ISIS and SISI – Both are doomed

Posted on June 25th, 2014 in Uncategorized by Karl

By Thomas Friedman, NYTimes 6/25/2014

The past month has presented the world with what the Israeli analyst Orit Perlov describes as the two dominant Arab governing models: ISIS and SISI.

ISIS, of course, is the Islamic State in Iraq and Syria, the bloodthirsty Sunni militia that has gouged out a new state from Sunni areas in Syria and Iraq. SISI, of course, is Abdel Fattah el-Sisi, the new strongman/president of Egypt, whose regime debuted this week by shamefully sentencing three Al Jazeera journalists to prison terms on patently trumped-up charges — a great nation acting so small.

ISIS and Sisi, argues Perlov, a researcher on Middle East social networks at Tel Aviv University’s Institute for National Security Studies, are just flip sides of the same coin: one elevates “god” as the arbiter of all political life and the other “the national state.”

Both have failed and will continue to fail — and require coercion to stay in power — because they cannot deliver for young Arabs and Muslims what they need most: the education, freedom and jobs to realize their full potential and the ability to participate as equal citizens in their political life.

We are going to have to wait for a new generation that “puts society in the center,” argues Perlov, a new Arab/Muslim generation that asks not “how can we serve god or how can we serve the state but how can they serve us.”

Perlov argues that these governing models — hyper-Islamism (ISIS) driven by a war against “takfiris,” or apostates, which is how Sunni Muslim extremists refer to Shiite Muslims; and hyper-nationalism (SISI) driven by a war against Islamist “terrorists,” which is what the Egyptian state calls the Muslim Brotherhood — need to be exhausted to make room for a third option built on pluralism in society, religion and thought.

The Arab world needs to finally puncture the twin myths of the military state (SISI) or the Islamic state (ISIS) that will bring prosperity, stability and dignity. Only when the general populations “finally admit that they are both failed and unworkable models,” argues Perlov, might there be “a chance to see this region move to the 21st century.”

The situation is not totally bleak. You have two emergent models, both frail and neither perfect, where Muslim Middle East nations have built decent, democratizing governance, based on society and with some political, cultural and religious pluralism: Tunisia and Kurdistan. Again both are works in progress, but what is important is that they did emerge from the societies themselves. You also have the relatively soft monarchies — like Jordan and Morocco — that are at least experimenting at the margins with more participatory governance, allow for some opposition and do not rule with the brutality of the secular autocrats.

Indeed, the Iraq founded in 1921 is gone with the wind. The new Egypt imagined in Tahrir Square is stillborn. Too many leaders and followers in both societies seem intent on giving their failed ideas of the past another spin around the block before, hopefully, they opt for the only idea that works: pluralism in politics, education and religion. This could take a while, or not. I don’t know.

We tend to make every story about us. But this is not all about us. To be sure, we’ve done plenty of ignorant things in Iraq and Egypt. But we also helped open their doors to a different future, which their leaders have slammed shut for now. Going forward, where we see people truly committed to pluralism, we should help support them. And where we see islands of decency threatened, we should help protect them. But this is primarily about them, about their need to learn to live together without an iron fist from the top, and it will happen only when and if they want it to happen.

Life Lessons from the World’s Most Successful People

Posted on June 5th, 2014 in Uncategorized by Karl

In 30 years at Fortune, I’ve interviewed CEOs and billionaires and other titans about what makes them succeed. Here are 10 things I’ve learned, plus wisdom from Warren Buffett.

The best career advice is universal. It applies to a CEO of a Fortune 500 company and to a kid aspiring to make it through college.

I tried to keep this in mind last week when I spoke at Allentown Central Catholic High School, which in 1978 sent me on my way from Pennsylvania to what has turned out to be a thrilling and very satisfying life and career. I told the CCHS students, who packed Rockne Hall for inductions of their new Student Council and class officers, that I’ve spent the past 30 years at Fortune ”going to school on success.” That is, my job profiling some of the world’s most successful people–fromOprah Winfrey to Yahoo (YHOO) CEO Marissa Mayer to Rupert Murdoch (NWS) to Melinda Gates–is to learn and explain what makes these extraordinary people win and adapt to all sorts of challenges. I pared my message to 10 pieces of advice, which include a few obvious truths and, I hope, some enlightening points that are universal.

1. Don’t plan your career.  Most of the really successful people I’ve met and interviewed these past 30 years at Fortune had no clue what they wanted to do when they were in high school or even in college. They stayed flexible and open to possibilities.

2. Forget the career ladder; climb the jungle gym. In a world that’s unpredictable and changing faster than ever, who knows what tomorrow’s ideal jobs will be? Think of your career as a jungle gym. Sharpen your peripheral vision and look for opportunities over here or over there, and swing to them. Facebook (FB) COO Sheryl Sandberg kindly credits me in Chapter 3 of her best-seller, Lean In, for introducing the concept of the jungle gym.

3. Pick people over pay. Work with good people who are smarter than you are, so you can stay stimulated and learn everyday.

4. Do every job as if you were going to be doing it for the rest of your life. If you spend your time thinking about what you want to do next, you’re not fully focused on your current assignment. And unless you focus, you won’t compete successfully with people who are “all in.”

5. Do the job that you’re supposed to do, but think: What’s not getting done? Always consider how you can contribute to the bigger whole — and don’t be afraid to stumble. I wrote a 1995 cover story called “So you fail, so what!” Today, recovering from failure is a badge of honor that bosses want to see in people they hire.

6. Be curious. Everyone you meet is worth learning from. People derail in their careers, studies show, when they stop learning. Yes, continual learning matters more than where you go to school or how many degrees you rack up.

7. Be nice to everyone. As you get older, you’ll have fewer degrees of separation with more and more people. Who knows how someone who doesn’t matter to you today might matter critically tomorrow? Don’t burn any bridges. Build your bridges now to last forever.

8. Listen. Listen more than you talk. I was shy in high school. I’m still a closet introvert, but I’m a good conversationalist because I’m extraordinarily interested in people, I ask questions (sometimes too many) and I listen carefully. Listening to someone carefully is giving them a gift.

9. To lead, line up your followers. Leadership has no long-term value without followers on track to become as strong as you are. Show a generosity of spirit that makes people want to work with you, because they know you’ll make them better.

10. Be honest and true. If people are in a foxhole with you, do they trust you to protect and help them? Make sure they do completely, by doing what you say you’re going to do, always.

I closed my talk with wisdom from Warren Buffett, who told me during an interview last year how he defines success. The Berkshire Hathaway (BRKA) chief actually has two definitions: 1. Success is having what you want and wanting what you have. 2. Success is having the people whom you love love you.  Isn’t it reassuring that one of the wealthiest men in the universe doesn’t equate success with money?

Post by: Patricia Sellers

Oncology Pathways – Good Idea. Ain’t Working.

Posted on May 28th, 2014 in Uncategorized by Karl

The attached WSJ article describes yet another push for oncology pathways from the payers in their effort to reduce the oncology drug spend.

What I found interesting is that docs are effectively using the precision medicine argument to counter the payers’ insistence that providers adhere to therapeutic pathways for most of their cancer patients.  Docs have always been successful in waving the clinical card when payers have attempted to restrict the way they practice.  However, using precision medicine and molecular sequencing against any payer mandated oversight is pure genius.  The payer will lose this fight.

The only real solution to our uncontrollable (and unsustainable) healthcare spend (and oncology is up there as one of the worst offenders) is to include healthcare providers in the solution by encouraging them to take on financial risk of treating patients.

http://online.wsj.com/article/SB10001424052702304587704579588170876612100.html

Hot Spotters in Healthcare

Posted on April 30th, 2014 in Uncategorized by Karl

The Intermountain Health, the largest health system in Utah and Idaho, just wrote a Harvard Business Review Blog that stated alarming numbers on their “hot spotter” patients.  Hot spotters are the most expensive healthcare consumers (ie. the sickest patient population).  At Intermountain, the top 1% (or bottom 1%, depending on how you view it) of patients consume 28% of overall healthcare dollars.  Moreover, the top 5% consume 50% of the expense.  Wow!  Thus, if Intermountain focused on the sickest 5% of patients, it could reduce 50% of its healthcare expense.

To date, these top 5% were HUGE revenue generators.  In a fee-for-service environment, these “frequent-flier” patients should have been given red carpet treatment as they generated a lot of revenue for the hospital.

However, the reimbursement world is changing.  In an ACO environment, Intermountain and other health systems need to thoughtfully care for these patients and focus on both quality and COST of care.  Additionally, Intermountain needs to solve one of the biggest problems:  coordination of care.  Hot spotters typically have 3-4 comorbidities and, thus, see several medical specialists.  The traditional problem is that no one healthcare provider (doctor or nurse) is coordinating/quarterbacking all of these specialists for the benefit of the patient.  So the end result is that the right hand often doesn’t know what the left hand is doing (or what they have prescribed).  This results in a big, fat waste of money and crappy results.

A link to Intermountain’s HBR Blog can be found here.

 

Even Steve Jobs suffered from “Uncoordinated Care”

Posted on April 30th, 2014 in Uncategorized by Karl

I was rereading the biography of Steve Jobs by Walter Isaacson over the weekend and was struck by the following passage on page 549.  It essentially describes how Steve Jobs’ care was uncoordinated among his oncologist, pain specialist, nutritionist, hepatologist and hematologist.

This was one of the most famous people in America—a VIP of VIPs—being treated at one of the most famous medical centers in America and even he had uncoordinated care.  If Steve Jobs couldn’t get coordinated care, then, if you are an employer, you can almost guarantee that your employees are not getting coordinated care.  Tests and even medications are either being duplicated or ‘not ordered’ because each doctor assumes that the other doctor is ‘taking care of it.’

Specific examples of uncoordinated care that may affect healthcare consumers are:

1) Cardiovascular care–patient has a PCP and a cardiologist and each doctor assumes the other doctor is managing the patient’s high blood pressure and as a result the patient is ‘compliant’ with their doctors orders, but new medication or higher dosages are never prescribed.  RESULT—the patient has uncontrolled hypertension and is at higher risk of heart attack and stroke.

2) Arthritis pain—patient has an orthopedist and a rheumatologist and both doctors prescribe anti-inflammatory pain medications in a class called NSAIDS: the orthopedist prescribes Naproxen and the rheumatologist prescribes Diclofenac.  Both medications don’t ‘interact,’ but they are duplicative and can damage the lining of the stomach and impair kidney function—especially if both are taken at the same time.  RESULT—when the  patient gets the stomach flu and becomes mildly dehydrated it results in temporary kidney failure and a 5 day hospital stay.

The list could go on and on.

What does this mean for employee benefits professionals and healthcare consumers?

  • For every employee that has multiple doctors, it should be assumed that their care is uncoordinated until proven otherwise.  Think Steve Jobs.
  • You as an employer and healthcare consumers themselves must play an active role in coordinating their own care.  Take ownership.  You are not necessarily an expert, but you will ‘care’ more than anyone else.  In Steve Jobs’ case, it was his wife that took ownership and got all of his doctors in a room together to talk—they had never done that before!

Posted by Dr. Eric Bricker, April 14, 2014

ACOs Explained – article by Kaiser Foundation

Posted on April 28th, 2014 in Uncategorized by Karl

The Kaiser Foundation just published a good (and balanced) background piece on what Accountable Care Organizations (ACOs) are and the challenges that exist today.  The best line in the article is:

“Some people say ACOs are HMOs in drag,” says Kelly Devers. But there are some critical differences – notably, an ACO patient is not required to stay in the network.

 

 

 

Meaning of a Successful, Fulfilling Life

Posted on April 28th, 2014 in Uncategorized by Karl

When I heard this week that Michael Phelps was planning to return to competitive swimming, my first reaction was to feel a little sad for him. I honor Mr. Phelps for the discipline, grit and passion he needed to win a record 18 gold medals. But I also sense that he’s going back to swimming because he’s chasing a high that hasn’t held up.

In the same way, I respect Michael Jordan for all he achieved in basketball. But after reading Wright Thompson’s brilliant article about him in ESPN Magazine, I was struck by the emptiness of his life since he retired as a player 11 years ago.

We celebrate and envy people’s extraordinary individual accomplishments and successes, but the pleasure they derive from their efforts is often surprisingly fleeting. And there is a reason for that. What generates an enduring experience of meaning and satisfaction in our work is the sense that what we’re doing really matters — that we’re truly adding value in the world.

Or as Viktor Frankl put it so eloquently: “Don’t aim at success. The more you aim at it and make it a target, the more you are going to miss it. For success, like happiness, cannot be pursued, it must ensue, and it only does so as the unintended side effect of one’s personal dedication to a cause greater than one’s self.”

For me, the threshold question is this: In the service of what?

It’s the question I find myself asking when I read about the amazing wealth being accrued by hedge fund managers. I respect the financial acumen of someone like David Tepper, who earned $3.5 billion last year or John Paulson, who earned $1.9 billion, or Carl C. Icahn, who earned $1.7 billion. But ought we to revere these investors simply for accumulating ever more wealth? Building one’s own value to feel more valuable is ultimately a losing game.

Imagine instead that Mr. Tepper decided he had enough money for himself and his family, and truly dedicated himself instead to a greater cause. Mr. Tepper could use the $3.5 billion he earned in 2013 — or even just keep $100 million — and hire 75,000 people at $40,000 each over the next year to create his own Works Projects Administration and take on our crumbling infrastructure. Or he could use that money to support tens of thousands of passionate but struggling artists, or give generous grants to thousands of worthy scientists whose critical research isn’t funded sufficiently, if at all.

It’s great that a group of billionaires, led by Warren E. Buffett and Bill Gates, have pledged to give away half of their fortunes when they die. But why wait? Why not right now?

Of course, “In the service of what?” isn’t just a question for billionaires. It’s one we all need to be asking ourselves.

I’ve long been haunted by an article called “The Tragedy of the Commons” written by the ecologist Garrett Hardin for the magazine Science in 1968. The article focuses on the dangers of overpopulation, but Mr. Hardin’s broader argument is about how individuals, acting from their rational but narrow self-interest, can collectively destroy something they all need to survive and prosper. He uses the example of an open pasture to which struggling herdsmen are invited to bring their cattle to feed. Eager to improve their economic circumstances, the herdsmen naturally want to feed as many cattle as possible. The problem is that over time, overgrazing takes a progressive toll on the commons, and, ultimately, it’s destroyed for everyone.

We need to redefine self-interest to recognize that it requires serving the commons — even if only for the selfish reason that our survival, and the survival of our children, depends on protecting our shared planet.

The answer to “In the service of what?” is to add more value to the commons than we take out, and not to discount any good that we can do.

“We must not, in trying to think about how we can make a big difference,” said the children’s rights advocate Marian Wright Edelman, “ignore the small daily differences we can make, which, over time, add up to big differences that we cannot foresee.”

Personal accomplishments make us feel good. Adding value to other people’s lives makes us feel good about ourselves. But there is a difference. The good feelings we get from serving others are deeper and last longer. Think for a moment about what you want your children to remember about you after you’re gone. Do more of that.

NYT, April 28, 2014

Biotech Stocks – Where to from here?

Posted on April 23rd, 2014 in Uncategorized by Karl

Last month’s 10% drop in the Nasdaq iShares’ Biotechnology Index — not to mention the fact that biotech stocks, after a torrid two years, are up less than 4%  year-to-date — has investors worrying that the sector’s two-year boom is over.

We’re living through major changes in how medicines are developed that will improve our lives for the better. But that doesn’t meant biotech stocks won’t retreat. Quite the opposite: Biotech innovation is funded in great part by investors whose timing is wrong, and who get left holding the bag at the end of the sector’s inevitable boom cycles, only to have some of the companies, products, and technologies they bet on succeed later on. The biotech boom has been fueled in part by fundamentals: stunningly lucrative new drug launches and research breakthroughs. But some investors seem to be seeing rainbows and missing the rain. Here are three things I’ve heard from investors and executives, or seen in the invaluable polls of buy siders run by ISI Group’s Mark Schoenebaum, that I think are misplaced optimism.

1. We have not reversed the decline in R&D productivity. We probably haven’t even slowed it. Back in 2009, investors seemed to believe that no experimental medicine would ever succeed again. Now it seems we’ve forgotten that more than 90% of the drugs that start clinical trials fail.

The whole drug industry — and biotech companies are separated from larger drug companies by distinctions of business model, not fundamental science — has been caught up in what has coyly been termed “Eroom’s law”: the amount of R&D money sunk per molecule is rising exponentially. There’s no proof that this multi-decade trend has abated.

Geoffrey Porges, an analyst at Bernstein research, recently looked at the drugs in development at large biotechnology companies such as Celgene CELG -1.24% (the best-performer over the past year), Gilead, and Biogen Idec BIIB -0.34%. He points out that many of these firm’s R&D successes have actually been “derivative” products based on approaches that were already known to work. Celgene’s success has come through drugs derived from its original success, repurposing thalidomide as a treatment for multiple myeloma and from Abraxane, an improved version of the 1990s cancer drug Taxol. Biogen’s big hit, Tecfidera for multiple sclerosis, is a new formulation of a drug that had been used to treat psoriasis in Germany. 

Porges points out that Celgene is now betting on a new first-in-class molecule, sotatercept. And Biogen’s big event this year will be data for its anti-LINGO program, which is a brand new way to treat multiple sclerosis. He says Alexion and Vertex are likely facing longer odds than they have in the past. Drug research: it’s really, really hard.

2. The FDA is not fundamentally friendlier to companies than it was in the past. Another trope that’s gotten passed around a lot is the idea that the Food and Drug Administration is friendlier to companies, better at communicating, and more likely to approve drugs than it used to be. This kind of thinking is dangerous, and I say that having fallen into the FDA-got-easier-trap several times myself — and been wrong.

There was a period, starting a decade ago, when the FDA, normally relatively friendly to industry, became unusually negative because there were a lot of drug safety controversies, including those over the pain medicine Vioxx and the antidepressant Paxil. Regulators who were afraid Congress would go after them were noticeably more reticent to approve drugs. And there has been movement to make the FDA bureaucracy easier to manage, particularly with the creation of the “breakthrough” designation for important drugs. And in cancer, in particular, where there are more drugs in development than in any other disease area, the FDA does seem to be working more closely with companies.

Look at how the FDA publicly (justifiably) took down Aveo Pharmaceuticals when patients on its drug survived less long than those in the control group. Novo Nordisk found itself years behind competitors because the FDA insists on a heart safety study of its new insulin. Amarin and Omthera, both makers of fish oil pills, both told investors the FDA said it would allow them to market their products to a broader population if they started big studies to prove the pills prevent heart attacks and strokes; then the FDA apparently changed its mind. The bull case for Sarepta Therapeutics SRPT +0.49% was that the need for its drug for muscular dystrophy was so great that the FDA would allow it to file to be approved on a study so small it would have been unprecedented. That didn’t happen. Nice friend, biotech.

I’d interpreted the FDA’s decision to let Avandia back on the market as a sign that it was becoming more friendly to industry. I now think Steven Nissen was right when he wrote that the FDA’s goal was to “avoid accountability for its role in the Avandia tragedy.”

Sure, there has been a bump in the number of new drugs approved, perhaps in part because of a slight easing at the FDA and a slight improvement in R&D productivity from its nadir earlier this decade. Or maybe it’s just that bugaboo of investors in any time period: random chance changes that don’t mean anything.

3. Pricing Power May Not Last Forever The most important question for biotechnology and drug companies isn’t how many new drugs they can invent but how much they can charge for them. Fears surrounding Congressional noise about the high price of Gilead’s Sovaldi for hepatitis C seem to have started the current drop in stock prices.

And here the news is pretty good. In the U.S. in particular companies seem to be able to command huge premiums for important drugs. Canada is playing hardball over the cystic fibrosis drug Kalydeco, saying it won’t pay the full price of $307,000 per patient per year. But even if it gets a discount, the cost is likely to be fairly close to that sum.

None of this is a reason to abandon biotechnology stocks en masse. Plenty of companies are likely to be launching promising new drugs and racking up impressive sales on those they have already launched. Wall Street is justifiably worried that Gilead’s Sovaldi is not going to be able to maintain its sales, but a medicine that seems likely to have some of the best annual sales ever has got to be worth something. Regeneron and partner Sanofi have several potential blockbusters in their shared pipeline, including not only their PCSK9 cholesterol drug but medicines for rheumatoid arthritis and asthma. Personally, I think Vertex’s combination therapy for cystic fibrosis could show positive results later this year. There are always going to be good biotech stocks to pick, even in the worst market. A breakthrough drug remains one of the most profitable products you can ever sell, and it will for the foreseeable future — maybe as long as there are sick people.

But investors should avoid thinking that the drug business has undergone a fundamental change in the past few years. It hasn’t.

Forbes, 3/27/2014

US Healthcare is the Most Expensive by a Mile!

Posted on April 22nd, 2014 in Uncategorized by Karl

We probably didn’t need another study to tell us that health care is the U.S. is expensive. But we may not have realized just how expensive until now.

Data released Thursday by the International Federation of Health Plans points out it costs more — way more — in the U.S. for common drugs and procedures than in eight other developed nations around the world. According to the report, the average cost of one night’s hospital stay is $4,293 in the U.S., nearly double New Zealand’s $2,491 and more than triple Australia’s $1,308.

Argentina and Spain were the other two countries highlighted in that one-day hospital cost comparison with respective prices of $702 and $481.

Among the study’s other  findings:

  • A heart bypass in the States is a whopping $75,345, compared with $42,130 in Australia, $40,368 in New Zealand and $15,742 in the Netherlands.
  • A normal baby delivery in the U.S. costs on average about $10,000 while it’s $8,307 in Switzerland and $2,251 in Spain. If that delivery becomes a C-section, the cost in the U.S. increases to $15,240 on average, but would cost $5,492 in the Netherlands.
  • Drug costs can also be quite different. Celebrex, used for pain relief, might cost $225 in the U.S. — and $51 in Canada. Cymbalta, commonly used for depression, anxiety and fibromyalgia, costs $194 in the U.S., but it’s $46 in England. Industry publication Vox presented some of the findings in an interesting way, pointing out the acid reflux prescription drug Nexium costs $215 on average in the U.S., more than 3.5 times the cost in Switzerland and almost 10 times more than what Dutch people pay.

The price comparisons are interesting in light of new recommendations released Wednesday from industry stakeholders pushing for health care price transparency, as The Washington Post reported. The group’s recommendations call for specifying who should be responsible for providing pricing information to patients, they said.

Though, that’s if we want to know how much it’s costing us.

(Article from Washington Business Journal, April 19, 2014)

What is driving healthcare costs? JAMA is pointing fingers at docs (not patients).

Posted on April 22nd, 2014 in Uncategorized by Karl

The simple equation for rising healthcare costs is:

Healthcare cost = (number of units of healthcare consumed) X (price per unit).

A November 2013 article the Journal of American Medical Association (JAMA) states that the top four drivers for rising healthcare costs are all on the cost side (as opposed to the demand side).  JAMA says the cost drivers are:

1) Admin costs – 5.6% per year.  Mainly derived from health insurance costs

2) The price of healthcare services (4.2% per year, especially hospital charges)

3) Price of drugs and medical devices (4% per year)

4) Price of professional services (3.6% per year, comprised of doctor fees and other healthcare professional fees)

JAMA goes on to say that DEMAND for healthcare services are NOT the root cause of increased healthcare expenditures.  It’s the cost side of the equation that is out of control.  I have stated many times in my blog posts that healthcare pricing is broken and lacks any real transparency.  In the US a patient does not know the price of a healthcare service prior to consuming it.  Next time you enter a doctor’s office or hospital, try asking…”before we get started on _____ procedure, what’s this going to cost me?”  Then, sit back and watch everyone in the doctor’s office or hospital start squirming since they have no way of giving you an answer.

You can link to the JAMA article at: http://jama.jamanetwork.com/article.aspx?articleID=1769890