On the Ground instead of in a Parachute: How to Think when Choosing a Career

Most career books advise imagining a circumstance where you have an infinite or an unbelievably large sum of money and have no need to work. They ask; what would you do then? Where would you want to be? How would your ambition change? The answers to these questions are supposed to guide you to your calling or that daily endeavor that holds true personal value.

Make it more real. The questions are legit, but the hypothetical scenario suggested is just too fantastical. Think about it in terms of what you earn now (which also eliminates that initial desire to go on a superfluous shopping spree). If you could have the salary you have now without having to do the work you do now for it, what then? Say you earn $50,000/year and it was guaranteed no matter what. How would you plan your day to day?

Bottomline: Our imaginations are powerful and may be a little too convincing. Who hasn’t dreamed about possibly earning a million dollars? Planning out career options based on that dream though is a little far-fetched and unrealistic. Work with the numbers you have now because they actually affect your lifestyle. It’s a clearer perspective when you can understand it on today’s rather than tomorrow’s terms.

Prenup Economics: A friendly conversation on losing your shirt and then some

I had a conversation with a friend the other day about who a prenup matters to most. Someone with $80M dollars or someone with $20,000. Assume net worth here, and also assume that without the prenup, each person potentially faces to lose half their net worth.

My friend’s theory was the person with $20,000 has a lot more to lose without a prenup because his purchasing power decreases at a much greater magnitude than the person with $80M. The wealthier party’s lifestyle isn’t too dramatically affected by a 50% loss, whereas the opposing party most likely won’t be able to pay the bills anymore. So the poorer person should care about the prenup more.

I disagree and on the same basis of purchasing power. First of all, $10,000 is a lot easier to recover than $40M. Regardless of the person’s working capabilities, it will certainly take much less time for any given individual to redeem the smaller amount. Second, and the guiding principle behind my argument; the wealthier person can just do that much more with more money. This isn’t about buying cadillacs and islands, its about translating purchasing power to production power.

$10,000 will pay the bills and could possibly be invested/gambled/leveraged to produce more money. Considering the wealthier person’s expenses are proportional to the less wealthy person, the $40M will also be used to pay the bills, but the remaining balance will still produce greater relative purchasing power. So the wealthier person should care about the prenup more.

Bottomline: Prenups have a relative repugnancy cost depending on culture. Net worth may not be as important as other personal costs in determining the need for a prenup. Based on divorce rates upwards of 50% in America, it bodes well for most people to get a prenup. As the argument stands though, the wealthier person should care more about the prenup and not necessarily for the most obvious reasons.

1975-1985: The Liaison Generation

I use the computer for everything now, but I remember waiting in lines to sign up for courses and using library cards to find books and turning my homework in on paper! I’m not as plugged-in as 12 year olds, but I’m not adapting as much as someone 40+. Of course this is a generalization with quite a few outliers (one of my favorite people to work with is a 56-year old grandmother who is also a systems analyst for a 250-member physician group), yet I’ve found that people born between the 1975 and 1985 tend to share similar traits due to similar transitional experiences as they were growing up. They’re liaisons bridging the “old” and the “new” way of doing things.

The biggest disadvantage for this liaison generation is not belonging to either group. Just think of all the buzzwords that have emerged for the identity roadblocks faced earlier than ever before; quarter-life crisis, career angst, job hopping, corporate distrust, etc. The decade’s worth of experience with one mode – the “old” way – is lacking and the innate response to use technology as the first mode for anything – the “new” way – is also lacking.

Out of this though comes the advantage of being translators. Connecting the “old” and the “new”, using what works best depending on the situation, and most of all helping others along the way. For the “new”bies, the liaison generation can provide a sense of origin, where things began and grew from and why. For the “old”ies it’s much more obvious; providing a simple way to adjust to ever-evolving technology and convert from desk to desktop.

Bottomline: What does all this mean and why is it important? It’s about defining a role. Offering one possible reason (out of many) for the confusion faced by an entire generation. There are business opportunities here, jobs to be created, organizations that face to benefit. A unification of perspective can only help this cohort of liaisons pave its path more certainly.

Health Care Undercover or: How to better manage the doctor-patient relationship

Undercover or fake patients seemingly pose ethical and annoying dilemmas for docs. How are doctors and practices rated? Is it fair for a fake patient to take up the time that could be used for a real patient? Is there a long-range view towards improvement or is this just hastily doled-out criticism?

These "mystery patients", similar to the mystery shoppers of retail clothing, come off as lone mercenaries; experienced patient-actors formerly found in med school classrooms looking to make a little more cash. There's no organization, no national quality board, no clear follow-up on the "dirt" they uncover. They're the symptoms of a larger problem of worsening physician-patient communication, lengthy wait times, and poor service by the administrative staff.

Why not just educate patients to be smarter medical shoppers? Teach them to look out for the same things the undercover types are meant to probe; waiting room ambiance, front-desk rapport, total visit time, total time with doctor, total wait time, bedside manner, clarity of medical explanations, the list goes on.

Why not give doctors the checklist of items they'll be evaluated on? Considering that physicians go into the business of patient care because they're humane and conscientious people, you can assume they seek to improve their health care services. If they were made aware of unmet patient expectations, they'd concentrate their efforts to meet them. How many of us go through life thinking we're doing right by our loved ones, friends and colleagues? In order to find out, all we have to do is ask.

Bottomline: Health care is defined by the relationship between a doctor and a patient. Everything else is either contributory or detrimental to that relationship. The problems may be complex, but the equation is simple. Instead of sprouting more and more side industries to correct the health care "problem", lets focus on the two sides that matter most and redirect all our time, money and energy towards their betterment.

Health Insurance Potholes To Watch Out For

Each insurance company is different so first thing figure out coverage restrictions.

• Do they cover routine visits or only sick visits?
• What's your deductible and how much do they cover before and after you meet it?
• How are inpatient hospitalizations covered?
• What about surgeries (major v. minor, inpatient v. outpatient)?

The first two are important to know from the get-go, but for the rest its good to just have the benefits and coverage guidelines printed out or bookmarked somewhere for reference purposes.

Few other things you'll come across after going to the doctor are prescriptions, labs, and image results.

• Does your insurer have a discounted formulary for prescriptions or pharmacies they contract with? (HUGE savings here)
  
• Does your doctor send your labs out to a company that's covered by your insurer? If not, you could owe a lot of money for processing your lab results. Worth checking both with your doctor and insurance company on this one!
• Who reads and interprets your images (MRIs, X-rays, CT scans, etc.)? Same as labs, if the diagnostic imaging company or the doctor interpreting your image results is not covered under your plan, you'll get a separate fee.

Whoa!...I know. I've lost $750 and several brain cells dealing with the issues above. Now I annoy secretaries, nurses and insurance representatives to no end BEFORE and DURING my doctor's visit so I can avoid major money and time headaches AFTER the fact. Its like the law. You don't realize how powerful it is until it impacts you personally. No wonder 59% of doctors support a single-payer national health insurance system!

What makes a company attractive?

Stock value? Growth rate? Philanthropic fundraising?

No. Its always the employees. And why? Because they do things like inject codes into their programs that have no intrinsic value but to entertain or put their dog in the company's founders profile as their mascot.

This makes the company a zany and fun place to work. When work is a life given, you need more than just money as a driver. An organization's social vibe affects its commercial value in the eyes of consumers and potential future employees. Personal happiness comes from interpersonal interactions.

Debt, repugnancy & the primaries

1. Hospitals auctioning debt online: its all about expectations. Not expecting patients to fall through on their credit, hospitals are being crushed under bad debt. Expecting a patient not to pay at least allows hospitals to provide charity care and write it off. In the meanwhile they're giving the highest bidder (mostly debt collectors) a chance to see if they can get the money back themselves.

2. NYC's idea for an organ-recovery ambulance: mile-long waiting lists for kidneys and livers drive this and legalized organ selling would certainly boost more entrepreneurial ventures in this niche. Only if we could get over our repugnancy costs.

3. Incredible interactive graphic breaking down voter demographics for the Democratic Primary: a very revealing data-driven perspective on differences in voting by age, race, gender, income and education. Make your own judgments on what this primary was really all about.

Should a doctor think like a clinician or a businessman?

In the U.S., most physicians often think like both. Oh wait, add accounting to the mix too. Clinical care, administration, and billing make up the 3-part mental framework of a physician in the U.S. The two business components represent all the paperwork doctors do after the patient leaves. Exact details of what the person came in for, documentation of the treatment protocol advised, and the appropriate billing code so doctors can get paid by the insurance company. Multiply this by say 30 patients and you have a typical day at the doctor's office. And that's just for one medical provider.

This is a lot of work. Many practices have an "administrative session/day" set up once a week when physicians can catch up on all this paperwork. A physician's day just seems so fragmented that I wonder how they concentrate on the one thing that matters; patient care. I explored this a bit through an international lens, seeing how other countries did it. Do nationalized health care systems like the ones in UK or Canada take away the business component or add more bureaucracy? What does a market-based system such as the one in the U.S. have to offer that they don't? Regardless of all the politics around which system is "better", I focused on just one thing; what occupies a physician's mind on a daily basis making the rounds and taking care of patients?

It comes down to incentives, in many cases monetary. In the U.S., most physicians get a good portion of their income on a fee-for-service (FFS) basis, whereas nationalized docs primarily tend to be salaried. I reached out to fellow blogger, Jason Shafrin of the Healthcare Economist, on this and he said,

"while salaried doctors may be more "objective" they do not have the incentive to innovate as would be the case in the FFS system. Physicians can invent new technologies to better care for patients if they know they will be reimbursed for their efforts in a FFS system. However, if the physician is salaried, the incentive to innovate is lower."

U.S. physicians certainly work harder. The more they do, the more they make. And that's where all the paperwork comes in. The insurance companies, along with Medicare & Medicaid, want to make sure they're not paying for frivolous tests and procedures. There's a very close watch over what physicians do in the U.S. Fraud litigation and skyrocketing malpractice rates are evidence of this. And ironically, the other major component of malpractice, medical errors, drives physicians to practice medicine more defensively and order more and more tests to cover themselves. Talk about a rock and a hard place.

In salaried systems this is less the case. We have a few major ones in the U.S. such as Kaiser Permanente originating from the West Coast and the government-run Veterans Affairs (VA) department. And countries such as Canada and the UK provide much larger-scale examples. From a basic day-to-day care perspective, these systems do provide freedom from the business side of medicine and allow physicians to focus on patient care. But as mentioned above, the trade off is less innovation and less incentive to work hard. On top of that, Jason mentions,

"while the physicians may be salaried, someone is being paid not on a salaried basis. The organization is usually paid on a per person basis (capitation) or fee-for-service. Even if physicians are paid on a salaried basis, management may compel them to increase or decrease procedure rates. For instance, the NHS may put managerial pressure on physicians to reduce utilization of services in order to reduce costs."

Bottomline: Even mental resources have to be allocated. If a physician isn't business-minded, someone else will be on his/her behalf. The economics don't necessarily favor a national or a market system since you lose drive for growth in the former and create drive to overdo in the latter. Maybe the U.S. could benefit from a nationalized sub-specialty system and a market-based primary care system. The hybrid methodology seems to be more favorable here, but that hasn't been tried and tested. The question of optimal patient benefit still remains within this incentive-based catch-22.