Acceptance
• No one can be turned down for any reason, especially pre-existing conditions.
• Coverage cannot be turned down for any reason, , except fraud or dual coverage, though policy holders may decide to switch.
• The doctor and patient decide on what the treatment, based on the recommendations by the doctor.
• Limits will be placed on what people can sue for. If a reasonable offer is made before the court case begins, the looser will pay the opposing parties double court costs.
Management
• Should an insurance company fail then these policies will be split amongst the remaining insurance companies. They will be split based on the relative size of the companies, the larger companies taking a ratio more of the policies. The policies will be taken by a simple, blind draw.
Costs
• The difference between the top and bottom monthly fee for insurance will not exceed 100%. For example, if the lowest monthly cost is $100, then the most expensive option will be $200, no matter what the reason (excluding the fines and fees outlined below).
• Each state will organize all of the insurers for covering the costs of claims more than $500,000. Once the initial claim exceeds this amount, then the claim will be paid by the state catastrophic (CAT) claim fund. All insurance companies will contribute based on the number of policies they have in that state.
• A national catastrophic claim fund will be started to cover claims that exceed $1,500,000. All insurance companies will contributed based on the number of policies they have nationally.
• Basically, the two catastrophic claim funds means that there are no limits on treatments (except that heroic measures, defined as beyond a statistical model of less than 25% success, may not be fully covered, depending upon discussions between the insurer, doctor and patient).
• Any insurance profits over 10% will be split 50% to Medicare and 25% to the state’s and national CAT funds. Losses can be carried forward 5 years to reduce profits for the purpose of this split.
Fees/Fines
• If you don’t go to a GP for an annual physical, the “fine” would be $200
• If you don’t follow the directions of you GP, there is a “fine” of $100
• For products that can impact the health, a license will need to be purchased:
o Cigarette purchase license, $50
o Chewing tobacco purchase license $50
o Alcohol purchase license $50
• Weight has a significant impact on health, so the following annual fines will be in place (based on measurement better than BMI like fold calipers or immersion):
| Doctor’s Rating | Fine |
|---|---|
| Underweight | $5.00 per lb |
| Overweight | $5.00 per lb |
| Obese | $10.00 per lb |
• General fitness, if you can’t run 1 mile in less than 10 minutes, there is a $150 fine assessed yearly.
Leadership
We expect business and political leaders to actually lead by example. Here are the guidelines for fee and fine payments listed above:
• Healthcare workers will pay double
• Local, civic, state and national politicians will pay triple
• Doctors will pay quadruple
• Business leaders (AVP/ director level and above) will pay triple
Quality
• Each location that performs health care services (hospitals, medical devices and other locations) will publically publish quality numbers like:
o Infections
o Mistakes
o Number of services/ products provided
o Customer ranking (Net Promoter Value)
User Payments
• Each user will have the equivalent of an HSA account to cover off the first $1500 of fees. For those under a certain income level, the rollout will give those people the initial $1500 credit those people the initial $1500 on their income tax return. Those that make too little income to be taxable at, or above $1,500 on the year of claim, will receive reimbursement upon proof of payment.
• Doctors and health care providers will provide cost estimates for treatment options that would include ALL costs. This information will be part of the discussion with the doctor and patient.
• They payment of the first $1500 and seeing all of the bills are a critical part of controlling costs. People will pay attention when they are paying and the costs will be exposed to everyone that is incurring them.
• Quality ratings of potential service providers will be discussed with the patient.
• All costs for a given visit or treatment will be combined on a single bill to be given to the patient.
Single Patient Record
• To help defray costs, the health care and insurance providers have until Dec, 2010 to have all of a patients records in a single, integrated form. For example:
o All prescriptions would be shown, so inappropriate or excessive medications will be obvious
o All treatments, observations and notes will be visible
o All information will be readable by the patient and any of their health care providers
o Note that all information that is currently gathered now will be covered:
X-rays, cat scans, interview notes, nursing observations
• Fines
o Insurance companies will pay $500/day/claim for information not in this system
o Health care providing institutions (hospitals, dentists, pharmacies, etc) will pay $1000/patient for each missing piece of information
o Doctors who are overseeing treatment will pay $200/patient for each missing piece of information
o Care givers will pay $25 for each missing piece of information
• Security/treatment of information
o Treatment, DNA or other diagnostic information cannot be used to disqualify someone from employment or insurance
o Only the patient and people involved with the treatment may see the information. HIPPA rules would apply.
o In the case of multiple systems, they will be able to seamlessly transfer the data securely.
Here are some things I tried and what seemed to work eventually:
I hope that helps someone fix it faster than I did.
]]>There examples on the web that don’t work which leads you down a lot of different paths. I found this site to be very helpful as it had sections of code that I could get to work: http://www.ruby-lang.org/ja/man/html/OpenSSL_Cipher_Cipher.html . This site does not jump out at you with google, maybe because of the Japanese characters (but it did not stop me — but I was desperate!) . Here are three tests that I put into an rspec, of which I could not get the middle one to run:
require "spec"
require 'openssl'describe “encrypt and decrypt” do
# Called before each example.
before(:each) do
# Do nothing
end
# Called after each example.
after(:each) do
# Do nothing
end
it “should encrypt with DES” do
p a123 = “0123456789″
pass = “hogehoge”
enc = Cipher.new(”DES”)
enc.encrypt
enc.pkcs5_keyivgen(pass)
p a = enc.update(a123)
p b = enc.final
s = a + b
dec = Cipher.new(”DES”)
dec.decrypt
dec.pkcs5_keyivgen(pass)
p a = dec.update(s)
p b = dec.final
p a + b #=> “0123456789″
end
#this test fails for some reason
#it “should encrypt with aes” do
#c1 = Cipher.new(”AES-256-CBC”)
#c2 = Cipher.new(”AES-256-CBC”)
#pass = “open sesame!”
#data = “Hello world!”
#c1.pkcs5_keyivgen(pass)
#s1 = c1.encrypt.update(data) + c1.final
#c2.pkcs5_keyivgen(pass)
#s2 = c2.decrypt.update(s1) + c2.final
#p(data == s2) #=> true
#end
it “should encrypt with triple des” do
# Triple DES
c1 = Cipher.new(”DES-EDE3-CBC”)
c2 = DES.new(:EDE3, “CBC”)
pass = “open sesame!”
data = “Hello world!”
c1.pkcs5_keyivgen(pass)
s1 = c1.encrypt.update(data) + c1.final
p s1
c2.pkcs5_keyivgen(pass)
s2 = c2.decrypt.update(s1) + c2.final
p(data == s2) #=> true
end
end
I’m still learning Ruby. There is something going on with the namespaces. If I add “include OpenSSL::Cipher”, this code does not work. The “DES-EDE3-CBC” works for me, so I thought that might be helpful.
]]>One: Get or Update PostgisAdapter: http://github.com/nofxx/postgis_adapter/tree/master. Now the instructions are posted (and the updated code) on github, but the instructions still list the svn location (which I suspect is out of date). Now I’m not sure why, but it states to remove Spatial Adapter before installation, which I did like this - ruby script/plugin remove spatial_adapter. You should see the spactial_adapter directory under vendor/plugins has been deleted. To install this adapter as a gem, I ran the following: “gem install nofxx-postgis_adapter –source http://gems.github.com”. This fixed my post_gis_adapter argument error.
After this, I tried to run the zipcode example I had working before. It no longer worked, as the envelope method was now missing. I determined this was part of the spacial_adapter, so now I needed to re-install it.
Two: Re-install spatial_adaptor. There seems to many locations for this, which the lates seems to be here: “http://github.com/dougcole/spatial_adapter/tree/master”. At this location Doug Cole talks about getting the post_gis_adapter to work with Rails 2.3. To get this to install properly on windows, I ran the install in the gitbash shell (download and install it on your windows machine). Here is what I ran in the project directory (installing a plugin): ruby script/plugin install git://github.com/dougcole/spatial_adapter.git. Now my zipcode example worked! And my argument error was still fixed!
]]>I believe if you are not doing the following, then you are not doing “Lean”:
1. Empowering people and teams, so when management comes up with a “good idea”, employees feel no issues with challenging that idea. Management is there to:
a. Help set direction,
b. Ensure principles are followed,
c. Encourage the team, and
d. To remove roadblocks.
2. Have your process defined and measured from an end-customer’s perspective. The end customer may be split between the person who pays your company and the person who ultimately consumes your product. The measurements are:
a. Time to deliver from original request to end-customer,
b. Quality determined by end-customer, and
c. Competitiveness in marketplace determined by end-customer.
3. More than two process evaluations per month that would include some improvements/ changes done every single month.
I agree with authors like Wolmak/Jones and Emiliani, who indicate “Lean” is a system of management, not of manufacturing. A lot of resistance to improvement is caused by the organization structure and existing management thinking, not just limitations allocated to existing staff. Lean is evolving the job of “manager” to “leader”, which is not a job for the meek of heart. The leader will outline the principles and empower the employees to do whatever it takes. Teams are encouraged to speak up and suggest new ideas, including ideas that impact the management team. This includes “stopping the line”, where an employee can stop the line when they determine a significant problem is at hand. That person is empowered, but also has to be willing to face challenges from their co-workers who working to keep their productivity numbers up. In this case, the line was stopped because the principle of “quality” overrode a possible interpretation of “productivity”.
If you don’t have a value stream map of your process and measurements around it, you are not “doing Lean”. Without a process definition and measurements, you can’t determine problems with:
• Waste
• Flow
• Over-stress
So this leads me to Kanban, with is a tool or approach to help with flow. There are some implications that a shop that is applying Kanban is a Lean shop, but not necessarily. For example, if they don’t have a value stream and see the improvement that Kanban delivers, I don’t think they are a Lean shop. Without the process measurements in place, there is a high likelihood that the improvements won’t survive a change in management. The evidence provided by the measurements won’t be there to ensure the process improvements are supported by the new boss.
Related to the first point of engagement and leadership, if you don’t have real changes being made every couple of weeks, then you don’t have a “Lean” shop. When ideas come up, they need to be tracked and worked on. If there is no follow up, your employees will quickly figure out that you are not “walking the talk”, that this is just another great management idea that will pass.
I believe the biggest challenge to Lean is point #1 above. Most shops will significantly resist changes that a Lean approach will demand. How do you get your teams to switch if they are not on board? To me, this is the biggest rub or issue – how to use “command and control” to move people away from “command and control”. This is the fine line that the new “Lean leader” needs to walk – how to apply just enough force to move an organization into a Lean Management system. Maybe this is the key “cloud” that needs to be evaporated to - use TOC terminology.
So what do you think? Is using Kanban alone enough to qualify your shop as a Lean shop?
]]>Hi Robert.
Thanks for the careful answers! It is good the boss is driving this, because leaning out software development usually implied some big organization changes. Without support from the top guy, nothing will really change.
To Gustave’s question about applying lean to software development, it certainly is possible. You might have heard about Agile Software Development, which has many tools that can be applied to “lean out” a software development process. You would probably use more DFSS as you are constantly building “custom” components. The inventory still builds up at various transition points and a value stream model will point out many delays as different work products shift from department to department. Mary and Tom Poppendieck have written a couple of books about this.
Thinking about the “two team” situation, this can be very dangerous, as your discussion implied some cost and time frame measurement. Measurements are a two edged sword and many variations can contribute to the differences in cost, where one team might have:
• A “legacy” application which is a mess, making it twice as hard to work in
• No safety net of automated tests to verify new changes don’t have damaging side effects, delivering much more defect correction work
• Unclear requirements forcing many changes in the development process
• Different tools that are more complex/ harder to use
• Demoralized environment where many have given up the fight
• Ineffective technical leadership that is not improving the knowledge base and skills of the team
• Inept project management that cannot say no to unreasonable dates, and
• The list could go on….
So what measurements are in place would help you detect and correct one or more of the above problems? Or on the flip side, which existing measurement is causing one or more of the problems? Dr. Deming suggests it is often management’s fault that things are going poorly. The dangerous part is the tendency to compare two teams, and many times it is an “apples to oranges” comparison that does not yield much valuable information. A valid and more useful comparison is between where a given team is now and where they end up 6 months from now.
I like what Gustave had to say: “…upper management is rarely the group who knows what to do with LEAN.” This is where I like what Bob Emiliani says in “Better Thinking, Better Results”, that Lean is a management system, not a means of manufacturing. From that book, one of the key principles is Respect for People. Here the managers have the job of engaging the people who really know the details of what is going on – their employees. If they apply lean principles and double the productivity of each team (which is certainly achievable with leaning out traditional software development approaches), are they going to fire some people? (Barry Jeffery mentioned this as well) Applying lean management is a real test in leadership and getting the employees engaged.
This is where the “respect for people” principle of lean management comes into play. If they don’t deal with people fairly and respectfully, there will be no motivation for any more process improvement. For example, if they lay off 25% of the development staff after the first round of lean improvements, who is going to be motivated to perform real changes in the second round of improvements? The reaction is likely that the people will go into self preservation mode and sabotage the process improvements. In this case, they might be best off to evaluate the two teams, make smart cuts to make the budget and retain people who are more likely to be adaptable to the new lean environment. With the people that are left, start aggressive changes to improve productivity, quality and engagement at the same time. There will also be a commitment to the people that are left is that no one will loose their jobs as a direct result of the process improvements.
Shane
First a comment on what you get out of TDD. I think one of the major benefits is that you get a “testable” application, especially in the sense of an automated test mechanism. If you have a potential of 10 designs to solve a problem, but only two are really testable, a real TDD approach will eliminate 8 of your potential designs. How is that valuable to the end user?
My studies indicate that without significant automated testing, you will have 10x (1 order of magnitude) more production defects with just significant automated functional testing. Now the production defects may not be actual outages, where the application is not available, but defects where some functionality is not operating as the end user would like. From my perspective, removing these defects is a very valuable result for the end user and the productivity of the team.
Along the line of productivity, imagine the detection and correction time related to all of the production defects. By the time the software has hit production, sometimes it is difficult for the developer to remember what they were really doing. Now someone needs to:
1. Understand the defect,
2. Understand the section of the application the defect happened in,
3. Determine the cause of the defect,
4. Put in a fix,
5. Test that the defect was corrected and
6. Test that no unintended side effects resulted in the code change.
Imagine how much faster that cycle occurs when a TDD approach is used and the original developer has just written the code. You actually eliminate steps 1 and 2 and speed up the remaining steps. Now multiple this productivity improvement by the size of your application or development team to get a rough idea on the overall value to the organization. I believe that overall value to the customer, including productivity, will be significantly improved with TDD.
Shane
http://www.linkedin.com/in/pshayes