Posts Tagged ‘Medicare’

ACO’s or SSP’s: “Change or Die”

September 6th, 2011

“Walk the Walk” author Alan Deutschman’s previous book kind of said it all in the title, “Change or Die.” In that book, Alan carefully lays out the statistical survivability matrix, and poses the question:

Alan Deutschman - Author of Change or Die and Walk the Walk - Nick Jacobs, HACHE - Healing Hospitals

Alan Deutschman

“What if you were given that choice? For real. What if it weren’t just the hyperbolic rhetoric that conflates corporate performance with life and death?…What if a well-informed, trusted authority figure said you had to make difficult and enduring changes in the way you think and act? If you didn’t, your time would end soon — a lot sooner than it had to. Could you change when change really mattered? When it mattered most? “

Then, he articulates the actual outcomes of studies. Talk about “tough love.”

“…The odds? You want the odds? Here are the odds that the experts are laying down, their scientifically studied odds: nine to one. That’s nine to one against you. How do you like those odds?”

So, as a nation, as healthcare leaders, as human beings in a country that is currently facing the realities of potential economic disintegration, we are faced with what can only be described as another enormous challenge: a financially unsustainable healthcare system. Regardless of your politics, regardless of your personal beliefs regarding the competency of the federal government and its ability or inability to fix anything, the law has been passed, the train is moving and it’s moving directly toward you and your hospital.

Over the past three years, we have repeatedly presented money-saving and money-making ideas to help begin to position your healthcare organization for the impending tsunami of change that has been launched. As a veteran of TQM, Six Sigma, Baldridge, and a half dozen other consultant-delivered “fixes,” I’m sure I can hear the words going round and round in your head, but, not unlike the clamor that arose from the HMO/PPO days of yesteryear, this ACO/SSP challenge has to be met and dealt with intelligently, and it has to be done in such a way as to not destroy your hospital or health system.

Let’s face it, we’re all pretty smart folks. We’ve all been in permanent white water for years, and the last thing that many of us want to take on is the ole captain of the ship without a rudder, during a hurricane while the lighthouses are being moved around on the shore.  But, once again, it’s here. It’s upon us, and we must deal with this challenge in an intelligent manner.

One possible alternative for smaller organizations is the SSP, a Shared Savings Program, the alternative put forth by CMS, the Center for Medicare and Medicaid Services, to a full-blown ACO, an Accountable Care Organization. Either way, however, SSP or ACO, the primary, overarching goal is to try to improve quality, decrease costs, and provide patient-centered care in a meaningful way. Not unlike the old HMO/PPO days, the effort requires infrastructure (and plenty of it…the average participant in the demonstrations spent about $1.7M on this one, single aspect of managing the healthcare new world order.)

What do you need? Well, you need 5,000 patients, to start. Then:

  1. Decide if you will use Medicare only or other patient groups.
  2. Determine the exact service area that you will target.  How many square miles?
  3. Decide which reimbursement model will work for your organization, i.e., an SSP that is more risk-based, or capitated.
  4. Figure out which provider groups will be involved.
  5. Examine IT reporting capabilities and process improvement methodologies.
  6. Identify patient-related strategies such as enhanced experience for the patients or faster throughput as well as reduction in errors.
  7. Then, dig deep into the organizational strategies for improvement.

Infographic: Medicare Margins - Nick Jacobs, FACHE - SunStone ConsultingLet’s face it. From 2001 until 2008, total Medicare inpatient margins for acute care hospitals have decreased every single year.  (Source: Journal of Healthcare Management)   Reimbursements have decreased while your bad debt has increased.  So, regardless of your tolerance for risk or change, cost control simply must become the culture of every healthcare organization in the United States. We have seen the variances in costs based on geography in this country and treble charges in one area as opposed to another will not go on into the future. Joel Allison, CEO of Baylor Health has stated that this movement is “All about…focusing on wellness, on prevention.” (Arnst, 2010)

We need our primary care docs, we need physician participation to a far greater degree than we currently have, and, at the same time, the physicians must be partners in the effort.  Employing physicians is also a critical element.

SunStone Management Resources can assist you in this effort on numerous levels, but the time to act is now!

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The Alpha and Omega of Healthcare in the United States

August 27th, 2011

While serving as a hospital administrator for over twenty years, I was aware of numerous people who had died in the emergency room because they had no insurance, had not yet qualified for Medicaid and were terrified that the cost of care would force them to live on the street.  Consequently, they waited too long to come in for treatment, and they died.

Rep. Paul Ryan (R-W) and Gov. Peter Shumlin (D-VT) - Nick Jacobs, FACHE - Healing HospitalsModern Healthcare’s August 22nd edition has listed the 100 Most Influential People in Healthcare in 2011. (Somehow they’ve missed me again.)  They’ve listed Republican  Congressman Paul Ryan of Wisconsin as the number one most influential person, and the Democratic Governor of Vermont, Peter Shumlin, as number two. Ryan is interested in a complete re-make of the Medicare and Medicaid programs, and Shumlin wants to move the citizens of the State of Vermont to a government-run, single-payer system.

Needless to say, these are very different views. It’s interesting that they both agree that employer-based insurance should be eliminated, so that neither portability nor employment is an issue. They differ in that Ryan believes that each individual citizen should receive a refundable tax credit for healthcare and that providers should compete based upon quality, price and outcomes. Shumlin, on the other hand, wants to do away with “fee for service healthcare,” but clearly understands the American’s public’s concern about government-run anything, and even says, “Government has gotten it wrong, every single time.”

According to Modern Healthcare, both want to fix the system that is bankrupting the nation. Ryan wants to “maintain a world class system built on innovation and excellence,” while Shumlin wants that single payer system to eliminate waste, administrative overhead and insurance company profits. It is Shumlin’s contention that enacting all of the Tea Party cuts and taxing the wealthy would still lead to the same federal budget challenges in the trillions of dollars that we face now.

Ryan wants to cut $750 billion in Medicare spending by making the allocation a block grant. People like Rose Ann DeMoro, executive director of the AFL-CIO- affiliated National Nurses United labor union say, “The market isn’t magic and it doesn’t trickle down…the Paul Ryans of the world don’t want a society.  They want individuals and corporations to make ungodly amounts of money.”

And so the debate continues. There is no magic elixir that will fix this without huge disagreements and turf battles.  As the Obama legislation began to unfold, the initial reaction from many within his own party was that his administration had “sold out” to Big Pharma and numerous other lobbies, and, as the Republican plan continued to be unveiled, the response was similar to DeMoro’s, because it was so heavily skewed toward big business and the free market, while providing only marginal assistance for the underserved of this nation.

UPMC vs. Highmark (Illustration by Ted Crow, Post-Gazette) - Nick Jacobs, FACHEIronically, as I look out my window and then drive a block from my apartment in Pittsburgh, I see another new “colony” of homeless people living under the bridge, and as I round the corner under Route 279N, there is a virtual apartment building under that road comprised of sheets and blankets hung to create separate partitions for the individual homeless people to live. At the next light leading to the North Side, a 30ish young mom begs on the corner for money for her kids, and two blocks past her is a homeless Veteran asking for money as well.

In the midst of all of this, the $9 billion UPMC battle with the nearly $4 billion Highmark juggernaut continues over an insurance company owning a hospital, and a hospital owning an insurance company.  Surely, in the richest country in the world, there are answers to these challenges that do not bankrupt the pharmaceutical or insurance companies, do not make our physicians second class citizens, and do not close two thousand small and medium sized hospitals while still providing care for everyone.

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Posted in Healthcare, Hospital

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Geographic Variances in Medicaid Spending – And the Winner Is?

July 7th, 2011

Health Affairs cover - Nick Jacobs, FACHE - Medicare - MedicaidWhen Health Affairs released a first-ever study of geographic variances in Medicaid spending on July 7th, it was a new twist on transparency that is just the beginning of what will become a detail-by-detail exposé of care and treatment of patients in the United States.  Just imagine a few years from now, when every record is electronic and every detail will be instantly available to the government.  Like this variance report, we will begin to see the good, the bad and the ugly of how medicine is practiced in this country.  So… how do you spell transparency?

A few weeks ago, the New York Times ran an article in which the “overuse of Medicare-funded CT scans” was explored. Featured in the digital version of this article was an interactive map showing virtually every hospital in the United States, and as the mouse was passed over each hospital, the percentage of inappropriate CT scans appeared above the facility’s name. If yours was one of the hospitals that was 80+ percent over using this device in multiple single-day scans, you were, as they say, “busted.”

Well, this release exposed at least one entire section of the country that is overusing Medicaid on numerous levels.  Although the study revealed a wide variance in per-beneficiary spending, one geographic region outshined them all.  The findings showed that after adjusting for the case-mix of patients, variations are driven mostly by volume of services provided and, to a lesser degree, by price.  Per-beneficiary spending in the ten highest states was $1,650 above the national average, mostly caused by the greater number of services provided.

Image credit: New York Times

One of the most significant findings revealed by this study was that the supply of primary care physicians in specific areas was associated with reduced rates of admissions for diabetes, lung disease, and adult asthma.  The authors suggest that this finding might point to the fact that increased access to primary care providers may result in improved management of common chronic diseases for people on Medicaid.

So, by now you’re asking, “Who won?  Who used more money per capita to treat Medicaid patients?”  It was The Mid-Atlantic States : New Jersey, New York and Pennsylvania used more Medicaid funds per capita than any of the regions in the United States. For example, the per beneficiary cost in New York was twice that of California; $21,195 for New York vs. $11,200 for California.

As a region, New England used the least amount of Medicaid resources and as a state, Washington provided the best example of “how things should be.”  How did they do it?  They increased access to primary care and reduced hospital care.

Todd P. Gilmer, Ph.D.

Todd P. Gilmer, Ph.D. - UCSD

Finally, places that had higher numbers of hospital beds and specialists were associated with higher numbers of hospital admissions while higher numbers of primary care physicians were associated with reduced rates of hospital admissions… Todd P. Gilmer, PhD, professor of health economics in the Department of Family and Preventive Medicine at the University of California – San Diego said, “By looking at service mix, access and price, states can find ways to make their programs work better.”

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Along the Way…Things Became Very Interesting

January 31st, 2011

Two years ago I began this new journey, but not until a few months ago did my work in consulting really begin to take shape in a way that could never have been predicted.

As the challenges of our present economic times have become increasingly daunting, my personal and professional journey has become even more dedicated to innovation and creativity. One goal has been to provide new alternatives to past practices that will create value for patients. This means making a contribution to saving and transforming lives, while producing cost savings and financial stability, and developing new markets to enable provider growth in their missions.

Olympic National Park, Port Angeles, WA - Nick Jacobs, FACHE - Healing Hospitals - SunStone Consulting

The driving force behind my exploration began with asking how we can begin to control those out of control expenses that are currently blurring the lines between continued care for our population, and rationing or elimination of services?  But, the answer(s) must enable us to continue to add healing opportunities for our patients at every turn.

Because my creative energies have always been focused on producing more ways to generate new monies for whatever organizations I have personally represented,  it seemed somewhat foreign to me to spend more time on fiscal issues than creative alternatives.  However, with literally millions of Baby Boomers coming of age each year, it was obvious that our entire culture is at risk both fiscally and socially. Consequently, after listening carefully to my peers, several opportunities presented themselves that would address all levels of these concerns.

Through the combination of their proprietary software and dozens of years of combined knowledge in the healthcare finance field, SunStone Consulting, LLC, spends each and every working day addressing the challenges of finding monies that should already have been captured by hospitals and physician practices, while also creating new opportunities that have heretofore not been explored. That’s where SunStone Management Resources comes into play.

SunStone Consulting - Nick Jacobs, FACHE

We have identified new companies, new entrepreneurs and new creatives who can not only improve healthcare, but also significantly improve the bottom line of those organizations willing to embrace their programs. One such company with whom we are partnering can increase Emergency Room productivity by as much as 35 to 50%.  They can also help do the same for cancer centers and operating rooms. They utilize robotic systems that communicate patient needs and simultaneously seek out the appropriate medical services required as soon as the patient is triaged. The patient’s condition and potential requirements are communicated to every individual who will or should have contact with them throughout their hospital stay.

We have also identified what I refer to as “no brainer” opportunities. By making otherwise locked fiscal percentages  a commodity, even small and medium sized organizations can save huge dollar amounts. How? By changing out only the electronic reading devices used hospital-wide. This simple change has resulted in huge fiscal savings for clients.

Add to examples like those above the introduction of  a new invention that, in the right hands, can help to extend some types of Stage 3B and Stage IV cancer patients’ lives from months to years through a relatively simple post-surgical procedure. Also consider the invention of new materials that would support bone growth, while virtually eliminating the need for casts or even slings. Imagine a series of protocols that have brought over 40 people out of deep, irreversible comas. Then, on a completely different path, consider having access to  the cumulative knowledge garnered from over a hundred million dollar investment in breast cancer care.  (This is about to be made available to small and medium sized hospitals across the world.)

These are but a sampling of  just some of the opportunities currently driving my passion in this new healthcare world order.

You may want to make a simple inquiry into what’s behind the innovative, practical, and incredible creations of the brilliant people doing this work.  It’s not just so many words on a page.  It is the future, and the future for you and your organization could be now.

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Posted in Boomers, Healthcare, Hospital Administration

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$500 Billion From Where?

October 26th, 2010

In a recent conversation with a long time healthcare CEO, he made the following observation:

“There are about 2,750 pages to Obamacare.  I have no idea what the implications are of the first 2,700 pages, but I do know that at least 50 pages allude to the fact that $500B will be cut from hospital reimbursements in order to support the new legislation, and it’s also clear that these monies will be cut based upon quality.  Pay-for-performance will be the new catch phrase of the reimbursement world, and our peers are not ready for this stark reality.”

How does one move from a non-transparent system to one that allows anyone to log onto healthcare websites and search every detail relating to the success rates, scores, and capabilities of any given institution?  One very obvious “missing element” in hospital-related problems is the lack of dedication to getting to the “root cause” of most issues.  We are great at work arounds, but rarely take the time, energy, and have the cultural commitment to dig deeply enough to literally stop the root cause of the problem.  Is that why there are a reported 98,000 people killed by our facilities, and about an equal number injured each year?


Several organizations have attempted to take on these issues, but few have gone beyond scratching the surface of the real problems.  As bundled payments become the norm, a commitment to getting the highest available reimbursement for procedures will take on a new meaning.  Imagine a great doctor in an under-performing medical center where his or her work is not rewarded equally to a peer in a stronger hospital, because that bundled reimbursement was lowered due to institutional medical imperfections. Charles Kenney in  The Best Practice, and Steven Spear in The High-Velocity Edge have both addressed some of the nuances of this new culture, this new world order, but for hospital administrators, physicians, and staff to “get their arms around it,”  there will need to be transformational shifts in the fundamental culture of the organization.

Leadership will be forced to accept personal responsibility for virtually everything that occurs in an organization.  Employees will need to be empowered to embrace shared values, and key targets such as patient and employee safety will need to be identified so that goals can be set that stop nothing short of a level of complete PERFECTION.

The healthcare establishment will also need to embrace transparency within their organizations, and that information must be shared with everyone.  Most importantly, it must include the human element.  What is the human impact of each and every error or mistake?  This point alone will represent a major cultural shift in the way we do business.

Truman's phrase "The Buck Stops Here" - F. Nicholas Jacobs, FACHE

Employees, physicians, and administrators will need to actually be taught to see risk, and be provided with data upon which actions may be taken.  Most importantly, however, problem solving must be encouraged and supported at every level of the organization.

How is this all possible?  I was recently on a speaking tour to several hospitals, and the bottom line at these facilities was that their leadership was “new age.”  They had worked diligently to decrease the hierarchy and to reduce and reorganize the roles of those in operations in order to support the fastest possible improvements.

The tsunami is coming, however slowly it may appear to be; it is approaching our healthcare shores, and quality – no, perfection, is the only means left for achieving success or, in many cases, is the only way to survive.  We must discipline ourselves to see problems and not simply try to work around them.  We must establish a problem solving culture.  We must set our goals and empower all of the players to do what is needed to solve these problems once and forever.  Harry Truman’s phrase, “The Buck Stops Here,” should become every CEO’s mantra, and the journey will finally begin, the journey to solve the myriad repeating problems in our current system.

Nick Jacobs, FACHE - HealingHospitals.com

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Posted in Healthcare, Hospitals, medical errors

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Could We Do It Better?

August 8th, 2010

Several months ago, I met a white-haired gentleman of average stature at a meeting.  When I asked him what he did, he replied, “I’m a patient advocate.”  “So am I,” I said. “I even wrote a book, ‘Taking the Hell out of Healthcare’ about it.  “Yes,” he continues, “but I found a way to make a living from doing this.”  His name is Harry and he is an actuary.  In those yin and yang posters, that would put us at opposite ends of the proverbial left brain/right brain spheres.  He had analyzed health care records for about thirty years and could prove what we all know, that between 5 and 7% of our employees use up about 80% of our healthcare dollars. That, my friends, is not rocket science.   All you need to do is hang around some sick people for a while, and you’ll realize that “our system” is set up to keep doing things to them over and over again.  Usually, it’s not to help them eliminate the problem, but to maintain their life in a chronically challenged situation.

Ryan Is An Actuary. Look It Up. Flickr photo credit: evaxebra - © all rights reserved

Flickr photo credit: evaxebra © all rights reserved

So, I asked Harry what he does, and he indicated that he hires nurses, pays doctors and employs “MANAGED CARE’S GREATEST HITS.”   Now every health insurance company in the world will claim the same thing, but everyone who has ever been turned down for anything by any health insurance company knows that: 1.) the bottom line reason was usually their bottom line, or: 2.) it’s a nurse against your doc, and your doc has not employed all of the verbal and intellectual tricks to convince him or her to allow you to have the test or take the drug that he thinks you need.

Harry went on to explain that these “5  percenters”  usually have anywhere from nine to fifteen docs with whom they interact on a yearly basis, and, not coincidentally, these physicians usually don’t do a great deal of interacting with each other, hence the need for patient advocates.  This is where Harry’s nurses come into the picture.  He assigns a nurse to each high-risk patient, allows the patient to pick their “favorite quarterback doc,” and then pays that physician to help hold down the duplication of unnecessary tests.  Makes sense, huh?  I can just hear my Internal Medicine physician saying, “Nick, you don’t need those 13 other chest x-rays this month, the first one will do fine for all of us.”

Interestingly enough, this system WORKS, and it works pretty darn well because it’s not about saving money for the insurance company;  it’s not about depriving the patient of needed tests;  it’s not about controlling the patient, or preventing him or her from having what they need, but it is about eliminating wholly unnecessary tests, meds, and procedures.  Harry had letter after letter from grateful patients, families, and employers thanking his people for helping them navigate their way through the maze of this very complex, sometimes-disconnected, procedure-oriented system.

The other interesting thing is that Harry likes to go to a town and start first with the hospitals, because their employees are the most comfortable with using everything, and have the easiest access to the most doctors.  It’s a great way to prove  the system works.  From that point on, he then works to bring all of the major employers into the fold, and ties them into the primary hospitals.  It’s something that only an actuary could have accomplished, because, as Harry readily states, “It’s taken me about 30 years to perfect this system.”  The patient is protected from being over-tested in an indiscriminate manner; the hospitals or businesses save a considerable amount of money, thus limiting reases in their annual healthcare costs, and the savings are cumulative over the years.  So, why not try something that will improve the employee morale, patient satisfaction, and quality?

If you are interested in learning more about this program, give me a call.

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Posted in Healthcare, Hospitals, patient-centered care

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Staying Humanly Grounded and Healthcare Reform

December 26th, 2009

Each year I put up the tree and begin to believe that it is magic. The room feels and looks warmer. Often, I’ve considered leaving it up all year as a symbol of joy, love, and happiness, but when I returned home last evening it hit me that it was not the tree as much as it was the carefully wrapped packages beneath it. Once they were gone, the room seemed void of its magic.

It hit me that those packages represented anticipation, love, and sharing in ways that truly touch your soul. Those acts of love represent the essence of that entire experience, price or cost don’t really matter.  It’s the giving.

Healing Hospitals: little girl in hospital bed with caring doctorI try to end every night by reading CarePages from a local children’s hospital website; stories of young children that have many times reached the end of effective treatment and are waiting to meet their destiny decades before their time might have been.  The outpouring of the deep, soulful hurt that their parents, siblings, and grandparents are experiencing from this journey is always profoundly moving to me.  In many of these instances, the only gifts that we have left to give them are our  love and support.  That, however, is not the case for the majority of our fellow men in this country.

It won’t be long until the final product of the healthcare reform effort will appear.  We all know by now that it will be a patchwork quilt of sometimes horrendous compromise.  We can also count on the fact that the negative rhetoric will reach decibel levels typically heard only when standing in close proximity to a jet engine.  The pundits will parade up and down the isles of righteousness, and they will be spouting off their theories regarding what should have happened.  At the end of the day, however, when we approach our bathroom and bedroom mirrors for that last inevitable look, we must all dig into our humanity and ask one very real question: “Will it be better for the uninsured than it had previously?”

As a former hospital CEO, it became evident to me in the first six months of my administrative training that only those without insurance were destroyed by the system.  Only those who were not under Medicaid or an other insurance were hit with the awful burden of paying for everything at the full, retail price.  The fallout was clear.  Due to the risk of having to pay full costs to the hospital, they either were too frightened to go for treatment until it was too late, or they lost what little they had; their homes, their savings, and their possessions.

In a country with such unbelievable abundance, where not just the number but also the quality of the cars, clothes, and even pets that we own are held up as barometers of success, we have often allowed our fellow man to suffer and die for economic reasons.

That fact is no more obvious than at any children’s hospital in Pennsylvania, where you’ll see parents from conservative states where childhood transplantation surgeries were always denied, so as to avoid increased taxes.  You’ll see these parents waiting in line to establish residency here so that they can at least have a chance to save their child’s life.

Healing Hospitals: Mother kisses son in hospital bed

Regardless of your politics, regardless of the dysfunctional (mal-)functioning of our government, in which some of our representatives and senators have taken us to the brink of collapse due to their inability to co-operate; regardless of these issues, we are looking at the beginning of health care reform.  I just pray that we don’t revert to the inhuman practices of our recent past.

It’s time for a human win.

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Posted in Current Affairs, Healthcare, Public Policy

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Nine Trillion Dollars in the Hole?

August 22nd, 2009

Let me be the first to admit that I was and am all about change. Change has been the only consistent thing in my life.  Today, however, when the deficit projection was revealed to be nine trillion dollars over the next ten years, my non-economist mind began to wonder where this is all going?

My son-in-law is coming home in the next several days from a one year deployment that saw him in harms way in Iraq for the last eight months, and now we all sit with our fingers crossed that we will not be facing a similar deployment not too many months from now to Afghanistan.

How does one maintain two wars, keep soldiers stationed post-World War II in Italy, Germany, and Turkey, to name a few, and in South Korea plus continuing to remain in Iraq, and now push more and more into Afghanistan without bankrupting this country?  Is it possible that very very smart people are not capable of figuring out that in a down economy, the finances will continue to go south until we are, like the USSR in the Cold War, going broke?

When do we begin to see that the previous several administrations lead us into a mindset of borrowing against our future to the extent that we may not have a future, and when will we say, “Okay, enough, let’s stop feeding trillions into wars, and start trying to figure out the rest of this economic equation?”  It clearly is no longer a war on terror, but what is it?  If it is an economic war intended to create jobs a.k.a., the argument for or against the F-22 cuts, can’t we find a better way?

health_debate_specterThe people who seem the most upset about the health care debate are clearly the people who have healthcare, and the people who are least likely to speak out are the young women and children who have no coverage.  Not only will they not speak out, they also don’t, for the most part, vote.  If anyone believes that we are not in some way paying for the 46 or 47 million uninsured now, they are clearly delusional.  Ask a hospital CEO how much the facility charges for an aspirin or a Q-tip.  It’s not because these items cost so much more in a hospital setting, it’s because there is not enough money to go around when patient after patient presents at their doors without healthcare coverage.

We have acquiesced to AIG, to the very large banking institutions, to the automobile manufactures, and to numerous major financial houses.  We have placed billions of our tax dollars into their hands and have watched as their CEO’s, like that of AIG, continue to make millions in salaries with millions more in bonuses.  We have continued to wage wars that were clearly called “Republican Wars” during the last administration, and have no name now.  And we are watching our Social Security and Medicare accounts dwindle more quickly than anyone could ever have imagined.

Far be it from me to take a political stand on such complex economic matters, but it does seem very certain that our futures are tied inextricably together and, unless we slow down our expenditures, find ways to be more fiacally responsible, and, take care of our fellow man, we seem to be heading down a very destructive path.  Alan Greenspan’s admission of missing the economic targets of not too many years ago rings in my ears as he said, “I underestimated the greed.”  Maybe we have all underestimated the greed for too long.

As a professional giver of advice, let me conclude by saying that we can make this work. We can pull back the reins, slow the spending, and still move the economy.  It’s no different than managing our own personal economics; live below your means, save, take care of the necessities, and realize that not all belts can wrap around a 44″ waist. But all of this takes some serious discipline, something that our leaders seem to have been missing for a very long time.  We can’t continue to talk our way out of trouble;  serious, positive action is the key.

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