
Our frustration in the bigger world,
Seeking the mutual understanding,
Contented smiles and laughter are musical.
So magical to me,
So attuned to each other’s feelings.
True happiness is so important.
I feel more at home with Deaf people
Of various color, religion, short or tall.
Than I do among my own hearing relatives.
And you wonder why?
Our language is common.
We understand each other.
Being at loss of control
Of the environment that is communication,
People panic and retreat to avoid
Deaf people like the plague.
But Deaf people are still human beings
With dreams, desires, and needs
To belong, just like everyone else.
–Dianne Kinnee (Switras)
Dr. Martin went on to describe their work in the school. She pointed out that about 95%of deaf children are born into hearing families. If hearing parents don’t learn sign language, as often happens, this can be very isolating for the deaf child. This is a particular problem in Bronx where many parents don’t speak English. For immigrant parents learning American Sign Language involves communicating in a doubly foreign language. [A universal sign language does not exist; each spoken language has its own way of signing]. The result of this is that even when deafness is identified early on deaf children may not receive a great deal of language stimulation at home.
The school has responded to this challenge by providing programs in which parents can bring their children to the school as early as 8 months of age. Children come to the school on their own starting at age 3 and stay through the 8th grade. The school also offers a 10 session class on Thursday evenings for people interested in learning how to sign. The cost is $50.
Ms. Aguilo then spoke at length about her personal experience. She had been born in the Dominican Republic where there were no services for the deaf. Her mother brought her to the Bronx and she had been diagnosed as deaf at Jacobi Hospital. This was a great blow for her mother. Fortunately, they had a Spanish-speaking counselor at Jacobi who was able to explain the situation in a language her mother could understand. Her mother found learning sign language difficult and so Ms. Aguilo had great difficulty in communicating with her Mom. Ms. Collins mentioned that often parents came to the school requesting that the school tell children about the death of relative or a pet. In these cases the school asked the parent to come in and the school provided translation services.
Ms. Aguilo had been a student at St. Joseph’s and later enrolled at Rochester Institute of Technology where she majored in fashion design. But she was homesick for the Bronx and returned after only a year and a half. Now she was working as a teacher’s assistant. She has three children of her own (“and all of them hear”) and has taught them ASL. Her kids are tri-lingual, speaking English, Spanish (with the abuela) and ASL (with Mom).
The topic of kids lead to a discussion of their use as interpreters. Ms. Aguilo spoke in forceful terms that the American Disability Act gives deaf people a right to a translator and this right should be respected. “Don’t write”, she said. “Don’t ignore our rights. It only makes us angry.” The use of children as interpreter has also been an issue with our southeast Asian patients. For a list of translation resources, see the end of this post. Ms. Aguil0 also spoke about the coverage limitations imposed by SSI particularly in terms of cost-sharing for hearing aids.
Ms. Aguilo noted to us that deaf people can drive cars. Deaf persons had initially experienced difficulty getting auto insurance so they formed their own company. Accident rates are lower for deaf drivers than for hearing drivers.
To some cochlear implants are the latest medical miracle. But many in the deaf community see it as an attempt by the medical community to eradicate deaf culture. Ms. Aguilo was blunt: “I like being deaf. And cochlear implants say to me that I am not ok.” She did not think they were appropriate for children born deaf. But they were an option for hearing people who were becoming deaf. Dr. Martin stated that the school was neutral with respect to implants.
New York Society for the Deaf: 212 366-0075 (9AM-5PM)
Mill Neck Manor School for Deaf Children: 516 512-6222
Deaf & Hard of Hearing Interpreting Services, Inc.: 212 647-1092 (8AM – 5PM, requests for interpreting by appointment; call same number after 5PM for emergency interpreting)
Video Relay Service (VRS): Sorenson VRS 866 327-8877. You need to have either the video number or the IP address for the Deaf person to call in addition to calling VRS.
Theorists predict that due to differential access to power and resources among subgroups in a population, disparities in health will be created or exacerbated by the introduction of new disease processes into the population or with any shock to the system. Those subgroups with better access to resources will always secure a health advantage in times of stress. Though disparities in health existed in Louisiana before the tragedy of Hurricane Katrina, this crisis and the inadequate government response clearly demonstrated this principle. Disparities in health outcomes worsened following the disaster with a disproportionate burden of morbidity, including new diagnoses such as post traumatic stress disorder, falling on disadvantaged groups. With the closure of Charity Hospital, the only access point to health care for many of the poor and uninsured in New Orleans, thousands of individuals were left without a source for care, which likely worsened these disparities. As Louisiana attempts to rebuild, there have been demands to fill the void left by Charity Hospital’s closure, but an important lesson should not be missed. Simply replacing Charity with another under-funded public hospital, and replicating a two tiered system that treats patients with private insurance differently than those dependent on charity care, misses the opportunity to replace the separate and unequal health care system of Louisiana with a more equitable one that serves all people.
While universal health care would not have completely eliminated disparities that existed before and after Hurricane Katrina, it is clear that the two tiered system of health care in New Orleans left thousands of individuals at risk. At the time of Katrina, statewide only adults with dependent children and incomes less than 20% of the federal poverty level (about $3000 per year) qualified for Medicaid. Due to such restrictive requirements for public coverage and the large number of small business employers not offering health benefits, 21% of non-elderly adults in Louisiana had no health insurance prior to Katrina. In New Orleans the number was 26%. Because Louisiana state law mandates universal access to health care, the state funds a public system to serve the poor and uninsured. Charity Hospital, the focal point of the public system, accounted for over 80% of care for the uninsured in New Orleans, with the surrounding private hospitals caring for mostly patients with commercial insurance (only 4% of their patients were uninsured). 82% of Charity patients were economically disadvantaged and two-thirds were African-American. When Charity Hospital was severely damaged by the disaster and could not reopen, low-income and uninsured residents of Orleans parish were left with no place else to go. In fall 2006, according to a Kaiser Family Foundation study following Hurricane Katrina, 49% of residents of the Greater New Orleans area reported problems with health care coverage or access to care. 61% of former Charity users had no source of care other than the emergency room; African-Americans were more likely than whites to lack a regular source of care; and 15% of individuals with chronic health conditions such as diabetes or asthma had no health insurance coverage. After Charity’s closure these uninsured patients with chronic disease who are most in need of continuity of care, were left to find a new source of care. With much damage to health care facilities and many physicians relocating outside of New Orleans, the already stressed health care system was not equipped to absorb such need.
In another early study of Katrina survivors, the impact of this impaired access to care is readily seen. 74% of the surveyed population reported a chronic health condition that preceded the disaster. Of this group, 21% needed to disrupt treatment because of barriers to care. Predictors of treatment disruption were age (with the non-elderly being at higher risk), social isolation, housing need, and lack of health insurance. Due to job loss, the already substantial problem of lack of insurance was compounded, and according to the US Census Bureau, the number of uninsured people increased at greater rates in Louisiana than any other state during the years immediately following Katrina. With more uninsured, and fewer sources of care for those without insurance, there was undoubtedly much avoidable suffering.
By spring 2008, three years after Katrina, with job recovery and Medicaid waivers to cover some hurricane survivors, the uninsured rate in New Orleans decreased to 22% among non-elderly adults, but disparities in health care access persisted and disparities in outcomes were already apparent. According to a follow-up Kaiser study, low income adults in New Orleans (those with incomes less than 200% of the federal poverty level or about $42000 for a family of four) were still more likely to report no regular source of care and less likely to have received preventive care than those of higher income. In the two Kaiser surveys, between 2006 and 2008, the rate of self reported fair or poor health status increased from 19% to 46% in the economically disadvantaged group. As a comparison, in 2008, only 19% of the higher income group rated their physical health as fair or poor. Rates of self defined fair or poor mental health were also significantly higher among low income adults, 25% vs. 16%, and had increased from 15% in 2006 in the economically disadvantaged group. Specifically, among former Charity patients, in 2008, 50% rated their physical health and 29% rated their mental health as poor or fair. While these numbers demonstrate significant disparities, they fail to capture the most extreme suffering, as those displaced to trailer parks and temporary shelters outside of New Orleans, reported even greater difficulty with access to care and much higher rates of physical and mental illness.
The reason for health disparities by socioeconomic status or race in New Orleans is not limited to lack of health insurance, and insurance coverage alone without a strong primary care infrastructure would not have increased access to care, however, the two tiered health system that exists in Louisiana, and all across the United States, one that treats patients differently based on ability to pay, leaves a large percentage of the population at increased risk. Our “safety net” for patients without insurance is porous, and sometimes, in the face of disaster, the inadequacy becomes painfully evident. An equitable health system would not have provided transportation for those trapped in the 9th ward as the flood waters rose, but after the disaster it may have helped diabetic former Charity patients find other sources of care and avoid interruptions in medical treatment. As New Orleans and Louisiana rebuild, local policy experts and community members will set priorities for their health care needs. However, following the injustices that were exposed and exacerbated by Katrina and the disproportionate burden of suffering that fell on the low-income, African-American population of Orleans Parish, a commitment to health equity could be symbolic for the rest of the country in how to treat all citizens with dignity. If we are going to build a healthy society in New Orleans, and across America, access to high quality affordable health care needs to be considered a right – not just charity. The uninsured and underinsured will always have second class health status until we guarantee health care for all.
One of the solutions offered to the chronic crisis in US health care is to introduce the “rationality of the market.” Overseas this has meant the introduction of US-style HMO‘s and the privatization of national health care systems. In the US, hospitals – even not-for-profits – are forced to adopt the methods and vocabulary of business. Patients become customers, clinical care becomes one more product line.
In clinical practice we strive (often not all that successfully) to base our actions on the best available evidence. This is the general idea behind what is called evidence-based medicine (EBM). It is striking, then, that the advice presented in these business books often seems to lack any supporting evidence other than a series of colorful anecdotes mixed with the equally colorful opinions of the author. This is what we in medicine have come to call “expert advice” and it is considered the lowest form of evidence for adopting a particular therapy. Expert opinion is not valueless, but there are better ways of getting at the truth.
The question occurred to me: What would happen if EBM standards were applied to the management books coming to medicine from the business community?
To answer this question I decided to write a peer review of Collin’s book From Good to Great. I write peer reviews for medical journals on a fairly regular basis and have some advanced (Master’s level) training in clinical research methods. Of course, I do not have content expertise (i.e. specific knowledge) in the business world. In addition, unlike most peer reviews, I know who is the author and also know a bit about the reaction to this books. So my review is not blinded. But with those caveats in mind, here is a peer review of Jim Collin’s Good to Great:
* * * *
Thank you for the opportunity to review this book.
Jim Collin’s book,Good to Great: Why Some Companies Make the Leap… And Others Don’t sets as its project to understand what makes companies great. The book is about the question “Can a good company become a great company and, if so, how? – and our search for timeless, universal answers that can be applied by any organization. (pg 5). [Although the research was conducted by a team I will refer to “the” author in this review.]
The author tries to answer this question using a case-control methodology. The author examined the universe of Fortune 500 corporations between the years 1965 to 1995. From this group of over 1400 companies, he selected those that had made a transition from being good companies to being great companies. This was done by finding corporations that had a 15 year period of average or below average stock returns (the “good” period) followed by an 15 year period during which stock returns were three times average stock market returns (the “great” period). Only 11 companies (00.77%) out of a universe of 1,435 met these strict criteria. They were then paired with control companies within their own industries whose stock returns were average during the same 30 year period.
To assess what factors might explain the success of the control companies the author then examined available public records about these 11 pairs (22 corporations) including financial records and published reports. The author also conducted 84 interview with the senior management and board members of the 11 case companies; no interviews were conducted with the control company management or board members.
Based on analyses the author and his team reached a series of conclusions which they report as being “empirical deductions directly from the data.” In the space of this brief review I will not comment on all of their findings since I will focus my review on the methodology. Let me just briefly touch on several findings which characterize the flavor of the book:
Leadership is key in the transition from good to great, particularly what the authors call “Level 5” leaders. Level 5 leaders are characterized by being modest (i.e. not self promoting), but intensely devoted to the mission of the company.
“Good to great companys are more like hedgehogs – simple, dowdy creatures that know “one big thing” and stick to it. The comparison companies are more like foxes – crafty, cunning creatures that know many things yet lack consistency.”
The Flywheel concept: Good to great transformations “never happened in one fell swoop. There was no single defining action, no grand program, no one killer innovation…” Rather there was “persistent pushing in a consistent direction over a long period of time…”
The various “good to great” principles are considered generalizable so that “almost any organization can substantially improve its stature and performance, perhaps even become great, if it conscientiously applies the framework of ideas we’ve uncovered.” (page 5)
The author has also published a Good to Great for the Social Sector which applies the principles of the book to the “social sector.” This does not appear to be based on any independent analysis of data but rather on how the author sees his principles enacted in the social sector. I will not discuss this since it is, in a sense, a series of case histories.
The author’s general project of distinguishing “good” companies from “great” companies needs better justification. Bad, good, and great companies (in terms of stock returns, the author’s metric) may fall upon a continuum without clear dividing lines. This can be illustrated with a simple, perhaps extreme, example. If one evening we were to follow a random group of 1435 gamblers playing slot machines at a casino in Atlantic City we would find a wide variety of outcomes from those who lost money, to those who broke even and those who won large amounts of money. We could pair the high winners (the top 11 gamblers) with the average winners and try to understand the differences between the “good” gamblers and the “great” gamblers. Given the human propensity to find reasons for anything, we might develop a theory of how great gamblers are different from good gamblers. But this would be nonsense. [This problem is similar to the “Texas Sharpshooter Fallacy“]
The author states the leaders of “great” companies “attribute much of their success to good luck, rather than personal greatness.” (p. 40). He states that this emphasis on good luck was puzzling. “After all, we found no evidence that the good-to-great companies were blessed with more good luck… than the comparison companies.” [This evidence and methodology for this statement is not presented] The author concludes that his interviewees are simply displaying modesty, a trait of great executives. But is the author perhaps not imposing his interpretation over that given by the interviewees?
A second important comment is that stock returns were the sole criteria for excellence. Thus Philip Morris, a tobacco company, is one of the 11 great companies. Cigarette smoking is the number one preventable cause of death in the US. Thus the inclusion of Philip Morris as a great company highlights the highly limited and certainly controversial definition of greatness. The author states that other criteria for excellence such as societal impact or employee welfare were not considered because “we could not conceive of any legitimate and consistent method for selecting on these other variables without introducing our own biases.” [pg 6]
This statement strikes this reviewer as odd. Is the sole criteria of profit really unbiased and value-free? Is it neutral to accept that as long as you make a profit, it’s ok to sell a product that kills people? In the author’s attempt to avoid bias, he merely reveals his lack of awareness of his own fundamental biases. This lack of self consciousness is of concern in an investigator.
It is also of particular concern to this reviewer that the author strives to find “timeless, universal answers.” To quote Stephen Penn’s Dicing with Death: Chance, Risk and Health“…the defining characteristic of science is not its infallibility but rather its self-correcting ability.” [p. xi]. This is especially true of case-control studies which are subject to multiple biases and whose results should always be confirmed by other stronger methodologies.
Variance from accepted research practice
The purpose of a case control study is to compare cases and controls. It is unclear why management in the control companies was not interviewed. I would argue that absent such control interviews, information obtained from case interviews should not be included in this study.
Limitations of the case control methodology
Even accepting the interview data, this data is subject to important biases:
Given the 15 year period of good returns necessary to become a case, any information obtained by the authors regarding the “transition from good to great” will refer to a time period at least 15 years prior to the study. In other words, a “great company” in 2000 would have made the “transition” in 1985. Other transitions might have occurred far earlier. This long delay limits the value of any interview data. People are being asked to provide detailed answers about events that occurred at least a decade and a half before the interviews. Many of the important people at the time of the transition may be dead or unavailable. This may introduce biases which the author does not address.
Case control studies are bedeviled by the problem of recall bias. For example, women who give birth to children with birth defects are likely to remember more about the drugs they took before and during pregnancy than mothers whose children were normal. One anticipates this as a major problem when executive are asked to explain “the transition” (this was the wording of the question posed to them, p. 239).
It seems plausible that interviewees would be very unlikely to offer socially unacceptable answers. For example, executives who engaged in illegal, immoral or grey activities (such as aggressive political lobbying) are unlikely to reveal these during interviews regarding their success. These are also precisely the types of data that are unlikely to be found in the public record.
I am struck by the fact that the authors interviewed senior management and members of the board. Surely there are more people in a corporation than those at the top. This is an important bias which I think weakens the evidence base for the author’s conclusions on the centrality of management.
Case control studies cannot control for confounding. In other words it may be that some factor X accounted for both Level 5 management and corporate success. In addition, even assuming that the associations found by the authors are valid it does not necessarily follow that level 5 management “caused” the success. It may be that the success “caused” the Level 5 management, a point I will return to.
Case control studies may provide interesting hypotheses but they should not be considered as proven without other lines of evidence.
Questions concerning theoretical models
The author uses the “hedgehog and fox” explanatory model derived from an essay about intellectuals by Isaiah Berlin. It may be that this concept can be easily extrapolated from intellectual life into the business world, but the author offers no proof that in fact this is a good model to understand business behavior. One would have preferred that he demonstrated that independent raters would have reached similar conclusions about the fox-iness and hedgehog-iness of companies before accepting this schema.
Similarly, I believe that the topology of management types requires some justification.
No formal statistical analysis is presented although formal statistical input was sought (see pages 211-212). One mathematician pointed out that the sample was non-random and that therefore differences between the samples would be non-random. And a second statistician made a calculation about how non-random. Again this simply reflects the purposeful sampling technique.
One of the most dramatic images of Good for Great is the flywheel, shown here. What is interesting is that the central image of the flywheel, the two companies diverging at the center- one to goodness, the other to greatness – is a not finding of the study. It is a result of the way the study was structured. The author has simply put his explanatory model on a highly unusual pairing.
Level Five Leadership:
The author makes a great point of emphasizing that he initially decided to “downplay the role of top executives so that we could avoid the simplistic ‘credit the leader’ or ‘blame the leader’ thinking common today.” [p. 21] But the author argues that “the data won” and the centrality of leadership was one of his findings.
But is such a finding not inevitable given the author’s methodology? One might logically begin with the idea that what makes a “great” retailer is different from what makes a “great” drug company. But the author assumes that “greatness” characteristics are independent of industry. This is an assumption that is neither discussed nor justified. It may however derive from his central bias that the goal is of the corporation is to make money regardless of the social consequences. However, having made greatness independent of industry, we are left only with greatness explanations involving something intrinsic to the corporate structure per se. It is hard to see how such a project – fed by press reports and management interviews – cannot but conclude that what distinguishes great corporations are the policies of their leaders. The author himself also may have a bias towards looking for management-centric answers. He wants to find the way to make a good corporation great and any principles will have to be implemented by management.
Generalizability: On page 5 the authors state that as a result of their research: “… one giant conclusion stands above the others: We believe that almost any organization can substantially improve its stature and performance, perhaps even become great, if it conscientiously applies the framework of ideas we’ve uncovered.” There is no empiric evidence supporting this statement since – at the time of publication – no organization had attempted to create change by applying the ideas outlined in the book. In other words, while it may be true that people who drink alcohol have less heart disease, this does not mean that if I start drinking alcohol I will reduce my risk of cardiac disease.
I think this conclusion illustrates the author’s incautious approach to his data and calls into question the validity of his findings.
The author claims the good-to-great principles caused the transformation of the companies. But it is also possible that the chain of causality worked the other way. Let us consider the hedgehog principle. It is possible that success causes companies to focus on what they are doing well rather than visa versa. Or that companies function as flywheels because they are making profits. Not visa versa.
Advice to the author
As noted above case control studies are useful for generating hypotheses. If the author believes his hypotheses are correct there are several ways in which they could be tested empirically. One simple way would be to present his data in a blinded fashion to independent researchers and see if similar conclusions would be drawn. Another way would be for the author to make predictions based on his schema and see how accurate such predictions would be and/or to see if independent observers using his framework would make the same predictions.
I would not publish this book in its present form. I think the author should present his conclusions as hypotheses and discuss ways in which they might be empirically validated. There should be a formal statistical analysis.
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This is my peer review of Good to Great.
Given the methodological weaknesses of this book it is intriguing to ask why it is so successful. What is it about the “good to great” story that makes it so attractive? Why do people in health care – who really should know better – accept this poor quality research?
The book’s veneer of scientific rigor is clearly important in establishing the authority of its conclusions. Yet it seems to me that the central attraction of this book lies in its endorsement of the essential morality of the capitalist market. People who are modest, dedicated, hardworking, and determined can achieve greatness, i.e. make lots of money. Virtue is rewarded even in a tobacco company. This is a satisfying morality tale which seems to be validated by science. This seems to be the key to the book’s commercial success.
Health care personnel venturing out into the world of business books should, however, remember that the market is not characterized by morality and rationality. Remember the Roman adage: Caveat emptor. Let the buyer beware.
Whenever I write a review, I always request feedback from the editor. Let me know what you think.
As stated in the Ottawa Charter for Health Promotion, a 1986 document produced by the World health Organization, peace is a fundamental condition for health. And yet, peace is elusive for millions around the planet. Such is the case of Gaza, a 1,5-million people enclave between Egypt and Israel, with little, if any, free access to the outside world, which was left with over 1,300 dead and over 5,320 wounded by the recent Israeli military incursion lasting about three weeks (from December 27 of 2008 to January 18 of 2009).
As details of this incursion come to light, the picture is not pretty: B’Tselem, a human rights organization which monitors Israel’s human rights responsibilities, recently issued a report examining breaches of international law during this incursion, including illegal use of weapons and human rights violations. The 23-page long report is worth reading in detail.
J.M. Souers and V. Lezcano at the Institute of Genetic Engineering and Biotechnology
Joanna Mae Souers, a US student studying at the Latin American Medical School (ELAM) in Havana, has sent us this update on her studies. For additional information on the ELAM program you can other posting at this link:
Every year, at the beginning of second semester, second-year students of the Latin American School of Medicine (Project ELAM), are responsible for choosing an elective course. 108 courses are offered on a variety of themes including, Microbiology, Pathology, Anatomy, Histology, History, Geography, Math, Medicine and Culture, etc.
Some of the courses I found more interesting include: “Clinical Microbiology and Infectious Pediatrics,” at the Pediatric Hospital of Central Havana, “Bacterial Diagnosis of Respiratory Illnesses,” at Hospital Calixto Garcia, and “The Practice and Theory Behind Sexually Transmitted Diseases” at the Ramon Gonzalez Coro Hospital of Gyno-obstretics. Some other students may have chosen “Preventative Detection of Cervical Cancer Associated with STDs,” “Acupuncture,” “Obesity Treatment,” “Effects of Electrical Current on the Human Body,” “Nanotechnology,” or even “Religions of African Origin and Health Care.”
After course selections were listed, I was pleased to be placed in “Preparation of Histological Slides for Morfophysiology,” a course in the theoretical and practical techniques of preparing and mounting histology slides. The course included several classes in the basic preparation of slides using different preservation, coloration and mounting techniques and a trip to the Herber Biotech Institute of Genetic Engineering and Biotechnology here in Havana, Cuba.
At the institute, doctors and technicians analyze trials to develop new vaccines, methods of diagnosis and new pharmaceuticals every year. We met with Dr. Viviana Falcon Cama, the director of the Electron Microscope Laboratory, who gave us an introductory overview of the institute and a history of the microscope.
Students practicing their technique with the ultramicrometer
After the introduction we were shown the step-by-step the process of preparing slides from samples of rat cerebrum infected with dengue fever. The samples were prepared using immunotechnological techniques to tag traces of dengue virus with gold particles to identify infected samples with the electron microscope.
We started the process with preserving the prepared sample tissue in resin, processed the resin imbedded samples using an ultramicrometer and finished the process mounting the samples on thin copper discs. After the preparation process we viewed our samples with the electron microscope.
The course was a success. It was a phenomenal experience and my first opportunity to manipulate an electron microscope. I was fascinated by the work they are accomplishing at the institute and amazed at the technology and tools available for research. Most people believe Cuba is suffering from a lack of resources. Though the embargo has greatly affected their ability to do business with many countries, they work hard to stay on the cutting edge of medical research and education.
It has been suspected, if not known, for over 200 hundred years that poverty, lousy jobs, bad housing, and bad food breed disease. Back in 1790, Johann Frank, the “father of public health”, in an address to graduating medical doctors, said it clearly: “The people’s misery is the mother of disease”. And such is the basic stance of the social medicine and public health tradition. So the fact that programs geared to providing decent housing, health care, food or education promote the health of the public, especially that of ordinary Americans who live from paycheck to paycheck, should be a no-brainer, right? Wrong, at least if you think like “moderate” US legislators.
And this is true in both parties. While we hear them claim repeatedly that they care about the American people, including American people’s health, they seem to find it hard to put their pockets where their mouth is. So they managed to trim 100 billion dollars (plus or minus) from programs geared precisely to providing services to the most vulnerable sectors of society.
“But”, you may wonder, “maybe they are truly concerned about ordinary folks like me, about not burdening future generations with unwarranted debts, and about protecting the economy”. Yet whichever their reasons might be to have fought tooth and nail for cutting corners, the problem is, things just do not work that way. In fact, a too timid stimulus plan may undermine precisely the badly and urgently needed economic recovery. As economist Dean Baker points out, “Stimulus creates jobs by spending money…If the government pays someone $30,000, then that person will be employed. They can be repaving a road, weatherising a building, teaching our kids, providing health care to the sick or replacing the sod on the national mall”. And if the stimulus is on the cheap, argues Baker, “Millions of people will needlessly go unemployed. People will lose their homes and families will break up. Millions more will be hungry and cold because they can’t afford food and heat”. Yep. Millions in Main Street. The very folks these legislators purport to represent and to desire to protect.
And the legislative committee set up to interrogate the CEOs of the eight biggest bailed out banks wasted the 7-hour hearing on platitudes and euphemisms (with rare exceptions) — maybe because virtually all members of the committee received financial contributions for the 2008 elections campaign for a total of 1.8 million dollars.(“Taxpayers on hook for 250 billion toxic assets“).
I do not know about you. But this is hardly change I can believe in.