Archivi del mese: ottobre 2012

Patients Know Best Blog

At a meeting in Copenhagen earlier this week Bertalan Mesko was introduced as “the world leader in social media and medicine.” After listening to him and looking at some of his websites I decided that this was not an exaggeration. If you want to be up to the minute on social media and medicine you need to know about Mesko and his works.

Mesko began his journey through social media in 1996 while at medical student in Hungary and has been as known as Dr Twitter since the New York Times described how he used Twitter to make a diagnosis on a 16 year old who had had six episodes of acute pancreatitis.  Mesko is clear that you won’t have such success by sending such a Tweet unless you have put in the work to build up a community of a knowledgeable group of followers whom you trust.


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Democrats versus Republicans: Two different approaches to Medicare @Medici_Manager @kevinmed

Possiamo chiedere ai nostri candidati alle prossime elezioni politiche, e ai giornalisti che li intervistano,  di farci sapere che cosa si impegnano a fare per il nostro Servizio Sanitario Nazionale?

by  on October 21st, 2012 in POLICY

The two party’s approaches are quite different.  Politicians realize that Medicare will not be able to continue on its current track. Something has to change since the country will simply not be able to afford the inexorable growth and expenditures. But politicians do not like to take away entitlements so proposals generally are couched in vague terms and often with positions that are unrealistic.

The Democrats’ plans are contained generally in the Affordable Care Act (ACA). The most commented upon action today is that the payments to Medicare providers will be reduced over ten years by $716 billion. These include reductions in hospital reimbursements and reductions in payments for Part C plans (Medicare Advantage.)

These cuts were instituted to free up dollars for other aspects of the ACA. Some would call this “robbing Peter to pay Paul.” But others would argue that it is simple prioritization of the funds available; kudos to those who accepted the responsibility for making the difficult decision. Basically these are “price control” mechanisms but price controls rarely work; providers will make up the difference with more visits, procedures, hospitalizations, etc. The proponents note that the plan only reduces payments to the providers; it does not cut benefits. How reducing provider payments will not ultimately result in less for the beneficiaries is a legitimate question.

Physician payments are scheduled to be cut by about 27 percent December 31, 2012. This was based on a formula established in 1997 called the Sustainable Growth Rate. It goes into effect unless Congress explicitly exempts it. Over the years, Congress has repeatedly given such an exemption but only for a short time, allowing themselves to claim that eventually they would enact the cuts and use them to offset budgets. The next cut is set for December 31, 2012. Almost certainly Congress – after the election – will create another short term exemption. Hardly a satisfactory way to govern.

The ACA recognizes that there is a shortage of primary care physicians (PCP) and that PCPs are under reimbursed. To this end, PCP reimbursements will be increased by about 10% over a few years’ time. Just how this increase corresponds with the 27% reduction is unclear.

The ACA also creates some new benefits for enrollees. Chief among them relates to prevention and wellness. Each enrollee is allowed an annual extensive preventive medicine evaluation with no deductibles and no co-pays. Medicare also pays the full cost of screening such as mammography and colonoscopy, cholesterol tests, etc. along with appropriate vaccinations.

The ACA created the Independent Payment Advisory Board (IPAB) whose job it will be to recommend steps to save dollars within Medicare without reducing benefits or without expecting beneficiaries to pay more – a tall order. They will be nominated by the President, ratified by the Senate, have prolonged terms and their recommendations become effective unless Congress votes them down en bloc, i.e., no cherry picking. Republicans have criticized this plan as allotting too much power in a small group of individuals not accountable to anyone. Democrats counter that the structure allows them to be honest brokers unaffected by competing constituencies.

Altogether, the Democrat’s plan is projected to reduce annual Medicare cost escalation from the currently expected about 4% to about 3.5% per year over the coming decade.

The Republicans’ proposals for Medicare are quite different in that they begin with fundamental structural changes that will convert Medicare from a defined benefit to a defined contribution plan. Congressman Paul Ryan, the Republication Vice-Presidential nominee, presented a proposal more than a year ago embedded in the House budget proposal. It was passed in the House only with all no votes from Democrats and died in the Senate. But then, after negotiations with Senator Ron Wyden, a Democrat, they offered a joint bipartisan plan. The essence is to allow individuals to stay with original Medicare or select a plan from a private insurer that offers the same benefits as Medicare. It has no effect until 2023, i.e. only affecting those less than age 55 today. At that time, the age of Medicare eligibility would gradually rise over ten years from age 65 to age 67. Second, each beneficiary could choose to remain with standard Medicare or chose a plan from a private insurer. The government would pay a set amount (“premium support”) towards either original Medicare or the private plan; the individual would have to pay any overage. The amount of premium support, according to the proposal, would be equal to the second lowest plan among the competing insurers, including Medicare, during the first year. Individuals of limited means would be able to purchase at discounted rates. The annual rate of rise of premium support would be limited to the rate of rise of the GDP plus 0.5%. This means that if expenses and hence premiums rose to a greater level, the individual would have to shoulder the excess. In short, the Republican plan counts on competition in the marketplace to drive down costs. In practice, this is very similar to the way the Part D drug benefit works today. Thus Republicans point to the success of Part D to bolster their claim. The Democrats fault this plan in that if costs are not controlled, the onus falls on the enrollee, the one most vulnerable, especially in older ages, and not the insurer nor the government.

Since the Republicans also state that they would repeal or largely repeal the ACA, then the added benefits to Medicare enrollees found in the ACA such as the annual health and wellness review and the preventive care/screening at no cost would presumably be repealed along with the IPAB and the enhanced reimbursement to PCPs. Presumably, the Republican plan would also be to cut physician reimbursement by the formula driven 27% of the SGR although, again, this is very unlikely to ever happen.

The end result of the Republican’s plan (or Ryan-Wyden bipartisan plan) would be to cut the rate of growth of Medicare to about 3.5%, the same as the Democrats’ plan but using a much different methodology.

Two approaches, two very different methodologies each attempting to achieve some slowing of the rate of rise of Medicare cost escalation. Both have pro and cons. Maybe after the election, the parties will come together and develop a truly bipartisan plan – we should hope so because it is surely needed.

Democrats versus Republicans: Two different approaches to Medicare

Stephen C. Schimpff is an internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center and is chair of the advisory committee for Sanovas, Inc. and the author of The Future of Medicine – Megatrends in Healthcare and The Future of Health Care Delivery- Why It Must Change and How It Will Affect You from which this post is partially adapted. 

Candidates Talk Medicaid In Washington Governor’s Race @Medici_Manager

By Ruby de Luna, KUOW

OCT 25, 2012 

This story is part of a reporting partnership that includes KUOWNPR and Kaiser Health News.

Medicaid – and how to expand the program – has become an issue in the competitive governor’s race in Washington State.

In June, the U.S. Supreme Court ruled that the Affordable Care Act went too far by requiring states to expand Medicaid or else lose all federal funding for the program that covers the poor and disabled.

The ruling left it up to states to decide whether or not to open up the program to cover more low-income people without insurance.  In Washington State, Chris Gregoire, the current Democratic governor, chose to continue with plans for expansion.  But Gregoire is not seeking reelection, and whoever is elected governor this fall could change that course.

Inslee (Photo by Ronald Woan via Flickr)

The issue is playing out in an extremely tight racepitting Democrat Jay Inslee, an eight-term congressman from Seattle, against Republican Rob McKenna, the attorney general.Inslee voted for the health law in Congress and he would follow Gregoire’s lead, expanding Medicaid as mandated by the Affordable Care Act. McKenna says he’s for expansion, but with restrictions. For example, he’d like to require current as well as new Medicaid beneficiaries to share costs.

“We’re only one of the few states where there’s not even a $5 co-pay… what we’re saying is that everyone has to have some financial skin in the game, even just a little bit,” McKenna said.

Currently more than 1.2 million Washington residents get health coverage through Medicaid.  Enrollment to the program has gone up since 2008. The state restricts Medicaid to low income children and their parents, people with disabilities, and the elderly.

After expansion, the program will open up to include adults without children.  And eligibility will be based on income. For a single person, that threshold is just under $15,000 in annual income.  For a family of four, it’s $30,657.

McKenna (Photo by KCTS 9 via Flickr)

McKenna’s position is not a standard issue Republican stance. He doesn’t support the reform plan put forward by the Republican presidential ticket of Mitt Romney and Paul Ryan.  As Washington Attorney General, McKenna joined the lawsuit that challenged the Affordable Care Act, but only the part of the lawsuit that opposed the mandate that most individuals must buy insurance.

The Supreme Court rejected that argument, but  McKenna says the Medicaid portion of the ruling gives states some leverage to negotiate with the feds on how to run the program.

Early projections found that about 500,000 Washington residents would qualify under the expanded program, and roughly half of them would enroll.

McKenna wants Medicaid to be maintained as a safety net.  But he fears that many employers will stop providing health insurance for their lower wage employees and those people will end up on Medicaid. He wants more flexibility from the federal government to keep that from happening.

“Our goal needs to be keeping as many people on private coverage as much as possible, and not moving as many people as possible on to Medicaid.”

Inslee says the expansion will help people without insurance, but there are fiscal benefits for the state as a whole, too, because right now everyone bears the cost for those who don’t have health coverage.

“We know that when people do not have insurance, they get their health care in one place, and that’s the emergency room,” Inslee said. “Instead of getting routine treatment for the flu, their asthma, or whatever, from a primary care doctor, they go into the emergency room.  And that costs four to five times more money to have the same treatment in the emergency room.  And you know who it costs—it costs you and me.”

Inslee says those charges are billed to insurance carriers, and the carriers pass on those costs to consumers.  He also argues that expanding Medicaid is one way to make sure that federal taxes paid by Washington residents are used to help Washington.

“Look, we’re going to pay these taxes one way or another.  This money is going to Washington, D.C. one way or another.  The question is where does it go then—does it go just to Florida and California, or does it come back to the state of Washington by hundreds of millions of dollars?”

If Washington continues with Medicaid expansion, the federal government will pick up 100 percent of the tab for the first three years.  Over time, the federal match tapers to 90 percent by 2020.

This story is part of a reporting partnership that includes KUOW, NPR and Kaiser Health News.

We want to hear from you: Contact Kaiser Health News


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Leadership Freak

Some leaders are born; most are made. But, all leadership is influence.

Long-term, powerful influence is never an accident; it’s always intentional.  Experience and research indicate these 22 principles and behaviors dramatically increase leadership-influence.

  1. Extend honor rather than demanding respect.
  2. Dream bigger for others than they dream for themselves.
  3. Serve others – they don’t serve you.
  4. Build confidence by spotlighting successes.
  5. Provide opportunities in new contexts. A series of small wins magnifies potential.
  6. Focus on next levels more than perfecting current skills.
  7. Struggles strengthen; don’t solve stresses for others – solve stresses with others. Expanded here.
  8. Give authority.
  9. Embrace high standards.
  10. Expect accountability.
  11. Listen to and occasionally speak into fears.
  12. Lift them to the point where they lift others.
  13. Question, occasionally suggest, always encourage, sometimes confront.
  14. Align correction with their values and vision not yours.
  15. Don’t pressure them; they will pressure themselves.
  16. Let them point out their own weaknesses…

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L’endorsement per Barack Obama del New York Times. @Medici_Manager

The economy is slowly recovering from the 2008 meltdown, and the country could suffer another recession if the wrong policies take hold. The United States is embroiled in unstable regions that could easily explode into full-blown disaster. An ideological assault from the right has started to undermine the vital health reform law passed in 2010. Those forces are eroding women’s access to health care, and their right to control their lives. Nearly 50 years after passage of the Civil Rights Act, all Americans’ rights are cheapened by the right wing’s determination to deny marriage benefits to a selected group of us. Astonishingly, even the very right to vote is being challenged.

That is the context for the Nov. 6 election, and as stark as it is, the choice is just as clear.

President Obama has shown a firm commitment to using government to help foster growth. He has formed sensible budget policies that are not dedicated to protecting the powerful, and has worked to save the social safety net to protect the powerless. Mr. Obama has impressive achievements despite the implacable wall of refusal erected by Congressional Republicans so intent on stopping him that they risked pushing the nation into depression, held its credit rating hostage, and hobbled economic recovery.

Mitt Romney, the former governor of Massachusetts, has gotten this far with a guile that allows him to say whatever he thinks an audience wants to hear. But he has tied himself to the ultraconservative forces that control the Republican Party and embraced their policies, including reckless budget cuts and 30-year-old, discredited trickle-down ideas. Voters may still be confused about Mr. Romney’s true identity, but they know the Republican Party, and a Romney administration would reflect its agenda. Mr. Romney’s choice of Representative Paul Ryan as his running mate says volumes about that.

We have criticized individual policy choices that Mr. Obama has made over the last four years, and have been impatient with his unwillingness to throw himself into the political fight. But he has shaken off the hesitancy that cost him the first debate, and he approaches the election clearly ready for the partisan battles that would follow his victory.

We are confident he would challenge the Republicans in the “fiscal cliff” battle even if it meant calling their bluff, letting the Bush tax cuts expire and forcing them to confront the budget sequester they created. Electing Mr. Romney would eliminate any hope of deficit reduction that included increased revenues.

In the poisonous atmosphere of this campaign, it may be easy to overlook Mr. Obama’s many important achievements, including carrying out the economic stimulus, saving the auto industry, improving fuel efficiency standards, and making two very fine Supreme Court appointments.

Health Care

Mr. Obama has achieved the most sweeping health care reforms since the passage of Medicare and Medicaid in 1965. The reform law takes a big step toward universal health coverage, a final piece in the social contract.

It was astonishing that Mr. Obama and the Democrats in Congress were able to get a bill past the Republican opposition. But the Republicans’ propagandistic distortions of the new law helped them wrest back control of the House, and they are determined now to repeal the law.

That would eliminate the many benefits the reform has already brought: allowing children under 26 to stay on their parents’ policies; lower drug costs for people on Medicare who are heavy users of prescription drugs; free immunizations, mammograms and contraceptives; a ban on lifetime limits on insurance payments. Insurance companies cannot deny coverage to children with pre-existing conditions. Starting in 2014, insurers must accept all applicants. Once fully in effect, the new law would start to control health care costs.

Mr. Romney has no plan for covering the uninsured beyond his callous assumption that they will use emergency rooms. He wants to use voucher programs to shift more Medicare costs to beneficiaries and block grants to shift more Medicaid costs to the states.

The Economy

Mr. Obama prevented another Great Depression. The economy was cratering when he took office in January 2009. By that June it was growing, and it has been ever since (although at a rate that disappoints everyone), thanks in large part to interventions Mr. Obama championed, like the $840 billion stimulus bill. Republicans say it failed, but it created and preserved 2.5 million jobs and prevented unemployment from reaching 12 percent. Poverty would have been much worse without the billions spent on Medicaid, food stamps and jobless benefits.

Last year, Mr. Obama introduced a jobs plan that included spending on school renovations, repair projects for roads and bridges, aid to states, and more. It was stymied by Republicans. Contrary to Mr. Romney’s claims, Mr. Obama has done good things for small businesses — like pushing through more tax write-offs for new equipment and temporary tax cuts for hiring the unemployed.The Dodd-Frank financial regulation was an important milestone. It is still a work in progress, but it established the Consumer Financial Protection Bureau, initiated reform of the derivatives market, and imposed higher capital requirements for banks. Mr. Romney wants to repeal it.If re-elected, Mr. Obama would be in position to shape the “grand bargain” that could finally combine stimulus like the jobs bill with long-term deficit reduction that includes letting the high-end Bush-era tax cuts expire. Stimulus should come first, and deficit reduction as the economy strengthens. Mr. Obama has not been as aggressive as we would have liked in addressing the housing crisis, but he has increased efforts in refinancing and loan modifications.Mr. Romney’s economic plan, as much as we know about it, is regressive, relying on big tax cuts and deregulation. That kind of plan was not the answer after the financial crisis, and it will not create broad prosperity.
Foreign Affairs
Mr. Obama and his administration have been resolute in attacking Al Qaeda’s leadership, including the killing of Osama bin Laden. He has ended the war in Iraq. Mr. Romney, however, has said he would have insisted on leaving thousands of American soldiers there. He has surrounded himself with Bush administration neocons who helped to engineer the Iraq war, and adopted their militaristic talk in a way that makes a Romney administration’s foreign policies a frightening prospect.Mr. Obama negotiated a much tougher regime of multilateral economic sanctions on Iran. Mr. Romney likes to say the president was ineffective on Iran, but at the final debate he agreed with Mr. Obama’s policies. Mr. Obama deserves credit for his handling of the Arab Spring. The killing goes on in Syria, but the administration is working to identify and support moderate insurgent forces there. At the last debate, Mr. Romney talked about funneling arms through Saudi Arabia and Qatar, which are funneling arms to jihadist groups.Mr. Obama gathered international backing for airstrikes during the Libyan uprising, and kept American military forces in a background role. It was smart policy.In the broadest terms, he introduced a measure of military restraint after the Bush years and helped repair America’s badly damaged reputation in many countries from the low levels to which it had sunk by 2008.The Supreme CourtThe future of the nation’s highest court hangs in the balance in this election — and along with it, reproductive freedom for American women and voting rights for all, to name just two issues. Whoever is president after the election will make at least one appointment to the court, and many more to federal appeals courts and district courts.Mr. Obama, who appointed the impressive Justices Elena Kagan and Sonia Sotomayor, understands how severely damaging conservative activism has been in areas like campaign spending. He would appoint justices and judges who understand that landmarks of equality like the Voting Rights Act must be defended against the steady attack from the right.

Mr. Romney’s campaign Web site says he will “nominate judges in the mold of Chief Justice Roberts and Justices Scalia, Thomas and Alito,” among the most conservative justices in the past 75 years. There is no doubt that he would appoint justices who would seek to overturn Roe v. Wade.
Civil Rights
The extraordinary fact of Mr. Obama’s 2008 election did not usher in a new post-racial era. In fact, the steady undercurrent of racism in national politics is truly disturbing. Mr. Obama, however, has reversed Bush administration policies that chipped away at minorities’ voting rights and has fought laws, like the ones in Arizona, that seek to turn undocumented immigrants into a class of criminals.The military’s odious “don’t ask, don’t tell” rule was finally legislated out of existence, under the Obama administration’s leadership. There are still big hurdles to equality to be brought down, including the Defense of Marriage Act, the outrageous federal law that undermines the rights of gay men and lesbians, even in states that recognize those rights.Though it took Mr. Obama some time to do it, he overcame his hesitation about same-sex marriage and declared his support. That support has helped spur marriage-equality movements around the country. His Justice Department has also stopped defending the Defense of Marriage Act against constitutional challenges.Mr. Romney opposes same-sex marriage and supports the federal act, which not only denies federal benefits and recognition to same-sex couples but allows states to ignore marriages made in other states. His campaign declared that Mr. Romney would not object if states also banned adoption by same-sex couples and restricted their rights to hospital visitation and other privileges.Mr. Romney has been careful to avoid the efforts of some Republicans to criminalize abortion even in the case of women who had been raped, including by family members. He says he is not opposed to contraception, but he has promised to deny federal money to Planned Parenthood, on which millions of women depend for family planning.For these and many other reasons, we enthusiastically endorse President Barack Obama for a second term, and express the hope that his victory will be accompanied by a new Congress willing to work for policies that Americans need.

Fact and fiction in the US election healthcare debate @Medici_Manager

Interessante puntualizzazione di Michael McCarthy sul BMJ!

Associazioni di pazienti: una questione di trasparenza @Medici_Manager @SIHTA_Italia

Nel 2007 una prestigiosa rivista medica come il British medical journal lanciava l’indagine Le associazioni di pazienti devono ricevere soldi dall’industria farmaceutica?. A distanza di anni il tema è ancora dibattuto, ma troppe associazioni di pazienti non sono ancora consapevoli di quanto e come il conflitto di interessi le tocchi direttamente, quali rischi comporta, come si possono affrontare. E soprattutto sono ancora poche le associazioni che lo dichiarano, in particolare in Italia.

Su 157 siti di associazioni di pazienti e cittadini italiane, poco meno del 30% dichiara di ricevere soldi dall’industria farmaceutica. Tutte però ricevono finanziamenti, come risulta dai siti delle industrie farmaceutiche finanziatrici. E’ il risultato di un’indagine condotta dall’Istituto Mario Negri e pubblicata di recente sulla rivista ad accesso libero PLoS ONE. L’ammontare dei finanziamenti viene riportato solo da tre associazioni, pari al 6% delle associazioni dichiaranti, le attività finanziate dalla metà.

Una situazione analoga accade in altri Paesi, con qualche differenza: su 69 siti di associazioni di pazienti e cittadini con sede negli Stati Uniti, Regno Unito, Australia, Sud Africa e alcune associazioni internazionali, di cui nessuna italiana, il 45% dichiara di ricevere finanziamenti dall’industria farmaceutica, nessuno dichiara l’entità dei finanziamenti.

Il punto critico della trasparenza non riguarda solo le associazioni di pazienti: dall’indagine dell’Istituto Mario Negri risulta che anche le industrie farmaceutiche, in particolare quelle con sede in Italia, lasciano a desiderare riguardo alla completezza delle informazioni sulle sponsorizzazioni riportate sui propri siti. Tra le 17 industrie farmaceutiche considerate, 13 (76%) dichiarano almeno un’associazione finanziata, di queste solo il 15% dichiara l’ammontare dei finanziamenti, il 30% le attività finanziate. Tutte hanno dato soldi ad almeno un’associazione di pazienti o cittadini considerata nell’indagine, come risulta dai siti delle associazioni.

Come per i finanziamenti ai medici, anche per i rapporti con le associazioni di pazienti le industrie farmaceutiche dovrebbero dichiarare le associazioni che finanziano, quanti soldi danno, per quali attività e progetti, pubblicando informazioni complete, aggiornate e accessibili sui propri siti internet. Allo stesso modo dovrebbero essere dichiarate le forme di sostegno indiretto, molto frequenti, come per esempio pagare spese o iscrizioni per partecipare a corsi o convegni, o fornire strutture e servizi.

Anche le associazioni di pazienti e cittadini che ricevono soldi dall’industria devono andare in questa direzione, e dichiarare in modo accessibile e completo i finanziamenti ricevuti.

Per alcune associazioni questo in parte già succede, e il dibattito interno su questi temi è avviato da tempo, molte altre sono ancora agli inizi: avviare un confronto tra associazioni di volontariato su questi temi può aumentare la consapevolezza critica e favorire uno scambio sulle pratiche di gestione dei rapporti con gli sponsor.

Questo testo è stato pubblicato su Partecipasalute

Per saperne di più

Kent A. Should patient groups accept money from drug companies? Yes. BMJ 2007; 334: 934-935.
Mintzes B. Should patient groups accept money from drug companies? No. BMJ 2007; 334: 334:935
Colombo C, Mosconi P, Villani W, Garattini S. Patient organizations’ funding from pharmaceutical companies: is disclosure clear, complete and accessible to the public? An italian survey. PLoS One. 2012;7(5):e34974. Epub 2012 May 9.
Ball DE, Tisocki K, Herxheimer A. “Advertising and disclosure of funding on patient organisation websites: a cross-sectional survey” BMC Public Health (2006) 6:201.
Godlee F. A sunshine act for Europe. BMJ 2011;343:d6593

Love or nothing: The real Greek parallel with Weimar @Medici_Manager @martinmckee

Athenians sitting in front of anti-government graffiti

Of all the operas written during Germany’s Weimar Republic (1919-33), probably the most haunting is the last.

Kurt Weill’s The Silver Lake, written with playwright Georg Kaiser, tells the story of two losers – a good-hearted provincial cop and the thief he has shot and wounded – as they make their way through a society ruined by unemployment, corruption and vice.

After spending a week again in Greece – amid riots, hunger and far right violence – I finally understood it.

The opera was meant to be Weill’s path back into the mainstream. It was his first break from collaborating with Bertolt Brecht, and was scheduled to open simultaneously in three German cities on 18 February 1933.

But on 30 January Adolf Hitler was appointed Germany’s chancellor.

The first performances of The Silver Lake were disrupted by Nazi activists in the audience and on 4 March 1933 it was banned. The score was torched, together with its set designs, in the infamous book-burning ceremony outside the opera house in Berlin.

It is easy to see why the Nazis didn’t like The Silver Lake. Weill was Jewish; the Nazi theatre critics found the music “ugly and sick”. Moreover the plot contains an allegory of the political situation on the eve of the Nazis’ rise to power.

But there has always been something else about The Silver Lake that goes beyond politics. Something hard to fathom.

Spending time in Greece, as the far right Golden Dawn party breaks up theatre performances with impunity, and street violence is common, I finally know what that something is.

The Silver Lake is ultimately about how people feel when they switch from resistance to hopelessness. And about how strangely liberating hopelessness can be.

Greece right now is a place with a lot of hopelessness. Its own prime minister, Antonis Samaras, has compared its atmosphere to that of the Weimar Republic.

“Greek democracy stands before what is perhaps its greatest challenge,” Mr Samaras told the German newspaper Handelsblatt. He said social cohesion is “endangered by rising unemployment, just as it was toward the end of the Weimar Republic in Germany”.

The comparison seems plausible: there are far right gangs meting out violence on the streets – a report last week identified more than half of all officially recorded racial attacks as perpetrated by people in paramilitary uniforms. Every demonstration ends with tear gas and baton charges.

There is mass unemployment. There is the collapse of mainstream parties. The press and broadcast media are struggling to remain independent, indeed solvent.

Yet the comparison with the “end of Weimar” only holds if you know nothing about the Weimar Republic itself.

Sadly this condition is common. School students are rightly taught lots about Nazi Germany – but not very much about the detail of how it came into being.

Here’s a short summary. In the elections of 1928 the Nazis, who had – like Golden Dawn in Greece – been reduced to a splinter group in the years of economic recovery, got just 2.7%.

But in March 1930, as the Wall Street Crash cratered the German economy, a cross-party coalition government of the centre left and right collapsed. It was replaced by the first of three “appointed” governments – designed to avoid either the communists or the now-growing Nazis gaining power.

It was led by Heinrich Bruning. Faced with a recession, Bruning followed a policy of austerity, while keeping Germany’s currency pegged to the Gold Standard (much as Greece as follows a policy of austerity dictated by euro membership). This made the recession worse.

As unemployment rocketed, so did the Nazi vote: in a shock breakthrough they came second in the elections of September 1930, with 18%. But Bruning was determined to crack down on both the right and left: he banned the Nazi paramilitary organisation, the sturmabteilung, along with the rival communist uniformed militia.

As recession worsened, the Nazis grew massively: they won the election in 1932, gaining 14 million votes (37%). The socialists and communists combined polled higher. And the parties of the centre collapsed. Yet the presidential system of appointing governments now allowed these very centrist parties to go on ruling Germany – now under a new Chancellor, the aristocrat Franz Von Papen.

Von Papen unbanned the Nazi stormtroopers in June 1932 and, as historian Ian Kershaw puts it in his definitive biography of Hitler: “The latent civil war… was threatening to become an actual civil war.”

By the end of 1932, with the communists now also growing rapidly, the political establishment made one last final attempt to keep Hitler out of power. Right wing general Kurt Von Schleicher was appointed chancellor, and tried to form a government with everybody from the left wing of the Nazis to the socialist trade unions. But this too fell, opening the door to Hitler.

Kershaw wrote: “Only crass errors by the country’s rulers could open up a path [for Hitler]. And only a blatant disregard by Germany’s power elites for safeguarding democracy – in fact, the hope that economic crisis could be used as a vehicle to bring about democracy’s demise and replace it by a form of authoritarianism – could induce such errors. Precisely this is what happened.” (Hitler: Hubris)

These names – Bruning, von Papen, Schleicher – troublesome though they are to remember, should be as famous as the words Stalingrad, Arnhem and Dunkirk.

These were the men who tried and failed to use a mixture of austerity, tough policing and what we might now call “technocratic” rule to save German democracy. They failed.

And herein lies the parallel with Greece: a country committed to austerity, whose centrist parties are clustered into a coalition which represents the forces of conservatism and social democracy. The coalition sees itself as the last bulwark against a government of the far left and is trying to crack down on extremism using a police force which has itself been criticised for extremist leanings.

But despite these parallels, Greece is not on the brink of a Weimar-style collapse.

Nor is it “in civil war” as claimed by a leader of the far right Golden Dawn movement on Newsnight last week. If anything, Greece has levels of instability and political radicalisation close to the levels seen in Germany in early 1930, not late 1933.

The problem is: Greece is approaching 1933 levels of economic collapse.

Unemployment was 30% in Germany when Hitler took power; it is 25.1% and rising in Greece. GDP collapsed by about 7% in both 1931 and 1932 in Germany. Its current rate of collapse in Greece is roughly the same: 7% per year. Germany’s banks had gone bust in 1931. Greek banks are effectively part nationalised already.

You can see the physical impact of this on Stadiou Street in Athens. I have reported from there numerous times in the past two and a half years, but this last time it looked desolate.

There was an arcade where, just over a year ago, I remember blogging about how small specialist businesses in Greece were doomed: the pen shop, the stamp collecting shop, the stationary store. They’re all gone now.

So is much of the street itself. The Art Nouveau cinema burned out last year; the Marfin Bank, next door, torched with the deaths of three workers during a riot in 2010.

On the walls somebody has spray-canned “Love or Nothing”. Right now there is a heck of a lot of nothing: shops closed, stripped, barred, graffitied, the fascias chipped off as ammunition in riots, burned out, gone.

And nowhere is the human impact of this weird situation, clearer than when you talk to young people.

I met Yiannis and Maria in a bare flat in Exarchia, the bohemian district of Athens. Despite their bruises and bandages they took some persuading to go on camera – anonymously and in their hoodies – to put on record their allegations of brutality in police custody.

What struck me, beyond their allegations (which are denied by the police,but partially corroborated by a coroner’s report), was their detachment from regular life.

They expected the police to be brutal, and to be fascists. They were outraged that they’d had to listen (they allege) to Golden Dawn propaganda in the police cells. But they were reluctant to bring a complaint within the system.

For tens of thousands of young people life is already lived in a semi-underground way: squatting instead of renting; cadging food and roll-ups from their friends. Drifting back to their grandparents villages, sofa surfing. Yiannis is a sporadically employed technician in a cultural industry; Maria a highly qualified professional who waits table.

The British author Laurie Penny has captured the situation in a recent memoir of a trip to Athens: “We came here expecting riots. Instead we found ourselves looking at what happens when riots die away and horrified inertia sets in.” (Penny L and Crabapple M, Discordia, Random House 2012)

Horrified inertia is now seeping from the world of the semi-outlawed young activists into the lives of ordinary people.

What people do – whether it is the black-hoodied anarchists in Athens or the young farmers in Thessaly on their third of fourth bottle of beer by lunchtime – is retreat into the personal.

It’s no longer “the personal is political” – but the personal instead of the political. True, demonstrators still turn out in large numbers, as in last week’s General Strike. But they go through the motions – of demonstrating, of rioting even.

“It’s just for show on both sides, the cops and the anarchists,” I was told by my Greek fixer as we legged it through stampeding people and tear gas.

A year ago the buzzword was “anomie” – the fear of anomic breakdown, in which small groups and communities just give up on law and order and make their own. I reported on it then:

Watch Paul’s report on anomic breakdown from September 2011

There is not even much anomic activism anymore; the movement that defied road tolls and disrupted the sale of repossessed homes – which was large in the Spring – is tiny now.

If anything captures the buzzword of late 2012 in Greece it is the person who sprayed the slogan “Love or Nothing”. It’s less about anomie, more about depression.

What has depressed much of Greek society – from the liberal centre right to the liberal left – is the rapid rise of Golden Dawn.

In the two elections of May/June 2012 it scored between 6-7%. Nothing like a 1930-style breakthrough.

But it has begun to do DIY law enforcement against migrants with no intervention from the police. At street markets in Messolonghi and Rafina its uniformed activists checked the permits of migrant stallholders, demonstratively destroying those who did not have permits.

With electoral data showing – on one count – 45% police personnel voting for Golden Dawn, there is rising concern that support for the far right is beginning to skew the operational priorities of the police at local level.

When I challenged Golden Dawn’s second in command, Ilias Panagiotaros, he claimed support within the police at “60% or more”. And he gave a chilling explanation of how Golden Dawn’s extra-judicial actions were affecting the rule of law. Referring to the market stall attacks he said:

“With one incident, which was on camera, the problem was solved – in every open market all over Greece illegal immigrants disappeared. There was some pushing and some fighting – nothing extraordinary, nothing special – only with one phone call saying Golden Dawn is going to pass by the police is going there meaning the brand name [of Golden Dawn] is very effective…”

Greece, in truth, has a massive and apparent problem with illegal migration. The centres of many cities are – or were until this summer – full of young, male migrants from Afghanistan, Somalia, Sudan and increasingly Syria.

Many Greeks do fear them, and they perceive them as a threat to social order and a traditional lifestyle – in a country that never had any colonies and therefore did not experience high ethnic diversity until recently.

The new policy – known as “Hospitable Zeus” is to round migrants up and put them in camps: police in plain clothes or uniforms visibly stopping every person of colour on the street, checking their papers, and if the papers are not in order processing them ultimately to a migrant detention camp.

Even as human rights groups protest this, and demand access to the camps, Golden Dawn has protested outside them on the grounds that conditions are too good there, and that deportations are not fast enough (about six thousand have been detained, with maybe three thousand deported). And even as the police round up the migrants, Golden Dawn’s policy is to terrorise them off the streets, and mount a legal campaign against companies who employ them.

The Greek media, meanwhile, has taken its cue to reinforce the association of migrants with crime. For those seeking an alternative view there are only the newspapers of the far left: the main liberal newspaper – Eleftheropia, an equivalent to the Guardian – went bust and has closed.

Economically, the Greek coalition is getting ready to impose the latest and last round of austerity: 13.5bn euro a year cuts and tax rises, in order to release 31bn euro worth of bailout money.

The moment it puts this to parliament we can expect a big and unruly protest. After that the Coalition just has to hold on and hope that its own electoral support does not go the way the German centrist parties went after 1932.

Unfortunately for them, however, electoral support is slipping. While New Democracy has maintained its poll rating at 27% (compared to 29% in the election), Pasok – the former governing socialist party – is down to 5.5%, neck and neck with coalition partner Democratic Left. The combined poll rating of the pro-austerity parties is now 38%.

Golden Dawn polled 14% last week, while the left wing Syriza party is leading the polls at 30% (taking many votes from the Communists, who are now down to 5%).

However, these poll ratings are unlikely to be tested in an election anytime soon. The EU is working overtime to keep the current coalition together, and as Pasok’s support dwindles to rock bottom, it has no incentive to risk an election now.

So for the majority of people who want the austerity to stop, and who do not want to be gassed, truncheoned, menaced or even to go on strike, there is only the “love or nothing” strategy.

Anecdotally the use of anti-depressants is rising. Penny’s book tells numerous tales of former political activists simply stunned by drink and drugs.

Which brings us back to The Silver Lake.

The “love interest” in Kurt Weill’s opera doesn’t start until the second half, with the arrival of Fennimore, a young woman trapped in a castle with the two losers and a scheming, reactionary aristocrat who has duped them out of their money.

Once Fennimore appears, the music becomes mesmerised and lyrical; it focuses on the combined hopelessness of the two men and the girl.

And in the final sequence – a dream-like 15 minutes during which the men set out to cross the castle’s lake, certain they will drown – there is a mixture of ecstasy and despair.

“You escape from the horror,” Fennimore sings; “that may destroy all we know. Yet the germ of creation will struggle to grow.”

“All this can be a beginning

“And though time turns our day back to night

“Yet the hours of dark will lead onwards

To the dawning of glorious light.”

I have always struggled to understand this ending: why, in the last days of Weimar, did Kurt Weill not pen some anthem of defiance against Nazism rather than a work which, ultimately, expresses resignation?

On the streets of Athens there is already the answer. You can feel what it is like when the political system – and even the rule of law – becomes paralysed and atrophies.

The “hopeless inertia” begins to grip even the middle classes, as the evidence of organised racist violence encroaches into their lives.

Faced with an economic situation dictated by the European Central Bank and the International Monetary Fund, and a street atmosphere resembling Isherwood’s Berlin, the natural human urge is not fight but flight.

Flight away from danger – flight into the cocoon of drugs, relationships, alternative lifestyles, one’s iPod.

After the first-night disruption of The Silver Lake in Leipzig this is how its director, Douglas Sirk, described the scene at the theatre:

“The sturmabteilung filled a fairly large part of the theatre and there was a vast crowd of Nazi Party people outside with banners and god knows what, yelling and all the rest of it. But the majority of the public loved the play… And so I thought at first, well, things are going to be tough but perhaps it isn’t impossible to overcome…[But] no play, no song, could stop this gruesome trend towards inhumanity.” (quoted in Kurt Weill On Stage, by Foster Hirsch)

And this is how the director of Corpus Christi, Laertis Vasiliou, whose play was once again disrupted by far right demonstrators in Athens on Thursday night, described it in a message to me just now:

“We went ahead with the performance, which started with two hours of delay because of the fight outside the theatre between the police against the Christian fundamentalists and the Nazis. It was like hell. The noise from outside was clear inside the theatre during the performance. People were beaten up by Nazis and Christian fanatics.”

The differences with the final days Weimar, then, are clear. Under international pressure, the Greek state is still capable of upholding the rule of law; centrist parties, though atrophied, still hold the allegiance of more than one third of voters; there has been no decisive electoral breakthrough by the far right.

Crucially, no major business or media groups, and no significant portion of the elite, have swung behind the far right as happened in Germany.

But this flight to inertia, depression, to personal life may also be more pronounced than in Weimar. Weimar Germany was after all a society of intense political engagement; of hierarchical politics, lifelong commitment to social movements, trade unions, military veterans’ groups.

So while the crisis may be on a scale weaker than the one that collapsed democracy in Greece, the forces holding democracy together may also be weaker.

When I interviewed Golden Dawn MP, Ilias Panagiotaros, two weeks ago, he was clear as to the party’s project: if Syriza wins the election, “we will win the one after that”.

“Revolution will take place after two elections by giving first place to Golden Dawn; now we are third, and maybe we will get second place – so it’s not a dream that in one, two or three years we will be the first political party.”

The leaders of the international community, busy negotiating the last-ditch austerity package that is supposed to precede a strategic rescue of the country know what the stakes are.

If they fail, a whole generation of Greek young people will be left, like Weill’s protagonists in The Silver Lake, with a choice between love or nothing.

The Cost of Assuming Doctors Know Best @Medici_Manager @hesham_abdalla

Articolo pubblicato da The Atlantic (

The success of a hospital system in Washington state is a strong signal that patient decision aids are powerful quality-improving, cost-cutting tools — but change is stalled by bad financial incentives.


Group Health Cooperative, Bellvue, Washington (BenjaminBenschneider/AECOM)

In most industries, quality-improving and cost-cutting innovations don’t sit around for years while people keep muddling through with old technology. When an innovation is ready for widespread use, it disrupts the market, whether the market wants it or not. In the process, some entrepreneur usually makes a killing.

That process hasn’t worked in healthcare, though — and because of that, we have a whole set of rarely-used innovations that are ready for large-scale implementation, and that could start saving money today. Those technologies include simple things like broader use of generic drugs, which can reduce pharmaceutical costs significantly; and better hand washing, which reduces the transmission of disease within hospitals and doctor’s offices. They also include more complicated interventions like Lean management, which has been implemented successfully at hospitals like Virginia Mason Medical Center in Seattle and Thedacare in Wisconsin, to make their care processes more efficient by cutting out useless steps.

The habit of assuming the doctor knows best has created a system where huge numbers of patients aren’t getting the treatment they would have chosen if they were fully informed.

Then there’s shared decision making, which helps patients be better informed about their treatment choices and make better decisions — and might be the most promising of the bunch in terms of improving care and reducing spending.

Shared decision making is a way of dealing with the tough questions posed by “preference-sensitive conditions” — conditions where there are multiple treatment options, and none of those options is clearly better than the others. That includes conditions like arthritis in knees and hips, low back pain, stable angina (chest pain from heart disease), and early-stage prostate and breast cancer. (Obviously, it doesn’t include emergency conditions like heart attacks and hip fractures, or conditions where there is clearly only one treatment.)

Deciding on a treatment for preference-sensitive conditions involves weighing a variety of risks and possible benefits, and different patients will end up making different “right” decisions because they have different values and preferences. The best example here is women with early-stage breast cancer. They can choose lumpectomy (surgery that preserves the breast) or mastectomy (which removes it entirely). The two options are equally good in terms of reducing the risk of dying of breast cancer, but they require different kinds of follow-up and different women prefer one over the other.

Making such decisions means that patients must have the relevant information about all their treatment options, and doctors must understand their individual patients’ preferences — basically, what they want from treatment. But too often, patients only hear about one treatment option, the one the doctor usually uses — and doctors routinely assume they know what their patients want without actually asking them. And in many cases, the doctor is wrong.

This habit of assuming the doctor knows best has created a system where huge numbers of patients aren’t getting the treatment they would have chosen if they were fully informed. It also means that hundreds of thousands of patients are going through surgery that wasn’t really worth it, and that they wouldn’t have chosen had they understood their options.

Shared decision making is a process designed to ensure that patients are fully informed, and then use that information to get the treatment they want. A common though non-essential part of informing patients is a “patient decision aid.” Decision aids can be videos, websites, or pamphlets, and they present the available medical evidence on all reasonable treatment options — including the option to do nothing — in a way that patients can understand. Decision aids also help patients understand what they value and how much risk they’re willing to accept. Doctors can participate in the process, too, by clarifying things for the patient and helping make sure there’s a good match between the treatment and what the patient wants.

There have been more than 80 randomized controlled trials on the effects of patient decision aids, and the results are pretty clear. According to the Cochrane Collaboration, which reviews groups of studies, using patient decision aids improves the match between patients’ preferences, improves patients’ knowledge of the possible results of treatment, and reduces the number of patients who still don’t know what they want.

Here’s the icing on the cake in terms of health care spending: Patients also tend to choose less invasive (and therefore less expensive) treatment options.

Even after those impressive results, shared decision making hasn’t reached universal adoption. One reason may be that randomized control trials aren’t always able to be generalized to medical practice as a whole. In theory, they’re the scientific gold standard for measuring effectiveness, but the environment of the trial can sometimes skew the results (because patients or doctors in trials are different from their real-world counterparts, or because people behave differently when they’re being watched).

But a new study from a hospital system in Washington state should be a strong signal to other hospital systems that implementation is possible, and shared decision making and patient decision aids are just as powerful as we expected them to be. Soon patients will understand their effects, and hospitals that don’t use decision aids risk getting left behind.

The Washington legislature recognized back in 2007 that decision aids are a valuable tool for improving medical care by helping patients make better decisions. They passed a law providing greater legal protection to providers who use shared decision making, rather than standard informed consent, and that law required the state to study the effects of shared decision making. As part of that study, Group Health Cooperative (an integrated insurer and hospital system) gave all 660,000 of their patients access to decision aids when they were considering any of a dozen preference-sensitive treatments. They also made all of the doctors and staff watch the decision aids, and kept physicians informed of how many of their patients were choosing surgery.

The results were striking. The paper, published in the September edition of Health Affairs, covers two orthopedic procedures — knee replacement and hip replacement for arthritis of those joints. During the year and a half immediately after they introduced the decision aids, rates of hip replacement fell over 25%; knee replacement went down 38%. Total spending went down 21% on patients with hip osteoarthritis and 12% for knee patients — not just on those patients who skipped surgery, but for the whole study population. That amounts to well over $1000 a year in true medical savings — money that can be spent on something else entirely, and isn’t just shifted from one payer to another.

Allow us to reinforce something from that last paragraph: over a quarter of patients were choosing not to have surgery once they were better informed. Looking at that one way, it’s great news: We can save a ton of money and make patients better off, just by doing a better job of targeting elective surgery. But it’s also a vicious indictment of our current practices: every day we continue not using decision aids, our medical system knowingly puts patients at risk of a wrong-patient error.

If shared decision making is so wonderful, why aren’t we already using it in every hospital and every doctor’s office?

The answers are neither satisfying nor pleasant. The most important reason should be obvious: the way we finance healthcare is set up to reward doing more, rather than doing good. This is particularly the case when it comes to elective surgeries. Group Health was able to make money by using decision aids to improve care, because they’re an integrated insurer and delivery system. When patients spend less on unwanted surgery, Group Health doesn’t lose money. Similarly, all Group Health physicians are salaried, so their surgeons get paid the same amount whether their patients get lots of surgeries or not. Most healthcare organizations don’t work that way, though–doctors and institutions get paid based on some form of fee-for-service, meaning they take in more money when they do more procedures.

Changing that payment system will be tough, but it needs to be done, because fee-for-service payment isn’t just making us spend more money than we need to for good care — it’s actually making our medical system worse.

Shared decision making isn’t the only technology being held up by bad financial incentives. Lean management, as we mentioned earlier, has been incredibly successful in reducing both process waste and overuse in a number of hospital systems across the country. But the payment system still forces systems that eliminate duplicative tests and unnecessary treatments to risk losing needed revenue. It’s much easier to continue over-treating patients, and continue getting paid to do it. We need a system that rewards entrepreneurs for eliminating waste as well as it rewards them for giving us new options. We’re not taking full advantage of the technology we have until we only use it where it works.

SHANNON BROWNLEE & JOE COLUCCI – Shannon Brownlee is the acting director of the health policy program at the New America Foundation. She has written previously for The Atlantic,New York Times Magazine, and The New Republic, among others. Joe Colucci is a program associate in the New America Foundation’s Health Policy Program and editor of the program’s New Health Dialogue blog.

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Coaching Introverts @helenbevan @ReadyToManage @Medici_manager


Introverts are getting a great deal of attention recently, in part due to Susan Cain’s popular book, “Quiet: The Power of Introverts,” published last year and this year’s Scientific American article, The Power of Introverts: A Manifesto for Quiet Brilliance. In the past, introverts tended to be criticized as less, somehow, in need of being “fixed” or “brought out of their shell” by extroverts. This perception may have arisen from lack of knowledge and is explored in this article by examining how introverts might best be coached in the workplace as one factor among many in coaching skill-building.

First, we’ll tackle a few basic questions before moving on to specific coaching strategies. This initial groundwork looks at these questions: what is an introvert? how does an introvert generally relate to the world? and finally what percentage of the world is introverted versus extraverted?

What is an introvert?

According to Carl Jung, the psychologist who defined the terms introversion and extraversion in the language, Introversion is all about drawing energy from the internal world of thoughts and ideas, preferring depth and pausing for thought. Jung would say that the unconscious preoccupation of introverts is therefore privacy. Extraversion, on the other hand, is about drawing energy from the world of people, things, and activities, and dealing in breadth rather than depth. Jung would say that the unconscious preoccupation of extraverts is therefore access to people. Introverts then tend to focus on their own inner world of ideas and experiences. They direct their energy and attention inward and receive energy from their internal thoughts, feelings and reflections. They tend to enjoy quiet for concentration and do not mind working on one project for a long time. They usually prefer working alone and develop their ideas through reflection.

People who prefer introversion are energized when they are involved with the ideas, images, memories, and reactions that are a part of their inner world. Introverts often prefer solitary activities or spending time with one or two others with whom they feel an affinity, and they often have a calming effect on those around them.

Introverts often take time to reflect on ideas that explain the outer world. With their orientation to the inner world, introverts truly like the idea of something, often better than the something itself, and ideas are almost solid things for them.

So, in summary, people who prefer introversion are likely to:

  • Be mainly private and contained
  • Enjoy being calm and “centered” or reserved (preferring reflection in general). This means they tend to reflect before acting or speaking
  • Feel comfortable being alone and like solitary activities
  • Prefer fewer, more intense relationships socially (and may need time to recover from heavy socializing)
  • Sometimes spend too much time reflecting and may not move into action quickly (usually wanting to understand things thoroughly before acting)
  • Often like quiet space in which to work or concentrate
  • Sometimes forget to check with the outside world to see if their ideas really fit their experience (as they are drawn to inner world of thoughts and ideas)

To contrast the introvert with the extravert, the following table may help (and, you will notice that both lists start and end with how extraverts and introverts use energy: 

Extraversion Introversion
  • Energized by what goes on in the outer world
  • Need to talk to clarify what they think
  • Can be seen as accessible and understandable
  • Difficult for them to just sit and listen
  • Often work to change the world
  • Interests often have breadth
  • Interaction
  • Multiplicity of relationships
  • Expenditure of energies
  • Energized by what goes on in their own inner world
  • Need to reflect and clarify internally before they talk
  • Can be seen as subtle and difficult to know well initially
  • Work quietly, often without interruption
  • Often work to understand the world
  • Interests often have depth
  • Concentration
  • Limited relationships
  • Conservation of energies

How does an introvert generally relate to the world?

Quiet people may be introverted but this is not always the case, as extraverts can be quiet for a short period and some introverts can adopt more extraverted and non-quiet behaviors for a period. We can tune into the language that introverts tend to use to get a better idea of when individuals may have a greater preference for introversion. Hence, we might hear statements such as:

  • “I have to reflect on that” (although they may just do this and say nothing!)
  • “I have had one or two close friends most of my life.”
  • “I can usually concentrate/focus pretty well.”
  • “I prefer not to make speeches/presentations/talking in public.”
  • “Let me think about it and I’ll have an answer for you tomorrow.”
  • “I’d rather do it on my own.”

Outside of observing language clues we might also see the following general behaviors:

  • Often require a lot of time alone (but can often tune out very effectively and hence be alone in a crowd).
  • Dislike interruptions.
  • Can’t be easily pressured into talking about an issue until ready (may take quite a long time).
  • Is often intense and passionate even though it may often not show, seeming to take life very seriously.
  • Must generally understand a thing before trying it.
  • Generally think carefully before speaking or acting.
  • Often very good listeners.
  • Generally dislike small talk.

What percentage of the world is introverted versus extraverted?

It is popularly thought that introverts are only 25-30% of the total population. However, the managers of the Jungian based Myers-Briggs Type Indicator (or MBTI®) have more recently reported that in a population of hundreds of thousands of assessment-takes the split is 51:49 in favor of Introverts. For the purposes of this article we are going to assume that there is approximately the same amount of introverts as extraverts or it is a 50:50 split. An article on this subject can be found at the “Thoughtful self-improvement” site at 

Coaching the introvert

Now that we have understood more about introverted preferences, let’s turn our attention to how best to coach an introvert. Perhaps the best place to start is to look at the kind of frustrations and/or goals that introverts are likely to have in the workplace. Although this is both an incomplete and non-specific list below are ten of the most common ones:

1.  A wish to boost overall ability to interact (often confused with external show of confidence and self-esteem) – introverts (and not exclusively of course) may suffer from low self-esteem where they have become over-introspective and/or when they have lost confidence in their inner means to cope with their work environment. A coach may therefore need to help them to develop greater confidence (often by getting them to give more of their assistance and advice to others).

2.  A wish to contribute more in important workplace discussions and/or decisions – Extraverts may well become impatient with introverts in significant discussions when important decisions have to be made (especially when time is pressing) so an introvert may feel unheard or sidelined. However, introverts can typically be much more effective in difficult problem-solving situations and when complex issues need to be thought through and a coach can help in getting introverts to better promote these skills as a key step in important discussions or before key decisions are made. 

3.  A wish for a greater connection to others – Introverts can feel incompetent or unskilled in communicating and connecting with others (despite their need to spend time alone to think and reflect on a regular basis). A coach may therefore need to help them to develop approaches to connect with other people.

4.  A wish to overcome apparent shyness (at least to some degree) – Shyness may be a sign of introverts under-developed social skills and/or under-developed sense of self. There is a huge difference between an introvert who requires quiet time and an introvert who avoids people wherever possible. The former is taking necessary time and keeping his or her energy “battery” charged whereas the latter is being avoidant and potentially not helping him or herself and the team of which he or she is a part. A coach may therefore need to help an introvert to develop the ability to enjoy limited socializing that is commensurate and comfortable for the introvert’s overall temperament. 

5.  A wish to be less “perfectionistic” at times – Most introverts want to evolve thinking such that the output of their thinking is as near perfect as possible. But if this goes too far, the perfectionism may negatively impact the introvert and others (and create a sense of slowing things down unnecessarily). Coaching can help here by providing a more objective perspective on the introvert’s introspection and by identifying a way of being at least somewhat more pragmatic when time and circumstances demand it. 

6.  A wish to deal more effectively with the dominance of extraverts in the workplace – Most introverts see extraverts to be more assertive and even pushy, confident (perhaps overly so) and prone to jump-around a lot. This approach often puts them “in-charge” of tasks and projects (even if they are not the official leader). This can be irritating to an introvert, especially if he or she is the knowledge expert and he or she may therefore just withdraw and let the extravert “dig his/her own grave”. A coach therefore needs to work with the introvert to find common ground with the extravert by not withdrawing and getting information to them in different ways-such as ahead of time in writing or quietly on a one-on-one basis after a discussion.

7.  A wish to work more effectively in the fast-paced work climate that is often required – Today’s work environment often requires work to meet difficult to achieve deadlines. A coach can work with an introvert to help develop different ways to contribute that meet the pressure of a deadline, or sometimes show why changing a deadline (to allow for deeper thinking perhaps) may create a better result.

8.  A wish to promote their own agenda and needs at work and when networking – While an extravert will not be slow at putting him or herself forward, the introvert may find self-promotion to be extremely difficult. Here a coach can work with an introvert to pre-identify/pre-prepare important issues and contributions that should be made, so that they can put forward in pithy and impactful ways in more public environments.

9.  A wish to more effectively contribute effectively in meetings – Extraverts will often call meetings, chair them and do most of the talking (it is after all an extraverted communication format with lots of people talking about lots of things in a fixed time period). An introvert may never therefore feel totally comfortable in this climate but a coach can work with an introvert to ask questions of others and communicate both before and after to ensure their input is heard. This helps to emphasise that their input is important and insightful and worth sharing. (this in turn boosts their confidence in themselves/ their ability. They may need strong encouragement and strategies for getting their ideas on the table and to realize that an idea does NOT have to be carefully crafted before it is put into the outside world.

10. A wish to put themselves forward strongly enough to lead projects and even gain promotion – Introverts will put themselves forward for jobs they think they are capable of doing but may not see themselves to be the forceful leader that is required. A coach can therefore work with an introvert to increase confidence in his or her own ability and give them strategies for leadership that are a comfortable fit for his or her temperament. 

So, how should a coach relate to an introvert?

All of the above often boils down to one major issue – communication. Of course, both extraverts and introverts have helpful and hindering behaviors, as the table below illustrates:

Communicating – Extraversion and Introversion

Potentially helpful Potentially hindering
Extraversion  being outgoing and sociable; being spontaneous and enthusiastic; enjoying talking through ideas with peers and the people you manage; demonstrating energy overwhelming people; finding listening difficult; wanting to get to action too quickly; being easily distracted; appearing to have a ‘butterfly’ approach
Introversion  a reflective style which allows people space; listening attentively; concentrating on what is happening below the surface; staying calm appearing withdrawn or moody; lacking in social confidence; seeming over-intense; disliking large meetings; appearing lacking in presence

A coach can help an introvert in at least three of the four boxes in the above table. This is not only with the potentially hindering behavior of the extravert and introvert but also in helping the introverted individual to promote him or herself in the more positive ways that he or she can contribute to the team.  To do this there are effective strategies for a coach to adopt, as well as approaches to avoid as follows:

Effective coaching strategies to adopt with Introverts Coaching approaches to avoid with Introverts
Allow an introvert time to “mine” his or her internal feelings and thoughts-this means being more patient in general Don’t spend time on small talk
Always operate in a calm and considerate manner (avoiding too much gesticulation or histrionics) Don’t introduce multiple points one after the other or overwhelm with a lot of unrelated data
Listen carefully using occasional paraphrases to check for understanding Avoid “jumping in” too quickly and completing sentences or thoughts for introverts
Introduce points one at a time and allow them to be fully discussed Try to discourage too much introspection or unhelpful “wallowing” in an issue
Ask searching questions about complex issues Get them to respond to statements or questions immediately
Let silence reign and allow time for answers Don’t push for action too early
Encourage the introvert to partner with others (but perhaps just one or two people) on tasks and projects on a limited basis Don’t push them to be more extraverted
Allow them to talk about details or minor points (these may be more important than at first appears) Encourage them into group or team coaching
Assign homework and reading between sessions for study and reflection Don’t let a session ramble on too long-it will overwhelm the introvert who will want to escape.

And finally, how should an introvert relate to his or her coach?

If an introvert is dealing with an introverted coach, then there may be a more comfortable relationship. However, even here the coach may be pushing quite hard towards outcomes. Where the coach is an extravert, this pushing may be even more apparent however, and it is therefore up to the introverted person to play his or her part in managing the relationship to get the most from the experience. Here are therefore a few ways in which this can be done:

  • Always bring a notepad/journal to a coaching session – take notes and keep a record of thoughts/feelings for yourself.
  • Ask your coach for direct and candid feedback.
  • Speak up when you need more time to reflect on what has been asked of you or when a subject warrants it, or when you have a more important concern to discuss.
  • Specifically let your coach know when you are starting to share your private views–the ones that you keep to yourself in usual circumstances.
  • Let your coach know directly if you are not comfortable in sharing some information or you prefer not to answer a question that has been put to you.
  • When working with a highly extravert coach be prepared to apply a metaphorical “hammer” from time to time to get his or her attention.
  • After your coaching session, keep a running record of brief notes on what you thought after you have had time to ponder things – write down what you are learning.
  • Make a list of new questions or issues and bring it with you to your next coaching session.
  • Try and be as willing as possible to attempt something new or different that you may not otherwise consider. Small stretch tasks will eventually help to make bigger stretches.
  • Talk to new colleagues and build new relationships as you become comfortable in doing so when being coached – start with other introverts. Relate the experience to your coach.
  • Take the whole coaching journey step-by-step and let things unfold as slowly as you like. Your coach at your pace, you do not have to work at theirs. 


Introverts have much to bring to any workplace. In general they are more effective than extraverts at focusing or concentrating on important issues, thinking deeply about them and coming up with new, different or well thought through ideas (often noticing or picking up important details that extraverts may miss entirely). They may need a little more time and space to perform this role, and may need assistance in teasing out their ideas, but results usually make this extremely worthwhile. The more that extroverts therefore become knowledgeable about introverts, the less tension and misunderstanding there will be among the two and the higher overall workplace productivity will become. To finally summarize, if you don’t know what an extravert is thinking you haven’t been listening but if you don’t know what an introvert is thinking, you haven’t asked. And as a final contrast, albeit with tongue in cheek, the table below from counseling group New Reflections leaves no doubt about the differences.

An Introverts Versus Extraverts Lexicon

WORD  Extrovert’s Definition  Introvert’s Definition 
Alone, adj. Lonely. Enjoying some peace and quiet.
Book, n.  1) Doorstop.
2) Paperweight.
1) Source of comfort.
2) Safe and inexpensive method of travelling, having adventures, and meeting interesting people.
Bored, adj.  Not frantically busy. Stuck making small talk, and unable to escape politely.
Extrovert, n.  A nice, normal, sociable person. Never surprises you with anything weird. A boisterous person who may be very nice, but who is somewhat exhausting to spend time with. Usually not too deep, but fun.
Free time, n.  A time when you do group activities. (See Introvert’s Definition of work.) A time when you read without interruption until you’re in danger of going blind.
Friend, n.  Someone who makes sure that you’re never alone. Someone who understands that you’re not rejecting them when you need to be alone.
Good manners, n.  Making sure people aren’t left all by themselves. Filling in any silences in a conversation. Not bothering people, unless it’s necessary, or they approach you. (Sometimes you can bother people you know well, but make sure they aren’t busy first.)
Home, n.  A place to invite everybody you know. A place to hide from everybody you know.
Internet, n.  1) Another medium for advertising.
2) A place where geeks with no life hang out.
A way to meet other introverts. You don’t have to go out, and writing allows you to think before just blurting something out.
Introvert, n.  One of those who like to read. Moody loners. Be careful not to tick them off; some of them are serial killers. One who shows a perfectly natural restraint and caution when meeting new people. One who appreciates solitude. Often, one who enjoys reading and has a philosophical turn of mind.
Love, n.  Never having to do anything alone. Being understood and appreciated.
Music, n.  Background noise. Something with a tune and lyrics which may be moving and intelligent, or may be drivel.
Phone, n.  Lifeline to other people – your reason for living. Necessary evil, and yet another interruption. Occasionally useful, but mostly a nuisance.
Reading, v.  A chore that a teacher makes you do when you’re a kid. You have to do it in secret and pretend you don’t really do it, or people think you’re strange.
Shell, n.  Something you find on the beach. What people relentlessly nag you to come out of. Why do you have to leave it, if you’re happy there?
To go out, v.  Requires at least two people, and the more the better. Constant chatter, loud music, sports, crowds, and food consumption are all fun components of going out. Can be done alone or with others. Enjoyable if there’s some point to it; i.e., in order to see a band, a movie, a play, or perhaps to have a stimulating discussion with one or two close friends.
Work, n.  Having to read, write, listen, or concentrate on anything. Being pestered every five minutes about something trivial, and not allowed to concentrate.

From: New Reflections Counseling, Inc

Related Resources

The Innovation Matrix Reloaded, Again @helenbevan @timkastelle @Medici_Manager

by  on 1 April 2012 in innovation strategyThe Innovation Matrix

vedere anche : Xiameter Case Study: Adding Business Model Innovation

I’ve continued to test out the ideas behind The Innovation Matrix with senior managers, and it seems to be working its way towards becoming a useful tool. As I do this, it continues to evolve.

Today, I am going to revisit The Innovation Matrix as a broad concept, then over the next couple of weeks I will add posts that talk about each component specifically. This added detail should help to flesh out the tool.

Here is the latest version of The Innovation Matrix:

This is a bit of a distillation of observations over time.  I thought of it because I think that a lot of people that are trying to improve innovation within an organisation think that they can go from the bottom left (No Innovation Capability) to the top right (World Class Innovator) in one jump, simply by introducing some sort of innovation program.

This is impossible – you actually have to make the trip in a number of steps, and there are many different paths that you can take.

The table has two increasing dimensions.  Across the horizontal axis there is increasing Innovation Commitment.  This can include things like talking about how innovation is important, including it as a core value, putting in systems to support and improve innovation, and explicitly earmarking time, money and other resources to innovation. This is measuring innovation inputs. You can also think of this as top-down innovation initiatives.

Going up the vertical axis shows an increase in Innovation Competence – mainly the ability to generate and successfully execute new ideas. This can include things like the actual number and nature of innovations that are implemented, the organisation’s effectiveness across all phases of the idea management process, the breadth of innovations, and outputs across an innovation portfolio. This measures innovation outputs – and it is all about execution.

Here is a brief description of each box:

  1. Not Innovating Very Much: these firms don’t innovate.  This isn’t necessarily bad – there’s no value judgment being made. They can be successful if they have strong positions in stable industries, or they can be average performers or struggling in other circumstances.  I think we can probably all think of examples for this category.
  2. Thinking About Innovation: firms in this category are starting to talk about the importance of innovation.  They might add it to their list of core values, or have a CEO that is starting to talk it up.  Regardless of this increase in awareness and commitment, they are still not very good at it.  This is often the first step that organisations take in trying to improve innovation.
  3. Bewildered: the primary features of firms here are confusion and frustration.  They are talking the talk, with official innovation programs, commitment of time and resources, etc.  But they’re still lousy at actually executing ideas.  They may have an excessive focus on ideation, a bad selection process, or just not be very good at executing.
  4. Accidental Innovators: These would be firms that innovate under some other name – so they might be really good at process innovations through a continuous improvement or lean program.  They are able to execute ideas reasonably well, but they don’t have any structure in place to support it, nor do they think that they’re innovative. They innovate through stealth. Many startups operate in this space too.
  5. Fit for Purpose: these firms have some structure in place to support innovation, and they are getting better at doing it. In many industries, this is the baseline level of innovation needed to stay in the game over the long run. Several firms that I work with have gotten to this level after moving first to Talking About Innovation.
  6. Potential Stars: these firms are good at innovating, and they are putting more resources into getting better at it.  They have top-level commitment to innovation, good processes in place, and dedicated resources for innovation.  They are reasonably good at executing new ideas and have the potential to become extremely good.
  7. Unicorns: the problem with making a matrix is that you have to put something into every box, even if it’s mythical.
  8. Stars (at risk): this might seem like the perfect place to be – very good at executing new ideas, but with less structure. These firms aren’t sinking huge amounts of resources into the process, but they are consciously trying to innovate. The risk is that because they lack full commitment to innovation, it might not become systematized, and their performance could drop.
  9. World Class Innovatorsanother self-explanatory category. In these firms innovation is deeply embedded in the culture – everything is oriented around innovation. Think Google, Apple, 3M, Procter & Gamble etc.

How to use this:

Here are some things that I think we can do with this:

  • Use it to make a better model of how firms improve at innovation:  Many of the people I work with are in firms towards the bottom left, and many of the examples that we use to illustrate points are from firms in the top right (Google, P&G, 3M, etc.).  This might be too big a conceptual jump. Not every firm can get to the top right, and neither should every firm aim to. It is more productive to think of this as an incremental process of steps, rather than one big jump.
  • Track the evolution of firms: we can learn about how to best manage innovation by tracking how firms progress through this matrix.  For example, one firm I work with started by Not Innovating Very Much, then started talking about it and moved to Thinking About Innovation, and now that they are getting better at it they are Fit for Purpose. Tracking these trajectories will give us a better idea of which paths work, and which are riskier.  See the case study links at the bottom of this post for examples.
  • Realise that there are multiple targets to shoot for: Like I said, not every organisation can be Google. Thinking about innovation with this matrix, you can see that all of the categories in the top row are excellent at innovation. However, the farther you go to the right, the more resources you have to commit to build and maintain this level of excellence. There are many situations where you can try to be an excellent innovator with a more bottom-up, less resource-intensive system in place. Also, there are many cases where it is fine to be Fit for Purpose. Your differentiation doesn’t come directly from innovation, so you just need to be good enough.
  • Think About the Best Path to Follow: Almost everyone starts by increasing commitment.  The danger with this is that you can end up Bewildered.  I wonder if we should be figuring out ways to improve capability rather than commitment.  Or is this even possible? It’s an interesting question, and you can certainly make a strong argument in favour of increasing capability before you increase how much you talk about innovating.

The main point with The Innovation Matrix is that improving your innovation performance is a journey of many steps, not simply one big leap. The matrix is designed to help us think about this more accurately, and to be more successful at improving our innovation performance.

If you have any thoughts on this, we’d love to hear them.

Case Studies:

About Tim

Idea Connector – Studies innovation networks – author, speaker & consultant on innovation – University of Queensland Business School – links to academic papers, twitter, and so on can be found here.

The Philosophy of Motivation @helenbevan @Medici_Manager

Peter Drucker, the legendary management theorist, told us that we have to “accept the fact that we have to treat almost anybody as a volunteer.”

In other words, we can’t just order people around and expect them to do what we want, we have to get them to want what we want.  An entire industry of compensation consultants has emerged to answer that question, but nevertheless most employees feel unmotivated.

We need to drastically change how we think about incentives.  For years, compensation specialists have focused on rational benefits to employment, with poor results.  We’ve known for a long time that people don’t behave rationally.  Motivation is primarily an emotional business and at its root is not economic exchange, but human dignity.

A Failed Rational Model

Traditionally, employment has been viewed economically.  Employees exchange their labor for pay with which they can procure goods and services they enjoy.  They also value leisure time with their family and friends, training to increase their economic value and so on. Therefore, or so the thinking goes, motivating employees entails giving them more of the things that they want.

However, it should be clear that there is something wrong with that notion.  Many billionaires, after all, work obsessively long after monetary rewards have lost their meaning.  Highly skilled doctors forsake monetary rewards to go to remote parts of the world with Doctors Without Borders. People act contrary to economic interest all the time.

When motivated people wake up in the morning, they don’t think, “I have to send this e-mail, so that I can earn a certain amount towards my rent, a fraction of my vacation time and a sliver of my health benefits.  They want to achieve something.

As I argued previously, the reliance on rational explanations for behavior reflects a failed philosophy from centuries past.  In actuality, we base very little of our decision making on reason, most are emotionally driven.  Evolution has wired us that way.

The Importance of Dignity

Of course, accepting that employees are emotionally driven presents a problem.  We certainly can’t condone people throwing tantrums in meetings or freaking out in the hallways, nor can we make ourselves fully accountable for the happiness of others.  What we can do, however, is act in accordance with dignity.

Immanuel Kant, back in the 18th Century, explained that treating people with dignity means treating them as ends in themselves, rather than as simply means and that’s really the crux of it.  Where many organizations start with the question of how they can get employees to do more of what they want them to do, high performing ones focus on helping them achieve more.

In other words, motivation is much more about intrinsic rewards than extrinsic rewards.
Motivated people join an organization in good faith and expect to find meaning in their work, instead they get an incentive program.  No wonder they get discouraged.

Daniel Pink’s “Drive” Framework

Of course, there’s more than just philosophy at stake here, but results.  While it may be nice that employees feel good about what they do, unless there is clear evidence that doing so will produce better outcomes, then it’s all just fluffy talk.

In his book Drive, author Daniel Pink cites on decades of studies that show that for problem solving and creative tasks (i.e. most of what professionals do today), incentive pay often decreases productivity, especially for tasks that require creative thinking. He outlines his research in this video:

Autonomy:  Being able to organize and direct your own work is essential to dignity. Google is famous for the success of its “20% rule,” which lets (in fact demands) employees spend 20% of their time on their own projects.

However, it’s not just hi-tech companies that can benefit.  Whole Foods has achieved out-sized results in supermarkets by encouraging teams to self-manage.

Mastery: People like to get better at things.  They will even do it for free.  Why is it that Wikipedia, open source software platforms like Apache and Linux and blogs can unlock an enormous amount of creativity but many for-profit corporations cannot?

People expend enormous time and effort on these things because mastery is an end in itself, not a means to an end.

Purpose:  Uber-guru Gary Hamel, in his book The Future of Management, emphasizes the need to build a “community of purpose.”  While profits are important, the most talented people want to feel that their work contributes something more to the world than just a better bottom line.

The Passion Economy

Clearly, something has changed.  In times past, Rockefeller, Carnegie or Vanderbilt didn’t worry about how employees felt.  They were much more likely to respond to disgruntled workers with Pinkerton guards than with autonomy, mastery and purpose.  We have left the industrial economy behind long ago, we are now in a passion economy.

That makes all the difference.  In the industrial age, value was created by harnessing energy.  In the passion economy, value is created through superior design.  Google’s algorithms, Apple’s user interfaces, Whole foods selection and service, they all were created through passionate employees working with autonomy, master and purpose.

However, what’s often missed is that these companies succeed not just through superior practices, but superior philosophy.  They recognize that their employees achievements are not only a means to attaining greater objectives, they are, in fact, ends in themselves.

– Greg

Ed ora anche il welfare state si trasferisce in Asia @Medici_Manager @Keynesblog

Posted by keynesblog on 1 ottobre 2012 in EconomiaGlobalWelfare

di Andrea Pira/China Files (da

In Asia la famiglia allargata, dove spetta al figlio prendersi cura dei genitori anziani, sta venendo meno con l’industrializzazione e l’urbanizzazione. Stanno così nascendo varie forme di welfare. Un esempio su tutti è la riforma sanitaria approvata lo scorso ottobre in Indonesia. Ma anche Cina e Corea si muovono.

PECHINO – Manodopera e dipendenti giovani e freschi sono stati uno dei fattori della crescita economica asiatica. Ma con l’aumento delle aspettative di vita e il calo delle nascite i sistemi pensionistici della regione rischiano di essere insufficienti a coprire i bisogni di una popolazione che diventerà sempre più vecchia.

«Ci sono disuguaglianze tra aree urbane e rurali, tra pensionati del settore pubblico e del settore privato, tra quanti hanno un lavoro regolamentato e chi era impiegato in settori informali», ha spiegato Donghyun Park, capo economista dell’Asian Development Bank e curatore di Pension Systems in East and Southeast Asia, ultima pubblicazione in ordine di tempo dell’istituto di Manila sul tema. «Senza riforme, l’onere fiscale per i lavoratori potrebbe essere più costoso dei benefici», ha aggiunto in una nota di presentazione al volume.

Nonostante le differenze tra Paese e Paese la transizione demografica è una delle sfide che tutta l’Asia si troverà ad affrontare nel medio-lungo termine. Le classi dirigenti, si legge nell’introduzione, dovranno pertanto cercare di mantenere una crescita costante, sebbene con condizioni demografiche meno favorevoli, e garantire mezzi di sostentamento adeguati a un numero sempre maggiore di anziani, soprattutto per quanto riguarda le pensioni.

La maggior parte dei Paesi asiatici non ha tuttavia sistemi previdenziali capaci di garantire questa sicurezza economica. A rendere ancora più urgenti le riforme l’erosione di forme di previdenza sociale tradizionale. Il meccanismo sociale le famiglie allargate per cui spetta al figlio prendersi cura dei genitori diventati anziani sta venendo meno con l’industrializzazione e l’urbanizzazione dei paesi asiatici.

Entro il 2015 almeno 200milioni di cinesi avranno superato i 60 anni, più che la popolazione dell’intera Unione europea. Mentre si prevede che la popolazione in età lavorativa inizierà a calare dall’anno prossimo.

Il sistema pensionistico della Repubblica popolare è diverso a seconda che copra aree urbane, campagne o dipendenti pubblici. E i benefici variano da provincia a provincia. Nel settore privato i dipendenti contribuiscono con un quinto del proprio stipendio e una volta in pensione ricevono in media 1,440 yuan al mese (dati 2010), circa 164 euro.

Nel settore pubblico non devono invece versare niente. Se entrambi i sistemi sono obbligatori, quello per le aree rurali è invece su base volontaria ed è stato istituito nel 2008. Secondo gli analisti della Adb occorre inoltre riformare l’età pensionabile ancorata a quando l’aspettativa di vita era ancora bassa e oggi di 60 anni per gli uomini, 55 per le donne colletti bianchi, 50 per le operaie nelle aree urbane e 60 per le donne nelle campagne.

Nella più giovane Indonesia il sistema copre il 100 per cento dei dipendenti pubblici e dei militari, ma soltanto il 14 per cento di tutto il sistema privato formale. Ma, si legge, i programmi pensionistici dovrebbero essere estesi di almeno sette volte.

A rischio è anche il sistema sudcoreano introdotto 23anni fa e obbligatorio per tutti i lavoratori tra i 18 e i 59 anni. Il sistema ha quattro obiettivi: espandere la copertura, dare benefici adeguati, un’equa distribuzione dei costi tra le generazioni e una sostenibilità finanziaria di lungo termine.

Ma essendo quella sudcoreana, tra le società asiatiche, quella che invecchia a ritmo più alto, il sistema rischia di essere insostenibile e già oggi i benefici non sono adeguati alle esigenze. Sotto finanziato è il caso delle Filippine, mentre in Thailandia è coperto soltanto il 27 per cento dei lavoratori nel settore formale e in Vietnam il sistema introdotto nel 2010 copre 9,3 milioni di persone, il 20 per cento della forza lavoro e nei prossimi 30 anni potrebbe entrare in forte deficit.

Come evidenziato all’inizio di settembre da una lunga inchiesta dell’Economist, l’Asia si sta però avviando verso nuova rivoluzione: introduzione di un sistema di Stato sociale. Con l’opportunità di farlo, continua il settimanale britannico, potendo evitare gli errori che sono stati fatti in passato dall’Occidente.

Un esempio su tutti è la riforma sanitaria approvata lo scorso ottobre dalla Camera indonesiana. Ancora a febbraio l’attacco di un articolo del quotidiano Kompas spiegava che in Indonesia ammalarsi è un lusso che i poveri non si possono permettere e per molte famiglie un ricovero verrebbe a costare l’intero stipendio.

Dal 2014 un servizio di previdenza sociale fornirà la copertura sanitaria universale, con particolare attenzione alle fasce più povere delle popolazione che oggi non sono in grado di pagare assicurazioni private.

Il governo di Giacarta prevede di stanziare nella cosiddetta Bpjs Kesehatan 25mila miliardi di rupie, circa 2,1 miliardi di euro. Entro il 2019 la copertura sanitaria sarà garantita a tutti gli indonesiani.

Attualmente il 63 per cento della popolazione ha una copertura sanitaria di qualche tipo, di questi sono 76 milioni quelli che beneficiano dei programmi Jamkesma per i più poveri.

Come ricorda il Jakarta Post, assieme agli altri sistemi di previdenza sociale che prenderanno il via a gennaio del 2015, la sanità sarà uno dei temi su cui gli elettori tra due anni presseranno i candidati alle presidenziali e faranno le loro scelte.

La grande corsa alla Casa Bianca in dieci articoli @Medici_Manager

Possiamo chiedere ai nostri candidati alle prossime elezioni politiche, e ai giornalisti che li intervistano,  di farci sapere che cosa si impegnano a fare per il nostro Servizio Sanitario Nazionale?

Comunque, interessante sintesi de LINKIESTA

While constitutional, does the Affordable Care Act have merit? @kevinmd @Medici_Manager

Ecco come funziona l’informazione e la discussione su grandi temi politici nei paesi civili!

Possiamo chiedere ai nostri candidati alle prossime elezioni politiche, e ai giornalisti che li intervistano,  di farci sapere che cosa si impegnano a fare per il nostro Servizio Sanitario Nazionale?

by  in POLICY

President Obama enjoyed a towering victory that I feel leaves the GOP reeling, although they are spinning the Supreme Court’s validation of Obamacare as a great gust of wind at their backs. While I would not have expected a different response from them, I fear that there is a developing wind that may blow them away in November. I offer this analysis as a tepid Romney supporter who will be voting more against Obama than I will be voting to support Romney.

The phrase Obamacare is peppered throughout my blog. I was recently chastised by an unabashed whale-saving tree hugger that I should abandon this derisive term which detracts from my otherwise unvarnished objectivity. On the evening that the Supreme Court’s decision was announced, I was watching CNN and its pontificating pundits. Various panelists were spewing forth verbal pabulum telling us benighted listeners what we were supposed to think. John King, the moderator, and many members of the spin squad all used the term Obamacare freely and repeatedly. If CNN, the apotheosis of journalistic excellence, permits this term to be aired, then surely the Whistleblower is entitled to a free pass on this. For those who seek validation of why CNN is the “most trusted name in news,” simply zap this link for amusement. Because I am unfailingly fair and balanced, I disclose that Fox News was also eating crow.

We now know that Obamacare is constitutional which offers no support for the merits of the Affordable Care Act. While there are elements of the plan that I do support, I am deeply skeptical that the plan will control costs and increase medical quality. My fear is that medical costs will continue to escalate and that medical quality will suffer as physicians and hospitals compete in the Pay for Performance Follies where medical documentation and check mark medicine, not medical quality, is rewarded. Is the price for increased access to medical care for the uninsured medical mediocrity for all?

Here are just a few aspects of medical practice that won’t be counted but really counts.

  • Can the physician take an accurate medical history?
  • Can the physician skillfully examine patients? I’m a gastroenterologist. I’m supposed to know how to palpate the liver and perform other diagnostic tasks with my hands, eyes and ears. These skills will never be assessed by the government or insurance companies. Does that  that they don’t matter?
  • Does the physician know when a diagnostic test is not needed? (Tell me how you would test for this?)
  • Does a physician know when an incidental ‘abnormality’ on a CAT scan can be ignored?
  • Does a physician know how to deliver bad news to patients?
  • Does a physician know when watchful waiting is the right prescription?
  • Does the physician know how to manage medical issues on the phone at night when he does not know the patient? Which of them should be sent to the emergency room?  Why not send them all just to be safe?
  • Does the physician know when to consult a specialist? Is sending every patient with chest pain to a cardiologist good medicine even if patients and specialists encourage this practice.
  • Is this physician compassionate?

A majority of Americans oppose Obamacare in whole or in part. This opposition has developed even before the plan’s bitter medicine has been swallowed. Can the administration continue to spin this by suggesting that the public doesn’t yet grasp the plan?  Are we really that dumb?

Chief Justice John Roberts has pulverized the liberal argument that the Court is an arm of the Republican Party, as was bitterly alleged in Bush v Gore in 2000. While public support of the Court has been gradually ebbing, I have not personally believed that the justices pass their decisions through a political prism. Of course, they have different judicial philosophies, which is quite different from acting as a political partisan.

Not only did the Chief Justice validate Obamacare, but he did so by joining the Court’s 4 liberal members to do so. I would have never predicted this and I doubt that many readers what have either. Chief Justice Roberts has the long view, and sees the Affordable Care Act as a speed bump. His overriding priority is to protect and defend the integrity of his institution. I feel that he deserves praise and respect for his decision, even though I was hoping for a different outcome. Had he joined with the Court’s conservative members and overturned Obamacare, he would have been lambasted by the political left. Why aren’t they praising him now? Wouldn’t such a response from them be “fair and balanced”?

Fairness means applying the same standard in all circumstances.  Reminds me of the the iconic four word phrase carved into the facade of the Supreme Court.  Equal Justice Under Law.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.