What type of research is it (quantitative, qualitative, and design)?

What type of research is it (quantitative, qualitative, and design)?.

What type of research is it (quantitative, qualitative, and design)?

Paper details:
Quantitative Abstract
An abstract is a short description or synopsis of a journal article, research, or other written material. Abstracts
should be accurate, brief, clear, and include only the most essential information.
The purpose of this assignment is to become familiar with published research, research designs, and
methodologies. For the assignment, you will select a quantitative research study related to the field of nursing and
write an abstract of the investigation. You must attach the research study to your abstract.
Ensure the following questions are addressed in your abstract:
1. What type of research is it (quantitative, qualitative, and design)?
2. What was the research question(s) or hypothesis?
3. What is the sample, the sample size, and sample attributes?
4. What was the setting of the study?
5. What were the researcher?s findings? (Identify one.)
Qualitative Abstact
An abstract is a short description or synopsis of a journal article, research, or other written material. Abstracts
should be accurate, brief, clear, and include only the most essential information.
The purpose of this assignment is to become?????? familiar with published research, research designs, and
methodologies. For the assignment, you will select a qualitative research study related to the field of nursing and
write an abstract of the investigation. You must attach the research study to your abstract.
Ensure the following questions are addressed in your abstract:
1. What type of research is it (quantitative, qualitative, and design)?
2. What was the research question(s) or hypothesis?
3. What is the sample, the sample size, and sample attributes?
4. What was the setting of the study?
5. What were the researcher?s findings? (Identify one.)


 

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Initiate and explain change management methodologies appropriate to improving healthcare outcomes.

Initiate and explain change management methodologies appropriate to improving healthcare outcomes..

Initiate and explain change management methodologies appropriate to improving healthcare outcomes.

Order Description
Please find attached Subject description Health systems worldwide are facing increasing pressure to improve their efficiency and effectiveness while delivering safe, high quality and patient-centred care. Most countries accept that existing models of health care delivery are not sustainable for future decades, resulting in modern health services engaging in large system changes. Health service managers, planners and clinicians require competencies in understanding systems in the health services, implementing and leading change, and project management. This subject assists students to develop knowledge and skills in understanding and adapting health systems to achieve efficiency and effectiveness. The subject initially examines a range of change theories that can be applied to the healthcare environment as well as relevant leadership theories within the context of change. Finally the subject focuses on national health reform and a range of service improvement approaches and tools such as lean thinking, six sigma, clinical services and system redesign, clinical process mapping and patient flow analysis. A number of recent initiatives are presented that explain how to implement change at national, corporate, statewide and health care organisation levels.

Assessment task 3: Case study responses
Intent: This assessment item focuses on the ability to synthesise all the content delivered in this subject and apply it to two case studies.
It is important to be able to review real scenarios and provide guidance as to what the leadership and
change issues are and which strategies would be useful to implement. This assessment item will
reveal to the student how much they have learned about leadership and change, and provide them
with the confidence that they can apply these concepts in a hypothetical situation.
Objective(s): This assessment task addresses subject learning objective(s):
A, B and C

A. Critically appraise relevant strategies to implement individual or organisational change in the healthcare environment based on validated theories and models;
B. Consider factors that act as a stimulus for change, resistance to change and successful change in health care;
C. Propose fundamental leadership skills necessary to implement organisational change and act as a change agent;

This assessment task contributes to the development of graduate attribute(s):
1.1, 1.2 and 1.3

Critique, interpret and synthesise data and research findings to develop safe, effective and evidence-based solutions to healthcare challenges. (1.1)
Propose relevant problem solving and human factors theories to the analysis of common issues inherent in the management and evaluation of healthcare services . (1.2)
Initiate and explain change management methodologies appropriate to improving healthcare outcomes. (1.3)

Type: Examination

Weight: 30%
Task: 1. Read both case studies that focus on recent or
potential change or health service reform.
2. Provide answers to the questions presented in the examination during Day 3.
Length: 60 minute extended response examination

Criteria: 25% Analyses and reframes the major issues inherent in each of the case studies demonstrating a depth of knowledge of leadership and change management
25% Considers likely challenges in each of the case studies demonstrating a depth of knowledge
about leadership and change management
50% Recommends appropriate and focused strategies based on relevant theoretical frameworks to
address the major issues in each of the case studies

Assessment Item 3 ? Case Studies
92297 HEALTH SYSTEMS AND CHANGE Page 1
92297 HEALTH SYSTEMS AND CHANGE
ASSESSMENT ITEM 3 ? CASE STUDIES
CASE STUDY A
You have been appointed as the Director of Clinical Services at a large (600 bed) metropolitan hospital ? Ambrose Health. You are younger than the previous incumbent, being only 30 years of age and better qualified, having just completed a Master of Health Service Management and enrolled in a doctoral program. Most of your experience has been in smaller hospitals outside the metropolitan area. The executive management team made it clear to you at interview that they were interested in effecting change throughout the Clinical Services Division, which is why they were seeking an external appointment to the position. In particular, they were seeking an individual who could establish a cohesive and productive working team.
Shortly after commencing in the position it becomes obvious that much of what is achieved is as a result of ?who you know?. There are many instances when the usual communication channels or procedures are not followed because of ?system failures? which have never been brought to anyone?s attention. When running short of stock medications, for example, many nurses contact the nursing unit manager of the medical ward as she has a ?contact? in the pharmacy, rather than working through appropriate channels to correct the problem. Patients in the Coronary Care Unit are routinely admitted directly to the unit rather than through the Admissions Office because it is a slow and tedious process.
When you ask why these problems have never been addressed formally, the reply is along the lines of ?It has always been this way. I am a very experienced health professional ? I know the system and how to get around it to get what I need to do the job properly. I see no reason to change things when I think the system is working well.?

Assessment Item 3 ? Case Studies
92297 HEALTH SYSTEMS AND CHANGE Page 2
CASE STUDY B
You are a community health worker who has recently been awarded a grant from the commonwealth department of health for three years to establish a drug education program in an inner city suburb which is a known gathering point for drug addicts. The goal is to decrease rates of HIV/AIDS and hepatitis but more importantly, to decrease rates of drug use and overdose. The project will be evaluated at the end of the grant to determine whether continued funding is warranted. As project director, you have the funding to choose and hire four additional employees and manage the program as you desire.
The average age of those likely to use the service is 15 years, and most live on the streets. This suburb is known to have a high crime rate. Police patrols are more frequent than in previous years but petty theft, burglaries, assaults and prostitution are common. High unemployment rates are a feature of this suburb.
The local community has just been advised that the project is to commence shortly. They are becoming increasingly ?agitated? about the effects that the introduction of such a program may have on their local area. While accepting that there is a high proportion of drug addicts frequenting the area at the moment, they are concerned that raising the awareness of this community as a ?safe haven? may encourage even more individuals to congregate in the area, particularly during the day. The state department of health has endeavoured to counter this argument by organising several open forums where the issues can be discussed and fears allayed. This seems to have encouraged open debate but diminished acceptance of the proposal.
There are three primary schools in close proximity to the proposed site and a private co- educational high school two blocks away. It is the parents of children attending this school who appear to be most vocal. Their objections have increased since two children were expelled for drug-related offences. The local churches have thus far not contributed to the debate nor ventured any opinion on the proposal. To date, they have not become involved in providing any type of ?social welfare? to those who call the streets ?home?.


 

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Describe plan for data analysis for demographic variables (descriptive statistical tests).

Describe plan for data analysis for demographic variables (descriptive statistical tests)..

Describe plan for data analysis for demographic variables (descriptive statistical tests).

The final project consists of the development of a novel research proposal specific to your role specialization. The project must include an intervention appropriate to nursing practice and consistent with your MSN role option. An alternative to the above includes the selection of a specialty organization to focus research proposals based on the priorities of that organization. Examples of these organizations could include (but are not limited to): Sigma Theta Tau International, American Nurses? Foundation, Oncology Nursing Society, Association of Nurses in AIDS Care, American Psychiatric Nursing Association, American Association of Critical Care Nurses, National Association of Pediatric Nurse Associates and Practitioners, National League For Nursing, etc.

Throughout this course you have been developing various sections of the research proposal. This week you will assemble the final proposal (addressing faculty feedback). This paper is to be developed in APA format/style using the required template and not to exceed 15 pages (excluding title page/references/appendices).

Criteria:
Introduction
?Background and Significance of Problem
?Statement of the Problem and Purpose of the Study

Literature Review
?Summary of the Evidence for the Proposed Study

Research Question, Hypothesis, and Variables with Operational Definitions

Theoretical Framework
?Overview and Guiding Propositions(s) Described in Theory
?Application of Theory to Your Study?s/Project?s Focus

Methodology
?Sample/Setting: Number and criteria for inclusion and description of place in which data will be collected.
?Sampling Strategy
?Research Design: Type (e.g., Quasi-Experimental), description, and rationale for selection.
?Extraneous Variables (and plan for how controlled).
?Instruments: Description, validity, and reliability estimates, which have been performed (on a pre-established measure). Include plans for testing validity and reliability of generating your own instrument(s).
?Description of the Intervention
?Data Collection Procedures
?Data Analysis Plans ?Describe plan for data analysis for demographic variables (descriptive statistical tests).
?Describe plan for data analysis of study variables (descriptive and inferential statistical tests).

Ethical Issues
?Describe ethical considerations and your plan to protect human rights.

Limitation of Proposed Study
Implications for Practice
References
Appendices
?Informed Consent Letter ?Procedure section is clear, described in detail, specific, and all inclusive. Written in lay language (as documented by reading level score). Includes risks and benefits relevant to study. Address assent (if applicable).

Grading criteria that must be followed:

Introduction

Background and Significance of Problem
10 points

Statement of the Problem and Purpose of the Study
10 points

Literature Review
40 points

Research Question, Hypothesis, and Variables with Operational Definitions

Research Question, Hypothesis
10 points

Variables with Operational Definitions
5 points

Theoretical Framework

Overview and Guiding Propositions(s) Described in Theory
15 points

Application of Theory to Your Study?s/Project?s Focus
15 points

Methodology

Sample/Setting: Number and criteria for inclusion and description of place in which data will be collected.
15 points

Sampling Strategy
15 points

Research Design: Type (e.g., Quasi-Experimental), description, and rationale for selection.
10 points

Extraneous Variables (and plan for how controlled).
5 points

Instruments: Description, validity, and reliability estimates, which have been performed (on a pre-established measure). Include plans for testing validity and reliability of generating your own instrument(s).
20 points

Description of the Intervention
20 points

Data Collection Procedures
20 points

Data Analysis Plans
?Describe plan for data analysis for demographic variables (descriptive statistical tests).
?Describe plan for data analysis of study variables (descriptive and inferential statistical tests).

20 points

Ethical Issues

Describe ethical considerations and your plan to protect human rights.
10 points

Limitations and Implications

10 points

Scholarly Research

References and Appendices

10 points

Informed Consent Letter Procedure section is clear, described in detail, specific, and all inclusive. Written in lay language (as documented by reading level score). Includes risks and benefits relevant to study. Address assent (if applicable).
10 points

Academic Writing

Free of grammatical, spelling, or punctuation errors. Citations and references written in the correct APA Style.

30 points

TOTAL
300


 

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Describe plan for data analysis for demographic variables (descriptive statistical tests).

Identify examples of active and latent errors. Provide examples from your clinical experience, if possible. How can such errors be avoided to support better patient care?

Identify examples of active and latent errors. Provide examples from your clinical experience, if possible. How can such errors be avoided to support better patient care?.

Identify examples of active and latent errors. Provide examples from your clinical experience, if possible. How can such errors be avoided to support better patient care?

Order Description
Discussion Prompt #1
?Reflect upon the survey you took. In your initial response, address some of the following questions. Explain your answers.
?Did you find it easy to make confident and decisive decisions with several strongly agree or strongly disagree answers, or did you select mostly moderate responses?
?Did any subject areas trigger personal emotions or issues? If so, do you feel you were able to remain objective?
?Were any of the decisions especially difficult to make?
?Did you employ any critical thinking or resolution strategies to determine a response?
?Did you rely on policy or legal parameters to make your decisions?
?Would you be comfortable making your answers to the survey public, or do you prefer anonymity?
?Have you dealt with similar situations and could you perceive similar situations occurring in your clinical practice?
?How might a moral inventory such as this survey impact your clinical practice?

Discussion Prompt #2
?Identify examples of active and latent errors. Provide examples from your clinical experience, if possible. How can such errors be avoided to support better patient care?

References
text book
1.Nursing Ethics, 4th edition Janie B, Butts
2.Legal and ethical issues for health professionals ,4th edition George D. pozgar

Discussion Prompt #1
? Reflect upon the survey you took. In your initial response, address some of the following questions. Explain your answers.
? Did you find it easy to make confident and decisive decisions with several strongly agree or strongly disagree answers, or did you select mostly moderate responses?
? Did any subject areas trigger personal emotions or issues? If so, do you feel you were able to remain objective?
? Were any of the decisions especially difficult to make?
? Did you employ any critical thinking or resolution strategies to determine a response?
? Did you rely on policy or legal parameters to make your decisions?
? Would you be comfortable making your answers to the survey public, or do you prefer anonymity?
? Have you dealt with similar situations and could you perceive similar situations occurring in your clinical practice?
? How might a moral inventory such as this survey impact your clinical practice?
Please share additional thoughts as well.

Discussion Prompt #2
Identify examples of active and latent errors. Provide examples from your clinical experience, if possible. How can such errors be avoided to support better patient care?


 

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Identify examples of active and latent errors. Provide examples from your clinical experience, if possible. How can such errors be avoided to support better patient care?

Analyze the history of advanced practice nurses and the emerging role of your specialty area, and discuss what contributions you plan to make to advance the nursing profession

Analyze the history of advanced practice nurses and the emerging role of your specialty area, and discuss what contributions you plan to make to advance the nursing profession.

Analyze the history of advanced practice nurses and the emerging role of your specialty area, and discuss what contributions you plan to make to advance the nursing profession

Order Description
To prepare:
Review the SMART Goals Learning Resources
Consider professional goals that you might select to help focus on your transition from RN to NP practice.
For this Assignment, write a paper that addresses the following:
Identify at least three short-term goals (1-2 years)
Identify at least three long-term goals (3-5 years)
Explain why you selected each goal and how they relate to your professional career development
Create a strategic plan that explains how you might achieve each of these goals.

To prepare:
2.Complete the Risk Control Self-Assessment Checklist for Nurse Practitioners
Identify at least three strengths
Explain why you consider these strengths and what you can do to maintain them in your practice
Identify at least three weaknesses
Explain how you plan to address each weakness
Examine at least three clinical skills you need to obtain prior to exiting the program
Explain how you plan to master the clinical skills before exiting NP program
Analyze the history of advanced practice nurses and the emerging role of your specialty area, and discuss what contributions you plan to make to advance the nursing profession


 

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Analyze the history of advanced practice nurses and the emerging role of your specialty area, and discuss what contributions you plan to make to advance the nursing profession

Create a PowerPoint Presentation. The final product will be no longer than 20 slides including the title page and reference page. Students will use the note section of the PowerPoint to discuss, explain and support the reasoning for information presented in each slide.

Create a PowerPoint Presentation. The final product will be no longer than 20 slides including the title page and reference page. Students will use the note section of the PowerPoint to discuss, explain and support the reasoning for information presented in each slide..

Create a PowerPoint Presentation. The final product will be no longer than 20 slides including the title page and reference page. Students will use the note section of the PowerPoint to discuss, explain and support the reasoning for information presented in each slide.

Purpose: This assignment is the first of three assignments. Students will use the tools and apply concepts learned in this and previous business courses to demonstrate an understanding of how organizations develop and manage strategies to establish, safeguard and sustain its position in a competitive market.
Monitoring competitors? performance is a key aspect of performing an external environment analysis. This assignment provides students the opportunity to evaluate the competitive position of one of the organizations listed below and integrate that information in an External Factor Evaluation (EFE) matrix and Competitive Profile Matrices (CPM).
Students will present a PowerPoint presentation that meets the standards of an effective presentation. Learn about creating an effective PowerPoint presentation at:
Ten Tips for Effective PowerPoint Presentations
http://www.lifehack.org/articles/featured/10-tips-for-more-effective-powerpoint-presentations.html

Instructions:
Students will perform an external analysis on an industry where a company from the list below operates and competes. Alternative companies/industries may be studied but only with the instructor?s prior approval.
T. Cross
Fitbit
Citrix
Riverbed Technology
Darden Restaurants
The paper should focus on factors related to the company?s industry and the environment that it and its competitors make. The factors to measure are those identified in SWOT, 5 Forces, PESTEL, EFE, and CPM.

In completing the assignment, students will perform research on the selected company, its industry, and its competitors and respond to the required steps below:
Step 1: Create a PowerPoint Presentation. The final product will be no longer than 20 slides including the title page and reference page. Students will use the note section of the PowerPoint to discuss, explain and support the reasoning for information presented in each slide.
Step 2: Review assignment grading rubric.
Step 3: In completing the assignment, students are required to support the reasoning using in-text citations and a reference list. If information is taken from a source document, it has to be cited and referenced. Both in-text citations and an associated reference list are required. View the sample APA paper under Week 1 content. Students may also look under Course Resources>>Student Toolbox for APA resources.
Step 4: Complete an External Environmental Analysis:
Use tools, concepts and information from your own research to perform an external analysis of the company?s environment. Include the following:
Company overview
Industry analysis
2) Competitive analysis. [Use the company?s closest competitors plus the selected company.]
3) Techniques Analysis: PESTEL, Five Forces, OT from SWOT, EFE, and CPM.
Trends: Discuss trends significant to the industry and company and discuss key areas of uncertainty related to trends or events that potentially could impact the company?s strategy.
Utilize the Notes section to support each slide
Step 5: Using the grading rubric, ensure all required elements are presented in the presentation.
Step 6: Proofread for organization, spelling, and grammar and completeness.
Use the spell and grammar check in MS Word as a first measure;
Have someone who has excellent English skills to proof the paper;
Step 7: Submit the presentation in the Assignment Folder.

Saylor URL: http://www.saylor.org/books Saylor.org
1
This text was adapted by The Saylor Foundation under a Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License without
attribution as requested by the work?s original creator or licensee.
Saylor URL: http://www.saylor.org/books Saylor.org
2
Preface
Teaching strategic management classes can be a very difficult challenge for professors. In most
business schools, strategic management is a ?capstone? course that requires students to draw on
insights from various functional courses they have completed (such as marketing, finance, and
accounting) to understand how top executives make the strategic decisions that drive whether
organizations succeed or fail. Many students have very little experience with major organizational
choices. This undermines many students? engagement in the course.
Our book is designed to enhance student engagement. A good product in any industry matches what
customers want and need, and the textbook industry is no exception. It is well documented that
many of today?s students are visual learners. To meet students? wants and needs (and thereby create
a much better teaching experience for professors), our book offers the following:
? Several graphic displays in each chapter that summarize key concepts in a visually
appealing format.Chapter 1 “Mastering Strategy: Art and Science”, for example, offers graphic
displays on (1) the ?5 Ps? of strategy; (2) intended, emergent, and realized strategies; (3) strategy in
ancient times; (4) military strategy; and (5) the evolution of strategic management as a field of study.
The idea for the graphic displays was inspired by the visually rich and popular series on business
published by DK Publishing.
? Rich, illustrative examples drawn from companies that are relevant to many
students. As part of our emphasis on examples, each chapter uses one company as an ongoing
example to bring various concepts to life. In Chapter 1 “Mastering Strategy: Art and Science”, Apple is
used as the ongoing example.
? A ?strategy at the movies? feature in each chapter that links course concepts with a
popular motion picture. In Chapter 1 “Mastering Strategy: Art and Science”, for example, we
describe how The Social Network illustrates intended, emergent, and realized strategies.
Politicians in many states are paying more and more attention over time to the cost of a college
education, including the high prices of most textbooks. It is therefore reasonable to expect an everincreasing
number of professors to seek modestly priced textbooks. Professors still want to be
Saylor URL: http://www.saylor.org/books Saylor.org
3
assured of quality, of course. Both of us are endowed chairs at Research I universities. We have long
track records of publishing our research in premier journals, and we have served in a variety of
editorial and review board roles for such journals. Finally, we recognize that professors want to
minimize their switching costs when adopting a new book. Although every textbook is a little unique,
our table of contents offers a structure and topic coverage that parallels what market leading books
provide.
Saylor URL: http://www.saylor.org/books Saylor.org
4
Chapter 1
Mastering Strategy: Art and Science
LEARNING OBJECTIVES
After reading this chapter, you should be able to understand and articulate answers to the following
questions:
1. What are strategic management and strategy?
2. Why does strategic management matter?
3. What elements determine firm performance?
Strategic Management: A Core Concern for Apple
The Opening of the Apple Store
Image courtesy of Neil Bird, http://www.flickr.com/photos/nechbi/2058929337.
March 2, 2011, was a huge day for Apple. The firm released its much-anticipated iPad2, a thinner and
faster version of market-leading Apple?s iPad tablet device. Apple also announced that a leading publisher,
Random House, had made all seventeen thousand of its books available through Apple?s iBookstore.
Apple had enjoyed tremendous success for quite some time. Approximately fifteen million iPads were sold
in 2010, and the price of Apple?s stock had more than tripled from early 2009 to early 2011.
Saylor URL: http://www.saylor.org/books Saylor.org
5
But future success was far from guaranteed. The firm?s visionary founder Steve Jobs was battling serious
health problems. Apple?s performance had suffered when an earlier health crisis had forced Jobs to step
away from the company. This raised serious questions. Would Jobs have to step away again? If so, how
might Apple maintain its excellent performance without its leader?
Meanwhile, the iPad2 faced daunting competition. Samsung, LG, Research in Motion, Dell, and other
manufacturers were trying to create tablets that were cheaper, faster, and more versatile than the iPad2.
These firms were eager to steal market share by selling their tablets to current and potential Apple
customers. Could Apple maintain leadership of the tablet market, or would one or more of its rivals
dominate the market in the years ahead? Even worse, might a company create a new type of device that
would make Apple?s tablets obsolete?
Saylor URL: http://www.saylor.org/books Saylor.org
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1.1 Defining Strategic Management and Strategy
LEARNING OBJECTIVES
1. Learn what strategic management is.
2. Understand the key question addressed by strategic management.
3. Understand why it is valuable to consider different definitions of strategy.
4. Learn what is meant by each of the 5 Ps of strategy.
What Is Strategic Management?
Issues such as those currently faced by Apple are the focus of strategic management because they help
answer the key question examined by strategic management??Why do some firms outperform other
firms?? More specifically, strategic management examines how actions and events involving top
executives (such as Steve Jobs), firms (Apple), and industries (the tablet market) influence a firm?s
success or failure. Formal tools exist for understanding these relationships, and many of these tools are
explained and applied in this book. But formal tools are not enough; creativity is just as important to
strategic management. Mastering strategy is therefore part art and part science.
This introductory chapter is intended to enable you to understand what strategic management is and why
it is important. Because strategy is a complex concept, we begin by explaining five different ways to think
about what strategy involves (Figure 1.1 “Defining Strategy: The Five Ps”). Next, we journey across many
centuries to examine the evolution of strategy from ancient times until today. We end this chapter by
presenting a conceptual model that maps out one way that executives can work toward mastering
strategy. The model also provides an overall portrait of this book?s contents by organizing the remaining
nine chapters into a coherent whole.
Defining Strategy: The Five Ps
Defining strategy is not simple. Strategy is a complex concept that involves many different processes and
activities within an organization. To capture this complexity, Professor Henry Mintzberg of McGill
University in Montreal, Canada, articulated what he labeled as ?the 5 Ps of strategy.? According to
Mintzberg, understanding how strategy can be viewed as a plan, as a ploy, as a position, as a pattern, and
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as a perspective is important. Each of these five ways of thinking about strategy is necessary for
understanding what strategy is, but none of them alone is sufficient to master the concept. [1]
Figure 1.1 Defining Strategy: The Five Ps
Images courtesy of Thinkstock (first); Dave, K., Short, J., Combs, J., & Terrell, W. (2011). Tales of
Garc?n: The Franchise Players. Irvington, Wikipedia (third); Old Navy (fourth); James Duncan
Davidson from Portland, USA (fifth).
Strategy as a Plan
Saylor URL: http://www.saylor.org/books Saylor.org
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Strategic plans are the essence of strategy, according to one classic view of strategy. A strategic plan is a
carefully crafted set of steps that a firm intends to follow to be successful. Virtually every organization
creates a strategic plan to guide its future. In 1996, Apple?s performance was not strong, and Gilbert F.
Amelio was appointed as chief executive officer in the hope of reversing the company?s fortunes. In a
speech focused on strategy, Amelio described a plan that centered on leveraging the Internet (which at the
time was in its infancy) and developing multimedia products and services. Apple?s subsequent success
selling over the Internet via iTunes and with the iPad can be traced back to the plan articulated in 1996. [2]
A business model should be a central element of a firm?s strategic plan. Simply stated, a business model
describes the process through which a firm hopes to earn profits. It probably won?t surprise you to learn
that developing a viable business model requires that a firm sell goods or services for more than it costs
the firm to create and distribute those goods. A more subtle but equally important aspect of a business
model is providing customers with a good or service more cheaply than they can create it themselves.
Consider, for example, large chains of pizza restaurants such as Papa John?s and Domino?s.
Franchises such as Pizza Hut provide an example of a popular business model that has been successful worldwide.
Saylor URL: http://www.saylor.org/books Saylor.org
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Image courtesy of Derek Jensen, http://wikimediafoundation.org/wiki/File:Bremen-indiana-pizza-hut.jpg.
Because these firms buy their ingredients in massive quantities, they pay far less for these items than any
family could (an advantage called economies of scale). Meanwhile, Papa John?s and Domino?s have
developed specialized kitchen equipment that allows them to produce better-tasting pizza than can be
created using the basic ovens that most families rely on for cooking. Pizza restaurants thus can make
better-tasting pizzas for far less cost than a family can make itself. This business model provides healthy
margins and has enabled Papa John?s and Domino?s to become massive firms.
Strategic plans are important to individuals too. Indeed, a well-known proverb states that ?he who fails to
plan, plans to fail.? In other words, being successful requires a person to lay out a path for the future and
then follow that path. If you are reading this, earning a college degree is probably a key step in your
strategic plan for your career. Don?t be concerned if your plan is not fully developed, however. Life is full
of unexpected twists and turns, so maintaining flexibility is wise for individuals planning their career
strategies as well as for firms.
For firms, these unexpected twists and turns place limits on the value of strategic planning. Former
heavyweight boxing champion Mike Tyson captured the limitations of strategic plans when he noted,
?Everyone has a plan until I punch them in the face.? From that point forward, strategy is less about a
plan and more about adjusting to a shifting situation. For firms, changes in the behavior of competitors,
customers, suppliers, regulators, and other external groups can all be sources of a metaphorical punch in
the face. As events unfold around a firm, its strategic plan may reflect a competitive reality that no longer
exists. Because the landscape of business changes rapidly, other ways of thinking about strategy are
needed.
Strategy as a Ploy
A second way to view strategy is in terms of ploys. A strategic ploy is a specific move designed to outwit or
trick competitors. Ploys often involve using creativity to enhance success. One such case involves the
mighty Mississippi River, which is a main channel for shipping cargo to the central portion of the United
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States. Ships traveling the river enter it near New Orleans, Louisiana. The next major port upriver is
Louisiana?s capital, Baton Rouge. A variety of other important ports exist in states farther upriver.
Many decades ago, the governor of Louisiana was a clever and controversial man named Huey Long.
Legend has it that Long ordered that a bridge being constructed over the Mississippi River in Baton Rouge
be built intentionally low to the ground. This ploy created a captive market for cargo because very large
barges simply could not fit under the bridge. Large barges using the Mississippi River thus needed to
unload their cargo in either New Orleans or Baton Rouge. Either way, Louisiana would benefit. Of course,
owners of ports located farther up the river were not happy.
Ploys can be especially beneficial in the face of much stronger opponents. Military history offers quite a
few illustrative examples. Before the American Revolution, land battles were usually fought by two
opposing armies, each of which wore brightly colored clothing, marching toward each other across open
fields. George Washington and his officers knew that the United States could not possibly defeat bettertrained
and better-equipped British forces in a traditional battle. To overcome its weaknesses, the
American military relied on ambushes, hit-and-run attacks, and other guerilla moves. It even broke an
unwritten rule of war by targeting British officers during skirmishes. This was an effort to reduce the
opponent?s effectiveness by removing its leadership.
Centuries earlier, the Carthaginian general Hannibal concocted perhaps the most famous ploy ever.
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Hannibal?s clever use of elephants to cross the Alps provides an example of a strategic ploy.
Image courtesy of Wikipedia, http://en.wikipedia.org/wiki/File:Hannibal3.jpg.
Carthage was at war with Rome, a scary circumstance for most Carthaginians given their far weaker
fighting force. The Alps had never been crossed by an army. In fact, the Alps were considered such a
treacherous mountain range that the Romans did not bother monitoring the part of their territory that
bordered the Alps. No horse was up to the challenge, but Hannibal cleverly put his soldiers on elephants,
and his army was able to make the mountain crossing. The Romans were caught completely unprepared
and most of them were frightened by the sight of charging elephants. By using the element of surprise,
Hannibal was able to lead his army to victory over a much more powerful enemy.
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Ploys continue to be important today. In 2011, a pizzeria owner in Pennsylvania was accused of making a
rather unique attempt to outmaneuver two rival pizza shops. According to police, the man tried to
sabotage his competitors by placing mice in their pizzerias. If the ploy had not been discovered, the two
shops could have suffered bad publicity or even been shut down by authorities because of health concerns.
Although most strategic ploys are legal, this one was not, and the perpetrator was arrested. [3]
Strategy as a Pattern
Strategy as pattern is a third way to view strategy. This view focuses on the extent to which a firm?s actions
over time are consistent. A lack of a strategic pattern helps explain why Kmart deteriorated into
bankruptcy in 2002. The company was started in the late nineteenth century as a discount department
store. By the middle of the twentieth century, consistently working to be good at discount retailing had led
Kmart to become a large and prominent chain.
By the 1980s, however, Kmart began straying from its established strategic pattern. Executives shifted the
firm?s focus away from discount retailing and toward diversification. Kmart acquired large stakes in
chains involved in sporting goods (Sports Authority), building supplies (Builders Square), office supplies
(OfficeMax), and books (Borders). In the 1990s, a new team of executives shifted Kmart?s strategy again.
Brands other than Kmart were sold off, and Kmart?s strategy was adjusted to emphasize information
technology and supply chain management. The next team of executives decided that Kmart?s strategy
would be to compete directly with its much-larger rival, Walmart. The resulting price war left Kmart
crippled. Indeed, this last shift in strategy was the fatal mistake that drove Kmart into bankruptcy. Today,
Kmart is part of Sears Holding Company, and its prospects remain uncertain.
In contrast, Apple is very consistent in its strategic pattern: It always responds to competitive challenges
by innovating. Some of these innovations are complete busts. Perhaps the best known was the Newton, a
tablet-like device that may have been ahead of its time. Another was the Pippin, a video game system
introduced in 1996 to near-universal derision. Apple TV, a 2007 offering intended to link televisions with
the Internet, also failed to attract customers. Such failures do not discourage Apple, however, and enough
of its innovations are successful that Apple?s overall performance is excellent. However, there are risks to
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following a pattern too closely. A consistent pattern can make a company predictable, a possibility that
Apple must guard against in the years ahead.
Strategy as a Position
Viewing strategy as a plan, a ploy, and a pattern involve only the actions of a single firm. In contrast, the
next P?strategy as position?considers a firm and its competitors. Specifically, strategy as position refers
to a firm?s place in the industry relative to its competitors. McDonald?s, for example, has long been and
remains the clear leader among fast-food chains. This position offers both good and bad aspects for
McDonald?s. One advantage of leading an industry is that many customers are familiar with and loyal to
leaders. Being the market leader, however, also makes McDonald?s a target for rivals such as Burger King
and Wendy?s. These firms create their strategies with McDonald?s as a primary concern. Old Navy offers
another example of strategy as position. Old Navy has been positioned to sell fashionable clothes at
competitive prices.
Old Navy occupies a unique position as the low-cost strategy within the Gap Inc.?s fleet of brands.
Image courtesy of Lindsey Turner, http://www.flickr.com/photos/theogeo/2148416495.
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Old Navy is owned by the same corporation (Gap Inc.) as the midlevel brand the Gap and upscale brand
Banana Republic. Each of these three brands is positioned at a different pricing level. The firm hopes that
as Old Navy?s customers grow older and more affluent, they will shop at the Gap and then eventually at
Banana Republic. A similar positioning of different brands is pursued by General Motors through its
Chevrolet (entry level), Buick (midlevel), and Cadillac (upscale) divisions.
Firms can carve out a position by performing certain activities in a different manner than their rivals. For
example, Southwest Airlines is able to position itself as a lower-cost and more efficient provider by not
offering meals that are common among other airlines. In addition, Southwest does not assign specific
seats. This allows for faster loading of passengers. Positioning a firm in this manner can only be
accomplished when managers make trade-offs that cut off certain possibilities (such as offering meals and
assigned seats) to place their firms in a unique strategic space. When firms position themselves through
unique goods and services customers value, business often thrives. But when firms try to please everyone,
they often find themselves without the competitive positioning needed for long-term success. Thus
deciding what a firm is not going to do is just as important to strategy as deciding what it is going to do. [4]
To gain competitive advantage and greater success, firms sometimes change positions. But this can be a
risky move. Winn-Dixie became a successful grocer by targeting moderate-income customers. When the
firm abandoned this established position to compete for wealthier customers and higher margins, the
results were disastrous. The firm was forced into bankruptcy and closed many stores. Winn-Dixie
eventually exited bankruptcy, but like Kmart, its future prospects are unclear. In contrast to firms such as
Winn-Dixie that change positions, Apple has long maintained a position as a leading innovator in various
industries. This positioning has served Apple well.
Strategy as a Perspective
The fifth and final P shifts the focus to inside the minds of the executives running a
firm. Strategy as perspective refers to how executives interpret the competitive landscape around them.
Because each person is unique, two different executives could look at the same event?such as a new
competitor emerging?and attach different meanings to it. One might just see a new threat to his or her
firm?s sales; the other might view the newcomer as a potential ally.
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An old clich? urges listeners to ?make lemons into lemonade.? A good example of applying this idea
through strategy as perspective is provided by local government leaders in Sioux City, Iowa. Rather than
petition the federal government to change their airport?s unusual call sign?SUX?local leaders decided to
leverage the call sign to attract the attention of businesses and tourists to build their city?s economic base.
An array of clothing and other goods sporting the SUX name is available at http://www.flysux.com. Some
strategists such as these local leaders are willing to take a seemingly sour situation and see the potential
sweetness, while other executives remain fixated on the sourness.
Executives who adopt unique and positive perspectives can lead firms to find and exploit opportunities
that others simply miss. In the mid-1990s, the Internet was mainly a communication tool for academics
and government agencies. Jeff Bezos looked beyond these functions and viewed the Internet as a potential
sales channel. After examining a number of different markets that he might enter using the Internet,
Bezos saw strong profit potential in the bookselling business, and he began selling books online. Today,
the company he created?Amazon?has expanded far beyond its original focus on books to become a
dominant retailer in countless different markets. The late Steve Jobs at Apple appeared to take a similar
perspective; he saw opportunities where others could not, and his firm has reaped significant benefits as a
result.
KEY TAKEAWAY
? Strategic management focuses on firms and the different strategies that they use to become and remain
successful. Multiple views of strategy exist, and the 5 Ps described by Henry Mintzberg enhance
understanding of the various ways in which firms conceptualize strategy.
EXERCISES
1. Have you developed a strategy to manage your career? Should you make it more detailed? Why or why
not?
2. Identify an example of each of the 5 Ps of strategy other than the examples offered in this section.
3. What business that you visit regularly seems to have the most successful business model? What makes
the business model work?
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[1] Mintzberg, H. 1987. The strategy concept I: Five Ps for strategy. California Management Review, 30(1), 11?24.
[2] Markoff, J. 1996, May 14. Apple unveils strategic plan of small steps. New York Times. Retrieved
from http://www.nytimes.com/1996/05/14/business/apple-unveils-strategic -plan-of-small-steps.html
[3] Reuters. 2011, March 1. Philadelphia area pizza owner used mice vs. competition?police. Retrieved from
news.yahoo.com/s/nm/20110301/od_uk_nm/oukoe_uk_crime_pizza
[4] Porter, M. E. 1996, November?December. What is strategy? Harvard Business Review, 61?79.
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1.2 Intended, Emergent, and Realized Strategies
LEARNING OBJECTIVES
1. Learn what is meant by intended and emergent strategies and the differences between them.
2. Understand realized strategies and how they are influenced by intended, deliberate, and emergent
strategies.
A few years ago, a consultant posed a question to thousands of executives: ?Is your industry facing
overcapacity and fierce price competition?? All but one said ?yes.? The only ?no? came from the
manager of a unique operation?the Panama Canal! This manager was fortunate to be in charge of a
venture whose services are desperately needed by shipping companies and that offers the only simple
route linking the Atlantic and Pacific Oceans. The canal?s success could be threatened if transoceanic
shipping was to cease or if a new canal were built. Both of these possibilities are extremely remote,
however, so the Panama Canal appears to be guaranteed to have many customers for as long as
anyone can see into the future.
When an organization?s environment is stable and predictable, strategic planning can provide
enough of a strategy for the organization to gain and maintain success. The executives leading the
organization can simply create a plan and execute it, and they can be confident that their plan will
not be undermined by changes over time. But as the consultant?s experience shows, only a few
executives?such as the manager of the Panama Canal?enjoy a stable and predictable situation.
Because change affects the strategies of almost all organizations, understanding the concepts of
intended, emergent, and realized strategies is important (Figure 1.2 “Strategic Planning and
Learning: Intended, Emergent, and Realized Strategies”). Also relevant are deliberate and
nonrealized strategies. The relationships among these five concepts are presented in Figure 1.3 “A
Model of Intended, Deliberate, and Realized Strategy”. [1]
Figure 1.2 Strategic Planning and Learning: Intended, Emergent, and Realized Strategies
Intended and Emergent Strategies
Figure 1.3 A Model of Intended, Deliberate, and Realized Strategy
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Reproduced with permission
An intended strategy is the strategy that an organization hopes to execute. Intended strategies are usually
described in detail within an organization?s strategic plan. When a strategic plan is created for a new
venture, it is called a business plan. As an undergraduate student at Yale in 1965, Frederick Smith had to
complete a business plan for a proposed company as a class project. His plan described a delivery system
that would gain efficiency by routing packages through a central hub and then pass them to their
destinations. A few years later, Smith started Federal Express (FedEx), a company whose strategy closely
followed the plan laid out in his class project. Today, Frederick Smith?s personal wealth has surpassed $2
billion, and FedEx ranks eighth among the World?s Most Admired Companies according
to Fortune magazine. Certainly, Smith?s intended strategy has worked out far better than even he could
have dreamed.[2]
Emergent strategy has also played a role at Federal Express. An emergent strategy is an unplanned
strategy that arises in response to unexpected opportunities and challenges. Sometimes emergent
strategies result in disasters. In the mid-1980s, FedEx deviated from its intended strategy?s focus on
package delivery to capitalize on an emerging technology: facsimile (fax) machines. The firm developed a
service called ZapMail that involved documents being sent electronically via fax machines between FedEx
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offices and then being delivered to customers? offices. FedEx executives hoped that ZapMail would be a
success because it reduced the delivery time of a document from overnight to just a couple of hours.
Unfortunately, however, the ZapMail system had many technical problems that frustrated customers.
Even worse, FedEx failed to anticipate that many businesses would simply purchase their own fax
machines. ZapMail was shut down before long, and FedEx lost hundreds of millions of dollars following
its failed emergent strategy. In retrospect, FedEx had made a costly mistake by venturing outside of the
domain that was central to its intended strategy: package delivery. [3]
Emergent strategies can also lead to tremendous success. Southern Bloomer Manufacturing Company was
founded to make underwear for use in prisons and mental hospitals. Many managers of such institutions
believe that the underwear made for retail markets by companies such as Calvin Klein and Hanes is
simply not suitable for the people under their care. Instead, underwear issued to prisoners needs to be
sturdy and durable to withstand the rigors of prison activities and laundering. To meet these needs,
Southern Bloomers began selling underwear made of heavy cotton fabric.
An unexpected opportunity led Southern Bloomer to go beyond its intended strategy of serving
institutional needs for durable underwear. Just a few years after opening, Southern Bloomer?s
performance was excellent. It was servicing the needs of about 125 facilities, but unfortunately, this was
creating a vast amount of scrap fabric. An attempt to use the scrap as stuffing for pillows had failed, so the
scrap was being sent to landfills. This was not only wasteful but also costly.
One day, cofounder Don Sonner visited a gun shop with his son. Sonner had no interest in guns, but he
quickly spotted a potential use for his scrap fabric during this visit. The patches that the gun shop sold to
clean the inside of gun barrels were of poor quality. According to Sonner, when he ?saw one of those
flimsy woven patches they sold that unraveled when you touched them, I said, ?Man, that?s what I can do??
with the scrap fabric. Unlike other gun-cleaning patches, the patches that Southern Bloomer sold did not
give off threads or lint, two by-products that hurt guns? accuracy and reliability. The patches quickly
became popular with the military, police departments, and individual gun enthusiasts. Before long,
Southern Bloomer was selling thousands of pounds of patches per month. A casual trip to a gun store
unexpectedly gave rise to a lucrative emergent strategy. [4]
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Realized Strategy
A realized strategy is the strategy that an organization actually follows. Realized strategies are a product of
a firm?s intended strategy (i.e., what the firm planned to do), the firm?s deliberate strategy (i.e., the parts
of the intended strategy that the firm continues to pursue over time), and its emergent strategy (i.e., what
the firm did in reaction to unexpected opportunities and challenges). In the case of FedEx, the intended
strategy devised by its founder many years ago?fast package delivery via a centralized hub?remains a
primary driver of the firm?s realized strategy. For Southern Bloomers Manufacturing Company, realized
strategy has been shaped greatly by both its intended and emergent strategies, which center on underwear
and gun-cleaning patches.
In other cases, firms? original intended strategies are long forgotten. A nonrealized strategy refers to the
abandoned parts of the intended strategy. When aspiring author David McConnell was struggling to sell
his books, he decided to offer complimentary perfume as a sales gimmick. McConnell?s books never did
escape the stench of failure, but his perfumes soon took on the sweet smell of success. The California
Perfume Company was formed to market the perfumes; this firm evolved into the personal care products
juggernaut known today as Avon. For McConnell, his dream to be a successful writer was a nonrealized
strategy, but through Avon, a successful realized strategy was driven almost entirely by opportunistically
capitalizing on change through emergent strategy.
Strategy at the Movies
The Social Network
Did Harvard University student Mark Zuckerberg set out to build a billion-dollar company with more
than six hundred million active users? Not hardly. As shown in 2010?s The Social Network, Zuckerberg?s
original concept in 2003 had a dark nature. After being dumped by his girlfriend, a bitter Zuckerberg
created a website called ?FaceMash? where the attractiveness of young women could be voted on. This
evolved first into an online social network called Thefacebook that was for Harvard students only. When
the network became surprisingly popular, it then morphed into Facebook, a website open to everyone.
Facebook is so pervasive today that it has changed the way we speak, such as the word friend being used
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as a verb. Ironically, Facebook?s emphasis on connecting with existing and new friends is about as
different as it could be from Zuckerberg?s original mean-spirited concept. Certainly, Zuckerberg?s
emergent and realized strategies turned out to be far nobler than the intended strategy that began his
adventure in entrepreneurship.
The Social Network demonstrates how founder Mark Zuckerberg?s intended strategy gave way to
an emergent strategy via the creation of Facebook.
Image courtesy of Robert Scoble, http://www.flickr.com/photos/scobleizer/5179377698.
KEY TAKEAWAY
? Most organizations create intended strategies that they hope to follow to be successful. Over time,
however, changes in an organization?s situation give rise to new opportunities and challenges.
Organizations respond to these changes using emergent strategies. Realized strategies are a product of
both intended and realized strategies.
EXERCISES
1. What is the difference between an intended and an emergent strategy?
2. Can you think of a company that seems to have abandoned its intended strategy? Why do you suspect it
was abandoned?
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3. Would you describe your career strategy in college to be more deliberate or emergent? Why?
[1] Mintzberg, H., & Waters, J. A. 1985. Of strategies, deliberate and emergent. Strategic Management Journal, 6,
257?272.
[2] Donahoe, J. A. 2011, March 10. Forbes: Fred Smith?s fortune grows to $.21B. Memphis Business Journal.
Retrieved fromhttp://www.bizjournals.com/memphis/news/2011/03/10/forbes-fred-smiths-fortune-growsto.html;
Fortune: FedEx 8th ?most admired? company in the world. Memphis Business Journal. Retrieved
from http://www.bizjournals .com/memphis/news/2011/03/03/fortune-fedex-8th-most- admired.html
[3] Funding Universe. FedEx Corporation. Retrieved fromhttp://www.fundinguniverse.com/company –
histories/FedEx-Corporation-Company-History.html
[4] Wells, K. 2002. Floating off the page: The best stories from the Wall Street Journal?s middle column. New York:
Simon & Shuster. Quote from page 97.
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1.3 The History of Strategic Management
LEARNING OBJECTIVES
1. Consider how strategy in ancient times and military strategy can provide insights to businesses.
2. Describe how strategic management has evolved into a field of study.
Those who cannot remember the past are condemned to repeat it.
– George Santayana, The Life of Reason
Santayana?s quote has strong implications for strategic management. The history of strategic management
can be traced back several thousand years. Great wisdom about strategy can be acquired by
understanding the past, but ignoring the lessons of history can lead to costly strategic mistakes that could
have been avoided. Certainly, the present offers very important lessons; businesses can gain knowledge
about what strategies do and do not work by studying the current actions of other businesses. But this
section discusses two less obvious sources of wisdom: (1) strategy in ancient times and (2) military
strategy. This section also briefly traces the development of strategic management as a field of study.
Strategy in Ancient Times
Perhaps the earliest-known discussion of strategy is offered in the Old Testament of the
Bible. [1] Approximately 3,500 years ago, Moses faced quite a challenge after leading his fellow Hebrews
out of enslavement in Egypt. Moses was overwhelmed as the lone strategist at the helm of a nation that
may have exceeded one million people. Based on advice from his father-in-law, Moses began delegating
authority to other leaders, each of whom oversaw a group of people. This hierarchical delegation of
authority created a command structure that freed Moses to concentrate on the biggest decisions and
helped him implement his strategies (Figure 1.4 “Strategy in Ancient Times”). Similarly, the demands of
strategic management today are simply too much for a chief executive officer (the top leader of a
company) to handle alone. Many important tasks are thus entrusted to vice presidents and other
executives.
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In ancient China, strategist and philosopher Sun Tzu offered thoughts on strategy that continue to be
studied carefully by business and military leaders today. Sun Tzu?s best-known work is The Art of War. As
this title implies, Sun Tzu emphasized the creative and deceptive aspects of strategy.
One of Sun Tzu?s ideas that has numerous business applications is that winning a battle without fighting is
the best way to win. Apple?s behavior in the personal computer business offers a good example of this idea
in action. Many computer makers such as Toshiba, Acer, and Lenovo compete with one another based
primarily on price. This leads to price wars that undermine the computer makers? profits. In contrast,
Apple prefers to develop unique features for its computers, features that have created a fiercely loyal set of
customers. Apple boldly charges far more for its computers than its rivals charge for theirs. Apple does
not even worry much about whether its computers? software is compatible with the software used by most
other computers. Rather than fighting a battle with other firms, Apple wins within the computer business
by creating its own unique market and by attracting a set of loyal customers. Sun Tzu would probably
admire Apple?s approach.
Perhaps the most famous example of strategy in ancient times revolves around the Trojan horse.
According to legend, Greek soldiers wanted to find a way to enter the gates of Troy and attack the city
from the inside. They devised a ploy that involved creating a giant wooden horse, hiding soldiers inside
the horse, and offering the horse to the Trojans as a gift. The Trojans were fooled and brought the horse
inside their city. When night arrived, the hidden Greek soldiers opened the gates for their army, leading to
a Greek victory. In modern times, the term Trojan horse refers to gestures that appear on the surface to
be beneficial to the recipient but that mask a sinister intent. Computer viruses also are sometimes referred
to as Trojan horses.
A far more noble approach to strategy than the Greeks? is attributed to King Arthur of Britain. Unlike the
hierarchical approach to organizing Moses used, Arthur allegedly considered himself and each of his
knights to have an equal say in plotting the group?s strategy. Indeed, the group is thought to have held its
meetings at a round table so that no voice, including Arthur?s, would be seen as more important than the
others. The choice of furniture in modern executive suites is perhaps revealing. Most feature rectangular
meeting tables, perhaps signaling that one person?the chief executive officer?is in charge.
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Another implication for strategic management offered by King Arthur and his Knights of the Round Table
involves the concept of mission. Their vigorous search to find the Holy Grail (the legendary cup used by
Jesus and his disciples at the Last Supper) serves as an exemplar for the importance of a central mission
to guide organizational strategy and actions.
Lessons Offered by Military Strategy
Key military conflicts and events have shaped the understanding of strategic management (Figure 1.5
“Classic Military Strategy”). Indeed, the word strategy has its roots in warfare. The Greek
verb strategos means ?army leader? and the idea of stratego (from which we get the word strategy) refers
to defeating an enemy by effectively using resources. [2]
A book written nearly five hundred years ago is still regarded by many as an insightful guide for
conquering and ruling territories. Niccol? Machiavelli?s 1532 book The Prince offers clever recipes for
success to government leaders. Some of the book?s suggestions are quite devious, and the
word Machiavellianis used today to refer to acts of deceit and manipulation.
Two wars fought on American soil provide important lessons about strategic management. In the late
1700s, the American Revolution pitted the American colonies against mighty Great Britain. The
Americans relied on nontraditional tactics, such as guerilla warfare and the strategic targeting of British
officers. Although these tactics were considered by Great Britain to be barbaric, they later became widely
used approaches to warfare. The Americans owed their success in part to help from the French navy,
illustrating the potential value of strategic alliances.
Nearly a century later, Americans turned on one another during the Civil War. After four years of
hostilities, the Confederate states were forced to surrender. Historians consider the Confederacy to have
had better generals, but the Union possessed greater resources, such as factories and railroad lines. As
many modern companies have discovered, sometimes good strategies simply cannot overcome a stronger
adversary.
Two wars fought on Russian soil also offer insights. In the 1800s, a powerful French invasion force was
defeated in part by the brutal nature of Russian winters. In the 1940s, a similar fate befell German forces
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during World War II. Against the advice of some of his leading generals, Adolf Hitler ordered his army to
conquer Russia. Like the French before them, the Germans were able to penetrate deep into Russian
territory. As George Santayana had warned, however, the forgotten past was about to repeat itself.
Horrific cold stopped the German advance. Russian forces eventually took control of the combat, and
Hitler committed suicide as the Russians approached the German capital, Berlin.
Five years earlier, Germany ironically had benefited from an opponent ignoring the strategic management
lessons of the past. In ancient times, the Romans had assumed that no army could cross a mountain range
known as the Alps. An enemy general named Hannibal put his men on elephants, crossed the mountains,
and caught Roman forces unprepared. French commanders made a similar bad assumption in 1940.
When Germany invaded Belgium (and then France) in 1940, its strategy caught French forces by surprise.
The top French commanders assumed that German tanks simply could not make it through a thickly
wooded region known as the Ardennes Forest. As a result, French forces did not bother preparing a strong
defense in that area. Most of the French army and their British allies instead protected against a small,
diversionary force that the Germans had sent as a deception to the north of the forest. German forces
made it through the forest, encircled the allied forces, and started driving them toward the ocean. Many
thousands of French and British soldiers were killed or captured. In retrospect, the French generals had
ignored an important lesson of history: Do not make assumptions about what your adversary can and
cannot do. Executives who make similar assumptions about their competitors put their organizations?
performance in jeopardy.
Strategic Management as a Field of Study
Universities contain many different fields of study, including physics, literature, chemistry, computer
science, and engineering. Some fields of study date back many centuries (e.g., literature), while others
(such as computer science) have emerged only in recent years. Strategic management has been important
throughout history, but the evolution of strategic management into a field of study has mostly taken place
over the past century. A few of the key business and academic events that have helped the field develop
are discussed next (Figure 1.6 “The Modern History of Strategic Management”).
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The ancient Chinese strategist Sun Tzu made it clear that strategic management is part art. But it is also
part science. Major steps toward developing the scientific aspect of strategic management were taken in
the early twentieth century by Frederick W. Taylor. In 1911, Taylor published The Principles of Scientific
Management. The book was a response to Taylor?s observation that most tasks within organizations were
organized haphazardly. Taylor believed that businesses would be much more efficient if management
principles were derived through scientific investigation. In The Principles of Scientific Management,
Taylor stressed how organizations could become more efficient through identifying the ?one best way? of
performing important tasks. Implementing Taylor?s principles was thought to have saved railroad
companies hundreds of millions of dollars. [3] Although many later works disputed the merits of trying to
find the ?one best way,? Taylor?s emphasis on maximizing organizational performance became the core
concern of strategic management as the field developed.
Also in the early twentieth century, automobile maker Henry Ford emerged as one of the pioneers of
strategic management among industrial leaders. At the time, cars seemed to be a luxury item for wealthy
people. Ford adopted a unique strategic perspective, however, and boldly offered the vision that he would
make cars the average family could afford. Building on ideas about efficiency from Taylor and others, Ford
organized assembly lines for creating automobiles that lowered costs dramatically. Despite his wisdom,
Ford also made mistakes. Regarding his company?s flagship product, the Model T, Ford famously stated,
?Any customer can have a car painted any color that he wants so long as it is black.? When rival
automakers provided customers with a variety of color choices, Ford had no choice but to do the same.
In 1912, Harvard University became the first higher education institution to offer a course focused on how
business executives could lead their organizations to greater success. The approach to maximizing
performance within this ?business policy? course was consistent with Taylor?s ideas. Specifically, the goal
of the business policy course was to identify the one best response to any given problem that an
organization confronted. By finding and pursuing this ideal solution, the organization would have the best
chance of enjoying success.
In the 1920s, A&W Root Beer became the first franchised restaurant chain. Franchising involves an
organization (called a franchisor) granting the right to use its brand name, products, and processes to
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other organizations (known as franchisees) in exchange for an up-front payment (a franchise fee) and a
percentage of franchisees? revenues (a royalty fee). This simple yet powerful business model allows
franchisors to grow their brands rapidly and provides franchisees with the safety of a proven business
format. Within a few decades, the franchising business model would fuel incredible successes for many
franchisors and franchisees across a variety of industries. Today, for example, both Subway and
McDonald?s have more than thirty thousand restaurants carrying their brand names.
The acceptance of strategic management as a necessary element of business school programs took a major
step forward in 1959. A widely circulated report created by the Ford Foundation recommended that all
business schools offer a ?capstone? course. The goal of this course would be to integrate knowledge across
different business fields such as marketing, finance, and accounting to help students devise better ideas
for addressing complex business problems. Rather than seeking a ?one best way? solution, as advocated
by Taylor and Harvard?s business policy course, this capstone course would emphasize students? critical
thinking skills in general and the notion that multiple ways of addressing a problem could be equally
successful in particular. The Ford Foundation report was a key motivator that led US universities to create
strategic management courses in their undergraduate and master of business administration programs.
In 1962, business and academic events occurred that seemed minor at the time but that would later give
rise to huge changes. Building on the business savvy that he had gained as a franchisee, Sam Walton
opened the first Walmart in Rogers, Arkansas. Relying on a strategy that emphasized low prices and high
levels of customer service, Walmart grew to 882 stores with a combined $8.4 billion dollars in annual
sales by 1985. A decade later, sales reached $93.6 billion across nearly 3,000 stores. In 2010, Walmart
was the largest company in the world. In recent years, Walmart has arguably downplayed customer
service in favor of cutting costs. Time will tell whether deviating from Sam Walton?s original strategic
positioning will hurt the company.
Also in 1962, Harvard professor Alfred Chandler published Strategy and Structure: Chapters in the
History of the Industrial Enterprise. This book describes how strategy and organizational structure need
to be consistent with each other to ensure strong firm performance, a lesson that Moses seems to have
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mastered during the Hebrews? exodus from Egypt. Many people working in the field of strategic
management consider Chandler?s book to be the first work of strategic management research.
Two pivotal events that firmly established strategic management as a field of study took place in 1980.
One was the creation of the Strategic Management Journal. The introduction of the journal offered a
forum for researchers interested in building knowledge about strategic management. Much like important
new medical findings appear in the Journal of the American Medical Association and the New England
Journal of Medicine, the Strategic Management Journal publishes pathbreaking insights about strategic
management.
The second pivotal event in 1980 was the publication of Competitive Strategy: Techniques for Analyzing
Industries and Competitors by Harvard professor Michael Porter. This book offers concepts such as five
forces analysis and generic strategies that continue to strongly influence how executives choose strategies
more than thirty years after the book?s publication. Given the importance of these concepts, both five
forces analysis and generic strategies are discussed in detail in Chapter 3 “Evaluating the External
Environment” and Chapter 5 “Selecting Business-Level Strategies”, respectively.
Many consumers today take web-based shopping for granted, but this channel for commerce was created
less than two decades ago. The 1995 launch of Amazon by founder Jeff Bezos was perhaps the pivotal
event in creating Internet-based commerce. In pursuit of its vision ?to be earth?s most customer-centric
company,? Amazon has diversified far beyond its original focus on selling books and has evolved into a
dominant retailer. Powerful giants have stumbled badly in Amazon?s wake. Sears had sold great varieties
of goods (even including entire houses) through catalogs for many decades, as had JCPenney. Neither
firm created a strong online sales presence to keep pace with Amazon, and both eventually dropped their
catalog businesses. As often happens with old and large firms, Sears and JCPenney were outmaneuvered
by a creative and versatile upstart.
Ethics have long been an important issue within the strategic management field. Attention to the need for
executives to act ethically when creating strategies increased dramatically in the early 2000s when a series
of companies such as Enron Corporation, WorldCom, Tyco, Qwest, and Global Crossing were found to
have grossly exaggerated the strength of their performance. After a series of revelations about fraud and
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corruption, investors in these firms and others lost billions of dollars, tens of thousands of jobs were lost,
and some executives were sent to prison.
Like ethics, the implications of international competition are of central interest to strategic management.
Provocative new thoughts on the nature of the international arena were offered in 2005 by Thomas L.
Friedman. In his book The World Is Flat: A Brief History of the Twenty-First Century, Friedman argues
that many of the advantages that firms in developed countries such as the United States, Japan, and Great
Britain take for granted are disappearing. One implication is that these firms will need to improve their
strategies if they are to remain successful.
Looking to the future, it appears likely that strategic management will prove to be more important than
ever. In response, researchers who are interested in strategic management will work to build additional
knowledge about how organizations can maximize their performance. Executives will need to keep track
of the latest scientific findings. Meanwhile, they also must leverage the insights that history offers on how
to be successful while trying to avoid history?s mistakes.
KEY TAKEAWAY
? Although strategic management as a field of study has developed mostly over the last century, the
concept of strategy is much older. Understanding strategic management can benefit greatly by learning
the lessons that ancient history and military strategy provide.
EXERCISES
1. What do you think was the most important event related to strategy in ancient times?
2. In what ways are the strategic management of business and military strategy alike? In what ways are they
different?
3. Do you think executives are more ethical today as a result of the scandals in the early 2000s? Why or why
not?
[1] Bracker, J. 1980. The historical development of the strategic management concept.Academy of Management
Review, 5(2), 219?224.
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[2] Bracker, J. 1980. The historical development of the strategic management concept.Academy of Management
Review, 5(2), 219?224.
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1.4 Understanding the Strategic Management Process
LEARNING OBJECTIVES
1. Learn the strategic management process.
2. Understand the four steps in the strategic management process.
Modeling the Strategy Process
Strategic management is a process that involves building a careful understanding of how the world is
changing, as well as a knowledge of how those changes might affect a particular firm. CEOs, such as late
Apple-founder Steve Jobs, must be able to carefully manage the possible actions that their firms might
take to deal with changes that occur in their environment. We present a model of the strategic
management process in Figure 1.7 “Overall Model of the Strategic Management Process”. This model also
guides our presentation of the chapters contained in this book.
Figure 1.7 Overall Model of the Strategic Management Process
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The strategic management process begins with an understanding of strategy and performance. As we have
noted in this introductory chapter, strategic management is both an art and a science, and it involves
multiple conceptualizations of the notion of strategy drawn from recent and ancient history. In Chapter 2
“Leading Strategically”, we focus on how leading strategically is needed if the firm is to achieve the longterm
strong performance companies such as Apple have attained. Consequently, how managers
understand and interpret the performance of their firms is often central to understanding strategy.
Environmental and internal scanning is the next stage in the process. Managers must constantly scan the
external environment for trends and events that affect the overall economy, and they must monitor
changes in the particular industry in which the firm operates. For example, Apple?s decision to create the
iPhone demonstrates its ability to interpret that traditional industry boundaries that distinguished the
cellular phone industry and the computer industry were beginning to blur. At the same time, firms must
evaluate their own resources to understand how they might react to changes in the environment. For
example, intellectual property is a vital resource for Apple. Between 2008 and 2010, Apple filed more
than 350 cases with the US Patent and Trademark Office to protect its use of such terms as apple, pod,
and safari.
[1]
A classic management tool that incorporates the idea of scanning elements both external and internal to
the firm is SWOT (strengths, weaknesses, opportunities, and threats) analysis. Strengths and weaknesses
are assessed by examining the firm?s resources, while opportunities and threats refer to external events
and trends. The value of SWOT analysis parallels ideas from classic military strategists such as Sun Tzu,
who noted the value of knowing yourself as well as your opponent. Chapter 3 “Evaluating the External
Environment” examines the topic of evaluating the external environment in detail, and Chapter 4
“Managing Firm Resources” presents concepts and tools for managing firm resources.
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The importance of knowing yourself and your opponent is applicable to the knowledge of strategic
management for business, military strategy, and classic strategy games such as chess.
Strategy formulation is the next step in the strategic management process. This involves developing
specific strategies and actions. Certainly, part of Apple?s success is due to the unique products it offers the
market, as well as how these products complement one another. A customer can buy an iPod that plays
music from iTunes?all of which can be stored in Apple?s Mac computer. [2] In Chapter 5 “Selecting
Business-Level Strategies”, we discuss how selecting business-level strategies helps to provide firms with
a recipe that can be followed that will increase the likelihood that their strategies will be successful.
In Chapter 6 “Supporting the Business-Level Strategy: Competitive and Cooperative Moves”, we present
insights on how firms can support the business-level strategy through competitive and cooperative
moves. Chapter 7 “Competing in International Markets” presents possibilities for firms competing in
international markets, and Chapter 8 “Selecting Corporate-Level Strategies” focuses on selecting
corporate-level strategies.
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Strategy implementation is the final stage of the process. One important element of strategy
implementation entails crafting an effective organizational structure and corporate culture. For example,
part of Apple?s success is due to its consistent focus on innovation and creativity that Steve Jobs described
as similar to that of a start-up. Chapter 9 “Executing Strategy through Organizational Design” offers ideas
on how to manage these elements of implementation. The final chapter explores how to lead an ethical
organization through corporate governance, social responsibility, and sustainability.
KEY TAKEAWAY
? Strategic management is a process that requires the ability to manage change. Consequently, executives
must be careful to monitor and to interpret the events in their environment, to take appropriate actions
when change is needed, and to monitor their performance to ensure that their firms are able to survive
and, it is hoped, thrive over time.
EXERCISES
1. Who makes the strategic decisions for most organizations?
2. Why is it important to view strategic management as a process?
3. What are the four steps of the strategic management process?
4. How is chess relevant to the study of strategic management? What other games might help teach
strategic thinking?
[1] Apple Inc. litigation. Wikipedia. Retrieved from en.wikipedia.org/wiki/Apple_Inc._ litigation
[2] Inside CRM Editors. Effective strategies Apple uses to create loyal customers [Online article]. Retrieved
from http://www.insidecrm.com/features/strategies-apple-loyal -customers
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1.5 Conclusion
This chapter provides an overview of strategic management and strategy. Ideas about strategy span
many centuries, and modern understanding of strategy borrows from ancient strategies as well as
classic militaries strategies. You should now understand that there are numerous ways to
conceptualize the idea of strategy and that effective strategic management is needed to ensure the
long-term success of firms. The study of strategic management provides tools to effectively manage
organizations, but it also involves the art of knowing how and when to apply creative thinking.
Knowledge of both the art and the science of strategic management is needed to help guide
organizations as their strategies emerge and evolve over time. Such tools will also help you effectively
chart a course for your career as well as to understand the effective strategic management of the
organizations for which you will work.
EXERCISES
1. Think about the best and worst companies you know. What is extraordinary (or extraordinarily bad) about
these firms? Are their strategies clear and focused or difficult to define?
2. If you were to write a ?key takeaway? section for this chapter, what would you include as the material
you found most interesting?
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Chapter 2
Leading Strategically
LEARNING OBJECTIVES
After reading this chapter, you should be able to understand and articulate answers to the following
questions:
1. What are vision, mission, and goals, and why are they important to organizations?
2. How should executives analyze the performance of their organizations?
3. In what ways can having a celebrity CEO and a strong entrepreneurial orientation help or harm an
organization?
Questions Are Brewing at Starbucks
Starbucks?s global empire includes this store in Seoul, South Korea.
Image courtesy of Wikimedia,http://commons.wikimedia.org/wiki/File:Starbucks-seoul.JPG.
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March 30, 2011, marked the fortieth anniversary of Starbucks first store opening for business in Seattle,
Washington. From its humble beginnings, Starbucks grew to become the largest coffeehouse company in
the world while stressing the importance of both financial and social goals. As it created thousands of
stores across dozens of countries, the company navigated many interesting periods. The last few years
were a particularly fascinating era.
In early 2007, Starbucks appeared to be very successful, and its stock was worth more than $35 per share.
By 2008, however, the economy was slowing, competition in the coffee business was heating up, and
Starbucks?s performance had become disappointing. In a stunning reversal of fortune, the firm?s stock was
worth less than $10 per share by the end of the year. Anxious stockholders wondered whether Starbucks?s
decline would continue or whether the once high-flying company would return to its winning ways.
Riding to the rescue was Howard Schultz, the charismatic and visionary founder of Starbucks who had
stepped down as chief executive officer eight years earlier. Schultz again took the helm and worked to turn
the company around by emphasizing its mission statement: ?to inspire and nurture the human spirit?one
person, one cup and one neighborhood at a time.? [1]About a thousand underperforming stores were shut
down permanently. Thousands of other stores closed for a few hours so that baristas could be retrained to
make inspiring drinks. Food offerings were revamped to ensure that coffee?not breakfast sandwiches?
were the primary aroma that tantalized customers within Starbucks?s outlets.
By the time Starbucks?s fortieth anniversary arrived, Schultz had led his company to regain excellence,
and its stock price was back above $35 per share. In March 2011, Schultz summarized the situation by
noting that ?over the last three years, we?ve completely transformed the company, and the health of
Starbucks is quite good. But I don?t think this is a time to celebrate or run some victory lap. We?ve got a lot
of work to do.? [2] Indeed, important questions loomed. Could performance improve further? How long
would Schultz remain with the company? Could Schultz?s eventual successor maintain Schultz?s
entrepreneurial approach as well as keep Starbucks focused on its mission?
[1] Our Starbucks mission statement. Retrieved from http://www.starbucks.com/about-us/companyinformation/mission-statement.
Accessed March 31, 2011.
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[2] Starbucks CEO: Can you ?get big and stay small? [Review of the book Onward: How Starbucks fought for its life
without losing its soul by Howard Schultz]. 2011, March 28. NPR Books. Retrieved
from http://www.npr.org/2011/03/28/134738487/starbucks-ceo-can-you-get-big-and-stay-small.
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2.1 Vision, Mission, and Goals
LEARNING OBJECTIVES
1. Define vision and mission and distinguish between them.
2. Know what the acronym SMART represents.
3. Be able to write a SMART goal.
The Importance of Vision
Good business leaders create a vision, articulate the vision, passionately own the vision, and relentlessly
drive it to completion.
– Jack Welch, former CEO of General Electric
Many skills and abilities separate effective strategic leaders like Howard Schultz from poor strategic
leaders. One of them is the ability to inspire employees to work hard to improve their organization?s
performance. Effective strategic leaders are able to convince employees to embrace lofty ambitions and
move the organization forward. In contrast, poor strategic leaders struggle to rally their people and
channel their collective energy in a positive direction.
As the quote from Jack Welch suggests, a vision is one key tool available to executives to inspire the
people in an organization (Figure 2.1 “The Big Picture: Organizational Vision”). An organization?s vision
describes what the organization hopes to become in the future. Well-constructed visions clearly articulate
an organization?s aspirations. Avon?s vision is ?to be the company that best understands and satisfies the
product, service, and self-fulfillment needs of women?globally.? This brief but powerful statement
emphasizes several aims that are important to Avon, including excellence in customer service,
empowering women, and the intent to be a worldwide player. Like all good visions, Avon sets a high
standard for employees to work collectively toward. Perhaps no vision captures high standards better than
that of aluminum maker Alcoa. This firm?s very ambitious vision is ?to be the best company in the world?
in the eyes of our customers, shareholders, communities and people.? By making clear their aspirations,
Alcoa?s executives hope to inspire employees to act in ways that help the firm become the best in the
world.
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The results of a survey of one thousand five hundred executives illustrate how the need to create an
inspiring vision creates a tremendous challenge for executives. When asked to identify the most important
characteristics of effective strategic leaders, 98 percent of the executives listed ?a strong sense of vision?
first. Meanwhile, 90 percent of the executives expressed serious doubts about their own ability to create a
vision. [1] Not surprisingly, many organizations do not have formal visions. Many organizations that do
have visions find that employees do not embrace and pursue the visions. Having a well-formulated vision
employees embrace can therefore give an organization an edge over its rivals.
Mission Statements
In working to turnaround Starbucks, Howard Schultz sought to renew Starbucks?s commitment to
its mission statement: ?to inspire and nurture the human spirit?one person, one cup and one
neighborhood at a time.? A mission such as Starbucks?s states the reasons for an organization?s existence.
Well-written mission statements effectively capture an organization?s identity and provide answers to the
fundamental question ?Who are we?? While a vision looks to the future, a mission captures the key
elements of the organization?s past and present.
Organizations need support from their key stakeholders, such as employees, owners, suppliers, and
customers, if they are to prosper. A mission statement should explain to stakeholders why they should
support the organization by making clear what important role or purpose the organization plays in
society. Google?s mission, for example, is ?to organize the world?s information and make it universally
accessible and useful.? Google pursued this mission in its early days by developing a very popular Internet
search engine. The firm continues to serve its mission through various strategic actions, including offering
its Internet browser Google Chrome to the online community, providing free e-mail via its Gmail service,
and making books available online for browsing.
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Many consider Abraham Lincoln to have been one of the
greatest strategic leaders in modern history.
Image courtesy of Alexander Gardner,
http://wikimediafoundation.org/wiki/File:Abraham_Li
ncoln_head_on_shoulders_photo_portrait.jpg.
One of Abraham Lincoln?s best-known statements is that ?a house divided against itself cannot stand.?
This provides a helpful way of thinking about the relationship between vision and mission. Executives ask
for trouble if their organization?s vision and mission are divided by emphasizing different domains. Some
universities have fallen into this trap. Many large public universities were established in the late 1800s
with missions that centered on educating citizens. As the twentieth century unfolded, however, creating
scientific knowledge through research became increasingly important to these universities. Many
university presidents responded by creating visions centered on building the scientific prestige of their
schools. This created a dilemma for professors: Should they devote most of their time and energy to
teaching students (as the mission required) or on their research studies (as ambitious presidents
demanded via their visions)? Some universities continue to struggle with this trade-off today and remain
houses divided against themselves. In sum, an organization is more effective to the extent that its vision
and its mission target employees? effort in the same direction.
Pursuing the Vision and Mission through SMART Goals
An organization?s vision and mission offer a broad, overall sense of the organization?s direction. To work
toward achieving these overall aspirations, organizations also need to create goals?narrower aims that
should provide clear and tangible guidance to employees as they perform their work on a daily basis. The
most effective goals are those that are specific, measurable, aggressive, realistic, and time-bound. An easy
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way to remember these dimensions is to combine the first letter of each into one word: SMART.
Employees are put in a good position to succeed to the extent that an organization?s goals are SMART.
A goal is specific if it is explicit rather than vague. In May 1961, President John F. Kennedy proposed a
specific goal in a speech to the US Congress: ?I believe that this nation should commit itself to achieving
the goal, before this decade is out, of landing a man on the moon and returning him safely to the
earth.? [2]Explicitness such as was offered in this goal is helpful because it targets people?s energy. A few
moments later, Kennedy made it clear that such targeting would be needed if this goal was to be reached.
Going to the moon, he noted, would require ?a major national commitment of scientific and technical
manpower, materiel and facilities, and the possibility of their diversion from other important activities
where they are already thinly spread.? While specific goals make it clear how efforts should be directed,
vague goals such as ?do your best? leave individuals unsure of how to proceed.
A goal is measurable to the extent that whether the goal is achieved can be quantified. President
Kennedy?s goal of reaching the moon by the end of the 1960s offered very simple and clear measurability:
Either Americans would step on the moon by the end of 1969 or they would not. One of Coca-Cola?s
current goals is a 20 percent improvement to its water efficiency by 2012 relative to 2004 water usage.
Because water efficiency is easily calculated, the company can chart its progress relative to the 20 percent
target and devote more resources to reaching the goal if progress is slower than planned.
A goal is aggressive if achieving it presents a significant challenge to the organization. A series of
research studies have demonstrated that performance is strongest when goals are challenging but
attainable. Such goals force people to test and extend the limits of their abilities. This can result in
reaching surprising heights. President Kennedy captured this theme in a speech in September 1962: ?We
choose to go to the moon. We choose to go to the moon in this decade?not because [it is] easy, but
because [it is] hard, because that goal will serve to organize and measure the best of our energies and
skills.?
In the case of Coca-Cola, reaching a 20 percent improvement will require a concerted effort, but the goal
can be achieved. Meanwhile, easily achievable goals tend to undermine motivation and effort. Consider a
situation in which you have done so well in a course that you only need a score of 60 percent on the final
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exam to earn an A for the course. Understandably, few students would study hard enough to score 90
percent or 100 percent on the final exam under these circumstances. Similarly, setting organizational
goals that are easy to reach encourages employees to work just hard enough to reach the goals.
It is tempting to extend this thinking to conclude that setting nearly impossible goals would encourage
even stronger effort and performance than does setting aggressive goals. People tend to get discouraged
and give up, however, when faced with goals that have little chance of being reached. If, for example,
President Kennedy had set a time frame of one year to reach the moon, his goal would have attracted
scorn. The country simply did not have the technology in place to reach such a goal. Indeed, Americans
did not even orbit the moon until seven years after Kennedy?s 1961 speech. Similarly, if Coca-Cola?s water
efficiency goal was 95 percent improvement, Coca-Cola?s employees would probably not embrace it. Thus
goals must also be realistic, meaning that their achievement is feasible.
You have probably found that deadlines are motivating and that they help you structure your work time.
The same is true for organizations, leading to the conclusion that goals should be time-bound through
the creation of deadlines. Coca-Cola has set a deadline of 2012 for its water efficiency goal, for example.
The deadline for President Kennedy?s goal was the end of 1969. The goal was actually reached a few
months early. On July 20, 1969, Neil Armstrong became the first human to step foot on the moon.
Incredibly, the pursuit of a well-constructed goal had helped people reach the moon in just eight years.
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Americans landed on the moon eight years after President Kennedy set a moon landing as a key
goal for the United States.
Image courtesy of NASA Apollo Archive,
http://upload.wikimedia.org/wikipedia/commons/8/8b/5927_NASA.jpg.
The period after an important goal is reached is often overlooked but is critical. Will an organization rest
on its laurels or will it take on new challenges? The US space program again provides an illustrative
example. At the time of the first moon landing, Time magazine asked the leader of the team that built the
moon rockets about the future of space exploration. ?Given the same energy and dedication that took
them to the moon,? said Wernher von Braun, ?Americans could land on Mars as early as 1982.? [3] No new
goal involving human visits to Mars was embraced, however, and human exploration of space was deemphasized
in favor of robotic adventurers. Nearly three decades after von Braun?s proposed timeline for
reaching Mars expired, President Barack Obama set in 2010 a goal of creating by 2025 a new space
vehicle capable of taking humans beyond the moon and into deep space. This would be followed in the
mid-2030s by a flight to orbit Mars as a prelude to landing on Mars. [4] Time will tell whether these goals
inspire the scientific community and the country in general (Figure 2.4 “Be SMART: Vision, Mission,
Goals, and You”).
KEY TAKEAWAY
? Strategic leaders need to ensure that their organizations have three types of aims. A vision states what
the organization aspires to become in the future. A mission reflects the organization?s past and present by
stating why the organization exists and what role it plays in society. Goals are the more specific aims that
organizations pursue to reach their visions and missions. The best goals are SMART: specific, measurable,
aggressive, realistic, and time-bound.
EXERCISES
1. Take a look at the website of your college or university. What is the organization?s vision and mission?
Were they easy or hard to find?
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2. As a member of the student body, do you find the vision and mission of your college or university to be
motivating and inspirational? Why or why not?
3. What is an important goal that you have established for your career? Could this goal be improved by
applying the SMART goal concept?
[1] Quigley, J. V. 1994. Vision: How leaders develop it, share it, and sustain it. Business Horizons, 37(5), 37?41.
[2] Key documents in the history of space policy: 1960s. National Aeronautics and Space Administration. Retrieved
from http://history.nasa.gov/spdocs.html#1960s
[3] The Moon: Next, Mars and beyond. 1969, July 15. Time. Retrieved
fromhttp://www.time.com/time/magazine/article/0,9171,901107,00.html
[4] Amos, J. 2010, April 15. Obama sets Mars goal for America. BBC News. Retrieved from
http://news.bbc.co.uk/2/hi/8623691.stm
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2.2 Assessing Organizational Performance
LEARNING OBJECTIVES
1. Understand the complexities associated with assessing organizational performance.
2. Learn each of the dimensions of the balanced scorecard framework.
3. Learn what is meant by a ?triple bottom line.?
Organizational Performance: A Complex Concept
Organizational performance refers to how well an organization is doing to reach its vision, mission, and
goals. Assessing organizational performance is a vital aspect of strategic management. Executives must
know how well their organizations are performing to figure out what strategic changes, if any, to make.
Performance is a very complex concept, however, and a lot of attention needs to be paid to how it is
assessed.
Two important considerations are (1) performance measures and (2) performance referents (Figure 2.5
“How Organizations and Individuals Can Use Financial Performance Measures and Referents”).
A performance measure is a metric along which organizations can be gauged. Most executives examine
measures such as profits, stock price, and sales in an attempt to better understand how well their
organizations are competing in the market. But these measures provide just a glimpse of organizational
performance. Performance referents are also needed to assess whether an organization is doing well. A
performance referent is a benchmark used to make sense of an organization?s standing along a
performance measure. Suppose, for example, that a firm has a profit margin of 20 percent in 2011. This
sounds great on the surface. But suppose that the firm?s profit margin in 2010 was 35 percent and that the
average profit margin across all firms in the industry for 2011 was 40 percent. Viewed relative to these two
referents, the firm?s 2011 performance is cause for concern.
Using a variety of performance measures and referents is valuable because different measures and
referents provide different information about an organization?s functioning. The parable of the blind men
and the elephant?popularized in Western cultures through a poem by John Godfrey Saxe in the
nineteenth century?is useful for understanding the complexity associated with measuring organizational
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performance. As the story goes, six blind men set out to ?see? what an elephant was like. The first man
touched the elephant?s side and believed the beast to be like a great wall. The second felt the tusks and
thought elephants must be like spears. Feeling the trunk, the third man thought it was a type of snake.
Feeling a limb, the fourth man thought it was like a tree trunk. The fifth, examining an ear, thought it was
like a fan. The sixth, touching the tail, thought it was like a rope. If the men failed to communicate their
different impressions they would have all been partially right but wrong about what ultimately mattered.
Figure 2.5 How Organizations and Individuals Can Use Financial Performance Measures and
Referents
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This story parallels the challenge involved in understanding the multidimensional nature of organization
performance because different measures and referents may tell a different story about the organization?s
performance. For example, the Fortune 500 lists the largest US firms in terms of sales. These firms are
generally not the strongest performers in terms of growth in stock price, however, in part because they are
so big that making major improvements is difficult. During the late 1990s, a number of Internet-centered
businesses enjoyed exceptional growth in sales and stock price but reported losses rather than profits.
Many investors in these firms who simply fixated on a single performance measure?sales growth?
absorbed heavy losses when the stock market?s attention turned to profits and the stock prices of these
firms plummeted.
The story of the blind men and the elephant provides a metaphor for understanding the
complexities of measuring organizational performance.
Image courtesy of Hanabusa Itcho,
http://en.wikipedia.org/wiki/File:Blind_monks_examining_an_elephant.jpg.
The number of performance measures and referents that are relevant for understanding an organization?s
performance can be overwhelming, however. For example, a study of what performance metrics were used
within restaurant organizations? annual reports found that 788 different combinations of measures and
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referents were used within this one industry in a single year. [1]Thus executives need to choose a rich yet
limited set of performance measures and referents to focus on.
The Balanced Scorecard
To organize an organization?s performance measures, Professor Robert Kaplan and Professor David
Norton of Harvard University developed a tool called the balanced scorecard. Using the scorecard helps
managers resist the temptation to fixate on financial measures and instead monitor a diverse set of
important measures (Figure 2.6 “Beyond Profits: Measuring Performance Using the Balanced
Scorecard”). Indeed, the idea behind the framework is to provide a ?balance? between financial measures
and other measures that are important for understanding organizational activities that lead to sustained,
long-term performance. The balanced scorecard recommends that managers gain an overview of the
organization?s performance by tracking a small number of key measures that collectively reflect four
dimensions: (1) financial, (2) customer, (3) internal business process, and (4) learning and growth. [2]
Financial Measures
Financial measures of performance relate to organizational effectiveness and profits. Examples include
financial ratios such as return on assets, return on equity, and return on investment. Other common
financial measures include profits and stock price. Such measures help answer the key question ?How do
we look to shareholders??
Financial performance measures are commonly articulated and emphasized within an organization?s
annual report to shareholders. To provide context, such measures should be objective and be coupled with
meaningful referents, such as the firm?s past performance. For example, Starbucks?s 2009 annual report
highlights the firm?s performance in terms of net revenue, operating income, and cash flow over a fiveyear
period.
Customer Measures
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Customer measures of performance relate to customer attraction, satisfaction, and retention. These
measures provide insight to the key question ?How do customers see us?? Examples might include the
number of new customers and the percentage of repeat customers.
Starbucks realizes the importance of repeat customers and has taken a number of steps to satisfy and to
attract regular visitors to their stores. For example, Starbucks rewards regular customers with free drinks
and offers all customers free Wi-Fi access. [3] Starbucks also encourages repeat visits by providing cards
with codes for free iTunes downloads. The featured songs change regularly, encouraging frequent repeat
visits.
Internal Business Process Measures
Internal business process measures of performance relate to organizational efficiency. These measures
help answer the key question ?What must we excel at?? Examples include the time it takes to manufacture
the organization?s good or deliver a service. The time it takes to create a new product and bring it to
market is another example of this type of measure.
Organizations such as Starbucks realize the importance of such efficiency measures for the long-term
success of its organization, and Starbucks carefully examines its processes with the goal of decreasing
order fulfillment time. In one recent example, Starbucks efficiency experts challenged their employees to
assemble a Mr. Potato Head to understand how work could be done more quickly. [4] The aim of this
exercise was to help Starbucks employees in general match the speed of the firm?s high performers, who
boast an average time per order of twenty-five seconds.
Learning and Growth Measures
Learning and growth measures of performance relate to the future. Such measures provide insight to tell
the organization, ?Can we continue to improve and create value?? Learning and growth measures focus on
innovation and proceed with an understanding that strategies change over time. Consequently,
developing new ways to add value will be needed as the organization continues to adapt to an evolving
environment. An example of a learning and growth measure is the number of new skills learned by
employees every year.
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One way Starbucks encourages its employees to learn skills that may benefit both the firm and individuals
in the future is through its tuition reimbursement program. Employees who have worked with Starbucks
for more than a year are eligible. Starbucks hopes that the knowledge acquired while earning a college
degree might provide employees with the skills needed to develop innovations that will benefit the
company in the future. Another benefit of this program is that it helps Starbucks reward and retain highachieving
employees.
Measuring Performance Using the Triple Bottom Line
Ralph Waldo Emerson once noted, ?Doing well is the result of doing good. That?s what capitalism is all
about.? While the balanced scorecard provides a popular framework to help executives understand an
organization?s performance, other frameworks highlight areas such as social responsibility. One such
framework, the triple bottom line, emphasizes the three Ps of people (making sure that the actions of the
organization are socially responsible), the planet (making sure organizations act in a way that promotes
environmental sustainability), and traditional organization profits. This notion was introduced in the
early 1980s but did not attract much attention until the late 1990s.
The triple bottom line emphasizes the three Ps of people (social concerns), planet (environmental
concerns), and profits (economic concerns).
Reproduced with permission
In the case of Starbucks, the firm has made clear the importance it attaches to the planet by creating an
environmental mission statement (?Starbucks is committed to a role of environmental leadership in all
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facets of our business?) in addition to its overall mission. [5] In terms of the ?people? dimension of the
triple bottom line, Starbucks strives to purchase coffee beans harvested by farmers who work under
humane conditions and are paid reasonable wages. The firm works to be profitable as well, of course.
KEY TAKEAWAY
? Organizational performance is a multidimensional concept, and wise managers rely on multiple measures
of performance when gauging the success or failure of their organizations. The balanced scorecard
provides a tool to help executives gain a general understanding of their organization?s current level of
achievement across a set of four important dimensions. The triple bottom line provides another tool to
help executives focus on performance targets beyond profits alone; this approach stresses the
importance of social and environmental outcomes.
EXERCISES
1. How might you apply the balanced scorecard framework to measure performance of your college or
university?
2. Identify a measurable example of each of the balanced scorecard dimensions other than the examples
offered in this section.
3. Identify a mission statement from an organization that emphasizes each of the elements of the triple
bottom line.
[1] Short, J. C., & Palmer, T. B. 2003. Organizational performance referents: An empirical examination of their
content and influences. Organizational Behavior and Human Decision Processes, 90, 209?224.
[2] Kaplan, R. S., & Norton, D. 1992, February. The balanced scorecard: Measures that drive performance. Harvard
Business Review, 70?79.
[3] Miller, C. 2010, June 15. Aiming at rivals, Starbucks will offer free Wi-Fi. New York Times. Section B, p. 1.
[4] Jargon, J. 2009, August 4. Latest Starbucks buzzword: ?Lean? Japanese techniques. Wall Street Journal, p. A1.
[5] Our Starbucks mission statement. Retrieved on March 31, 2011, fromhttp://www.starbucks.com/aboutus/company-information/mission-statement.
Accessed March 31, 2011.
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2.3 The CEO as Celebrity
LEARNING OBJECTIVES
1. Understand the benefits and costs of CEO celebrity status.
2. List and define the four types of CEOs based on differences in fame and reputation.
3. Be able to offer an example of each of the four types of CEOs
Benefits and Costs of CEO Celebrity
The nice thing about being a celebrity is that when you bore people, they think it?s their fault.
Henry Kissinger, former US Secretary of State
The word celebrity quickly brings to mind actors, sports stars, and musicians. Some CEOs, such as Bill
Gates, Oprah Winfrey, Martha Stewart, and Donald Trump, also achieve celebrity status. Celebrity CEOs
are not a new phenomenon. In the early twentieth century, industrial barons such as Henry Ford, John D.
Rockefeller, and Cornelius Vanderbilt were household names. However, in the current era of mass and
instant media, celebrity CEOs have become more prevalent and visible (Figure 2.7 “CEO”). [1]
Cornelius Vanderbilt was one of the earliest celebrity CEOs; Vanderbilt University serves as his
legacy.
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Image courtesy of Mathew Brady and Michel Vuijlsteke,
http://en.wikipedia.org/wiki/File:Cornelius_Vanderbilt_Daguerrotype2.jpg.
Both benefits and costs are associated with CEO celebrity. As the quote from Henry Kissinger suggests,
celebrity confers a mystique and reverence that can be leveraged in a variety of ways. CEO celebrity can
serve as an intangible asset for the CEO?s firm and may increase opportunities available to the firm.
Hiring or developing a celebrity CEO may increase stock price, enhance a firm?s image, and improve the
morale of employees and other stakeholders. However, employing a celebrity CEO also entails risks for an
organization. Increased attention to the firm via the celebrity CEO means any gaps between actual and
expected firm performance are magnified. Further, if a celebrity CEO acts in an unethical or illegal
manner, chances are that the CEO?s firm will receive much more media attention than will other firms
with similar problems. [2]
There are also personal benefits and risks associated with celebrity for the CEO. Celebrity CEOs tend to
receive higher compensation and job perks than their colleagues. Celebrity CEOs are likely to enjoy
increased prestige power, which facilitates invitations to serve on the boards of directors of other firms
and creates opportunities to network with other ?managerial elites.? Celebrity also can provide CEOs with
a ?benefit of the doubt? effect that protects against quick sanctions for downturns in firm performance
and stock price. However, celebrity also creates potential costs for individuals. Celebrity CEOs face larger
and more lasting reputation erosion if their job performance and behavior is inconsistent with their
celebrity image. Celebrity CEOs face increased personal media scrutiny, and their friends and family must
often endure increased attention into their personal and public lives. Accordingly, wise CEOs will attempt
to understand and manage their celebrity status. [3]
Types of CEOs
Icons are CEOs possessing both fame and strong reputations. The icon CEO combines style and substance
in the execution of his or her job responsibilities. Mary Kay Ash, Richard Branson, Bill Gates, and Warren
Buffett are good examples of icons. The late Mary Kay Ash founded Mary Kay Cosmetics Corporation. The
firm?s great success and Ash?s unconventional motivational methods, such as rewarding sales
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representatives with pink Cadillacs, made her famous. Partly because she emphasized helping other
women succeed and ethical business practices, Mary Kay Ash also had a very positive reputation. Richard
Branson has created an empire with more than four hundred companies, including Virgin Atlantic
Airways and Virgin Records. Branson?s celebrity status led him to star in his own reality-based show. He
has also appeared on television series such as Baywatch and Friends, in addition to several cameo
appearances in major motion pictures. Bill Gates, founder and former CEO of Microsoft, also has fame
and a largely positive reputation. Gates is a proverbial ?household name? in the tradition of Ford,
Rockefeller, and Vanderbilt. He also is routinely listed among Time magazine?s ?100 Most Influential
People? and has received ?rock star? receptions in India and Vietnam in recent years.
Former Microsoft CEO Bill Gates exemplifies a CEO who has reached icon
status.
Image courtesy of World Economic Forum,
http://en.wikipedia.org/wiki/File:Bill_Gates_in_WEF_,2007.jpg.
Warren Buffett is perhaps the best-known executive in the United States. As CEO of Berkshire Hathaway,
he has accumulated wealth estimated at $62 billion and was the richest person in the world as of March
2008. Buffett?s business insights command a level of respect that is perhaps unrivaled. Many in the
investment and policymaking communities pay careful attention to his investment choices and his
commentary on economic conditions. Despite Buffett?s immense wealth and success, his reputation
centers on humility and generosity. Buffett avoids the glitz of Wall Street and has lived for fifty years in a
house he bought in Omaha, Nebraska, for $31,000. Meanwhile, his 2006 donation of approximately $30
billion to the Bill and Melinda Gates Foundation was the largest charitable gift in history.
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CEOs who display high levels of relative fame but low levels of reputation are in the group called
scoundrels. These CEOs are well known but vilified. The late Leona Helmsley was a prototypical
scoundrel. Leona Helmsley?s life was a classic rags-to-riches story. Born to immigrant parents, Helmsley
became a billionaire through her work as the head of an extensive hotel and real estate empire. While
certainly famous, her reputation was anything but positive, as reflected by her nickname: the Queen of
Mean. During Helmsley?s trial for tax fraud, her housekeeper quoted her as proclaiming, ?We don?t pay
taxes. Only the little people pay taxes.? Following twenty-one months in jail, Helmsley was required to
perform 750 hours of community service. One hundred fifty hours were added to this sentence after it was
discovered that employees had performed some of her service hours. Helmsley?s apparent arrogance,
combined with her cruelty to employees and her reputation as the ultimate workplace bully, cemented her
position as a scoundrel.
The corporate governance scandals of the early 2000s revealed several CEOs as scoundrels. Perhaps the
best known were Kenneth Lay and Dennis Kozlowski. Both men rose to prominence as their firms? success
and stock prices soared but were undone by dubious activities. Lay was once revered as the son of a poor
minister who founded Enron and built it into a giant in the energy business. In 2001, however, he became
the face of corporate abuses in the United States after Enron?s collapse led to scenes, captured on
television, of employees left jobless and with retirement accounts full of worthless Enron stock. Lay was
convicted of fraud in 2006 but died before sentencing.
Also born to a poor family, Kozlowski started at Tyco as an accountant and worked his way up to the
executive suite. In May 2001, a BusinessWeek cover story lauded Kozlowski as ?the most aggressive CEO?
in the country and detailed his strategy for building Tyco into the next General Electric by using
acquisitions to gain the first or second position in all the industries in which it competed. By 2002,
Kozlowski?s reputation was in jeopardy. He was indicted for avoiding more than $1 million in sales taxes
on art purchases. Media stories described in detail a $2 million birthday party Kozlowski threw for his
wife (billing half of it to Tyco as a company function), a $19 million apartment Tyco purchased for him,
and $11 million worth of furnishings for the apartment (including an infamous $6,000 shower curtain).
Accusations that Kozlowski and another Tyco executive stole hundreds of millions of dollars from the firm
ultimately led to a prison sentence of eight to twenty-five years.
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Hidden gems are CEOs who lack fame but possess positive reputations. These CEOs toil in relative
obscurity while leading their firms to success. Their skill as executives is known mainly by those in their
own firm and by their competitors. In many cases, the firm has some renown due to its success, but the
CEO stays unknown. For example, consider the case of Anne Mulcahy. Mulcahy, CEO of Xerox, started
her career at Xerox as a copier salesperson. Despite building an excellent reputation by rescuing Xerox
from near bankruptcy, Mulcahy eschews fame and publicity. While being known for successfully leading
Xerox by example and being willing to fly anywhere to meet a customer, she avoids stock analysts and
reporters.
Silent killers are the fourth and final group of CEOs. These CEOs are overlooked and ignored sources of
harm to their firms. While scoundrels are closely monitored and scrutinized by the media, it may be too
late before the poor ethics or incompetence of the silent killers is detected. In this sense, silent killers are
sometimes worse than scoundrels. One example of a silent killer is Harding Lawrence, former CEO of
defunct Braniff International. Lawrence initiated a massive expansion of the airline following industry
deregulation in the late 1970s. The result was a bloated firm, ill-equipped to survive the extremely
competitive setting that evolved in the early 1980s. Howard Putnam, the CEO of a small regional carrier
named Southwest Airlines, was hired in a failed effort to save the company. By the time Braniff went
bankrupt, Putnam was left to explain its demise, and the name of the main culprit was all but forgotten.
Ironically, had Putnam declined the opportunity to try to save Braniff, perhaps he and not Herb Kelleher
would have become an icon at the helm of Southwest.
Strategy at the Movies
Iron Man
Has Tony Stark gone crazy? This was the question that many stakeholders of Stark Industries were asking
themselves in the 2008 blockbuster Iron Man. Tony Stark, CEO of Stark Industries, stunned his
shareholders, employees, and the world when he announced that he was changing Stark Industries?
mission from being one of the world?s leading weapons manufacturers to being a socially responsible,
clean energy producer. Following his announcement, Stark faced fierce opposition from his board of
directors, employees, the media, and clients such as the US military. The changes at Stark Industries
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attracted tremendous attention in part because of the glamorous Stark?s status as a celebrity CEO.
Initially, Stark is seen by the public as a scoundrel that pays little attention to the social impact his
company makes. After shifting the direction of Stark Industries, however, Stark is viewed as an icon that
is just as attentive to the social performance of the company as he is to its financial performance. Iron
Man illustrates that while changing elements such as firm mission and CEO status is difficult, it is not
impossible.
Iron Man: The Greatest Creation of Fictional Celebrity CEO Tony Stark
Image courtesy of Pop Culture Geek, http://www.flickr.com/photos/popculturegeek/4858995531.
Celebrity Rehabilitation
Anything I say or do is now at risk of showing up on the front page of a national daily newspaper and
therefore, I need to be much more conscious about the implications of everything that I say or do in all
situations.
John Mackey, CEO of Whole Foods Market
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Achieving the level of success that brings about celebrity is seldom a completely smooth process. Even
well-regarded celebrity CEOs seldom have totally untarnished reputations. Bill Gates has been portrayed
as a ruthless and devious genius, for example, while General Electric CEO Jack Welch was attacked in
media outlets for an extramarital affair.
One of the more interesting recent cases of a tarnished reputation centers on John Mackey, founder and
CEO of Whole Foods Market. His strategy of offering organic food and high levels of service allowed
Whole Foods to carve out a profitable and growing niche in an industry whose overall margins have been
squeezed as Walmart?s Supercenters have gained market share. Under Mackey?s leadership, Whole Food?s
stock price tripled from 2001 to 2006. Mackey?s efforts to make food supplies healthier and his teamworkcentered
management approach attracted publicity, and he appeared headed for icon status.
But in 2007 Mackey and Whole Foods were embarrassed by the revelation that Mackey had been
anonymously posting negative information about a rival, Wild Oats, online. Through his online persona
?rahodeb? (a scrambling of his wife?s name), Mackey asserted that Wild Oats? stock was overpriced and
that the firm was headed toward bankruptcy. This was viewed by some observers as a possible effort to
manipulate Wild Oats? stock price prior to a proposed acquisition by Whole Foods. Meanwhile, in e-mails
to other Whole Foods executives, Mackey noted that the acquisition of Wild Oats could allow them to
avoid ?nasty price wars.? This caught the eye of Federal Trade Commission (FTC) regulators who were
concerned about the antitrust implications of the acquisition.
Whole Foods CEO John Mackey?s celebrity status was amplified when it was revealed that he had posted negative
information online about competitor Wild Oats.
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Image courtesy of Joe M500, http://en.wikipedia.org/wiki/File:John_Mackey,_of_Whole_Foods_in_2009.jpg.
What should a CEO do when his or her reputation takes a hit? As the old saying goes, honesty is the best
policy. An example is offered by David Neeleman, founder and CEO of JetBlue. The reputations of JetBlue
and Neeleman took a severe blow after a widely reported February 2007 debacle in which travelers were
stranded in airplanes for excessive periods of time during a busy holiday weekend. Neeleman took a giant
step toward restoring both his and JetBlue?s reputation by issuing a public, heartfelt apology. He not only
issued a written apology to customers but also bought full-page advertisements in newspapers, posted a
video apology online, and created a new ?bill of rights? for JetBlue customers.
Mackey apologized for his actions via his blog in 2008. As part of this apology, Mackey acknowledged that
he had failed to recognize how expectations change when one becomes a celebrity. Mackey noted that
when Whole Foods was a smaller company, ?I was seldom interviewed and few people knew or cared who
I was. I wasn?t a public figure and had no desire to become one.? As his company grew, however, Mackey
became subject to more scrutiny. As Mackey put it, ?At some point in the past 10 years I went from being a
relatively unknown person to becoming a public figure. I regret not having the wisdom to recognize this
fact until very recently.?[4] A big part of managing celebrity status is realizing that one is in fact a celebrity.
KEY TAKEAWAY
? The media exposure common to modern CEOs provides the opportunity for such top executives to reach
celebrity status. While this status can provide positive benefits to their firms such as increased
performance, CEOs should be aware of and manage the potential for increased scrutiny associated with
this status.
EXERCISES
1. Can you identify another example of a celebrity CEO, such as Cornelius Vanderbilt, that existed prior to
the 1900s?
2. Identify examples of icons, scoundrels, hidden gems, and silent killers other than the examples offered in
this section.
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3. Would you enjoy the media attention associated with CEO celebrity, or would you prefer to hide from the
limelight? Does your answer have implications for your future career choices?
[1] This section of the chapter is adapted from Ketchen, D., Adams, G., & Shook, C. 2008. Understanding and
managing CEO celebrity. Business Horizons, 51(6), 529?534.
[2] Ranft, A. L., Zinko, R., Ferris, G. R., & Buckley, M. R. 2006. Marketing the image of management: The costs and
benefits of CEO reputation. Organizational Dynamics, 35(3), 279?290.
[3] Wade, J. B., Porac, J. F., Pollock, T. G., & Graffin, S. D. 2008. Star CEOs: Benefit or burden? Organizational
Dynamics, 37(2), 203?210.
[4] John Mackey?s blog. 2008, May 21. Re: Apology. Retrieved
fromhttp://www2.wholefoodsmarket.com/blogs/jmackey/2008/05/21/back-to-blogging/#more-26.
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2.4 Entrepreneurial Orientation
LEARNING OBJECTIVES
1. Understand how thinking and acting entrepreneurially can help organizations and individuals.
2. List and define the five dimensions of an entrepreneurial orientation.
The Value of Thinking and Acting Entrepreneurially
When asked to think of an entrepreneur, people typically offer examples such as Howard Schultz, Est?e
Lauder, and Michael Dell?individuals who have started their own successful businesses from the bottom
up that generated a lasting impact on society. But entrepreneurial thinking and doing are not limited to
those who begin in their garage with a new idea, financed by family members or personal savings. Some
people in large organizations are filled with passion for a new idea, spend their time championing a new
product or service, work with key players in the organization to build a constituency, and then find ways
to acquire the needed resources to bring the idea to fruition. Thinking and behaving entrepreneurially can
help a person?s career too. Some enterprising individuals successfully navigate through the environments
of their respective organizations and maximize their own career prospects by identifying and seizing new
opportunities (Figure 2.8 “Understanding Entrepreneurial Orientation”). [1]
As a college student, Michael Dell demonstrated an entrepreneurial
orientation by starting a computer-upgrading business in his dorm room.
He later founded Dell Inc.
Image courtesy of Ilan Costica,
http://en.wikipedia.org/wiki/File:Michael_Dell_at_Oracle_OpenWorld.J
PG.
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In the 1730s, Richard Cantillon used the French term entrepreneur, or literally ?undertaker,? to refer to
those who undertake self-employment while also accepting an uncertain return. In subsequent years,
entrepreneurs have also been referred to as innovators of new ideas (Thomas Edison), individuals who
find and promote new combinations of factors of production (Bill Gates? bundling of Microsoft?s
products), and those who exploit opportunistic ideas to expand small enterprises (Mark Zuckerberg at
Facebook). The common elements of these conceptions of entrepreneurs are that they do something new
and that some individuals can make something out of opportunities that others cannot.
Entrepreneurial orientation (EO) is a key concept when executives are crafting strategies in the hopes of
doing something new and exploiting opportunities that other organizations cannot exploit. EO refers to
the processes, practices, and decision-making styles of organizations that act entrepreneurially. [2] Any
organization?s level of EO can be understood by examining how it stacks up relative to five dimensions: (1)
autonomy, (2) competitive aggressiveness, (3) innovativeness, (4) proactiveness, (5) and risk taking.
These dimensions are also relevant to individuals.
Autonomy
Autonomy refers to whether an individual or team of individuals within an organization has the freedom
to develop an entrepreneurial idea and then see it through to completion. In an organization that offers
high autonomy, people are offered the independence required to bring a new idea to fruition, unfettered
by the shackles of corporate bureaucracy. When individuals and teams are unhindered by organizational
traditions and norms, they are able to more effectively investigate and champion new ideas.
Some large organizations promote autonomy by empowering a division to make its own decisions, set its
own objectives, and manage its own budgets. One example is Sony?s PlayStation group, which was created
by chief operating officer (COO) Ken Kutaragi, largely independent of the Sony bureaucracy. In time, the
PlayStation business was responsible for nearly all Sony?s net profit. Because of the success generated by
the autonomous PlayStation group, Kutaragi later was tapped to transform Sony?s core consumer
electronics business into a PlayStation clone. In some cases, an autonomous unit eventually becomes
completely distinct from the parent company, such as when Motorola spun off its successful
semiconductor business to create Freescale.
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Create a PowerPoint Presentation. The final product will be no longer than 20 slides including the title page and reference page. Students will use the note section of the PowerPoint to discuss, explain and support the reasoning for information presented in each slide.

Appended to Karen Davis? oral testimony is a set of 24 insightful exhibits that are loaded with Medicare information. For this module?s discussion, please interpret, assess, cite, and debate the Medicare reform implications of the facts and figures from this set of 24 exhibits.

Appended to Karen Davis? oral testimony is a set of 24 insightful exhibits that are loaded with Medicare information. For this module?s discussion, please interpret, assess, cite, and debate the Medicare reform implications of the facts and figures from this set of 24 exhibits..

Appended to Karen Davis? oral testimony is a set of 24 insightful exhibits that are loaded with Medicare information. For this module?s discussion, please interpret, assess, cite, and debate the Medicare reform implications of the facts and figures from this set of 24 exhibits.

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Appended to Karen Davis? oral testimony is a set of 24 insightful exhibits that are loaded with Medicare information. For this module?s discussion, please interpret, assess, cite, and debate the Medicare reform implications of the facts and figures from this set of 24 exhibits.

THE FUTURE OF MEDICARE: CONVERTING TO PREMIUM SUPPORT OR CONTINUING AS A GUARANTEED BENEFIT PROGRAM
Karen Davis The Commonwealth Fund One East 75th Street New York, NY 10021 kd@cmwf.org http://www.commonwealthfund.org
Invited Presentation House of Representatives Democratic Steering and Policy Committee Forum on Saving Medicare for Seniors Today and in the Future October 2, 2012
This testimony benefitted from the work of Sara R. Collins and Stuart Guterman and the report by Sara R. Collins, Stuart Guterman, Rachel Nuzum, Mark A. Zezza, Tracy Garber, and Jennie Smith, Health Care in the 2012 Presidential Election: How the Obama and Romney Plans Stack Up, The Commonwealth Fund, October 2012; the research assistance of Kristof Stremikis; and the editorial assistance of Deborah Lorber of The Commonwealth Fund. The views presented here are those of the author and not necessarily those of The Commonwealth Fund or its directors, officers, or staff.
2
THE FUTURE OF MEDICARE: CONVERTING TO PREMIUM SUPPORT OR CONTINUING AS A GUARANTEED BENEFIT PROGRAM
Oral Statement
Today, Medicare works to provide access to care and financial protection for 50 million seniors and disabled beneficiaries. These men and women contributed to the program throughout their working lives and continue to contribute substantially to their own medical expenses through premiums for supplemental coverage and out-of-pocket expenses. Although Medicare covers people who are poorer, sicker, and more expensive to care for than private insurance plans do, it is a better buy than private coverage. Medical and administrative costs are lower than those in private coverage because of administrative efficiencies and the leverage Medicare exercises as the largest purchaser of health care in our country. The Affordable Care Act is projected to achieve estimated Medicare savings of $716 billion between 2013 and 2022. This will be achieved by phasing out the overpayments to private Medicare Advantage plans, reducing provider payment productivity updates (which has been accepted by the hospital industry in large part because covering the uninsured will reduce hospitals? bad debts), and various provider payment changes and improvements. The Affordable Care Act?s major payment and delivery system reforms are projected to slow Medicare spending per beneficiary to 3.1 percent annually over 2012?2021, extending the solvency of the Medicare Hospital Insurance (Part A) Trust Fund to 2024. A major concern, however, is that the retirement of the post-World War II generation will increase the numbers of beneficiaries at the same time that the decline in fertility rates in the 1970s and 1980s has lowered the number of active workers in the labor force. As a result, expenses are projected to grow faster than payroll tax revenues. To bring the Trust Fund into balance, more revenues will be needed, spending growth will need to be further restrained, or beneficiaries will need to pay more of their own health care expenses either directly or through premiums. Given this dilemma, a national debate on the future of Medicare, with careful consideration of the consequences of alternative strategies, is appropriate. Converting Medicare to a fixed sum of money capped at the growth of the economy, without effective health care cost control, would shift costs to beneficiaries who already struggle with out-of-pocket medical expenses and limited incomes. An alternative approach of continuing guaranteed benefits and rewarding hospitals and physicians for providing
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high-quality care in an efficient manner has the potential to achieve needed budgetary savings while reducing, not increasing, financial risk to beneficiaries.
Premium Support and Repeal of the Affordable Care Act The philosophy behind premium support holds that patients are best positioned to eliminate overuse of services, shop for lower-cost care, and pick lower-cost health plans. Rather than guaranteeing that Medicare will pay the cost of a defined set of benefits, under the most recent Medicare premium proposal advanced by vice presidential candidate Rep. Paul Ryan, chair of the House budget committee, beneficiaries would receive an allowance based on their age, health status, and income to be applied toward the purchase of a health plan. Over time, the dollar allowance would be capped at the rate of gross domestic product (GDP) growth per person plus 0.5 percent. Governor Mitt Romney endorses this Medicare premium support strategy. Because the federal government would cap future allowances by the rate of economic growth rather than the rising costs of health insurance premiums or medical care cost, this approach would result in the federal government spending less over time as beneficiaries spent more, assuming health care costs continued to rise at current rates. The value of the allowance or defined contribution for private insurance would erode over time, resulting in higher premiums for beneficiaries and/or reductions in benefits. The Congressional Budget Office (CBO), in fact, estimated that the latest Ryan premium support proposal, which shaped the 2012 House Budget Resolution, will raise costs for beneficiaries, with beneficiary cost rising over time. Our estimate is that average private health insurance premiums would exceed the allowance by $4,250 in 2030. It is also important to weigh the merits of choosing among competing private plans. As previously noted, private health insurance is more costly than public coverage given its larger administrative costs, higher provider payments, and less-efficient risk pooling. CBO estimates that utilizing private coverage for a set of benefits similar to what is currently covered by traditional Medicare would be 12 percent more expensive than traditional Medicare in 2022. By 2030, private coverage of the same benefits would be about 40 percent more expensive than traditional Medicare. The nation?s experience with the Medicare Advantage program suggests that beneficiaries would be less satisfied and more likely to experience access problems when opting for a private plan. Thirty-two percent of Medicare Advantage beneficiaries report at least one access problem because of cost, compared with 23 percent of those with traditional coverage. The widespread use of competing private plans under a premium support scenario has the potential to undermine the stability and effectiveness of Medicare by fragmenting the risk pool. Even if Medicare beneficiaries retained a choice of enrolling in traditional
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Medicare as called for in the latest Ryan proposal, physicians and hospitals could receive substantially higher payment from private plans and would be likely to opt out of participation in traditional Medicare, nullifying it as a genuine choice for beneficiaries. Dividing Medicare beneficiaries across multiple private plans would undermine the leverage the program currently has to drive efficiency among providers and widespread change across the entire U.S. health system. Moreover, while the premium support proposal contained in the latest House budget resolution included some protections against risk selection (or ?cream- skimming?) by private insurance companies, officials would need to be particularly vigilant about plans covering a relatively low number of beneficiaries with complex health care needs. Along with premium support, Governor Romney endorses increasing the age of eligibility for Medicare by two months per year starting in 2022 until it reached 67 in 2033. Romney also calls for the full repeal of the Affordable Care Act, including the coverage and Medicare benefit improvement provisions as well as repeal of the Medicare savings provisions. Repeal of the ACA would increase the federal budget deficit by $109 billion over the next decade and shorten the time until the Medicare Part A Trust Fund becomes insolvent from 2024 to 2016. Romney would also replace Medicaid with a block grant to states, which could put long-term care benefits for Medicare and Medicaid beneficiaries at risk, and sharply restrict the growth in the federal budgetary commitment to Medicare and Medicaid over time.
Continuing Medicare as an Essential Benefit by Building on the Affordable Care Act A different approach to preserve Medicare?s guaranteed benefits would be to retain and build on the innovations in the Affordable Care Act. Instead of shifting financial costs onto beneficiaries, this approach would hold health care providers accountable for achieving high-quality care, excellent outcomes for patients, and ensuring that the total cost of health care is in line with what the nation can afford. It puts the accountability in the hands of those directly responsible for providing care. The Affordable Care Act permits physician-led accountable care organizations to share in savings if they hold costs below a target rate of growth. The Center for Medicare and Medicaid Innovation is testing a variety of pilot payment innovations to reward providers for lowering cost while improving quality. It also gives the Secretary of Health and Human Services authority to spread successful innovation throughout the Medicare program if innovations lower cost, improve quality, or both, without being to the detriment of either. President Obama, in continuing to implement the Affordable Care Act, would expand Medicare beneficiaries? access to preventive care, reduce the cost of prescription
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drugs, provide more help for low-income beneficiaries, provide better information for beneficiaries to make more informed health care choices, and encourage more coordinated care. The Affordable Care Act also places payments to private Medicare Advantage plans on an equal footing with traditional Medicare, slows the increase in provider charges, and raises premiums for high-income beneficiaries, extending the solvency of the Medicare Hospital Insurance Trust Fund. President Obama?s continued implementation of the Affordable Care Act would change how care is organized, delivered, and paid for. Many of the law?s provisions are focused on Medicare, as well as Medicaid and the Children?s Health Insurance Program, but it encourages the participation of multipayer initiatives that include both the public and private sectors. Models that emphasize the role of primary care and the need to coordinate care across providers and settings, like the patient-centered medical home and the accountable care organization, are being developed to improve care and stabilize costs. The Affordable Care Act would give physicians, hospitals, and other health care providers an incentive to reduce the rate of growth in Medicare outlays by creating opportunities for them to share in savings. President Obama has further stated that through these reforms he would attempt to hold the rate of growth in health care spending to GDP plus 0.5 percent, the same goal as under the premium support proposal. However, under the premium support strategy, the beneficiary is at financial risk when private insurance premiums exceed the Medicare spending target (Exhibit ES-1). Under the shared savings strategy, providers have the opportunity to reap benefits when costs are below the target for Medicare spending. Beneficiaries also gain from lower Medicare costs, as their premiums and out-of-pocket expenses are reduced by the slower growth in Medicare spending. As policymakers and the nation confront the urgent need to control health spending while continuing to improve the quality and efficiency of care delivered, these activities provide a foundation on which to build, with the potential to control health spending while moving toward a high performance health system.
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Exhibit ES-1. Medicare Spending per Beneficiary Under Premium Support and Shared Savings Scenarios, 2012?2050
Source: Commonwealth Fund calculations based on Congressional Budget Office, The Long-Term Budgetary Impact of Paths for Federal Revenues and Spending Specified by Chairman Ryan , (Washington: Congressional Budget Office, March 2012), and Congressional Budget Office, The 2012 Long-Term Budget Outlook (Washington, D.C.: Congressional Budget Office, June 2012).
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Private Insurance
Medicare Spending Goal of GDP per capita + 0.5%
Shared savings opportunity for providers
Beneficiary at financial risk under premium support
$4,250
Nominal $
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THE FUTURE OF MEDICARE: CONVERTING TO PREMIUM SUPPORT OR CONTINUING AS A GUARANTEED BENEFIT PROGRAM
Karen Davis
For almost 50 years, Medicare has provided access to health care and protection against ruinous medical bills to millions of elderly and disabled beneficiaries. Medicare was enacted in 1965 because half of seniors lost their private insurance when they retired at age 65. Middle-class families were at great financial risk when an elderly parent needed life-saving care. Guaranteeing that Medicare continues to meet its basic goal of providing health and economic security to 50 million current beneficiaries, as well as the post- World War II generation as it reaches retirement, is an essential priority for the nation. Starkly different choices have been proposed for the future of the program: namely, converting it to a fixed dollar premium support system or continuing Medicare as a guaranteed benefit program. As it is currently structured, Medicare works to provide access to care and financial protection for millions of vulnerable seniors and disabled individuals who have contributed to the program throughout their working lives and continue to contribute substantially to their own medical expenses through premiums for supplemental coverage and out-of-pocket expenses for noncovered services. Medicare is a good buy: medical and administrative costs are lower than those in private insurance plans because of administrative efficiencies and the leverage Medicare exercises as the largest purchaser of health care in our country. Converting Medicare to a fixed sum of money capped at the growth of the economy without effective health care cost control would shift cost to beneficiaries who already struggle with out-of-pocket medical expenses and limited incomes. An alternative approach of continuing guaranteed benefits and rewarding hospitals and physicians for providing high-quality care in an efficient manner has the potential to achieve needed budgetary savings while reducing, not increasing, financial risk to beneficiaries.
Medicare Works Medicare is a critical public program that works for beneficiaries far poorer, sicker, and more expensive to care for than those typically covered by private insurance (Exhibit 1).1 Nearly half of all Medicare beneficiaries report incomes of less than 200 percent of the 1 Henry J. Kaiser Family Foundation, Medicare at a Glance (Washington, D.C.: Henry J. Kaiser Family Foundation, Nov. 2011).
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federal poverty level?$21,780 in 2011. Forty-five percent report living with three or more chronic conditions, and more than a quarter of all beneficiaries have a cognitive or mental impairment (29%) or consider themselves in fair or poor health (28%). A significant proportion of the Medicare population has functional impairments?this includes disabled individuals under age 65 (17%) or those reporting two or more limitations in daily living (15%). Despite these challenges, decades of research demonstrate that Medicare is working to fulfill the two main purposes of health insurance?ensuring access to needed care and providing adequate financial protection from burdensome medical expenses. Medicare achieves these goals better than employer coverage and particularly better than individual coverage sold on the private insurance market. Elderly Americans are significantly more likely to report better outcomes on a host of questions related to affordability, access, and coordination relative to the under-65 insured population in the United States (Exhibit 2). A recent Commonwealth Fund study found that only 8 percent of elderly Medicare beneficiaries rated their insurance as fair or poor, compared with 20 percent of adults with employer insurance and 33 percent of those who purchased insurance on their own (Exhibit 3).2 Adults with employer-based insurance or individual insurance reported medical bill problems at almost twice the rate of Medicare beneficiaries. And about 37 percent of adults with employer coverage and 39 percent of those with individual coverage went without needed care because of costs, compared with less than one-fourth of Medicare beneficiaries. Within the Medicare program, traditional Medicare outperforms private Medicare Advantage plans. Six percent of beneficiaries enrolled in traditional Medicare rate the coverage as fair or poor, compared with 15 percent in Medicare Advantage plans (Exhibit 4). Further, those beneficiaries enrolled in Medicare Advantage plans were more likely to report access problems because of cost (32% vs. 23% in traditional Medicare). Medicare is a good buy for beneficiaries and taxpayers. Costs in Medicare are lower than those in private coverage because of administrative efficiencies and leverage the program exercises as the largest purchaser of health care in our country. Administrative costs in Medicare average less than 3 percent of expenditures, compared with 5 percent to 15 percent of premiums in large employer plans and 25 percent to 35 percent of premiums in the pre-reform, small-group market, and 41 percent in the
2 K. Davis, K. Stremikis, M. M. Doty, and M. A. Zezza, ?Medicare Beneficiaries Less Likely to Experience Cost- and Access-Related Problems than Adults with Private Coverage,? Health Affairs Web First, published online July 18, 2012.
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individual market (Exhibit 5).3 Traditional Medicare administrative expenses are 2 percent, compared with 11 percent in Medicare Advantage, and 20 percent in Medigap (Exhibit 6). Costs are also lower in Medicare because the program pays hospitals, physicians, and other health care providers lower prices than those offered by private insurance (Exhibit 7). Even so, Medicare continues to experience high provider participation rates. According to a recent survey of physicians, almost three-quarters (74%) of providers are accepting all or most new patients with Medicare.4 While beneficiaries are highly satisfied with Medicare, many elderly and disabled Americans still report significant financial burdens related to health care. The Medicare benefit package contains substantial cost-sharing, inducing many enrollees to purchase costly supplemental Medigap coverage. On average, Medicare picks up 74 percent of the medical expenses of beneficiaries, compared with 85 percent in large employer preferred provider organization (PPO) plans and 83 percent in the Federal Employees Health Benefit Program Standard Option (Exhibit 8). In fact, Medicare households devote a much larger share of their more limited incomes to health care. Median health expenses in 2009 accounted for almost 15 percent of the average Medicare household?s income, three times the rate of non-Medicare households (Exhibit 9).5 This is projected to rise to 26 percent in 2020 (Exhibit 10). Beneficiaries with serious health problems or low incomes often report significant out-of- pocket spending burdens.6 In 2006, beneficiaries in poor health reported out-of-pocket health care spending at 20 percent of income (Exhibit 11). Even premiums are a major expense for Medicare beneficiaries. The elements? $177 a month for Medigap supplemental coverage, $33 a month for Part D premiums, and $100 a month for Part B premiums?add up to $3,720 a year.7 That does not include out-of-pocket costs for prescription drugs and uncovered services such as dental care, eye care, and hearing aids. These are major expenses for a household living on Social Security income, which averaged $14,760 in 2012.
3 The Commonwealth Fund Commission on a High Performance Health System, The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way (New York: The Commonwealth Fund, Feb. 2009). 4 Center for Studying Health Systems Change, HSC 2008 Health Tracking Physician Survey, Sept. 2009. 5 J. Cubanski, A. Damico, L. Dawson et al., Health Care on a Budget: The Financial Burden of Health Spending by Medicare Households, Kaiser Family Foundation Program on Medicare Policy Data Spotlight, June 2011. 6 D. Yamamoto, T. Neuman, and M. K. Strollo, How Does the Benefit Value of Medicare Compare to the Benefit Value of Typical Large Employer Plans? (Menlo Park, Calif.: Henry J. Kaiser Family Foundation, Sept. 2008). 7 R. Rabin, ?Grappling with Details of Medicare Proposals,? The New York Times, Sept. 17, 2012.
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Medicare and the Federal Budget In many ways, Medicare is a low-cost program. Its actuarial value is less than typical employer plans and the Federal Employees Health Benefits Program standard option plan, it has lower administrative costs, and it uses its leverage as a major purchaser to get good rates from hospitals and physicians while still enjoying widespread provider participation. Further, the Affordable Care Act of 2010 (ACA) is projected to achieve savings estimated at $716 billion between 2013 and 2022. This will include $156 billion in savings from phasing out the overpayments to private Medicare Advantage plans, $415 billion in savings from provider payment productivity updates (which have been accepted by the hospital industry because covering the uninsured will reduce hospitals? bad debts), and the remaining from various provider payment changes and improvements.8 As a result of these provisions, Medicare is now projected to grow more slowly on a per capita basis than the gross domestic product (GDP) per capita (Exhibit 12). Between 2012 and 2021, per capita Medicare spending will grow at an annual rate of 3.1 percent, below that of GDP per capita at 4.1 percent. Even if Medicare physician fees grow with inflation, Medicare spending will grow at 3.8 percent over the decade, and between 3.1 percent and 3.8 percent if fees are frozen or offsetting savings to modifying the sustainable growth rate formula is achieved.9 Medicare is the largest payer for health care. The program will spend almost $600 billion in 2012 for its more than 50 million beneficiaries, accounting for more than 20 percent of U.S. national health expenditures.10 Like the rest of the health care system, Medicare faces rising health care costs. Private health spending per person is projected to increase 5.0 percent annually over the period 2012 to 2021, well in excess of projected Medicare spending. There is encouraging early evidence that overall health system spending is slowing and that Medicare spending in particular is slowing. CBO and the HHS Office of the Actuary substantially overestimated growth in health spending and Medicare spending pre-reform. In 2020, Medicare spending is now projected to be $935 billion, 12.7 percent below pre-reform estimates of $1.1 trillion for a cumulative reduction of $689 billion over 2011?2020 (Exhibit 13). This lower spending rate has improved the fiscal outlook for Medicare. Prior to the enactment of ACA, the Medicare Hospital Insurance (Part A) Trust Fund, which pays 8 Congressional Budget Office, ?Letter to the Honorable John Boehner providing an estimate for H.R. 6079, the Repeal of Obamacare Act? (Washington, D.C.: Congressional Budget Office, July 2012). 9 J. Holahan and S. McMorrow, ?Medicare and Medicaid Spending Trends and the Deficit Debate,? New England Journal of Medicine, Aug. 2, 2012 367(5):393?95. 10 Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Expenditure Data, accessed July 2012 at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends- and-Reports/NationalHealthExpendData/index.html.
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for hospital and other facility-based services and is financed by an earmarked payroll tax, was projected to become insolvent by 2017.11 Immediately after enactment, it was estimated to be solvent to 2029. Now?even with the economic contraction in 2008 that reduced payroll tax revenues?it is projected to be solvent until 2024. One major reason for this improved outlook is the ACA itself?particularly the freeze on Medicare Advantage plan payments and the productivity update adjustment in provider payments. But it also may reflect more fundamental changes in the health care delivery system as a result of a decade-long focus on quality improvement and efforts by the industry to position itself to take advantage of new payment and delivery system innovations. David Cutler of Harvard University and I argued, at the time of ACA enactment, that CBO was not giving sufficient weight to the impact of provider payment and delivery system innovations.12 Projected trends in our report suggest that the ACA will achieve Medicare savings of $686 billion over 2011-2020, compared to $510 billion estimated by CBO (Exhibit 14). Now CMS projections for Medicare spending over this period are $689 billion lower than their pre-reform estimate?in large part attributable to ACA as well as savings occurring as a result of changes in the pharmaceutical and health care services industry and positioning of the industry to take advantage of future changes in Medicare. There is concern, however, that the retirement of the post-World War II generation will increase the numbers of beneficiaries at the same time that the decline in fertility rates in the 1970s and 1980s has lowered the number of active workers in the labor force. The number of Medicare beneficiaries is projected to grow to 80 million in 2030 while the number of workers per beneficiary has dropped from 4:1 in 2000 to 3.4:1 in 2010 and is projected to drop further to 2.3:1 in 2030 (Exhibit 15). As a result, expenses?or outflow from the Part A Trust Fund?is projected to grow faster than payroll tax revenues, or inflow to the Part A Trust Fund. To bring the Trust Fund into balance, more revenues will be needed, spending growth will need to be further restrained, or beneficiaries will need to pay more of their own health care expenses either directly or through premiums. Requiring current beneficiaries to pay more premiums or out-of-pocket costs is a difficult choice, given that beneficiaries are already paying significant shares of their incomes on health care and have limited retirement savings. Very few beneficiaries have high incomes. Only 3 percent have incomes over $100,000 in 2006, and only one-fifth have incomes over $40,000 (Exhibit 16). Higher- 11 Both Supplementary Medical Insurance (Part B), which pays for physician and other ambulatory care and medical supplies, and Prescription Drug Coverage (Part D) are financed by beneficiaries? monthly premiums and open-ended draws on general revenues, so they are fully financed by definition, but they represent a progressively greater burden on both beneficiaries? resources and the federal government?s budget. 12 D. M. Cutler, K. Davis, and K. Stremikis, The Impact of Health Reform on Health System Spending (Washington, D.C. and New York: Center for American Progress and The Commonwealth Fund, May 2010).
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income beneficiaries already pay higher income-related Part D and Part B premiums. Since the early 1990s, workers with higher incomes have paid Medicare payroll taxes on their entire incomes, which are not subject to an earnings ceiling like Social Security. So high-income beneficiaries have contributed significantly to Medicare over their working lifetimes and continue to do so in retirement. Additional revenues may well need to be part of the solution. The Medicare trustees estimate that increasing the payroll tax 1.35 percentage points from 2.90 to 4.35 percent would balance the Part A Trust Fund for the next 75 years.13 Alternatively, immediately reducing expenditures by 26 percent would achieve long-run stability, but would do so only at the risk of suppressing spending faster than hospitals and other providers can innovate to improve productivity and efficiency. Given this dilemma, it is appropriate to have a national debate on the future of Medicare with careful consideration of the consequences of alternative strategies. One strategy would limit the government?s fiscal liability by converting Medicare to a premium support program and capping the rate of growth of government contributions. Another strategy is to transform the health care delivery system, providing significant incentives for physicians, nurses, hospitals, and other health care providers to deliver high-quality care while holding total expenditures on health care to the same growth as the rest of the economy and stabilizing the share of the economy devoted to health care. This directly attacks the overall health care cost problem, rather than assuming the elderly and disabled beneficiaries can achieve significant economies in their care.
Converting Medicare to ?Premium Support? Guaranteeing that Medicare continues to meet its basic goal of providing health and economic security to 50 million current beneficiaries?as well as the post-World War II generation as it reaches retirement?is an essential priority for the nation. Starkly different choices have been proposed for the future of the program: converting it to a fixed dollar premium support system or continuing Medicare as a guaranteed benefit program. Despite the successful track record of Medicare and that fact that its projected spending growth over the coming decade is below the growth in the economy, some policymakers have proposed major restructuring of the program in an effort to lower federal spending on health and reduce the federal budget deficit further. The philosophy behind premium support proposals holds that patients are best positioned to eliminate overuse of services, shop for lower cost care, and pick lower-cost health plans. Rather than guaranteeing that Medicare will pay the cost of a defined set of benefits, beneficiaries would receive an allowance based on their age, health status, and 13 Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, 2012 Annual Report (Washington: CMS, April 2012).
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income to be applied toward the purchase of a health plan. Over time, the dollar allowance would be capped at the GDP growth rate per capita plus 0.5 percent (in the 2012 House Budget version). If the premium exceeded the dollar allowance, the enrollee would be financially responsible for the excess. If the premium is less than the dollar allowance, the enrollee could keep the savings. A number of different premium support proposals have been advanced, with variations in whether the enrollee would have the option of using the allowance to buy traditional Medicare and how growth in the allowance would be capped over time. Three versions are particularly relevant: ? The 2011 House of Representatives Medicare premium support proposal put forward by Rep. Paul Ryan, chairman of the House budget committee, along with the repeal of the ACA coverage and Medicare benefit improvement provisions but retention of the Medicare savings provisions, which was passed by the House but not acted upon by the Senate. ? The 2012 House of Representatives Medicare premium support proposal, also put forward by Rep. Ryan, and passed by the House in 2012 along with the repeal of the ACA coverage and Medicare benefit improvement provisions, but retention of the Medicare savings provisions. ? Governor Romney?s Medicare position which endorses the premium support strategy and the full repeal of the ACA including the coverage and Medicare benefit improvement provisions as well as repeal of the Medicare savings provisions.
2011 House of Representatives Budget Resolution?Medicare Premium Support Provisions Budget Chairman Paul Ryan included a Medicare premium support plan in a budget proposal that passed the U.S. House of Representatives in April 2011.14 It was part of a budget resolution to cut the top rate on taxes for individuals and corporations, exempt military spending from cuts, and make deep cuts in domestic spending. It would have repealed the health insurance expansion provisions and capped growth in federal budget outlays for Medicare and Medicaid. The plan was estimated to reduce federal spending by $5.8 trillion over 10 years, $4.2 trillion of which would have been used to finance tax cuts, leaving $1.65 trillion for deficit reduction. The House proposal would have converted Medicare to a fixed dollar contribution toward the purchase of private health insurance when individuals now under age 55 14 K. Davis, ?Stark Choices: The Health Care Budget Proposals from the President and the House of Representatives,? The Commonwealth Fund Blog, April 29, 2011.
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qualified for Medicare, and would have repealed the health reform provisions expanding health insurance coverage, restored the doughnut hole in Medicare prescription drug coverage, replaced Medicaid with a block grant to states, and sharply restricted the growth in the federal budgetary commitment to Medicare and Medicaid over time. For those under age 55, the House budget resolution would have replaced Medicare benefits with a fixed dollar premium support allowance toward the purchase of private insurance. All beneficiaries becoming eligible for Medicare on or after January 1, 2022 would have been given a voucher equal to $8,000 on average, or the projected amount of the government?s contribution for traditional Medicare in that year. This payment would have been used by beneficiaries to purchase coverage from competing private plans offered in a newly established Medicare exchange. Starting in 2022, the allowance would have been capped and risen each year with the consumer price index, estimated by the Congressional Budget Office to increase 3 percentage points less than the rise in health care costs each year. The premium support allowance would have varied with health status, age, and income. In particular, people in the top 2 percent of the income distribution would have received 30 percent of the allowance, and the next 6 percent would have received 50 percent of the allowance. Beginning in 2022, the age of eligibility for Medicare would have increased by two months per year until it reached 67 in 2033. Under the 2011 House resolution, the federal government would lose its leverage as a major purchaser of health care and therefore, its ability to lower the rising health care costs that are at the center of the budget deficit problem. Without effective measures to control costs, such as incentives to reduce hospitalizations, the cuts in Medicare and Medicaid would translate into considerably higher costs for vulnerable low-income, elderly, and disabled individuals, as well as working families. Some specific consequences of the 2011 House budget resolution included:
? Tight limits on growth in federal budget outlays for Medicare and Medicaid The House resolution would have indexed the Medicare voucher and Medicaid per capita outlays with the consumer price index, which is projected to grow at 2.5 percent annually. Private health spending per capita, by contrast, is projected by the Centers for Medicare and Medicaid Services to grow almost 3 percentage points faster?5.1 percent annually?over the coming decade. As a result, Medicare and Medicaid would have covered a lower portion of health care spending over time under the House resolution. According to the Congressional Budget Office (CBO), federal spending on Medicare, Medicaid, the Children?s Health Insurance Program, and subsidies for health insurance premiums would be reduced by 63 to 66 percent in 2050 relative to current baseline projections.
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? Higher cost of private coverage for Medicare beneficiaries The CBO estimated that privatizing Medicare would cost, rather than save, money. Initially, private coverage for similar benefits as currently covered by Medicare would be 12 percent more expensive than Medicare because of higher administrative costs and higher provider payment rates. By 2030, private coverage would be about 40 percent more expensive than Medicare for the same benefits.15 Simply put, at the outset, federal costs could go up and less federal dollars would go to providing benefits and more would go to insurance profits and higher payments to providers.
? Higher costs for Medicare beneficiaries Since the federal government would have tied future vouchers to the consumer price index, rather than the rising costs of health insurance or medical care, the federal government would spend less over time as beneficiaries spend more. By replacing Medicare with an allowance or defined contribution for private insurance that buys less for the premium dollar, the value of the voucher would erode over time, resulting in higher premiums for beneficiaries and/or reductions in benefits. CBO estimated that by 2022, new enrollees would have to pay at least $6,400 more out-of-pocket to buy coverage comparable to traditional Medicare. By 2030, out-of-pocket costs would triple, and the portion of a typical 65-year- old?s health care expenses paid for by the beneficiary would increase from 30 percent currently to 68 percent under the House of Representatives budget resolution. High-income beneficiaries would pay nearly all of their own health care costs. CBO also indicated that some beneficiaries would simply be unable to purchase any plan and would become uninsured. The Kaiser Family Foundation illustrated the implications for a typical beneficiary turning 65 in 2022. 65-year old beneficiaries would pay $5,630 including both their out-of-pocket costs and Part B and D premiums in 2022 (Exhibit 17). Under the alternative fiscal scenario which assumes that the sustainable growth rate formula for Medicare physician fees would be changed, beneficiary cost would increase to $6,260. Under the Ryan Premium Support proposal, it would be $12,500 with based on the extended baseline projection scenario. Beneficiary spending for a typical 65-year old would increase from one- fourth of average Social Security income in 2022 to almost half of their Social
15 Commonwealth Fund calculation based on Figure 1, Page 22 in CBO letter to the Honorable Paul Ryan, April 5, 2011, available at http://www.cbo.gov/ftpdocs/121xx/doc12128/04-05-Ryan_Letter.pdf.
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Security checks ($12,500 or 49% of average Social Security income of $25,560) (Exhibit 18). The higher cost to beneficiaries results in large part because private insurance is more costly than Medicare. Total spending for a 65-year old in 2022 would be $13,530 under the extended baseline scenario, $14,760 under the alternative fiscal scenario, and $20,500 under the Path to Prosperity scenario.
2012 House of Representatives Budget Resolution?Medicare Premium Support Provisions In the most recent Ryan proposal,16 reflected in the Budget Resolution passed by the House of Representatives in March 2012,17 individuals becoming eligible for Medicare beginning in 2023 would be given a choice of private plans competing with traditional Medicare in a newly-created Medicare Exchange. In addition, the age of eligibility would be increased gradually to age 67 by 2034. Each beneficiary would be provided with a premium support subsidy equal to the lesser of the premium charged by the second-least expensive private plan available in their area or local per capita costs in traditional Medicare. The per capita allowance would be limited to the rate of growth in the nation?s GDP per capita, plus 0.5 percentage points. If a beneficiary chooses a costlier plan, he or she would be responsible for paying the difference between the premium support subsidy amount and the chosen plan?s monthly premium. Conversely, if the beneficiary chooses a less costly plan, he or she would receive a rebate for the difference. Private health plans participating in the exchange would be required to cover at least the actuarial equivalent of the traditional Medicare benefit package and to offer coverage to all beneficiaries. In addition, the federal contribution to beneficiaries? health plans would be adjusted to account for their age and health status. Lower-income beneficiaries would be eligible for subsidies. The CBO has estimated the impact on the federal budget using assumptions based on Chairman Ryan?s proposal and his report, Path to Prosperity.18 As expected, projected federal spending on Medicare would be significantly lower in the long run under the Ryan proposal than under current law. By 2050, spending for new enrollees under the Ryan proposal would be 35 percent lower than under current law, but Medicare beneficiaries could bear substantial additional costs. The latest Ryan premium support allowance is capped at the growth of GDP per capita plus 0.5 percent rather than the CPI. CBO estimated it will also raise costs for 16 Congressman Paul Ryan?s Web site, http://paulryan.house.gov/issues/issue/?IssueID=9969. 17 U.S. House of Representatives, Committee on the Budget, Concurrent Resolution on the Budget? Fiscal Year 2013, Report 112?421 (Washington, D.C.: Government Printing Office, March 23, 2012). 18 Congressional Budget Office, The Long-Term Budgetary Impact of Paths for Federal Revenues and Spending Specified by Chairman Ryan, March 2012, available at http://www.cbo.gov/sites/default/files/cbofiles/attachments/03-20-Ryan_Specified_Paths_2.pdf.
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beneficiaries, with beneficiary cost rising over time (Exhibit 19). Our estimate is that average private health insurance premiums would exceed the allowance by $4,250 in 2030 (Exhibit 20). This reduced government spending would come with consequences?increasing beneficiary cost substantially and increasing total cost of care for beneficiaries as a result of higher payments to physicians, hospitals, and other providers. Beneficiaries would bear the full fiscal brunt of rising costs, while insurance companies and providers would experience increased revenues. It is important to consider several facts when weighing the merits of any proposal that places the onus for cost control on beneficiaries choosing among competing private plans. First, as previously noted, private health insurance is more costly than public coverage given its larger administrative costs, higher provider payments, and less efficient risk pooling. The Congressional Budget Office estimates that utilizing private coverage for a set of benefits similar to what is currently covered by Medicare would be 12 percent more expensive in 2022.19 By 2030, private coverage would be about 40 percent more expensive than Medicare for the same benefits. The nation?s experience with Medicare Advantage program suggests that beneficiaries would be less satisfied and more likely to experience access problems when opting for a private plan. Thirty-two percent of Medicare Advantage beneficiaries reported at least one access problem due to cost, compared with 23 percent of those with traditional coverage. This may, in part, reflect Medicare Advantage beneficiaries? experiences with private health maintenance organization (HMO) plans that offer lower premiums in return for limited access to a smaller network of providers. The widespread use of competing private plans under a premium support scenario has the potential to undermine the stability and effectiveness of Medicare by fragmenting the risk pool. Even if Medicare beneficiaries retained a choice of enrolling in traditional Medicare, physicians and hospitals that could receive substantially higher payment from private plans would be likely to opt-out of participation in Medicare nullifying it as a genuine choice for beneficiaries. Dividing Medicare beneficiaries across multiple private plans would undermine the leverage the program currently has to drive efficiency among providers and widespread change across the entire U.S. health system. Moreover, while the premium support proposal contained in the latest House budget resolution included some protections against risk selection (or ?cream skimming?) by private insurance companies, officials would need to be particularly vigilant about plans covering a relatively low number of beneficiaries with complex health care needs. 19 Congressional Budget Office, Long-Term Analysis of a Budget Proposal by Chairman Ryan (Washington, D.C.: Congressional Budget Office, April 2011).
18
Romney?Ryan Medicare Policy Position Governor Romney has embraced the Medicare premium support strategy capped at the rate of growth of GDP per capita plus 0.5 percent (although other specifics are not available), and supports repealing the ACA, including its Medicare savings provisions. Doing so would restore the higher levels of payments to providers and private plans. Under this proposal, beneficiaries would have a choice between traditional Medicare and private plans?using a ?premium support? contribution from the government, adjusted for the beneficiary?s income and health status, toward the premium payment with any additional cost borne by the beneficiary. He otherwise vows not to change the program for those nearing retirement, but would gradually raise the age of eligibility for Medicare to age 67 between 2023 and 2034. Repeal of the ACA would increase the federal budget deficit by $109 billion over the next decade and shorten the time until the Medicare Part A Trust Fund becomes insolvent from 2024 to 2016.20CBO recently estimated that repealing the Affordable Care Act would increase Medicare program spending by $716 billion over the 10-year period from 2013 through 2022.21 The largest portion of that increase would come from undoing changes to provider payments reflecting increases in productivity and restoring the gradual elimination of overpayments to Medicare managed care plans that benefit insurance companies and a minority of beneficiaries at the expense of all Medicare beneficiaries.22 A majority of these savings come from trimming payment increases to hospitals by 1 percentage point annually, reducing overpayments to Medicare managed care plans, and instituting various provider payment reform initiatives. Repealing the law entirely would increase the federal deficit. Repeal of the Affordable Care Act would also eliminate provisions that improve benefits for beneficiaries. These include provisions intended to help reduce costs for prescription drugs, expand coverage for preventive care, provide more help for low- income beneficiaries, provide information for beneficiaries to make more informed health care choices, deter fraud and abuse, and support high-quality, coordinated, and comprehensive care.23 Starting in 2010, Medicare beneficiaries who reached the coverage gap?or ?doughnut hole??in prescription drug coverage ($2,830) automatically received $250 rebates. In 2011, a new Medicare coverage gap discount program provided a 50 20 Centers for Medicare and Medicaid Services, Medicare Stable, But Requires Strengthening (Washington, D.C.: CMS Office of Public Affairs, April 2012). 21 D. Elmendorf, Letter to John Boehner, Speaker, U.S. House of Representatives on the Direct Spending and Revenue Effects of H.R. 6079, the Repeal of Obamacare Act (Washington, D.C.: Congressional Budget Office, July 24, 2012). 22 Ibid. 23 S. Guterman, K. Davis, and K. Stremikis, How Health Reform Legislation Will Affect Medicare Beneficiaries (New York: The Commonwealth Fund, March 2010).
19
percent discount on brand-name drugs to Medicare Part D enrollees who spend enough on prescription drugs to enter the doughnut hole. Under the program, manufacturers provide discounts to eligible beneficiaries at the point-of-sale in the pharmacy or by mail order. Additional discounts on brand-name and generic drugs are phased in to completely close the doughnut hole for all Part D enrollees by 2020. Millions of beneficiaries have already benefitted from these new provisions in the law: ? Closing the Medicare prescription drug benefit doughnut hole. An estimated 5.1 million people with Medicare saved over $3.1 billion through rebates and the 50 percent discount over 2010 and 2011. In 2012, 70,000 people with Medicare benefitted from the discount, saving approximately $65 million. ? New preventive care services without cost sharing and annual wellness visit with no copay. More than 32.5 million seniors have already received one or more free preventive services, including the new annual wellness visit.
Repeal of the Affordable Care Act would also eliminate provisions supporting delivery system innovation, including models like the patient-centered medical home and the accountable care organization. Both models emphasize the role of primary care and the need to coordinate care across providers and settings, are being developed to improve care and stabilize costs, and encourage meaningful use of health information technology. A major set of ACA reforms also changes the way hospitals and other health care providers are paid to focus more on the quality and effectiveness of care patients receive, rather than solely rewarding providers for the volume and intensity of their services regardless of the value to patients. Repealing the law would also eliminate provisions to provide information for beneficiaries to make more informed health care choices, deter fraud and abuse, and support safe, accessible, coordinated, and comprehensive care that effectively responds to patients? needs.
Continuing Medicare as an Essential Benefit by Building on the Affordable Care Act A different approach to preserve Medicare?s guaranteed benefits as the post-World War II population reaches retirement is retaining and building on the innovations contained in the Affordable Care Act. This strategy is based on the philosophy that doctors, nurses, and other health professionals are best positioned to eliminate waste, duplication, overuse of services, and costly and harmful medical errors. Instead of shifting financial costs onto beneficiaries, it would hold health care providers accountable for achieving high-quality care, excellent outcomes for patients, and ensuring that the total cost of health care is in line with what the nation can afford. It puts the accountability in the hands of those directly responsible for providing care.
20
It permits physician-led accountable care organizations to share in savings if they hold costs below a target rate of growth (Exhibit 21). The Center for Medicare and Medicaid Innovation is testing a variety of pilot payment innovations to reward providers for lowering cost while improving quality. The Affordable Care Act invests in rapid and systematic testing of innovative models of health care delivery and payment to learn what works best. It also gives the Secretary of Health and Human Services authority to spread successful innovation throughout the Medicare program. It contains many provisions that improve benefits for beneficiaries, allow providers to be rewarded for delivering high- quality care, and place the program on more stable financial footing. Moving the U.S. health system toward a higher level of performance, with sustainable access to affordable care, improved quality and patient-centeredness, greater accountability for health outcomes and treatment costs, and enhanced population health cannot be accomplished by the federal government alone. State and local governments, businesses, providers, and households are under increasing pressure due to the unsustainable rate of cost growth and all must play a role. A high performance health system is not only consistent with, but also necessary for, controlling health care spending into the future. Policies to slow health spending growth must address factors across the health system so that the immediate problems facing governments at all levels?as well as businesses and households?can be ameliorated while at the same time achieving long-term stability (Exhibit 22, 23).
The Future of Medicare: Converting to Premium Support or Continuing as a Guaranteed Benefit Program President Obama, in continuing to implement the Affordable Care Act, would expand Medicare beneficiaries? access to preventive care, reduce the cost of prescription drugs, provide more help for low-income beneficiaries, provide better information for beneficiaries to make more informed health care choices, and encourage more coordinated care. The Affordable Care Act also slows the growth of payments to private Medicare Advantage plans and providers and raises premiums for high-income beneficiaries, extending the solvency of the Medicare Hospital Insurance Trust Fund. Governor Romney, in repealing the Affordable Care Act, would shorten the life of the Trust Fund, increase the federal budget deficit, and eliminate improved prescription drug and preventive services for Medicare beneficiaries. Over time, he would reduce Medicare program spending by increasing the eligibility age for Medicare coverage and converting Medicare into a defined contribution program. Under this program, beneficiaries would have a choice between traditional Medicare and private plans?using a ?premium support? contribution from the government, adjusted for the beneficiary?s income and
21
health status, toward the premium payment with any additional cost borne by the beneficiary. This would increase the typical beneficiary?s out of pocket burden for health care. President Obama?s continued implementation of the Affordable Care Act also would move forward with changes in how care is organized, delivered, and paid for. Many of the law?s provisions are focused on Medicare, as well as Medicaid and the Children?s Health Insurance Program, but the law also encourages multipayer initiatives that include both the public and private sectors. Models like the patient-centered medical home and the accountable care organization, which emphasize the role of primary care and the need to coordinate care across providers and settings, are being developed to improve care and stabilize costs. Both models encourage meaningful use of health information technology. It permits physician-led accountable care organizations to share in savings if they hold costs below a target rate of growth. The Center for Medicare and Medicaid Innovation is testing a variety of pilot payment innovations to reward providers for lowering cost while improving quality. The Affordable Care Act invests in rapid and systematic testing of innovative models of health care delivery and payment to learn what works best. It also gives the Secretary of Health and Human Services authority to spread successful innovation throughout the Medicare program if innovations lower cost, improve quality, or both, without being to the detriment of either. It contains many provisions that improve benefits for beneficiaries, allow providers to be rewarded for delivering high-quality care, and place the program on more stable financial footing. The Affordable Care Act would give physicians, hospitals, and other health care providers an incentive to reduce the rate of growth in Medicare outlays by creating opportunities to share in savings. President Obama has further stated that through these reforms he would attempt to hold the rate of growth in health care spending to GDP plus 0.5 percent, the same goal as under the premium support proposal. However, under the premium support strategy, the beneficiary is at financial risk when private insurance premiums exceed the Medicare spending target. Under the shared savings strategy, providers have the opportunity to reap benefits when costs are below the target for Medicare spending. Beneficiaries also benefit from lower Medicare costs as their premiums and out-of-pocket expenses are reduced by the slower growth in Medicare spending (Exhibit 24). As policymakers and the nation confront the urgent need to control health spending, while continuing to improve the quality and efficiency of care delivered, these activities provide a foundation on which to build, with the potential to control health spending while moving toward a high performance health system.
22
Percent of total Medicare population:
Note: ADL is activity of daily living. Sources: Income and savings data from Urban Institute/Kaiser Family Foundation analysis, 2011. All other data from Kaiser Family Foundation analysis of the Centers for Medicare and Medicaid Services Medicare Current Beneficiary 2008 Access to Care file.
Exhibit 1. Characteristics of the Medicare Population
Per Capita Annual Income Below $22,000 Per Capita Savings Below $53,000 3 or More Chronic Conditions Cognitive/Mental Impairment
Fair/Poor Health
Under-65 Disabled
2 or More ADL Limitations
Age 85+
Long-Term Care Facility Resident
Exhibit 2. Affordability, Access, and Coordination Experiences in the Past Year, by Age and Insurance Among U.S. Adults
Source: C. Schoen, R. Osborn, D. Squires et al., ?New 2011 Survey of Patients with Complex Care Needs in 11 Countries Finds That Care Is Often Poorly Coordinated,? Health Affairs Web First, published online Nov. 9, 2011.
Percent
23
Exhibit 3. Elderly Medicare Beneficiaries More Satisfied with Insurance, Less Likely to Experience Cost- or Access-Related Problems than Those Covered by Employer or Individual Health Plans
33**
39 39
20
39 37
8***
21*** 23***
0
10
20
30
40
50
Fair or poor insurance rating
Any medical bill or debt problem
Any access problem because of cost
Individual insurance (ages 19?64) Employer-sponsored coverage (ages 19?64) Medicare beneficiary (age 65+)
Notes: Medical bill problems include: not able to pay bills, contacted by a collection agency for unpaid medical bills only, had to change way of life because of medical bills, or have medical bills or debt being paid off over time. Access problems include: did not fill prescription, did not get needed specialist care, skipped recommended test or follow-up, had medical problems but did not visit doctor. Indicates significant difference from employer insurance: ** p<0.01, *** p<0.001. Source: K. Davis, K. Stremikis, M. M. Doty, and M. A. Zezza, ?Medicare Beneficiaries Less Likely to Experience Cost- and Access-Related Problems than Adults with Private Coverage,? Health Affairs Web First, published online July 18, 2012.
Adjusted percentage
Exhibit 4. Beneficiaries with Traditional Coverage More Satisfied, Less Likely to Experience Access Problems than Those with Medicare Advantage
15
27
32
6**
22 23*
0
10
20
30
40
50
Fair or poor insurance rating
Any medical bill or debt problem
Any access problem because of cost
Private Medicare Advantage (age 65+) Traditional Medicare coverage (age 65+)
Notes: Medical bill problems include: not able to pay bills, contacted by a collection agency for unpaid medical bills only, had to change way of life because of medical bills, or have medical bills or debt being paid off over time. Access problems include: did not fill prescription, did not get needed specialist care, skipped recommended test or follow-up, had medical problems but did not visit doctor. Indicates significant difference from Medicare Advantage: * p<0.05, ** p<0.01. Source: K. Davis, K. Stremikis, M. M. Doty, and M. A. Zezza, ?Medicare Beneficiaries Less Likely to Experience Cost- and Access-Related Problems than Adults with Private Coverage,? Health Affairs Web First, published online July 18, 2012. Adjusted percentage 24 12.7 40.9 35.8 31.1 26.5 21.8 15.3 13.5 10.4 6.7 4.5 3.0 0 10 20 30 40 50 Total Indivi- duals 2 to 4 5 to 9 10 to 19 20 to 49 50 to 99 100 to 499 500 to 2,499 2,500 to 9,999 10,000 or more Medi- care Percent Source: Commonwealth Fund Commission on a High Performance Health System, The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way (New York: The Commonwealth Fund, Feb. 2009); Congressional Budget Office, Designing a Premium Support System for Medicare , (Washington: Congressional Budget Office, Dec. 2006). Exhibit 5. Administrative Costs in Medicare Are Lower than Those in Private Coverage Because of Efficiencies Group size 13 3 2 11 20 0 5 10 15 20 25 Total Private Medicare Traditional Medicare Private Medicare Advantage Medigap Percent Source: Commonwealth Fund Commission on a High Performance Health System, The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way (New York: The Commonwealth Fund, Feb. 2009); Congressional Budget Office, Designing a Premium Support System for Medicare , (Washington: Congressional Budget Office, Dec. 2006); and S. Sheingold, A. Shartzer, and D. Ly, Steven Sheingold, Adele Shartzer, and Dan Ly, Variation and Trends in Medigap Premiums , (Washington: HHS Assistant Secretary for Planning and Evaluation, Dec. 2011). Exhibit 6. Administrative Costs in Private Medicare Advantage Coverage Are Five Times Higher than Traditional Medicare 25 Exhibit 7. Aggregate Hospital Payment-to-Cost Ratios for Private Payers, Medicare, and Medicaid, 1990?2010 Note: (1) Includes Medicaid Disproportionate Share payments. Source: Avalere Health analysis of American Hospital Association Annual Survey data, 2010, for community hospitals. Medicare Medicaid(1) Private Payer 70% 80% 90% 100% 110% 120% 130% 140% 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 74% 85% 83% Medicare Typical Large Employer PPO Plan FEHBP Standard Option Exhibit 8. Medicare Is Less Generous than FEHBP and Other Large Employer Plans Note: The FEHBP (Federal Employees Health Benefits Program) standard option is offered through Blue Cross Blue Shield. Employer plans include dental benefits. Source: Hewitt Associates analysis for the Kaiser Family Foundation, 2008. Total Average Medical Spending = $14,270 Share of Total Spending Paid by Plan in 2007 26 Source: Kaiser Family Foundation analysis of the Bureau of Labor Statistics Consumer Expenditure Survey Interview and Expense Files, 2009, ?Health Care on a Budget, The Financial Burden of Health Spending by Medicare Households, An Updated Analysis of Health Care Spending as a Share of Total Household Spending,? June 2011. Transportation Transportation Health Care Non-Medicare Household Spending Medicare Household Spending Exhibit 9. Distribution of Average Household Spending by Medicare and Non-Medicare Households, 2009 Average Household Spending = $50,143 Average Household Spending = $30,966 Exhibit 10. Historical and Projected Healthcare Spending Burden Among Medicare Beneficiaries, 1997?2020 Source: Kaiser Family Foundation analysis of CMS Medicare Current Beneficiary Survey Cost and Use files, 1997?2006; projections based on data from historical trends on income and health care spending in Medicare Current Beneficiary Survey Cost and Use files, 1997-2006, ?How Much ?Skin in the Game? is Enough? The Financial Burden of Health Spending for People on Medicare, An Updated Analysis of Out-of-Pocket Spending as a Share of Income,? June 2011. Projected Historical 27 Notes: Includes Medicare Advantage enrollees, and includes institutionalized and non-institutionalized beneficiaries. In 2006, the federal poverty level was $9,800 for an individual, and $13,200 for a couple. Source: Kaiser Family Foundation analysis of CMS Medicare Current Beneficiary Survey Cost and Use File, 2006, ?How Much ?Skin in the Game? is Enough? The Financial Burden of Health Spending For People on Medicare, An Updated Analysis of Out-of-Pocket Spending as a Share of Income,? June 2011. Exhibit 11. Median Out-of-Pocket Health Care Spending as a Percent of Income Among Medicare Beneficiaries, by Demographic Characteristics, 2006 Age Percent of Federal Poverty Level Health Status Exhibit 12. Health Care Spending and Economic Growth, 2012?2021 Average annual growth rate (%) Note: Medicare spending projections will be slightly higher without the physician-fee cut included in current law. Source: J. Holahan and S. McMorrow, ?Medicare and Medicaid Spending Trends and the Deficit Debate,? New England Journal of Medicine, Aug. 2, 2012 367(5):393?95. 6.0 6.1 8.5 5.0 0.9 2.9 4.7 0.9 5.0 3.1 3.6 4.1 0 1 2 3 4 5 6 7 8 9 Private Insurance Medicare Medicaid Gross Domestic Product Total spending Enrollment Spending per enrollee Total Population Per capita 28 Exhibit 13. Projected Medicare Spending in 2020 $136 Billion Lower Than Pre-Reform Predictions Cumulative Reduction of $689 Billion over 2011?2020 $1,070.4 $943.1 $934.9 $0 $200 $400 $600 $800 $1,000 $1,200 Pre-Reform* After Reform** Latest Estimate*** Estimated Medicare Spending in 2020 ($ billions) 12.7% * CMS projection as of February 2009 assuming no reform; ** CMS projection as of September 2010 after enactment of reform; *** CMS projection as of July 2012 after enactment of reform. Source: CMS spending projections from 2009, 2010, and 2012; Commonwealth Fund estimates extrapolating trends in past one to two years assuming continuation of compounded annual growth rate. $510 $686 $689 $0 $100 $200 $300 $400 $500 $600 $700 $800 CBO 2010 estimate of Medicare payment and delivery system savings Cutler-Davis 2010 estimate of Medicare payment and delivery system savings Latest CMS projection Exhibit 14. Total 10-Year Medicare Savings Relative to Pre-Reform Projections, 2011?2020 Billions Data: Authors? estimates based on trends in: The Congressional Budget Office, Analysis of H.R. 4872, Reconciliation Act of 2010, Mar. 20, 2010, http://www.cbo.gov/doc.cfm?index=11379&type=1; CMS Spending projections from 2009 and 2012; and D. M. Cutler, K. Davis, and K. Stremikis, The Impact of Health Reform on Health System Spending, Center for American Progress and The Commonwealth Fund, May 2010. 29 Exhibit 15. Historical and Projected Number of Medicare Beneficiaries and Number of Workers Per Beneficiary Source: 2010 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Number of Beneficiaries (in millions) Number of Workers per Beneficiary Exhibit 16. Annual Income of Medicare Beneficiaries, 2006 16% 28% 20% 13% 8% 4% 2% 2% 1% 1% 3% Notes: Annual income includes that of individual respondents and their spouses, if applicable. Estimates do not sum to totals in text because of rounding. Source: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost and Use File, 2006. Median annual income, 2006 = $22,800 $0? $10,000 $10,001? $20,000 $20,001? $30,000 $30,001? $40,000 $40,001? $50,000 $50,001? $60,000 $60,001? $70,000 $70,001? $80,000 $80,001? $90,000 $90,001? $100,000 >$100,000
30
Exhibit 17. Federal and Medicare Beneficiary Contributions to Total Health Care Spending for a Typical 65-Year-Old, 2022 Current Medicare vs. ?Path to Prosperity? Proposal
Note: Numbers are rounded. Sources: Kaiser Family Foundation analysis. Beneficiary health care spending under Medicare (extended baseline scenario and alternative fiscal scenario) and Chairman Ryan?s proposal is calculated based on data in the CBO letter to Chairman Paul Ryan dated April 5, 2011, ?Proposed Changes to Medicare in the ?Path to Prosperity?, Overview and Key Questions,? April 2011.
Beneficiary?s Share of Spending (premiums and other out-of-pocket costs)
Government?s Share of Spending
Total: $13,530
Total: $14,760
Total: $20,500
$5,630 24%
$12,500 49%
Exhibit 18. Health Care Spending as a Share of Social Security Income for a Typical 65-Year-Old Medicare Beneficiary, 2022
Average Social Security Income, 2022 $25,560 $25,560
Beneficiary spending as a share of Social Security payment
Source: Kaiser Family Foundation analysis. Beneficiary health care spending under Medicare (extended baseline scenario) and Mr. Ryan?s proposal is calculated based on data in the CBO letter to Chairman Paul Ryan dated April 5, 2011. Social Security income for an average wage 65-year old retiring at age 65 is based on Social Security Administration data (Table VI.F10 of the 2010 Trustees Report) adjusted to current dollars (based on annual CPI projections in Table VI.F6. See http://www.ssa.gov/OACT/TR/2010/lr6f6.html factors).
Traditional Medicare ?Path to Prosperity? Proposal
31
Exhibit 19. Approximate Average Inflation-Adjusted Medicare Spending for Beneficiaries of Certain Ages
$5,800 $6,100
$8,500
$12,900
$17,100
$5,800 $6,200
$9,800
$14,200
$19,000
$5,900
$7,500
$9,800
$11,100
$0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 $16,000 $18,000 $20,000
2011 2023 2030 2040 2050
Extended Baseline Alternative Fiscal Scenario Ryan 2012
Source: Congressional Budget Office, The Long-Term Budgetary Impact of Paths for Federal Revenues and Spending Specified by Chairman Ryan (Washington, D.C.: Congressional Budget Office, March 2012).
Age 65
Age 66
Age 67 2011 dollars
Exhibit 20. Medicare Spending per Beneficiary Under Premium Support Scenario, 2012?2050
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Private Insurance
Ryan Premium Support (GDP per capita + 0.5%)
Source: Commonwealth Fund calculations based on Congressional Budget Office, The Long-Term Budgetary Impact of Paths for Federal Revenues and Spending Specified by Chairman Ryan , (Washington, D.C.: Congressional Budget Office, March 2012), and Congressional Budget Office, The 2012 Long-Term Budget Outlook , (Washington, D.C.: Congressional Budget Office, June 2012).
Nominal $
Beneficiary at financial risk
$4,250
32
Exhibit 21. Medicare Spending per Beneficiary Under Shared Savings Scenario, 2012?2050
Source: Commonwealth Fund calculations based on Congressional Budget Office, The Long-Term Budgetary Impact of Paths for Federal Revenues and Spending Specified by Chairman Ryan , (Washington, D.C.: Congressional Budget Office, March 2012), and Congressional Budget Office, The 2012 Long-Term Budget Outlook , (Washington, D.C.: Congressional Budget Office, June 2012).
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Medicare Spending Goal of GDP per capita + 0.5%
Projected Under Shared Savings
Shared savings opportunity for providers
Nominal $
Exhibit 22. System Improvement Provisions of the Affordable Care Act
Supporting primary care, prevention, and wellness
Primary care 10% bonus for five years; Medicaid payment rates to primary care physicians no less than 100% of Medicare rates in 2013 and 2014; annual wellness visit and/or health risk assessment for Medicare beneficiaries; preventive services without cost-sharing; local and employer wellness programs; medical home initiatives
Payment reforms to encourage and support improved system performance
Value-based purchasing programs; reduced payment for hospital- acquired conditions and potentially preventable readmissions; bundled payment for acute and postacute care Accountable care organizations Accountable care organizations to share savings in Medicare
Controlling health spending
Independent Payment Advisory Board recommendations to meet Medicare expenditure target as well as total system spending nonbinding recommendations; productivity improvement update factor
Resources to promote system improvement
Center for Medicare and Medicaid Innovation; Patient-Centered Outcomes Research Institute; Medicare?Medicaid Coordination Office
Quality improvement and public reporting
Directs the U.S. Department of Health and Human Services to develop national quality strategy, public reporting
Accelerating the adoption of health information technology
Incentives to providers that encourage them to adopt and meaningfully use health information technology
Medicare private plan competition
Levels the playing field between Medicare Advantage and traditional Medicare fee-for-service plans
Source: Commonwealth Fund analysis.
33
Exhibit 23. Overview of Center for Medicare and Medicaid Innovation?Sponsored Initiatives
Bundled Payments for Care Improvement. Tests four different payment models to encourage improved care coordination and efficiency related to hospital admissions. Currently selecting participants. Pioneer ACO Model. Tests advanced ACO models. 32 organizations are participating. ACO Advance Payment Model. Tests whether advance payments will assist participation in the Medicare ACO programs for physician-led and rural organizations with limited access to start-up capital. 20 organizations are currently participating. Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration. Supports 500 FQHCs’ transformation to medical homes through $6 per member per month payment for each eligible Medicare beneficiary. Comprehensive Primary Care Initiative. Public and private payer collaborative to strengthen primary care, involving risk-adjusted, monthly care management fees, as well shared savings payments. 7 states and 500 primary care practices are currently participating. Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. Seeks to improve quality of care for people in nursing facilities by reducing preventable inpatient hospitalizations. Currently selecting participants. Partnership for Patients. Nationwide public?private partnership to support safer care and more effective transitions of patients from hospitals to other settings. $218 million was awarded to 26 organizations to be Hospital Engagement Networks, which help identify and spread solutions already working to reduce health care?acquired conditions. An additional $500 million is available for models improving care transitions and reducing readmissions for high-risk Medicare beneficiaries. Already, 47 participants have been selected for that program. Independence at Home Demonstration. Tests effectiveness of delivering comprehensive primary care at home, focusing on patients with multiple chronic conditions. 15 independent practices and 3 consortia participating. Medicaid Emergency Psychiatric Demonstration. Tests whether Medicaid can support higher-quality care at a lower total cost by reimbursing private psychiatric hospitals for certain psychiatric services for which Medicaid reimbursement has historically been unavailable. 11 states and D.C. are participating. Medicaid Incentives for the Prevention of Chronic Diseases. Provides incentives to Medicaid beneficiaries participating in prevention programs and demonstrate changes in health risk. 10 states are participating. Financial Alignment Initiative. Aligns financial incentives of Medicare and Medicaid to provide Medicare?Medicaid enrollees with a better care experience. This opportunity is open to all states. Currently, one state is participating. State Innovation Models Initiative. A competitive funding opportunity for states to design and test multipayer payment and delivery models that deliver high-quality health care and improve health system performance. Up to $275 million will be made available for up to 30 grants. Health Care Innovation Awards. Provides grants up to $30 million to participants who are implementing innovative ideas to deliver better health, improved care, and lower costs. 107 grants totaling $894 were awarded. Nearly $2 billion in savings is expected over three years from these initiatives. Strong Start for Mothers and Newborns. Supports reducing the risk of significant complications and long-term health problems for both expectant mothers and newborns. Graduate Nurse Education Demonstration. Provides hospitals with funds for clinical training of advanced practice registered nursing (APRN) students. 5 hospitals are participating. Innovation Advisors Program. Creates a network of delivery system reform experts. 73 advisors have been selected.
Exhibit 24. Medicare Spending per Beneficiary Under Premium Support and Shared Savings Scenarios, 2012?2050
Source: Commonwealth Fund calculations based on Congressional Budget Office, The Long-Term Budgetary Impact of Paths for Federal Revenues and Spending Specified by Chairman Ryan , (Washington: Congressional Budget Office, March 2012), and Congressional Budget Office, The 2012 Long-Term Budget Outlook (Washington, D.C.: Congressional Budget Office, June 2012).
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Private Insurance
Medicare Spending Goal of GDP per capita + 0.5%
Shared savings opportunity for providers
Beneficiary at financial risk under premium support
$4,250
Nominal $


 

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The post Appended to Karen Davis? oral testimony is a set of 24 insightful exhibits that are loaded with Medicare information. For this module?s discussion, please interpret, assess, cite, and debate the Medicare reform implications of the facts and figures from this set of 24 exhibits. appeared first on THE NURSING PROFESSIONALS.

Appended to Karen Davis? oral testimony is a set of 24 insightful exhibits that are loaded with Medicare information. For this module?s discussion, please interpret, assess, cite, and debate the Medicare reform implications of the facts and figures from this set of 24 exhibits.

Use the work by at least one theorist: Piaget (cognitive development), Erikson (social development), Cooley (looking glass ‘self’), Rogers (self-concept and self-esteem), Bandura (social learning theory of development)

Use the work by at least one theorist: Piaget (cognitive development), Erikson (social development), Cooley (looking glass ‘self’), Rogers (self-concept and self-esteem), Bandura (social learning theory of development).

Use the work by at least one theorist: Piaget (cognitive development), Erikson (social development), Cooley (looking glass ‘self’), Rogers (self-concept and self-esteem), Bandura (social learning theory of development)

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A topic word for this essay is human relationships and life transition, with the focus words of adolescence (12-18 years).
Aim: This assessment items aims to provide the student with an opportunity to explore the physical, sociocultural (psychosocial) and moral/cognitive issues in further detail in relation to adolescence development, and to examine the development of self-identity, self-concept and /or self-esteem where relevant.
Use the work by at least one theorist: Piaget (cognitive development), Erikson (social development), Cooley (looking glass ‘self’), Rogers (self-concept and self-esteem), Bandura (social learning theory of development), Vygotsky (sociocultural development), Bowlby (attachment/parenting), Kohlberg (moral development), Gilligan (moral development).
This essay must contributes to nursing and midwifery practice (use at least two NMBA (2016) standards for practice (with reference to supporting elements/sub-points of these standards)). The reference list must include a minimum of 6 recent references (2011 onwards) and peer-reviewed journal articles.
I only require 5 body paragraphs without introduction and conclusion.
The first body paragraph is identifies and discuss of all normative (predictable) adolescence of the relevant physical, socio-cultural (psychosocial) and cognitive aspects of developmental stage using at least one theorist’s.
The second paragraph is to identify and describe one non-normative life transitions which may occur within adolescence stage using at least one theorist’s.
The third paragraph is discuss/describe/illustrate how self-identity, self-concept and/or self-esteem develops in adolescence supported by relevant literature.
The fourth paragraph is following on from the previous paragraph which will contain a definition (s) of terms, identify factors which may subsequently impact on adolescence self-concept during the normative (predictable) and non-normative (unpredictable) transitions in adolescence stages.
The last paragraph is to justify (provide a rationale) for how an understanding of the normative and non-normative physical, sociocultural (psychosocial) and cognitive aspect in adolescence stage contributes to nursing and midwifery practice, and identify (state/describe) at least two standards (NMBA, 2016) to support justification.


 

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The post Use the work by at least one theorist: Piaget (cognitive development), Erikson (social development), Cooley (looking glass ‘self’), Rogers (self-concept and self-esteem), Bandura (social learning theory of development) appeared first on THE NURSING PROFESSIONALS.

Use the work by at least one theorist: Piaget (cognitive development), Erikson (social development), Cooley (looking glass ‘self’), Rogers (self-concept and self-esteem), Bandura (social learning theory of development)

Discuss the impact of culture on health and illness. Explore health seeking behaviors of a variety of cultures and explore how clinical nurse can adapt their practice to accommodate the behaviors.

Discuss the impact of culture on health and illness. Explore health seeking behaviors of a variety of cultures and explore how clinical nurse can adapt their practice to accommodate the behaviors..

Discuss the impact of culture on health and illness. Explore health seeking behaviors of a variety of cultures and explore how clinical nurse can adapt their practice to accommodate the behaviors.

Order Description
Discuss current thinking on different approaches to addressing diversity/inclusivity in the clinical and classroom environments. Identify a variety of ways in which different cultures perceive the learning experience. Focus on learning styles.
Discuss the impact of culture on health and illnesses. Explore health seeking behaviors of a variety of cultures and explore how clinical nurses can adapt their practices to accommodate the behaviors. .
Complete your discussion with a list of current citations and references.

Please respond to peers discussion and add one different comment to the discussion? Please respond to Irish Culture.

In both the healthcare arena and classroom, the topics of cultural competence and diversity are being discussed more frequently and openly. Cultural competence encompasses the capacity to identify, understand, and respect the values and beliefs of others (Diaz, Clarke & Gatua, 2015). Training on various cultures and their beliefs in regards to healthcare have allowed for individuals to be cared for in their own culturally accepted manner. Each person will perceive and handle their condition in different ways, and will expect and require different approaches to care?culture will undoubtedly play its role in this equation (Mendes, 2015) The clinical nurses must adapt their practices to provide patient-centered care with their cultural beliefs in mind. The nurse should feel comfortable having an open discussion with the patient about their cultural values and beliefs, in order to adhere to and respect those practices, which may be foreign to them.
A person?s faith may affect their treatment decisions and preferences, and importantly, advance care plans for their end-of-life care (Mendes, 2015). For example, a Jehovah?s Witness can sign a Bloodless Advanced Directive and have the ability to choose other means of life-saving products without going against their beliefs and accepting blood. A study in the British Journal of Midwifery discussed the birth plan preferences in Nigerian and Irish women in Ireland. The Irish women were more vocal on wanting an epidural for pain relief, while the Nigerian women did not want to use anything for pain relief in labor. In general, Nigerians appear to view childbirth as a natural, at times lengthy, phenomenon and as such it is not unusual to avoid analgesia and medical intervention, such as cesarean section delivery (Sheridan, Yekinni, Oyeye, Ogunleye, Oluyede, O?Sullivan, & Higgins, 2011). Since the publishing of this study, the healthcare providers in that area of Ireland have tailored their practices to respect the cultural differences and offer other methods of pain relief such as massage therapy, aromatherapy and hydrotherapy; this is a fantastic example of providing culturally competent care.
If the patient?s culture is respected and used in the plan of care, they will be more receptive to adhere to the recommendations and keep up with the regimen. Using culturally competent care encourages help-seeking behaviors among minority populations, because they know they will be cared for in a manner most comfortable and familiar to them. It will also result in earlier diagnoses and increased access to services and treatment; it is important to recognize the cultural identities of all individual [patients] increasing their personal quality of life, and in turn come closer to achieving the type of care provision we would all wish for our own loved ones (Mendes, 2015). Culture has a tremendous impact on health and illness, as stated earlier, it can make or break the patient?s willingness to follow a healthcare regimen. The way to ensure all nurses are prepared to care for diverse patients is through the promotion of diversity in nursing education programs, as well as fostering the development of cultural competence among all levels of nursing students (Diaz, Clarke & Gatua, 2015). This essential practice will prepare student nurses to deliver high quality, patient-centered care.
In nursing education, aside from preparing the students to provide culturally competent care, the educators are tasked with ensuring students from all different cultures, religions, genders, socioeconomic backgrounds, sexual orientation and age ranges are respected and feel included in the educational experience. The American Association of Colleges of Nursing (AACN) estimates approximately 73% of undergraduate nursing students are now considered non-traditional which refers to any student who meets one or more of the following criteria: aged 25 or older, commutes to school, enrolled part time, is male, is a member of an ethnic or racial minority group, speaks English as a second or additional language, has dependent children, and holds a general equivalency diploma (GED) or has required re-medial classes (Bednarz, Schim, & Doorenbos, 2010). Ensuring inclusivity in the classroom for all students should be every educators top priority. If every student feels valued for who they are, a sense of trust lives in the classroom, and that trust allows all students to feel comfortable enough to take intellectual risks (https://www.teachingtolerance.org). An approach to address the issues of diversity in the classroom would be to empower each student to be their best selves and allow for their success both in the classroom and in the healthcare field. Educators are challenged to recognize different learning needs and respect and utilize the knowledge and experiences that students bring to the learning settings (Bradshaw & Lowenstein, 2011). Students come from all different walks of life now, as the saying goes, but their method of learning is still the same: teaching needs to be tailored to the learner?s needs. By using the strengths and originality of diverse students, the final classroom product can be much stronger than the product of an assimilated, cookie cutter one (Bradshaw & Lowenstein, 2011). Each culture experiences learning in their own way and the educator must be aware of this. The students of Asian-American culture are accustomed to not participate or make eye contact when speaking, however, for an educator not aware of this cultural norm, it would mean the student was simply not interested in this class and would result in deduction of points for class participation (Bradshaw & Lowenstein, 2011). Many cultures also value work sharing and helping the whole group to achieve, whereas in the classroom, this practice may not be acceptable, especially when it comes to examinations (Diaz, Clarke & Gatua, 2015). Understanding the learning styles of each student given their diverse backgrounds will help the educator design various teaching methods to allow for the success of the classroom as a whole. Activities such as small group work, case studies, simulations and active discussions are just a few ways in which students can express themselves freely to learn about the material and from each other. A better knowledge and understanding of learning styles allows the educator to teach in a manner that both reaches the greatest number of students and challenges all students to grow as learners (Bradshaw & Lowenstein, 2011). Administering the VARK questionnaire, which determines if you learn best through visual, aural, read/write or kinesthetic method, on the first class meeting will allow for the student and the educator to see how they learn best and help provide the student with the appropriate tool to help them be successful.

References

Bednarz, H., Schim, S., & Doorenbos, A. (2010). Cultural Diversity in Nursing Education: Perils, Pitfalls, and Pearls. Journal of Nursing Education J Nurs Educ, 49(5), 253-260. Retrieved September 17, 2016.

Bradshaw, M. J., & Lowenstein, A. J. (2011). Innovative teaching strategies in nursing and related health professions (6th ed.). Boston: Jones and Bartlett.

Diaz, C., Clarke, P. N., & Gatua, M. W. (2015). Cultural Competence in Rural Nursing Education: Are We There Yet? Nursing Education Perspectives, 36(1), 22-26. Retrieved September 18, 2016.

Elliott, P. (2015, December 3). How to craft an open classroom. Retrieved September 17, 2016, from file:///Users/jenniferkeller/Desktop/How to Craft an Open Classroom | Teaching Tolerance – Diversity, Equity and Justice.

Mendes, A. (2015). Cultural competence: Part of good personalized dementia care. Nursing and Residential Care, 17(6), 338-341. Retrieved September 18, 2016.

Sheridan, C. P., Yekinni, I., Oyeye, G., Ogunleye, K., Oluyede, G., O?Sullivan, K., & Higgins, J. R. (2011). Comparing birth plan preferences among Irish and Nigerian women. Br J Midwifery British Journal of Midwifery, 19(3), 172-177. Retrieved September 16, 2016.

The VARK Questionnaire. Retrieved September 18, 2016, from https://vark-learn.com/the-vark-questionnaire/

Second Discussion
I. Discuss current thinking on different approaches to addressing diversity/inclusivity in the clinical and classroom environment. Identify a variety of ways in which different cultures perceive the learning experience. Focus on the learning style.
Today school is becoming highly complex and culturally diverse and educators face a lot of challenges for students to reach same academic goal and standard. Every classroom is a cultural community reflective of the discipline and perspective studied, the teacher and the student. Successful learning requires an intercultural approach where students are responsible to listen or observe in order to understand various perspectives. Culturally and linguistically diverse students vary in term of their educational background, native language, literacy, socioeconomic status, and cultural tradition (Stephenson, 2014). Cultural intelligence has become one of the key competences of the 21th century. As an educator myself in an LPN program in a multigenerational and culturally diverse group of mostly Hispanics and African Americans, there is an expectation among teachers to acquire expertise in transmitting curriculum and structuring the classroom for optimal learning (Moule 2013). Facing such a challenge, I believe that the given curriculum should emphasize a culturally intelligent curriculum format that provide students with analytical tools to deal with uncertainties and the ability to think critically in a wide variety of communicative contexts.
As an instructor in this type of setting, I have the influence and the obligation to create environment for students? retention and success across the school setting. Research indicates that teaching in diversity and multicultural sensitivity across disciplines can reduce prejudice, transform students?perspectives and is positively correlated with workplace readiness (Enberg et al. 2007, Denson 2009). Curricular and pedagogical practices that enhance cultural intelligence serve all our students by attending to the experiences of differences among and across our student population. (Harper and Hurtado 2007, Museus and Maramb 2011, Museus et al. 2008).
According to Roxanne Amerson (2006), keeping students awake and alert in the nursing classroom can be also a constant struggle. To involve students and create interactive learning opportunities, it is important to design cognitive strategies that attracts the students? learning preferences. Such creativity entails a certain willingness to think outside the box. Educators must be able to develop their teaching strategies beyond the common and expected classroom activities. The important factor to energizing the nursing lecture is to design an environment that urges students to be active participants. It is important to use creativity to create cognitive strategies that appeal to students? learning preferences.
Here are some methods to effectively enhance the students? learning:
1. Development of Cultural Intelligence. What is Cultural Intelligence? Cultural Intelligence is a person’s capability to adapt effectively to new cultural contexts and it has both process and content features (Earley & Ang 2003). Cultural intelligence is a multi-dimensional construct. Cognitive and metacognitive, motivational and behavioural components shape the whole of CQ (Ang, 2006).
2. The use of the Theory of Multiple Intelligence Learning in the classroom. This concept can be incorporated in a classroom setting. With an open mind and a willingness to forego traditional approaches, it can be accomplished. An example that puts this concept into practice involves client education and there are several steps:
a) INTERPERSONAL – begin the lecture by asking students to talk with peers about an instance in which a nurse or doctor taught them something.
b) MATHEMATICAL/LOGICAL and MUSICAL – review some common learning theories and then give students a written assignment. They will have five minutes to compare and contrast the theories and record their own beliefs about learning. Play soft background music during this activity.
c) VISUAL and VERBAL/LINGUISTIC – use a PowerPoint presentation with interactive graphics and fill-in-the-blank statements.
d) KINESTHETIC – randomly distribute to students laminated cards with criteria for a learning objective (i.e., client-centered, measurable, time-limited, realistic). Have students write their criteria on the board, giving examples of how these criteria are used in writing an objective.
e) INTRAPERSONAL – provide a journal article to read independently that focuses on providing effective patient teaching.
Additionally, with a little anticipation and planning, we have to integrate activities that meet the needs of seven of Gardner?s eight types of intelligences. It has been the author?s experience that student evaluations will reflect satisfaction with the willingness of the educator to step outside the normal traditions of the classroom to address a variety of learning preferences. The future task for nurse educators will be to implement these techniques and exhibit efficacy through research.
Thus, nurse educators regularly express their concern about not covering all the material and feeling obligated to complete as much lecture content as possible within a one- to two-hour period of time. The truth is that only certain students will learn when a teaching format is focused to meet the needs of certain types of learners. O?Hare (9) found out that, when nurses were taught new and difficult content through instructional methods that matched their learning style preferences, they scored higher on standardized achievement test scores. By designing short and interactive activities focused on specific intelligence styles that can be interspersed throughout the lecture, the nursing lecture can be interactive and energized.
Supplementing the above findings, academic cultures place great value on independence, from course development and delivery to scholarly honors. Independence is normed on middle class American society, privileging students from that socioeconomic stratum (Stephens, Fryberg, Markus, Johnson & Covarrubias, 2012). Introversion is rewarded through research hours and independent scheduling. On the other hand, collegiality is also not only valued, but required in order for academic gears to mesh and move institutional development forward. Social capital, with extended campus representatives, is essential to achieve college and career success (Becker, Krodel & Tucker, 2009). Of all cognitive abilities, critical thinking is most valued and commended. It is the basis of original thought and the gist of academic discourse. Even at the most basic logistical levels, academia presents unique cultural changes (Conley, 2007). Schedules are a moving target and require high-level tracking skills, self-motivation, and pacing. Self-reliance is essential when family members are not available to intervene or aware of impending deadlines. The learning pace is often a surprise to incoming freshmen, who have cruised through more relaxed standards in high school. Similarly, new college students are generally not prepared for the extent to which they must collaborate with student colleagues, experts in the field, staff members, and other faculty. Students must frequently allow themselves to criticism on paper and in front of the classroom when making presentations, and are expected to defend their viewpoints or integrate corrective feedback.
The ability, therefore, to successfully navigate in a new environment requires a sense of self, sense of others, and awareness about shared and different experiences within each interaction. Values, idiosyncrasies, communication patterns, physical gestures, moral reasoning, and behavioral cues all contribute congruently that influences social meaning within relationships. When incongruent messages dominate social interactions, attention is required to identify, interpret, and adjust to the differences. Under these circumstances, academic learning is compromised because cognitive processes are otherwise overloaded by sorting through the meaning associated with cultural variables. Sternberg?s Interactional Theory suggests that comprehensive intelligence is revealed by a person?s dynamic modifications in response to their environment (Early & Ang, 2003). In this case, however, institutional intelligence, instead of personal intelligence, is needed to generate effective modifications. If academic goals include success for Hispanic, first-generation, and low-income students; colleges and universities must first acknowledge the gap between students? incoming cultural milieus in contrast to the academic culture in which they are expected to succeed and then develop interventions to bridge that gap. In other words, colleges and universities must mediate the environmental transition for culturally diverse students into a different culture. It is only by doing so that we could secure the future of our students that on the one hand they become successful in their own fields, and on the other hand, can be very useful in the society at large.
II. Discuss the impact of culture on health and illness. Explore health seeking behaviors of a variety of cultures and explore how clinical nurse can adapt their practice to accommodate the behaviors.
Culture affects ones perception of health, illness and death. It has a major impact on a person?s belief about causes of disease, approaches to health promotion, and how illness and pain are experienced and expressed, as well as where (or from whom) patients seek help; and the type of treatment thepatient prefers (Canadian Pediatric Society, 2015).
Culture, as described by the Canadian Pediatric Society (2015) is the pattern of ideas, customs and behavior shared by a particular group of people in the society, which determine them from one another. The same organization, additionally, characterized culture as dynamic and evolving, learned and passed from one generation to the other. This is frequently identified through language, manner of dressing, music and behavior and is assimilated into all aspects of an individual?s life.
Interestingly, the United States of America remains a popular destination of the world?s international migrants (Zong and Batalova, 2015), In 2013, approximately 41.3 million immigrants lived in the Unites States totaling to 13% of the total U.S population (Zong nd Batalova, 2015), The significant change in the demographic landscape of America according to Buttaro, 2014, have impacted directly America?s health education, health care delivery and public health. One significant factor that directly affects health is culture (Buttaro, 2014).
A study conducted by Park, Chesla, Rehm and Chun in 2011, entitled Culturally Appropriate Mental Health Care for Asian Americans. It showed that Asian men in general feels pressured to be strong and find it difficult to express their feeling to other members of the family because they are known as the ?head of the family?. This study also showed that Asians prefer indirect communication due to the fact that it is less threatening and confrontational. This view is directly in contrast from the American society?s belief that direct communication is healthy and therapeutic (Park et al., 2011). In this mentioned research the care provider acts as messenger by apologizing to the family members and explaining the experiences that were causing pain and suffering to the patient (Park et al. 2011). By being sensitive to the hierarchical role and relationships within Asian American families, care provider may act as interpreter or mediator so that family members may understand each other while preserving the patient?s position as head of the family (Park, Chesla, Rehm & Chum, 2011). Furthermore, the clinical nurse can be a source of neutral, unbiased and objective information regarding the health of family member/s, whenever information is sought and whenever it is appropriate to be shared. This relieves the members in this particular group of the burden of having to be confrontational or emotional during some of the more pressure-laden conversations. The nurse should, however, best be careful not to sound or appear imposing or intrusive, as the role he/she needs to assume is more of a facilitator of communication and an interpreter where her/his expertise on health is needed or sought.
As a nurse growing up in a tightly knit community or culture or extended family type of setting, our belief system are mostly not to seek treatment in a profession setting i.e. (clinic, hospital or health center). We also preferred to use herbal medicines rather than over the counter medication that are available in the pharmacy. This behavior too is very evident to people living in remote or far flang areas. We tend to do our own health care remedies based on our experiences from our elders or we seek help from the village elder known as ?Albularyo? or also known as ?Quack doctor?. Most of these belief systems are directly influenced by people?s faith/ spiritual belief, experiences and socio-economic status.
As a professional nurse, I can?t say that the above practice is outrightly wrong for people find relief and sometimes alleviation from their maladies. We call it psychological or spiritual but the fact remains that they are cured in some way. But, my learning in this particular field will somehow better explain to them an alternative and may in some sense redirect this particular mind-set. Offering and explaining to them a much better option, which focuses directly on their illness will somehow move them to embrace a better understanding of their wellness. I believe that my enrichment in this particular field of study especially as I take up this course gives me a much better position to understand and enlighten some cultural inappropriateness in dealing with health care. Thus, by enlightening them, they will all the more appreciate their particular cultural practices and at the same time offer them the best possible option to a more life sustaining, prolonged, integrative and wholesome health care.
References:
Stephenson, V (2014). Teaching Strategies to Accommodate Culturally Linguistically Diverse Students in Online Nursing Courses. Master of Arts/Science in Nursing Scholarly Projects. Paper76.
Song, D., & Oh, E. (2011). Learning Style Based on the Different Cultural Background of KFL Learners in Online Learning. Multimedia-Assisted Language Learning, 14(3),133-154.
O?Hare, L. (2002). Effect of traditional versus learning-style presentation of course content in adult health nursing on the achievement and attitudes of baccalaureate nursing students. Unpublished doctoral dissertation, St. John?s University, Queens, NY.
Moule, J. (2015). Cultural Competence: A primer for educators. Wadsworth: Belmont. CA.
Gardner, H. (1999). Intelligence reframed: Multiple intelligence for the 21st Century. New York: Basic Books.
Boykin, A.W., & Noguera, P. (2011). Creating the opportunity to learn. Alexandria, VA: ASCD.
https://2014.wascarc.org/site/default/files/CARTER%20CQ@0Stem%20Carter%20Cianci_0.pdf. Retrieved September 17, 2016.
Buttaro, L. (2014). Cultural Competency: The Effects of Culture Shock and Language Stress in Health Education. International Journal of Business/ Humanities and Technology, 4(5), 27-34
Zong, J., & Batalova, J. (2015, February 26). Frequently Requested Statistics on Immigrants and Immigration in the United States. Retrieved September 15, 2016.
Park, M., Chelsea, C., Rehm, R., & Chum, K. (2011). Working with Culture: Culturally appropriate mental health care for Asian American. Journal of Advanced Nursing. 2373-2382.
https://www.kidsnewtocanada.ca/culture/influence. Retrieved September 15, 2016.


 

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The post Discuss the impact of culture on health and illness. Explore health seeking behaviors of a variety of cultures and explore how clinical nurse can adapt their practice to accommodate the behaviors. appeared first on THE NURSING PROFESSIONALS.

Discuss the impact of culture on health and illness. Explore health seeking behaviors of a variety of cultures and explore how clinical nurse can adapt their practice to accommodate the behaviors.