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111: Shawn Needham: How Consumers and Entrepreneurs Co-navigate Value Uncertainty in Healthcare

Austrian economics provides new insights into value: what it is, how it is created, and who creates it. The insights are summed up by Professors Per Bylund and Mark Packard in our E4B podcast episode #108. One of the most vivid images they paint is the picture of entrepreneurship as “the two-sided navigation of radical value uncertainty, both by producers and consumers, in that never-ending quest towards higher value states”.

Download The Episode Resource Navigating Healthcare Uncertainty – Download

The market for healthcare provides us with a pertinent example of co-navigation of radical value uncertainty. For consumers, there is no certainty available — they can’t know which doctors or providers will give them the best experience, they don’t know the right means to choose to attain their end (health), and they can’t use the usual market price signals in the search for value since the price of healthcare is not visible to them. They don’t purchase the product, they purchase insurance, a different financial product than the healthcare experience they really need.

Thus, the healthcare market is a natural medium for the co-navigation of value uncertainty that Professors Bylund and Packard described. In E4B podcast episode #111, Shawn Needham, a healthcare entrepreneur dedicated to helping the consumer in their navigation task, lays out 6 principles for entrepreneurs.

Key Takeaways & Actionable Insights

1. Help consumers to be proactive about their own health.

The healthcare system wants consumers who are sick. Chronic sickness is their most profitable line. A good way to help consumers is via what Shawn calls Pro-Health: encouraging the consumer mindset and commitment to actively make good health and lifestyle choices in diet, exercise, quality sleep and stress reduction. Entrepreneurs can share valuable knowledge and tools to help good decision-making, and to facilitate health creation by consumers.

2. Enable consumer sovereignty via cash, pay-out-of-pocket options.

It’s hard to discern the operation of consumer sovereignty in healthcare systems. End-users can become locked-in to a limited set of choices. Entrepreneurs can help by developing more choices, so that expressed consumer dissatisfactions can be actualized as new options.

Examples that are already in motion include Direct Primary Care (DPC), an arrangement whereby doctors charge a set monthly fee for access to primary care, and consumers pay cash in return for an improved experience, including more time with the doctor, easier scheduling and lower cost prescriptions.

DPC doctors are healthcare entrepreneurs who are enabling consumer sovereignty, having alertly discerned the signals of consumer dissatisfaction.

3. Entrepreneurial empowerment in employer health financing options.

Employers offer ways for employees to finance traditional healthcare insurance, usually via benefits programs. In episode #109, Professor Desmond Ng described the Austrian-inspired movement among employers to empower their employees to be more creative and entrepreneurial and less centrally-directed: he called the movement Entrepreneurial Empowerment.

Entrepreneurial empowerment can be granted to employees to unleash their creativity in searching for financing options for their healthcare. The use of Health Savings Plans provides consumers with an alternative approach to meeting healthcare expenses through dedicated savings. There may be other ways to re-direct the funds devoted to funding healthcare insurance through centrally-directed employer programs, such as freeing employees to opt out of company-paid insurance premiums, and to take the same amount as a deposit into a 401K, leaving the employee with a freer choice in healthcare financing.

4. When the consumer pays the bill, the benefits of free markets can emerge.

Another pay-out-of-pocket option development is Cash Fee For Service, which is a straightforward payment whenever a specific service is required. We’ve highlighted Surgery Center Of Oklahoma as a pioneering example.

When the consumer pays the bill, lower prices tend to result because of competitive free market processes, and the quality of care tends to increase for the same reasons. In his book, Shawn Needham cites cosmetic surgery and lasik eye surgery as two examples of free market forces at work to generate higher quality and lower costs.

5. Entrepreneurial initiative combined with consumer search for betterment can create new solutions.

Shawn identifies medical cost sharing programs as an innovation emerging from the consumer-entrepreneur co-navigation of value uncertainty in healthcare. In medical cost sharing, a voluntary community pools funds so that any unexpected major medical cost can be shared across the community. The firm that co-ordinates the community typically also offers services such as bill negotiation, concierge medical services, health coaching, and discounts on health-promoting resources. There’s a greater degree of consumer sovereignty than is typical in healthcare arrangements, such as a freer choice of which doctors and labs to use. Similarly, doctors who participate in these programs are freer to set their own rates and to compete for patient trust in lasting relationships.

The healthcare market is a process.

The healthcare market may appear to be an inflexible structure, built over many years to impede organizational innovation. But viewed in an Austrian way, as a process governed by consumer sovereignty and responsive entrepreneurial creativity, it is possible to discern emerging trends in favor of greater consumer choice, market flexibility, and the inevitable role of the price mechanism to disperse blockages and lower barriers to better consumer experiences.

Additional Resources

“Navigating Healthcare Uncertainty” (PDF): Download Here

A Sickened: How The Government Ruined Healthcare And How To Fix It by Shawn Needham – Download Here

The Austrian Business Model (video): https://e4epod.com/model

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72. Peter Klein: Four Considerations for the Delegation of Derived Judgment

Business books and business school courses tend to think of organization design as the structuring of a hierarchy, or the linkages of nodes in a network. The boxes and lines are departments, executives, assignments and communications flows.

Professor Peter Klein invites us to think in a different fashion. Organization design is the distribution of judgment among collaborators. The judgment of many people is necessary to the firm’s existence and value-facilitating practices.

Key Takeaways and Actionable Insights

For entrepreneurs, the future is not risky, it’s uncertain.

Risk is a calculable mathematical probability, like the result of 1000 tosses of a (fair) coin, or the likelihood of you being involved in a car accident in 40 years of driving on US interstate highways.

The outcomes of entrepreneurial decision making are not calculable. They can’t be computed. Yet entrepreneurs need to make decisions, without having all the facts in hand today, and without knowing the odds of the future results. That’s uncertainty.

Therefore they exercise judgment. Judgment is action. It’s business practice.

Judgment is not guessing, or speculating, or hoping. Judgment is action. Specifically, judgment is taking ownership of property and resources, combining and recombining them in different ways, and using them to make a product or service to offer to the market.

Judgment also incorporates spirit: the imagination, energy, creativity and bravery that entrepreneurs apply when they act. Judgment is human action.

And judgment is continuous. Entrepreneurs are called upon every minute of every day to make decisions of judgment.

Judgment quickly becomes team action.

As firms grow, the founder can’t be the sole exerciser of judgment, or the only one making commitments or acting creatively and imaginatively. In larger, more complex, multi-divisional forms, there are many executives, managers and employees who will be called upon to make judgments. And they will be well-qualified to do so, since they have special skills and tacit knowledge that the rest of the firm, including the founder, do not have.

In fact the founders or owners (or Board Of Directors) actively seek the judgment of the whole firm, in order to achieve the highest level of business success. Often, they make sure that everyone in the firm has enough “skin in the game” (in the form of incentives, commissions and supplemental compensation) to motivate them to give their best judgment.

How does judgment apply in complex organizations?

The firm develops a mix of original judgment and derived judgment (see Mises.org/E4E_72_PDF).

Derived judgment is Peter Klein’s term for the delegating of decision-making power and its distribution throughout the firm. Original judgment — the ultimate decision-making power — rests with the entrepreneur-founder, or may reside with a Board Of Directors or an appointed CEO. Derived judgment is granted to others throughout the firm who have special knowledge and skills to act creatively and imaginatively on the specific uncertainty they face in their positions.

The skill of original judgment is selecting the right people to exercise derived judgment, and designing the right combination of motivating incentives and appropriate controls.

What’s the best combination of incentives and control?

Austrian subjectivism and individualism, along with opportunity cost analysis, can point the way to the best mix of incentives and control.

Subjectivism tells us that there is no objective right answer to questions about which decision rights the owner should delegate to which employees under specific circumstances. The answer to those questions depends on the particular circumstances of the venture, its technology, its market, its business environment, the characteristics of the employees and the characteristics of the owner.

Individualism tells us that there are no generalizations about people — each one has different knowledge and skills and characteristics like reliability or trustworthiness, as well as creativity and imagination. The entrepreneur must judge each one individually, and match them as well as possible to specific circumstances.

Opportunity cost analysis tells us to always weigh the potential upsides and potential downsides of each choice and each appointment of an individual to a position in which they can exercise derived judgment. Exercise judgment about judgment.

Consequently there are four considerations:

  • Be as sure as you can to choose the individual with the most (and most relevant) tacit knowledge for the area in which they are going to exercise derived judgment.
  • Choose the individual who adds the greatest amount of experience as possible to the relevant knowledge.
  • Make sure the derived judgment of managers and employees is guided by a well-articulated mission (why we do what we do) and business model (how we do what we do). Pay attention to how well these are understood and shared.
  • Balance knowledge and experience against the potential for abuse (misjudgment) and the potential cost of that abuse should it occur. Don’t risk “destructive entrepreneurship”.

There are no “bossless” organizations.

Peter Klein points out that even in the flattest of organizational designs (think Wikipedia, Zappos, Spotify, or W.L. Gore) there is always some kind of governance, either of rules or of hierarchical authority, to limit the risk from derived judgment gone awry.

Don’t design an organization with an excessive amount of derived judgment relative to the controls that are in place.

How good are you at original judgment and at delegating derived judgment?

Entrepreneurship in action is real people in real-life situations. It’s not theory. Some are going to be better than others, as indicated by results and outcomes.

It will be useful for you — although not definitive — to self-assess your entrepreneurial judgment and how you delegate it. Gallup’s Builder self-assessment promises to help you build a thriving company and a winning team. Personality assessments like the Big 5 are less specifically tailored to entrepreneurial judgment but can nonetheless shed some light on personality traits that are applicable in entrepreneurship, whether in a small business, a growth firm or a corporate structure.

Free Downloads & Extras From The Episode

Uncertainty and Entrepreneurship: Our Free E4E Knowledge Graphic

Our latest free e-book, Austrian Economics in Contemporary Business Applications: (PDF): Our Free E-Book

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9. Peter Klein on Entrepreneurial Decision Making

Decision-making can feel particularly challenging for entrepreneurs. Entrepreneurs face the unpredictability of the future with a limited set of resources, limited information, very little history of what works and what doesn’t, and few, if any, people to help. There’s no corporate research department and not much big data. Decision-making can be daunting. How can economics help? Today we discussed this topic with Peter Klein.

Show Notes

Economics helps us understand the process of decision-making, and how to enhance it with human creativity and wisdom rather than spreadsheets and analytics. The first step is to recognize and embrace what economists call uncertainty. Entrepreneurs face it all the time. We can’t know the future, or even the number of possibilities. The world is organic and human, and future outcomes depend on the interactions of millions of humans. No-one can predict them. Don’t try. But don’t be intimidated by uncertainty.

Understand the difference between risk and uncertainty. Risk is a mathematically definable probability. When we roll a 6-sided die, we don’t know which number will come up but we can calculate the probabilities for each one of 6 possible outcomes. That’s a highly defined situation with a mathematical probability, as is insurance risk. Uncertainty is different – we can’t list the possible future outcomes or attach a probability to each one.

In uncertainty, think of decision-making as a continuous process, not a fork in the road. There is no need to fear decision making. It’s not a back-and-white choice, X or Y, right or wrong. Think of decisions as continuous; we decide, we try something out, we experiment, we get results, we adjust, we try again. Every piece of new information we obtain from experiments helps us make a more informed decision next time. Entrepreneurs are good at dealing with this continuous flow of decisions, and making adjustments as they go – like a basketball coach on the sideline. The system of decision making is far more important than any one single decision.

Peter Klein calls this process entrepreneurial judgement. Entrepreneurial judgement is reasoned, purposeful action regarding feasible outcomes. It’s not formal or mechanistic or mathematical, but nor is it blind guessing. The key is that it is the entrepreneur who makes the final decision. He or she is not executing decisions that others make. Entrepreneurs make their own reasoned judgement in a middle ground between guessing and mathematical certainty.

There is a face it all the time. to mitigate uncertainty. Dr. Klein defines the process as (1) defining what type of uncertainty you are facing (2) taking appropriate steps to narrow the scope of the particular type of uncertainty you are facing; (3) exercising judgement – i.e. making a decision and taking action – in a timely manner when uncertainty is reduced but not eliminated; (4) gathering feedback for your action and continuously repeating this process.

Environmental uncertainty is external to the entrepreneur and means that many possible outcomes could result from a decision. You plan to launch a new product. You don’t know how the competition will react, or how the consumer might change or what will happen to regulation. In this situation, entrepreneurs try to narrow the range of possible outcomes, using experience, history, testing and other means. For example, you could run a test of different price levels to ascertain which one generates the most purchases, and use the test results to narrow the possible outcomes.

Creative uncertainty is internal to the entrepreneur with a defined goal but many possible options of means to reach it. You want to sell a million units at $5, but don’t know which combination of messaging, media, and promotion is best to help achieve the goal. You narrow the range of possible options by hiring an expert marketing agency, instructing them to develop 6 alternatives, and choosing between the options based on consumer reactions.

Absolute uncertainty occurs when there is a wide range of possible outcomes, and a large set of possible options for action, in a dynamic environment of change. You want to start a company but you are not sure which consumer needs you are best placed to meet, or which of many options you would select to meet them. You have to find a way to narrow both the possible outcomes (which needs will I serve) and the possible options for action (what kind of a company will I launch). Dr. Klein used the example of Netflix. Reed Hastings wanted to start a tech company but wasn’t sure what kind – absolute uncertainty. He settled on direct delivery of VHS tapes, with moderate success, but at least he established a consumer need to fill. But then the technology environment changed, first to DVD’s (easier to ship) and then to streaming (better consumer solution but technologically very challenging). Netflix thought and re-thought the environmental uncertainty (changing technologies and consumer tastes) and the creative uncertainty (how would pricing, subscriptions, packaging etc affect outcomes?) in a continuous process of experimentation and recursion.

Entrepreneurial decision-making is evaluating and mitigating uncertainty. Narrow the range of your options and possible outcomes. Decide and act, and don’t be afraid to do so. Think of decision-making as a continuous process, one at which you can get better over time and with experience.

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Entrepreneurial Uncertainty Identifier

Decision-making can feel particularly challenging for entrepreneurs.

Entrepreneurs face the unpredictability of the future with a limited set of resources, limited information, very little history of what works and what doesn’t, and few, if any, people to help. There’s no corporate research department and not much big data. Decision-making can be daunting. How can economics help? We discussed this topic in a recent episode with Peter Klein who has already put considerable energy towards helping entrepreneurs identify the different types of uncertainty they face, and be better equipped to mitigate them.

Click here to download the PDF Version

Click here to download Peter Klein’s Research Paper on Entrepreneurial Uncertainty

Preview of Entrepreneurial Decision Making Under Uncertainty PDF