The ordinary nature of being exciting

by Michael S. Kaplan, published on 2010/10/16 07:01 -04:00, original URI: http://blogs.msdn.com/b/michkap/archive/2010/10/16/10076687.aspx

There are many things I cannot do, e.g. run, dance, ski.

Another is the ability to maintain a sustained anger about anything, really.

One could rightfully assume that my blog of a week ago on the Health Care changes at Microsoft (The exciting nature of being ordinary) came largely from such a place.

But it does not really tell the full story.

Several people at various levels of importance/seniority reached out to me and assumed I had not seen the Town Hall framing of the issues involved, but I had.

It did not really tell the full story, either.

A few others reached out to me, assuming my job was about to be lost, but they didn't understand the larger problems that would entail, or really the mindset of the people involved. This too is an interesting topic to me, though one I doubt I would cover unless I was leaving and felt like burning a lot of bridges. which for the most part I don't.

Some might think it too bad I am not angry now -- since that is the way to get Mini linking to you and if I had that as a goal then I suppose I could aim my content that way. I remember a lunch a few years back with Robert Scoble where he lectured me about all of the rules about "A" list blogging I routinely violate. I told him I wasn't trying to drive heavy traffic here, and that whatever popularity the blog has is accidental.

Although it has been an exciting week, I found it all to be pretty ordinary. So even when throughout the week friends of mine pointed out the Mini ref to see what I thought, it was hard to get excited about it. If felt ordinary....

Anyway, in this last week, after a listening tour, some authorized research, some not entirely authorized research, several conversations, and a few revelations, I feel that I have a much better idea what is going on.

I thought I might share my thoughts on thie matter with you, just in case you were interested in having some more discernible facts now that the anger has passed.

If you are not interested, please leave now. :-)

It all started with a Town Hall.

The Town Hall had a slide deck.

The slide deck had a chart in it.

The chart had a title on it: Microsoft U.S. Health Care Trends.

The title had a subtitle under it: (Per Employee Per Year).

The figures in the chart were alarming:

• Cost in 2000: $5,800
• Cost in 2009: $11,800
• Cost in 2020: $33,900 (estimated)

Since the chart notes a 203% difference (aka 103% growth) between the first and second points, and a 287% difference (aka 187% growth) between the second and third, this is obviously kind of alarming.

These stats, along with some basic stated principles of the company's health care policy, are the justification given for the suggested changes.

If you were there or saw the video then you knew all this, but I wanted to have a basis for understanding that even those who have not seen or cannot see the slides can have.

It leads us to the problem.

And the problem is?

Well, the chart of this slide deck of this Town Hall is more than just a little bit manipulative.

I'm going to take a moment and list our all of the ideas I can think of factors that can, over the course of 20 years, have statistically significant impact on those numbers, on that graph:

1. The cost of the underlying health care services are increasing
2. The age of the average employee is increasing
3. The number of dependents (spouse, domestic partner, and/or children) is increasing
4. A tendency to ignore preventative measures and favor ones that only apply once one is sick leads to ever-increasing expenses
5. As employees go through the natural process of sickness and recovery their general lack of attentive oversight leads to natural tendency of uncorrected mistakes to increase over time
6. Inefficiencies and lack of appropriate oversight in changes and coverage of new services occur, increased costs are incurred and there is insufficient review to correct the issue
7. As health care service providers realize the generous nature of Blue Cross when they only administer and Microsoft is paying the bill, the amount of service given increases, at times out of proportion to the need
8. As employees realize the generous nature of Blue Cross when they only administer and Microsoft is paying the bill, the amount of service given increases, at times out of proportion to the need
9. As health care service providers with the required mens rea realize the generous nature of Blue Cross when they only administer and Microsoft is paying the bill, they may find the actus reusto take advantage of it and commit the crimes of theft, fraud, and so forth
10. As employees with the required mens rea realize the generous nature of Blue Cross when they only administer and Microsoft is paying the bill, they may find the actus reus to take advantage of it and commit the crimes of theft, fraud, and so forth

You get the idea.

If I had spent another hour I could have thought of more (e.g. the overlap of Worker's Comp. cases covered via health care benefits due to the ease of doing it -- something i have witnessed and which while I cannot claim it is explicitly encouraged I can claim it is implictly encouraged -- and certainly not audited or monitored), but this covers the broad strokes.

Now on this list, item #1 is not changeable by the HR Benefits portion of Microsoft. It really is completely outside their power to do anything significant to "fix" it.

Items #2 and #3 are not changeable by the HR Benefits portion of Microsoft without severe and in many cases illegal changes to the core guidelines of how benefits and provided and how employees are let go. Given a general aversion to this, it is clearly in Microsoft's interest to reject any changes (e.g. not cover dependents, lay off sick or older employees for being sick or old) out of hand.

However, given the simple facts that those first three factors

• have a significant impact on the increase in cost of health care per employee, and
• are items that can be independently tracked and thus removed from the figures for the purpose of determining the impact

the simple fact that Microsoft has not stated they want to change the philosophical basis of the benefits means that trying to keep the chart simple in this way leads to very misleading numbers.

You can't talk about a problem honestly and openly when the proofs given are not honest and open themselves.

Anyway, to continue:

Items #7 and #8 are difficult to solve as long as the rules encourage it -- the water tends to flow where it is most natural to do so. The HR Benefits portion of Microsoft cannot do much here if it cannot change the nature of the coverage to change that perception.

Items #4 and #5 and #6 are also difficult to solve as long as there is no real change in mindset; and when the mindset is created by the rules the system works under, it is difficult to change without changing the rules.

Items #9 and #10 are crimes -- whether felony or misdemeanor or something to inspire civil suit if one wanted to recover damges. And the HR Benefits portion of Microsoft has a real vested interest in such actions when they happen.

There are, as I said, other items that could be added to the list, though one the whole I believe they all fit in one if these categories.

Microsoft's (pre-Health Care Change) Remedies

The issue, while new for most employees, is not new for the HR Benefits portion of Microsoft or the Executive Staff or the Leadership Team.

And people in the HR Benefits portion of Microsoft have been working the problem for several years now -- particularly:

• item #1 -- by trying to shift costs (e.g. having doctors do house calls is cheaper than having employees go to emergency rooms
• item #4 -- by openly encouraging preventative care measures
• item #6 -- by changing processes when they are identified that are not correct and lead to increased cost
• item #9 -- by attacking such fraud directly when it is discovered
• item #10 -- by attacking such fraud directly when it is discovered

However, they get no credit for going after these things first in my eyes as they did not announce these things the way they did the plan to share costs with he employees.

Note that in many cases these items are hard to address since the bullets that try to change employee behavior (the first two) have limited success when the employees do not feel they have enough reason to pay attention to them and take advantage of them, and the bullets that try to fix inefficiencies and problems and crimes (the last three) are hard to identify when no one reports them (and if no one is paying attention because there is no impetus to pay attention, then this is the behavior the system creates).

Additionally, problems with Blue Cross were being handled (and are still being handled) as external vendor management issues, so that even though the HR Benefits portion of Microsoft has been working on the problem for years and making great efforts to go after everyone other than the employees to preserve the original principle of not wanting them to worry about health care, they get no credit from me or many other employees because they didn't let us know this was happening and that they were trying to solve the problem years ago. From our standpoint, the first major step beyond tracking the problem was to tell us how much we were going to have to pay.

Sure, the most obvious "answer" to many problems here is to make employees pay more attention, but this pretty much impossible to do, beyond what they have been doing. And even doing that stuff has still led to increased costs (which as a side note suggests additional problems with the chart and the numbers that could be resolved by better use of the data, but I'll quit beating that dead horse).

The "easiest" way to get people to care is to get them involved.

To be honest, I myself know of only two ways to consistently motivate huge numbers of Microsoft people to do stuff: you have to either make stuff free (this works great with pizza and dove bars and lattes and beer), or make stuff cost something (preasumably the hope is that if employees were needing to pay they would pay more attention).

Okay this is an interesting plan they have.

There, I said it.

In fact, it is so interesting that it is too bad that they really are wrong, Wrong, WRONG here.

Perhaps I should explain why I think they are incorrect.

I'm going to categorize Microsoft employees into a few different groups here. Think of this as the broad over-generalizations portion of the blog today, which is an answer to even worse over-generalizations in the plan.

• The young and healthy (and probably single) group, who have minimal health care expenses. They may have used it a little, but now they will probably go to the Health Savings Plan and many of them will spend less than $1000 a year -- so that the money the HSP gives them for future health issues will be banked. The additional cost to Microsoft for these folks: up to $1000 a year (or $1500 during these next two years) that would not have been paid out as health care either. These are people who didn't cost Microsoft hardly anything under the old system.
  
  Note: what little they have in Health Care expenses, they'll likely be paying more attention, since some of their valuable saved up cash will be spent. Them looking can help solve many of the other problems that come with not paying attention, but as their expenses are so minimal it is not much benefit for Microsoft.
  
  Note 2: I expect that this group is not huge, though certainly these first two years are the ones where moving them over to the Health Savings Plan is critical since healthy people don't spend time thinking about health care but a cash bribeinducement is just the thing to attract them.
  
  Note 3: Getting this group thinking about health care is probably thought of a big win -- these are the ones who still think they are going to live forever.

• The mostly healthy group who have some Health Care expenses beyond the [still free, covered at 100%] ones. They may spend some percentage of the $1500/$1000 in the Health Savings Plan, but they are fairly break-even, Most likely -- not saving much in the Health Savings Account, but not overdrawing it, either. The additional cost to Microsoft for these folks: probably nothing, mostly -- they are in that sweet spot where they might have been spending that same amount as will be in the account. These are people who didn't cost Microsoft much under the old system.
  
  Note: This group is needing some Health Care, and they'll likely be paying more attention, since some of their valuable saved up cash will be spent. Them looking can help solve many of the other problems that come with not paying attention, and perhaps they are spending enough that the money their "extra eye' on the situation is can be worth watching.
  
  Note 2:I expect that this group is also not huge, though certainly these first two years are the ones where moving them over to the Health Savings Plan is critical since healthy people don't spend time thinkign about health care but a cash bribeinducement is just the thing to attract them.
  
  Note 3: Getting this group thinking about health care is probably thought of a big win.

• The "hell yeah I use the health care" group, who use more than the $1000 that would be handled by the deductible (which they can pay out of the Health Savings Account), but less than the $11000 total a year one would have to spend to get back to 100% coverage. The additional cost to Microsoft for these folks: Again probably nothing -- it is no accident that the total amount spent on health care ($11,000) so closely matches the average amount per employee. I suspect this group has a lot of people in it.
  
  Note: Getting this group thinking about health care is probably thought of a huge win and the driver of most of the decision.

• The critical accident group, who were in one of the other two and they have a huge unplanned event happen like falling off a mountain or being attacked by wolves or whatever. These people will cost Microsoft the most, since they are the ones who will spend enough on health care that they get to eventually move back into a "100% coverage" plan. The additional cost to Microsoft for these folks: not much. I mean, it will cost oodles, though it is more or less the same oodles as before. The user perception is that they are making $2000 less along the way and they really are (even though the Health Savings Plan's job is to pay for stuff that would be co-pay or whatever, it is too easy to look at a balance reduced as money lost that was once theirs. So even though it costs Microsoft about the same, the employee was forced to cough up money they weren't expecting to have to, making $2000 less after their accident.
  
  Note: Assuming the accident doesn't cause a long-term expense, the person may be back to normal by the next year, with nothing but the memory of how in their time of need Microsoft paid them less, that it cost them more.
  
  Note 2: They may or may not be reviewing medical stuff more closely during the period of accident than they would have otherwise (depending on how busy he accident recovery itself keeps them). Afterward? What people choose to remember for the future that is relevant to the Microsoft/health care situation will vary, but in future years they will probably remember what it is like to lose that whole $2000 more than anything else, and how they were being charged upfront for the first $1000 and then nickel-and-dimed for $1000 of the next $10,000 spent. While they were recovering.

• The Long term expensive illness group, the ones with multiple sclerosis (like me) or diabetes or AIDS or who found out that Dr. House's "It's not Lupus" shout can occasionally be wrong. They are people who are definitely so far from the $11,000 a year category of expense that the "charged upfront for the first $1000 and then nickel-and-dimed for $1000 of the next $10,000 spent" thing is an annual experience that may be over before they are through with February, and then for the rest of the year they don't care anymore. The additional cost to Microsoft for these folks: no appreciable difference, since the shared bit of cost is nothing compared to the actual cost.
  
  Note: While I don't personally take this whole issue as discrimination against the sick, I am friends with people who do (I think of it as a side effect whereas they don't distinguish on the intent here and/or are not as prepared to assume Microsoft is being honest in the intent). Given that many in this group already face genuine discrimination of one sort or another, it can be quite easy to believe that thinking of it differently is pointless and a true distinction without a difference, since the effect is the same.
  
  Note 2: This group does watch their medical care for quality and therefore perhaps are never in that "I don't pay attention" category. But at the same time I am very willing to accept both $1200 a month drugs that help me and the iBot wheelchair that Blue Cross paid for 100% despite it being from an out-of-network provider. And if Scott Hanselman had the opportunity to be able to use a system for his diabetes that was more automated and made his life more normal and yet cost two times or four times the price or more, he would probably want it because properly managing the disease is what keeps him from going blind or losing limbs or even dying (not uncommon when diabetes management is not done as well). From a fiscal Health Care at Microsoft standpoint this can thus be significantly more expensive than the savings the plan might save them.

If you carefully consider the impact of the health care change on each group, you may notice that the impact does not necessarily get felt where it is arguably most needed.

In an effort to maximize the awareness while minimizing the pain, they found a way to in several cases (including mine) maximize both.

I understand what they did and why they did it, but I have no respect for the way they did it as the inaccuracies in the presentation of data and the fact that this blunderbuss shotgun approach that will not have the best impact is hurting people like me currently and will almost certainly require significant changes and/or additional costs in the long run.

As en engineer who is on the front lines of the new costs, I can't claim to be happy about poor communication of a poor plan. That is both bad engineering and bad marketing.

As someone who recognizes the importance of both, screwing up either one is pretty bad; screwing up both is a poor way to present to a bunch of engineers and marketing people.

Also inescapable is the fact that it effectively discriminates most against those most sick (whether one believes that is the intent or not, or whether you believe the distinction matters or not), rather than discriminating against the three things that (in my opinion and in the opinion of others I have talked to) should be most penalized given the above:

• those who continue to fail to pay attention to Health Care service and administration, and
• those who attempt to defraud the company in one of the many ways I mentioned, and
• those policies that continue to make either of these things continue to be likely.

Hard problerm? Sure. But I thought Microsoft wasn't afraid to take on the hard problems.

Or to solve them properly.

Especially since (by loose analogy) after putting the wrong person in jail for a murder, you will still have the murderer out there killing people and therefore will have to do more to catch the murderer eventually....

What they have done here is a second rate solution, and I think we deserved, and that we deserve, better.

Donna L. on 16 Oct 2010 1:03 PM:

Michael S. Kaplan on 16 Oct 2010 1:59 PM:

Michael S. Kaplan on 16 Oct 2010 1:59 PM:

QF on 17 Oct 2010 11:31 PM:

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