Vol. 3. No. 3

me your candidates and we'll see if they are worthy of the name. In its three-dimensional representation, the BOHICA Award is a plaque with a certain part of the anatomy strategically placed and the words "BOHICA Award" under it. It leaves little to the imagination, and you can almost feel the discomfort as you see it.

I would now like to present my nominations for several candidates to receive this award, in this case because they created an obstacle or did the butt kicking, rather than being on the receiving end of getting their butts kicked.

Tom Scully, our infamous new administrator of CMS, who decided to rename HCFA instead of reshaping or reorganizing it. What's in a name? In this case nothing. The Center for Medicare and Medicaid Services (CMS) is not a center; it is a bureaucracy filled with people who obstruct needed services to seniors and indigent people throughout our nation. Does anyone there really understand the cost of health care? Does anyone there really know that their compliance regulations, reporting requirements, and forests of paper, not to mention the issuance of policies in stilted bureaucratic language that seniors cannot understand, are causing most of us to question our sanity when it comes to remaining in Medicare+Choice programs? Do they even care?

McCain, Kennedy, Frist and all the others who authored the Patient's Bill of Rights for HMOs without inserting one iota of common sense, have added to the litany of potential lawsuits to keep attorneys living comfortably for the next millennium, but have done nothing to truly facilitate the affordability and redesign of health benefits coverage for those who need it. Yes, we must afford due process to folks and follow ethical guidelines for dealing compassionately in situations where individuals are most troubled and vulnerable. That is the very basis of our integrity in organizing and delivering health care, and I thought it could be done effectively until I bought health plans and tried to make this happen in the face of regulatory obstructionists and financial institutions -- but that's another column and per-haps a whole new series of BOHICA Awards. So to all those political wonders of the world, have a BOHICA on me.

Banking institutions of all kinds. There is a song by singer/song-writer Cheryl Wheeler entitled "The Bank" that begins: "We're the bank, we're not your friend." It ends, "We're the bank, with hearts of steel, heads of stone." On "Saturday Night Live," there is a segment entitled "Deep Thoughts by Jack Handy" which are, of course, not very deep. So here's my deep thought for this month. Health insurance is just about the only industry where you can't borrow against your cash flow to finance expansion or to turn around the business. In other situations, you can finance your inventory until you sell it off, finance new equipment, or a new product line. Not in managed care. Banks don't want to take a chance lending against cash flow, even when they have tens of millions of your dollars in their coffers on which they are earning money by lending it every day. The only way for a start-up or turnaround growth company to borrow money is to personally guarantee it with collateral that is separate and apart from the health plan -- an approach that I have now labeled as "sure thing economics."

Given the banking situation when it comes to financing private enterprise in health care, some things are very clear. The consolidation in which the bigger get bigger and the smaller disappear or close down will continue. And the de-personalization that comes with centralization and outsourcing to reduce costs will increase. The bottom line for the future of entrepreneurial healthcare organizations trying to reshape managing care and taking risk is: "In God we trust, but you'd better have lots of cash!" So, for all of those short-sighted, risk averse bankers, investment bankers, venture capitalists, and other financial institutions who raise questions but don't help with creative problem solving, have a really big BOHICA on me.

Technology companies in managed care. The turmoil in this sector of the business is all too well known to those of us who have to deal with antiquated and inefficient systems, exorbitantly costly workarounds, and customer service mazes that would leave a rat screaming for mercy. And then there's the host of Internet companies that promise great solutions for problems which they will only magnify utilizing vapor technology that may, but probably won't, work from companies that really don't understand our needs or those of our customers. I wish I had a trap door in my office when, after five minutes, I wanted to end the discussion with a representative of one of those companies. They are all entitled to the big BOHICA Award too.

This is just my starter list; I'm sure our readers have lots more creative ideas. Just keep on laughing, because we really have no other choice as we confront change, chaos, and opportunity, all in the same breath. Soon, perhaps, I'll devote a column to another of my other favorite words, coined I think by the political commentator William Safire: "klong" -- the feeling that comes from a totally unexpected onrush of s..t to the heart.

Stay tuned!