What's Wrong With This Picture?

You've seen the picture - the lonely elderly person sitting in a wheelchair, where the only companion in a lonely hall of look-alike rooms is the cold, clinical flourescent lights. Ask 10 people what they think of a nursing home, and for 7 the first answer will be "it reeks!" Ask anyone, or better yet, yourself, if that is REALLY how you want to go out ... for most the answer is "no way!"

Government regulators and patient / resident advocates see a different picture (I'm going to broad-brush this, so don't shoot me): money-grubbing corporations who short change patient care to feed large bureaucracies and pursue profits. They see this resulting in deficient care, neglect, sometimes even abuse or actual harm to a patient. Take it a step further, and you will actually find health inspectors who are only really concerned with writing "tags" (or in lay language, penalties) for observed deficiencies. Some advocates are SO strung up the line that they refuse to think rationally about their demands of operators.

Operators of facilities can be segmented multiple ways ... some for-profit, others not-for-profit ... some large corporate, some small religious missions ... etc. Regardless of tax status claimed, operators of nursing facilities MUST pay the bills to keep the lights on, staff employed, food on the tables, etc. And the long term care industry isn't a margin rich environment - generally speaking over 2/3 of a facility's reimbursement comes from Medicare / Medicaid funding - and that's a tough business. Most operators live in fear of the state - seriously. Why? Because the state has the self-appointed power to de-certify a facility - they can walk in anytime and slap around the staff however they please with little or no repurcussions. For anything ... if they see something they don't like, they can find a regulation that is violated in accordance to their personal distaste and write the "tag."

Additionally, most for-profit operators exist to feed the monster above them, namely the corporate bureaucracy. It's rife with all the traditional corporate titles ... "regional director of ..." or "corporate vice-president of ..." or whatever. You get the idea. There's a bunch of chiefs sitting up there that need to be fed. So the "administrator" of the facility lives a life not unlike the proverbial whipping boy (or girl) - one minute bending over to take it from corporate, the next minute bending over to take it from the state, the next minute from an unhappy staff member, next from a resident or family member, and so on. Paralyzed. An existence of schizophrenia - who's going to take the next pound of flesh?

Not-for-profits typically aren't much better. We are twitterpated by their warm and cozy mission statements, and somehow "not-for-profit" sounds so ... so noble. But think about it - if their profit margin (revenue minus expenses) is less than zero, where do they get the money to make payroll, buy food and supplies, pay the bills, the rent, the fines, etc.? From what I've seen, any excess margin goes towards feeding a bureaucracy - until you end up in the same dilemma of the for-profit gang - paralysis.

Finally we have our good friends at CMS - yes the Department of Health's fine organization titled "Centers for Medicare & Medicaid Services" (http://www.cms.hhs.gov). Lovely. This is the government division charged with, among other things, dispersing our tax dollars into the hands of providers of medical services for citizens enrolled for coverage in the Medicare and Medicaid programs. They are also tasked with dispersing as few of those dollars as possible, hence the low reimbursement rates, especially for Medicaid programs. But wait, there's more. They are also tasked with ensuring that the dollars do not end up in the hands of fraudulent ilk (this is good), and with taking back as much of the $$ from providers who can't jump thru all the hoops to keep the money (this can be bad).

Got it so far? Let's recap ... state regulators want to enforce the MINIMUM standard that is legally required of nursing home operators. Some regulators want to write as many tags as they can. CMS wants to spend as little money as possible in the rehabilitation or long-term care of our loved ones - in fact they want to take back funds already distributed to facilities for any error they can find. If operators want to keep the money, they gotta jump thru those hoops. Regardless of "for-profit" / 'not-for-profit" status, most organizations have a hungry bureaucracy that needs to be fed off of the earnings of most facilities. So what, Dave?

Yeah, that's the problem. Bureaucracies are so busy trying to get fed by miniscule reimbursement that wise investment in the facility often goes by the wayside. Administrators are so busy trying to please the bureaucracy, or state, or CMS, or whoever, that they don't have time to sit down and think about what would be best for the facility and its residents. State regulators are so busy trying to enforce the MINIMUM standard that the entire industry decides that the MINIMUM is good enough. And who gets the shaft in the process? Exactly - the resident. Our grandparents, or our parents, or our whoever ... they're the ones who get the short end of the stick.

So what's wrong with the picture? Here's everyone SAYING that they're out for the best interests of our loved ones - but most everyone is so pre-occupied with the other players or themselves that noone is paying any attention to where they ought. The system works fine, just not for the residents / patients. That is what needs to change. Big time.

I certainly don't think I have all the answers. I'm sure there are smarter people than me grappling with this problem. But I do have some ideas - some thoughts on the philosophy and models of long term care. Hopefully they'll be taken as just that - ideas from a visionary.

The New Path

So much for consistency in posts. Much has changed and there is much to tell - I'll do my best to mix it up.

In 2005, a good friend of mine [dN] and I were chatting about a mutual friend of ours [bP] who had left a very cush job @ a Fortune 500 company for a small upstart company in the long term care industry. The job: administrator of a skilled nursing facility ... err, a nursing home. dN and I were puzzled (and humored) at the change - however, after watching bP for a while, we discovered he was 1) happy and 2) not doing too shabby. So, in May/June 2006 the curiosity overcame us and we decided to check it out. Long story short, we both interviewed (dN before me - I wanted to see his reaction) and were amazed by the plentitude of opportunities. For me, I saw endless possibilities to do fulfilling work and to potentially change the long term care landscape.

So, in late August 2006 I resigned my post at Microsoft. I had a cush job in pricing management, and before that had been the sales / business controller for Microsoft's US small & medium biz sales & partner group. Only $4.x billion in revenue, over 1,000 employees, and a team of outstanding employees scattered from Boston to San Francisco. There were opportunities to go ex-pat and work for 3-5 years in Microsoft's emerging markets (e.g. Russia, India, China) as the controller for the country, etc. Nice income, outstanding benefits, and the stock was accumulating in ever bigger piles as I passed the vesting milestones.

Earlier in my career at Microsoft, I was present at a business plan presentation by the company's HR VP to Steve Ballmer (CEO). During the presentation, Steve went off on a rant about employee attrition - he wanted visibility to the "good" (people who need to be pushed off the boat) and the "bad" (people who we want on the boat but jump of their own accord). Still ranting, he complained about the bad attrition, and said something to the effect of "Why would anyone ever want to leave Microsoft - the opportunities to do everything are right here in this company?"

That question was ringing in my head as I sat in my manager's office and explained that I was leaving the gucci world of Microsoft to run a skilled nursing facility. Yeah, the jokes were great, especially the ones about bed-pans. But the answer to the question is actually quite simple - when you're doing work that isn't fulfilling, or feels shallow in terms of its contribution to mankind, it's actually an easy jump off the ship. And that's how it was for me - after five years of long hours, leadership development, outstanding performance, and helping the company add millions upon millions to the bottom line, I felt used and empty. There was nothing coming back from my work that motivated me to go even further.

Today I work for a small company in Texas called Keystone Care, a subsidiary company of the Ensign Group. The Ensign Group was formed in 1999 by a group of entrepreneurs and industry veterans who felt there was a better way to deliver long term care services, namely by eliminating the bureaucracy of corporate structures and focusing on leadership at the facility level. The premise: insert a CEO minded leader as the Executive Director of the facility, and let that person call the shots and build an outstanding leadership team. Once in place, let the leadership team determine what they need to do to become the facility of choice in the market they serve. The result: an impressive track record of buying struggling facilities and turning them into successful operations - both clinically as well as financially.

What was the attraction? It's too hard to put my finger on any one thing, but here were the main factors:

• Oddly enough, the first thing on my list was the humility level of the leaders. So many of the "leaders" at Microsoft were inflicted with a rockstar mentality - it was as if they never made it beyond the syndrome of all 2-3 year-olds where the world revolves around them. I wanted to see leaders who were genuinely humble - and I did.
• Fulfilling work: something beyond the intellectual busy work and Power Point games. Who really cares if Microsoft makes another $50 or $500 million? Bill Gates doesn't need it, and the stock is so diluted and moved by so many factors that financial performance doesn't do much for it anyway. Look at the stock price history vs. financial bottom line results over the past 6 years - see what I mean? No, there had to be more to my work than making money for Bill - it had to be real.
• Entrepreneurial opportunity: I wanted a long leash - room to take risk and develop new services, products or companies. So far, I've had the freedom to do all three.
• Outstanding partners: I wanted to see stellar business partners - other facility CEOs with a committment to each other's success. I wanted to know there would be help if I needed it, that I could reach out and get a hand anytime, anywhere I needed it.

I found all of this and more. For me, there was a natural fit.

What will follow in subsequent blogs are my experiences, as well as my thoughts as they've developed over the past 7 months. It is time for the entire industry to be overhauled - and I mean the ENTIRE industry. I have seen so much mediocrity and bureaucracy that gets in the way of delivering outstanding care. The prevailing long term care philosophies are archaic and sad - and that is why people are scared - scared of placing a parent or loved one in a facility and even more scared for themselves.

An Executive Fish Fry

It would be hard for me to describe how liberating it is to have blog! As I lay in bed the other night, I was pondering the things in my mind that I wanted to share and discuss with the rest of world. I wondered if anyone from the rest of the world would stop by the shack - and then I realized I didn't really care. Simply having the forum to let some of this out was good enough for me. As a result, I tossed and turned, trying to list out the things in my mind that were really bothering me - things I haven't really had a chance to disclose - until now.

In 2002, a very large software company in the pacific northwest (I'm trying hard not to name names) announced the retirement of one of its senior vice presidents - this one happened to run the company's Human Resources division. A job search ensued, and towards the tail-end of 2002 the search ended with the announcement that it had hired an HR "executive" with an impressive resume. At the time, a couple points intrigued me about the selection:

• First, that the candidate was male: typically the senior HR role in a company is filled by a woman – now, before you hurl accusations that I’m making a sexist remark, let me assure you that I’m sharing my observations from what I see in the world
• And second, the company demoted the position from senior vice president to corporate vice president. Now, for those of you not familiar with this particular company, "senior" is exactly what it says in relation to its younger sibling, "corporate": it is senior. A corporate VP role is significantly less significant than a senior VP. The signal, intended or not, was that this position just wasn't impactful enough to warrant a "senior" title, nor was the candidate who filled it "senior" enough to pull the bigger title.
  

The first time I met him, I was under-whelmed. He was short, fidgety with little beady eyes, and noticeably suffering from early onset baldness. His actions and his speech clearly disclosed that here was a man suffering not only from a self-esteem complex, but also from short-man's syndrome in the worst way.

He was relocated from somewhere in the southern US. The relocation expense to move him was quite large - I would know, because I owned the financial policy and accounting for said corporation's relocations. At that time, the company had a policy of providing tax gross-up assistance for employees who had relocated and received taxable benefits as part of their relocation package. The rate at which the gross-up was calculated (at that time) was based on the IRS guidance on supplemental income - 25%. Tax gross-up is an important benefit as part of the package; often, many relocation activities, if reimbursed by the company, are considered a taxable gain to the employee. However, once the company pays the tax on the benefit, the IRS considers the payment of tax a taxable benefit as well - and so the company continues to pay the tax burden on successive tax payments until the benefit to the employee becomes negligible. An example might help:

Say an employee is relocated and receives a taxable benefit as part of the relocation package - we'll use reimbursement of real estate commissions. They sell a $500,000 home, pay 6% real estate commissions which translates to $30,000. The company reimburses the employee $30,000 to cover that expense. However, the IRS considers that reimbursement a taxable benefit (income). Using the supplemental tax rate (which I understand isn't the employee's real tax rate), the employee would owe $7,500 in tax. The gracious company, not wanting the employee to be put out as a result of the relocation, pays the $7,500 tax. But the IRS considers that payment a taxable benefit (income) as well, and requires the employee to pay tax on the $7,500, which at the 25% supplemental rate is $1,875 - the company picks that up as well, which the IRS also considers taxable, and so on until the taxable benefit is so small that the employee couldn't possibly be harmed by the incremental penny (or so) in additional tax liability.

Back to the story. The tax gross-up policy stated to use the 25% supplemental rate. However, when the new HR VP arrived, he was upset that his particular situation wasn't grossed-up at his marginal tax rate (which would have been 39% back then). Now, for those of you that have had the joyful experience of working with senior level “executives”, you will understand that they can, and often do, throw tantrums when things don’t go their way. So, it was no surprise that he threw a small fit about wanting the additional tax benefit.

As expected, our subject of small stature decided to change the policy since the relocation guidelines fell within his purview. The proposed change entailed an increase in the tax gross-up rate to the highest marginal rate for all senior level relocations (anyone at the corporate VP level or higher). Why is this problematic? Because his proposal grandfathered all relocations within a specific period of time … and wouldn’t you know it, the period encompassed his own relocation by no more than two weeks. He set the timeline to include his own relocation.

Now, just think about it, because I’m not going to disclose actual numbers. This impacted the company by millions of dollars, during a time where all of us were doing our best to control costs under a famous cost efficacy campaign. As part of the cost control efforts, the payroll and promotions increases were cut multiple years in a row. Thousands upon thousands of rank and file employees were taking it on the chin to support the operating margins of the world’s wealthiest company, and here you have an officer of the company implementing policy to enrich his own pocketbook.

In 2002, Sarbanes-Oxley became law and required greater financial transparency on the part of all publicly traded corporations. It also put greater fiscal responsibility on the officers of said companies to avoid implementing personally enriching policy decisions. In my book, this episode was, at the very least, a violation of the spirit of Sarbanes Oxley and certainly a violation of the trust given by the employees and fellow officers of the company (some of whom were also enriched by this policy decision).

Should I be so troubled by this incident – I don’t know, but I am. To be fair, it is my understanding that the policy was ratified by the CEO and the senior leaders of the company, so in a way they endorsed this executive’s proposal and thought it perfectly fine to allow him the liberty of setting a personally enriching corporate policy. But it certainly reinforces in my mind an impression of class and caste in the corporate culture … a ruling nobility and a struggling bourgeoisie. Despite the nobility’s claim to the contrary, they only seem interested in their own enrichment, welfare, and entitlement; their actions are usually in conflict with their stated objective of developing their people and promoting from within.

In the end, the “executive” who is the object of this blog left the company in disgrace as a result of having at least one extramarital affair with a subordinate. It turns out he truly was a man of no morals or ethics, and was only looking to satisfy whatever whim he might have had at the moment, be it his wallet or his … well you know what. It is a shame that the CEO allowed him to resign, as opposed to terminating the sorry little sod; that seems to be the way of the “executives” – rarely are they terminated – and thus they continue to spread their disease of self-interest and narcissism in other organizations.

Am I the only one who feels this way? Am I being too harsh about this? Something inside me says I’m not – that the disgust I feel is fully warranted, but maybe I’m out on the far end of that continuum. I have a few more stories that I’ll share later … for now, thanks for stopping by and I hope the fare was to your liking.

A Nation of Hyphens

Today's specialty: Immigration. Actually, it is broader than immigration - immigration is simply the act of "migrating" from one's country of origin to another. The broader issue is assimilation and cultural unity.

Today, America is a nation of politically correct hyphens, which in my book is simply a recipe for cultural schizophrenia. Keep in mind that this is based on the premise that America is a "melting pot" - yes, remember that term from 9th grade social studies? It infers that multiple streams or rivers of cultures come together in one point (the symbol here is often early 20th century Ellis Island) and MELT, or blend, into a new culture (that is singular, not plural - just wanted to be clear). Think of it as a process of melting multiple ores together to derive a new, refined metal - stronger, harder, better than the original.

The premise is that we all sacrifice our differences to embrace the new culture. If I immigrate to America, my forward view is that I'm American. I embrace all things American - taxes, English, work, accountability and financial prosperity. Whatever I was before I claimed United States nationality becomes a thing of the past, or said differently - my heritage. Does that mean I throw away my heritage, my culture, my language, etc.? Of course not - it just becomes secondary, and bows to the will and needs of my new nationality. But, my future is 100% American - no hyphens to qualify it.

Here's a quote I found today, from a letter written by Teddy Roosevelt in 1919, shortly before his death. I have to admit, it does sound a little harsh when considered w/in the charged atmosphere of political correctness - I'd encourage you to drop that baggage and consider it w/in the context of being an American, above all else.

Taken from: http://www.snopes.com/politics/quotes/troosevelt.asp

NEW YORK, Jan. 6. — What was the last public statement by Col. Roosevelt was read last night at an "All-American concert" here under the auspices of the American Defense society, of which he was honorary president.

"I cannot be with you and so all I can do is to wish you Godspeed," it read. "There may be no sagging back in the fight for Americanism merely because the war is over.

"There are plenty of persons who have already made the assertion that they believe the American people have a short memory and that they intend to revive all the foreign associations which more directly interfere with the complete Americanization of our people. Our principle in this matter should be absolutely simple.

"In the first place we should insist that if the immigrant who comes here does in good faith become an American and assimilates himself to us, he shall be treated on an exact equality with every one else, for it is an outrage to discriminate against any such man because of creed or birthplace or origin. But this is predicated upon the man’s becoming in very fact an American and nothing but an American.

"If he tries to keep segregated with men of his own origin and separated from the rest of America, then he isn't doing his part as an American.

"We have room for but one flag, the American flag, and this excludes the red flag which symbolizes all wars against liberty and civilization just as much as it excludes any foreign flag of a nation to which we are hostile. We have room for but one language here and that is the English language, for we intend to see that the crucible turns our people out as Americans, and American nationality, and not as dwellers in a polyglot boarding house; and we have room for but one soul [sic] loyalty, and that is loyalty to the American people."


Our nation (media, government, society, culture) is fixated on the "pluribus" in e pluribus unum. What happened to "unum"? Or, take our pledge of allegiance - forget whether or not you agree w/ the statement "under God" because that is a dish for another day - what are the key words? One nation, under God, indivisibile, with liberty and justice for all. We're supposed to be one nation folks - indivisibile means that nothing can divide us (not theology, not politics, not race, not heritage, etc.). Left unchecked, what we have on our hands is a recipe for the destruction of America as we know it, and we'll only have ourselves to blame (and our petty self-interests).