Tag Archives: management

Health vs health administration

One of the great patterns of government is that it continually expands adding overseers over overseers to guarantee that those on the bottom do their work honestly. There are overseers who check that folks don’t overcharge, or take bribes, or under-pay. There are overseers to check shirking, and prevent the hiring of friends, to check that paperwork is done, and to come up with the paperwork, and lots of paperwork to assert that no one is wasting money or time in any way at all. There have been repeated calls for regulation reform, but little action. Reform would require agreement from the overseers, and courage from our politicians. Bureaucracy always wins.

The number of health administrators has risen dramatically; doctors, not so much.

By 2009 the number of health administrators was rising dramatically faster than the number of doctors; it’s currently about 20:1.

The call for reform is particularly strong in healthcare and the current, Obamacare rules are again under debate. As of 2009 we’d already reached the stage where there were fourteen healthcare administrators for every doctor (Harvard Business Review), and that was before Obamacare. By 2013, early in the Obamacare era, the healthcare workforce had increased by 75%, but 95 percent of those new hires were administrators: we added 19 administrators per doctor. Some of those administrators were in government oversight, some worked in hospitals filling out forms, some were in doctors offices, and some were in the government, writing the new rules and checking that the rules were followed. A lot of new employment with no new productivity. Even if these fellows were all honest and alert, there are so many of them, that there seems no way they do not absorb more resources than the old group of moderately supervised doctors would by laziness and cheating.

Overseers fill ever-larger buildings, hold ever-more meetings, and create ever-more rules and paperwork. For those paying out of pocket, the average price of healthcare has risen to $25,826 a year for a family of four. That’s nearly half of the typical family income. As a result people rarely buy healthcare insurance (Obamacare) until after they are too sick to work. Administering the system take so much doctor time that a Meritt Hawkins study finds a sharp decline in service. The hope is that Congress will move to reverse this — somehow.

With more administrators than workers, disagreements among management becomes the new normal.

With more administrators than workers, disagreements among management becomes the new normal. Doctors find themselves operating in “The Dilbert Zone”.

Both Democrats and Republicans have complained about Obamacare and campaigned to change or repeal it, but now that they are elected, most in congress seem content to do nothing and blame each other. If they can not come up with any other change, may I suggest a sharp decrease in the requirements for administrative oversight, with a return to colleague oversight, and a sharp decrease in the amount of computerized documentation. The suggestion of colleague oversight also appears here, Harvard Business Review. Colleague oversight with minimal paperwork works fine for plumbers, and electricians; lawyers and auto-mechanics. It should work fine for doctors too.

Robert Buxbaum, September 19, 2017. On a vaguely similar topic, I ask is ADHD is a real disease, or a disease of definition.

A British tradition of inefficiency and silliness

While many British industries are forward thinking and reasonably efficient, i find Britons take particular pride in traditional craftsmanship. That is, while the Swiss seem to take no particular pride in their coo-coo clocks, the British positively glory in their handmade products: hand-woven, tweed jackets, expensive suits, expensive whiskey, and hand-cut diamonds. To me, an American-trained engineer, “traditional craftsmanship,” of this sort is another way of saying silly and in-efficient. Not having a better explanation, I associate these behaviors with the decline of English power in the 20th century. England went from financial and military preëminence in 1900 to second-tier status a century later. It’s an amazing change that I credit to tradition-bound inefficiency — and socialism.

Queen Elizabeth and Edward VII give the Nazi solute.

Queen Elizabeth and Edward VII give the Nazi solute.

Britain is one of only two major industrial nations to have a monarch and the only one where the monarch is an actual ambassador. The British Monarchy is not all bad, but it’s certainly inefficient. Britain benefits from the major royals, the Queen and crown prince in terms of tourism and good will. In this she’s rather like our Mickey Mouse or Disneyland. The problem for England has to do with the other royals, We don’t spend anything on Mickey’s second cousins or grandchildren. And we don’t elevate Micky’s relatives to military or political prominence. England’s royal leaders gave it horrors like the charge of the light brigade in the Crimean war (and the Crimean war itself), Natzi-ism doing WWII, the Grand Panjandrum in WWII, and the attack on Bunker Hill. There is a silliness to its imperialism via a Busby-hatted military. Britain’s powdered-wigged jurors are equally silly.

Per hour worker productivity in the industrial world.

Per hour worker productivity in the industrial world.

As the chart shows, England has the second lowest per-hour productivity of the industrial world. Japan, the other industrial giant with a monarch, has the lowest. They do far better per worker-year because they work an ungodly number of hours per year. French and German workers produce 20+% more per hour: enough that they can take off a month each year and still do as well. Much of the productivity advantage of France, Germany, and the US derive from manufacturing and management flexibility. US Management does not favor as narrow a gene pool. Our workers are allowed real input into equipment and product decisions, and are given a real chance to move up. The result is new products, efficient manufacture, and less class-struggle.

The upside of British manufacturing tradition is the historical cachet of English products. Americans and Germans have been willing to pay more for the historical patina of British whiskey, suits, and cars. Products benefit from historical connection. British suits remind one of the king, or of James Bond; British cars maintain a certain style, avoiding fads of the era: fins on cars, or cup-holders, and electric accessories. A lack of change produces a lack of flaws too, perhaps the main things keeping Britain from declining faster. A lack of flaws is particularly worthwhile in some industries, like banking and diamonds, products that have provided an increasing share of Britain’s foreign exchange. The down-side is a non-competitive military, a horrible food industry, and an economy that depends, increasingly on oil.

Britain has a low birthrate too, due in part to low social mobility, I suspect. Social mobility looked like it would get worse when Britain joined the European Union. An influx of foreign workers entered taking key jobs including those that with historical cachet. The Brits reacted by voting to leave the EC, a vote that seems to have taken the upper class by surprise, With Brexit, we can hope to see many years more of manufacturing by the traditional and silly.

Robert Buxbaum, December 31, 2016. I’ve also written about art, good and bad, about the US aesthetic of strength, about the French tradition of innovation, And about European vs US education.

American education how do we succeed?

As the product of a top American college, Princeton University, I see that my education lacks in languages and history compared to Europeans. I can claim to know a little Latin and a little Greek, like they do, but I’m referring to Manuel Ramos and Stanos Platsis.

Americans hate math.

Americans hate math.

It was recently reported that one fourth of college-educated Americans did not know that the earth spun on an axis, a degree of science ignorance that would be inconceivable in any other country. Strange to say, despite these lacks, the US does quite well commercially, militarily, and scientifically. US productivity is the world’s highest. Our GNP and GNP per capita too is higher than virtually any other country (we got the grossest national product). How do we do it with so little education?

One part of US success is clearly imported talent, Immigration. We import Nobel chemists, Russian dancers, and German rocket scientists but we don’t import that many. They help our per-capita GNP, but the majority of our immigrants are more in the wretched refuse category. Even these appear to do better here than the colleagues they left behind. Otto von Bismark once joked that, “God protects children, drunks, and the United States of America.” But I’d like to suggest that our success is based on advantages our outlook our education provides for our more creative citizens.

Most of our successful businesses are not started by the A students, but by the C student who is able to use the little he (or she) knows. Consider the simple question of whether the earth goes round the sun. It’s an important fact, but only relevant if you can use it, as Sherlock Holmes points out. I suspect that few Europeans could use the knowledge that the earth spins (try to think of some applications; at the end of this essay I’ll provide some).

Benjamin Jowett. His students included the heads of 6 colleges and the head of Eaton

Benjamin Jowett, Master of Balliol College, Oxford.

A classic poem about European education describes Benjamin Jowett, shown at right. It goes: “The first come I, my name is Jowett. There is no knowledge, but that I know it. I am master of this college. What I don’t know isn’t knowledge.” Benjamin Jowett was Master of Balliol College, Oxford. By the time he died in 1893, his ex-student pallbearers included the heads of 6 colleges, and the head of Eaton. Most English heads of state and industry were his students directly or second-hand. All learned a passing knowledge of Greek, Latin, Plato, law, science, theology, classics, math, rhetoric, logic, and grammar. Only people so educated were deemed suited to run banks or manage backward nations like India or Rhodesia. It worked for a while but showed its limitations, e.g. in the Boer Wars.

In France and continental Europe the education system is similar to England’s under Jowett. There is a fixed set of knowledge and a fixed rate to learn it. Government and industry jobs go largely to those who’ve demonstrated their ability to give the fixed, correct answers to tests on this knowledge. In schools across France, the same page is turned virtually simultaneously in the every school– no student is left behind, but none jump ahead either. As new knowledge is integrated, the approved text books are updated and the correct answers are adjusted. Until then, the answers in the book are God’s truth, and those who master it can comfort themselves to have mastered the truth. The only people hurt are the very few dummies who see a new truth a year before the test acknowledges it. “College is a place where pebbles are polished but diamonds are dimmed.” The European system appears to benefit the many, providing useful skills (and useless tidbits) but it is oppressive to many others with forward-thinking, imaginative minds. The system appears to work best in areas that barely change year-to-year like French grammar, geometry, law, and the map of Europe. It does not work so well in music, computers, or the art of war. For these students, schooling is “another brick in the wall. For these students, the schools should teach more of how to get along without a teacher.

The American approach to education leans towards independence of thought, for good or bad. American graduates can live without the teacher, but leave school knowing no language but English, hardly and maths or science, hardly any grammar, and we can hardly find another country on a map. Teachers will take incorrect answers as correct as a way to build self-esteem, so students leave with the view that there is no such thing as truth. This model works well in music, engineering, and science where change is fast, creativity is king, and nature itself is a teacher. American graduate-schools are preeminent in these areas. In reading, history and math our graduates might well be described as galumphing ignorants.

Every now and again the US tries to correct this, by the way, and join the rest of the world. The “no child left behind” movement was a Republican-led effort to teach reading and math on the French model. It never caught on. Drugs are another approach to making American students less obstreperous, but they too work only temporarily. Despite these best efforts, American graduates leave school ignorant, but not stupid; respectful of those who can do things, and suspicious of those with lengthy degrees. We survive as managers of the most complex operations with our bumptious optimism and distain for hierarchy. As viewed from abroad, our method is to greet colleagues in a loud, cheerful voice, appoint a subordinate to “get things done,” and then get in the way until lunchtime.

In any moment of decision, the best thing you can do is the right thing, the next bet thing is the wrong thing, and the worst thing you can do is nothing. An American attitude that sometimes blows up, but works surprisingly well at times.

Often the inability to act is worse than acting wrong.

The American-educated boss will do some damage by his ignorance but it is no more than  comes from group-think: non-truths passed as truths. America stopped burning witches far sooner than Europe, and never burned Jews. America dropped nobles quicker, and transitioned to electric lights and motor cars quicker, perhaps because we put less weight on what nobles and universities did.

European scholars accepted that nobility gave one a better handle on leadership, and this held them back. Since religion was part of education, they accepted that state should have an established religion: Anglican, in England, Catholicism in France; scientific atheism now. They learned and accepted that divorce was unnecessary and that homosexuality should be punished by prison or worse. As late as the early 60s, Turing, the brilliant mathematician and computer scientist, was chemically castrated as a way to cure his homosexuality. In America our “Yankee ingenuity,” as we call it, had a tendency to blow up, too (prohibition, McCarthyism, and disco), but the problems resolved relatively soon. “Ready, fire, aim” is a European description of the American method. It’s not great, but works after a fashion.

The best option, I think, is to work together with those from “across the pond.” It worked well for us in WWI, WWII, and the American Revolution, where we benefitted from the training of Baron Von Steuben, for example. Heading into the world cup of football (fifa soccer) this week, we’re expected to lose badly due to our lack of stars, and general inability to pass, dribble, or strategize. Still, we’ve got enthusiasm, and we’ve got a German coach. The world’s bookies give us 0.05% odds, but our chances are 10 times that, I’d say: 5%. God protects our galumphing side of corn-fed ignorants when, as in the Revolution, it’s attached to German coaching.

Some practical aspects of the earth spinning: geosynchronous satellites (they only work because the earth spins), weather prediction (the spin of hurricanes is because the earth spins), cyclone lifting. It amazes me that people ever thought everything went around the earth, by the way; Mercury and Venus never appear overhead. If authorities could have been so wrong about this for so long, what might they be wrong about today?

Dr. Robert Buxbaum, June 10, 2014 I’ve also written about ADHD on Lincoln’s Gettysburg Address, on Theodore Roosevelt, and how he survived a gun shot.

When to enter a neighbors war or family dispute

As I write this, our favored insurgents in Syria have been over-run by our disfavored insurgents, who may be over-run by the government we are trying to topple. We have also committed to help Japan and Vietnam in their disputes with China. I’ve also had the experience of dealing with a couple going through a bitter divorce. So here are five thoughts for myself and president Obama on getting involved in other people’s problems. I’ll hope that at least one person (me) listens.

1. Learn how to wait without committing to either side so you don’t step in something really smelly. Commiserate with both sides; yes you have grievances, yes what they’ve done isn’t nice. Suggest outside review. Just don’t commit until you feel comfortable sticking with this one side in victory, defeat, or (possible) reconciliation.

In a war, even simple gifts of food or transport are support; avoid these gifts, and especially avoid gifts to both sides. Assume any support to a side will be considered treason from the other side. Supporting both sides just causes havoc, and it’s always possible that your gifts will fall in the hands of the wrong side, as in Syria.

Being helpful isn't always helpful. Matthew Deffee, The New Yorker

Being helpful isn’t always helpful, or appreciated. Learn to wait. Matthew Deffee, The New Yorker

Remind yourself that disputes are a normal part of life, that peace always comes eventually, and that disputes are sometimes good in the long run. Offer sympathy only until you really want to support one side or the other — or until they make peace. When peace comes, it’s possible that the resolution will be better than the status quo-anti. As such, perhaps long-term non-intervention is the best cure. Time often answers what wisdom does not.

2.  If you choose to support a side, only support one that openly, and traditionally supports us. No Syrian leaders have openly pledged support to the US and its allies; why ally with someone who won’t support you? The enemy of your enemy might be another enemy, as with the Taliban. In a marriage dispute, lean to support your close relative or friend — it’s less offensive than the opposite, and less likely to cause hurt. As bad as it is when two sides attack each other, it’s worse when both attack you.

Only support someone who could rule reasonably honestly and well. Chaos is worse than a dictator. Kanin from the New Yorker.

Only support someone who could rule reasonably well. Chaos is worse than a dictator. Kanin from the New Yorker.

3. If you feel it’s important to act in a neighbor’s dispute, you don’t always have to ally with either side. You can retaliate for someone blowing up a ship or killing an advisor, or beating their children by intervening at a distance. Perhaps you can use a missile (ideally against a pointless target), or sanctions, or by the UN or a volunteer force (this tends to work for the US). In family disputes, it’s often best to send a councilor or the police or child protective services. There is room to escalate or de-escalate an action like this depending on how things play out. And it’s easier to distance yourself from a 3rd party’s actions than from one’s own. It is not necessary to support either side to achieve a personal goal or protect children in a divorce.

4.  If you decide to choose sides, make sure to keep in mind the end you seek: what good you want to do, what reasonable peace you seek, then act. Do not worry that you can not do everything, but make sure you target a viable end, and that you support a side that could win and rule. Try to pick a side that’s moral and perceived as legitimate from within, but if you can’t, at least pick one that could rule the country or manage the family without your help. Don’t support a loser, or one who can’t stand on his/her own. Chaos is worse than a crooked dictator; see, for example, the French Revolution. In a fight between parents, make sure the one you support could actually raise the kids. And once the goal is achieved, don’t stay too long. If a friend tells you to go, as in Afghanistan, leave quickly. Independence is the goal we hope for — for our children, our friends, and our neighbors.

Being a fair broker of peace is a great role -- in the proper time. From the New Yorker

Being a fair broker of peace is a great role — but only for the right person in the proper time. From the New Yorker

5. Be willing to serve as an honest broker of the peace. An honest broker is very valuable, and it requires that you’re perceived as unbiassed by both sides. Wait till the right moment before offering this service, and offer it like the precious jewel it is. Offer it when asked or when the fighting dies down. If the offer is refused, be willing to go away and return to the first rule. T. Roosevelt won the Nobel peace prize for ending the Russo-Japanese war because he was a good, honest broker: someone who understood the situation and could stand back when not needed.

Robert E. Buxbaum, Dec 18, 2013. Blessed are the peacemakers.