의료2014. 1. 7. 10:05

미국이 엄청 춥다고 합니다.  체감온도가 영하 60도나 되는 도시들도 속속 생겨나고 있다는 군요...수염 많은 분들은 고드름이 매달릴 정도라니...가히 빙하기에 비유할 만합니다.



(이분...집 근처의 눈 치우다가 자기 수염에 고드름이 생기는 줄도 몰랐다고 하십니다.)


 2013년의 미국의료이용 역시 빙하기였습니다.  미국시간 1월 6일 언론에 의료이용에 관한 정부산하연구원 자료가 발표되었습니다.  미국정부는 의료비용 감소 및 국민 의료이용 증가를 목표로 '오바마케어'를 밀고 있는데요...가뜩이나 경제가 시원찮은 마당에(회복세로 돌아섰다는 지표들이 보이긴 합니다만) 사활을 걸고 있는 정책 중의 하나인 오바마 케어가 얼마나 효과적이었는지를 볼 수 있는 리포트이기도 합니다. 그리고 한국에도 시사하는 바가 있다고 봐요^^ 오바마가 헬스케어 정책을 만들 때 한국의 제도역시 많이 참고했다고 합니다...읽어보시죠.


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Health Care Spending Slows To Historically Low Rate


For the first time in more than a decade, health care spending grew more slowly than the U.S. economy from 2010 to 2012, according to a new report by government auditors.

Total U.S. health care spending was $2.79 trillion in 2012, up 3.7 percent from the previous year -- that amounts to 17.2 percent of the national economy, the Office of the Actuary at the Centers for Medicare and Medicaid Services conclude in a report published by the journal Health Affairs. It's the first time since 1997 that health expenditures didn't outpace the gross domestic product.

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의료에 지출된 돈이 역사적으로 낮은 시점이다.

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The historic slowdown in the growth of health care spending since 2009 -- the lowest rate since the federal government began tracking the data in 1960 -- has sparked a debate about its causes. President Barack Obama partially credits elements of the Affordable Care Act, such as reduced fees for hospital services, for reduced inflation in national expenditures, but there's no consensus among experts. The actuaries at the Centers for Medicare and Medicaid Services are among those who believe the phenomenon is nothing more than a repeat of normal patterns that occur during and after economic recessions like the one that began in 2007.

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오바마는 의료비용의 감소가 오바마케어(ACA)라고 하지만, 전문가들 사이에 의견이 일치하진 않는다.

 - 사실 오바마케어로 1인당 의료비용은 감소할 수 있겠지만, 의료혜택을 받는 사람들의 수가 늘어나고 감소한 의료가격으로 인해 수요가 증가하기 때문에 이 모든 효과의 합은...예상할 때는 다 더해봐야 하고 실제론 어떤 일이 일어날지는 사실 해봐야 알겠죠.

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"The trends that we've seen in the last few years are consistent with the historical relationship that we've seen between health spending and overall economic growth," said Aaron Catlin, the deputy director of the National Health Statistics Group within the actuary's office, during a press briefing Monday prior to the report's release.

Expenditures on health care, including everything from hospital procedures to prescription medicines, rose less than 4 percent a year from 2009 through 2012, after growing by an average of more than 7 percent from 2000 through 2008 and by double digits in the previous decade.

In November, the White House issued a report highlighting slower health care spending growth and emphasizing that some categories of spending, especially by Medicare, aren't related to the economic cycle because those benefits aren't affected by job loss or other phenomena. The health care reform law reduced Medicare payment rates to hospitals and instituted other measures aimed at cutting spending and improving health, such as barring payments to hospitals when they re-treat patients for the same condition within 30 days.

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미국정부는 이런 정보들을 자기한테 유리하게 해석하고 있네요.  논외로 1달내 재치료시 환자한테서 돈 받지 않는다는 건 지혜로운 원칙인 것 같다는 생각이 듭니다.

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From 2010, when Obama signed the Affordable Care Act, until the end of 2012, however, the actuaries could discern only a meager impact from the law on national health care spending, said Anne Martin, an economist at the Office of the Actuary, during the press briefing. During that period, the law increased U.S. health expenditures by no more than 0.1 percent, she said.

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하지만 계리사(actuary...맞는지 확신이 없습니다)들은 ACA에 의한 영향은 매우 미미하다...경기 사이클 때문에 생긴 의료이용 감소라고 생각한다...

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빨간색이 의료이용(비용)

파란건 GDP

보라색은 GDP에서 의료비용이 차지하는 비율입니다

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"While our historical data cannot parse out the spending that was directly the result of the ACA, the projections model showed that there was minimal impact from the Affordable Care Act on aggregate national health expenditure trends from 2010 through 2012," Martin said.

A 2012 report by the Office of the Actuary projected that expanding coverage to tens of millions of individuals via the Affordable Care Act would increase national health spending by one-tenth of a percentage point each year through 2021, compared to what expenditures would have been absent the law.

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앞으로도 오바마케어가 의료비용이 미치는 영향은 미미할 것이다....결정적인 한방이로군요. 

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The new actuaries' report attributes recent levels of annual growth mainly to individuals who lost jobs, or at least lost their health insurance, during the recession and the sluggish recovery. "The period of stability is consistent with the historical experience when the share of GDP tends to stabilize after an overall economic recession, usually two to three years," Catlin said.

In 2012, the low rate of growth was a combination of decreases in some areas and increases in others. Spending on Medicare private health insurance premiums, prescriptions drugs and nursing-home care rose more slowly than during the previous year. Hospital, physician, Medicaid and consumers' out-of-pocket costs accelerated in 2012 compared to 2011.

health care spending

Source: Health Affairs

The uptick in spending growth on hospital care and visits to physicians, urgent care centers and other clinics was driven by patients receiving more, and more intensive, services, rather than by price increases, according to the report. Medical prices grew 1.7 percent in 2012, down from a growth of 2.4 percent in 2011. The increase in the use of health care services was partly based on more individuals having health insurance as a result of the economic recovery, the report suggests.

In September, the Centers for Medicare and Medicaid Services issued a report projecting that health care spending growth would remain below 4 percent in 2013 but would accelerate in later years. This year, as the Affordable Care Act expands health coverage to the uninsured, the spending increase will surpass 6 percent for the first time since 2007 and the law will account for 1.6 percentage points of that rise, that report predicts.

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각론입니다.  분야별로 증가한 부분과 감소한 부분을 살펴보고 있습니다. 큰 의미를 두진 않겠습니다...2014년엔 올해보다 의료비가 크게 증가할 거라고 예측하고 있군요.
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* 기사를 읽고보니 경기변동이 한국의 의료비에 미치는 영향이 매우 궁금하네요...우연의 일치인진 몰라도 보건복지부에서도 경기변동이 의료이용에 미치는 영향에 대해 연구한 결과가 발표되었더군요. 뉴스기사엔 전,월세가 의료이용에 미치는 영향이 매우컸다고 합니다~!



http://www.huffingtonpost.com/2014/01/06/health-care-spending_n_4549383.html

Posted by JsPark21
의료2013. 12. 28. 12:41

최근 지인 어머님께서 극심한 두통으로 응급실을 방문했는데, 뇌혈관이 늘어나는 뇌동맥류(intracranial aneurysm)으로 이를 치료하는 수술을 받으셨다..상당히 큰 시술이라 병원에도 오랫동안 누워있으셔야 했는데- 상태가 걱정된 지인이 내게 전화가 왔다.


'형, 어머니가 사람을 잘 못 알아보고 다른 것도 기억을 잘 못해요'


사실 전문의도 아닌 내게 질문수준이 너무 난감했지만, 최대한 도움이 되기 위해 일단 안심시키고 자료를 열심히 뒤적였다...만만치 않다고 생각했는데, 역시나 일반의의 상식을 뛰어넘는 지식을 요구했다..  



(뇌동맥류는 뇌혈관이 늘어나서 주머니처럼 된 것을 가리킨다.  이를 놔두면 두통, 간질, 마비 등의 신경학적 증상들이 생길 수 있고 이게 터져서 출혈이 생기는 등 심각한 합병증이 올 확률도 상당히 높은 위험한 질환이다. - 1%에선 사망한다. -  아래는 뇌동맥류의 수술법인 clipping이다.)






(시술법인 coiling이다.  사진 처럼 사지의 혈관으로 가느다란 줄을 죽죽 밀어넣어 뇌동맥류까지 간 다음, 줄들을 겹쳐 코일처럼 만들고 그 부분 피를 굳혀 버린다)


현재까지 뇌동맥류의 치료는 수술과 시술 두가지가 있다.  수술은 두개골을 열어 클립으로 뇌동맥류를 찝어 치료하는 방법이다. 효과가 상대적으로 증명된지 오래되었으나 두개골을 열어야 하기 때문에 환자 및 가족들에게 거부감이 크다.  시술은 최근에 나온 치료법으로, 효과가 증명되고 있으며 특정 상황에는 수술과 비슷하거나 오히려 낫다는 연구결과들이 쌓이고 있다.  하지만 아직 수술보다 더 낫다고 하기엔 증거가 모자라다.  특히 단점으로 다시 뇌동맥류가 생기거나 재수술을 해야 하는 상황이 수술보다 더 잘 생긴다는 것이 꼽힌다.  이 논의들은 전문의들도 논문 리뷰하면서 지식을 축적하고 있는 단계인 것이다...아직 효과도 다 연구가 되지 않았는데ㅠ 시술 후 부작용에 관한 내용들이 과연 확실하게 찾아질까? 라는 의문을 가지고 열심히 논문들을 뒤적였다. 아래가 나의 결론이다.


수술과 시술 중 무엇이 더 부작용이 큰가?


수술이 더 크다.  특히 환자의 기능적인 상태(움직임, 기억, 신경통 여부 등)에서 시술이 수술을 앞지른다.

하지만 사망률은 둘 사이의 차이를 느끼기 힘들다.


또한 6개월 이후의 기능적인 상태를 비교한 결과 수술과 시술이 차이가 거의 없는 것으로 드러났다...(-_-결국 시술/수술 후 6개월 내에서만 시술이 수술을 앞지른다는 거다)


http://www.medscape.com/viewarticle/776914_4 (2013)




뇌동맥류 시술(intervention) 후의 부작용들


주요 부작용은 뇌기능의 감소이다.  시술받은 환자 중 8%에서 일어났다.

나머지 부작용은 15%에서 일어났다. 시술 후 뇌동맥류 파열이 6%, 두개골 신경병증이 11%에서 일어났다.(여러 부작용이 있는 환자들을 다 세다 보니...주요 부작용보다 두개골 신경병증이 많이 나온 거라고 이해했다)

(67명에 관한 연구)

http://www.nice.org.uk/nicemedia/live/11158/31330/31330.pdf (2005)



장기적으로 뇌동맥류를 폐쇄하는 확률이 79%이다(나머지는 장기적으로 봤을 때 뇌동맥류를 확실히 잡지 못했다는 것)


수술주기 중풍(perioperative stroke: 증상이 있어 병원에 온 이후부터 수술 중, 수술받은 후 퇴원하기까지의 기간에 온 중풍)은 모든 환자중 4%에서 일어났다.


시술 중 뇌동맥류가 터질 확률은 1%이다.(매우낮다)

--------여기까진 터진 뇌동맥류 환자도 포함한 결과이다.


1년 후 좋은 임상적인 결과(good clinical outcome)가 나올 확률은 93%이다.

--------이건 안터진 뇌동맥류 환자만 해당되는 얘기이다.

(상기 연구는 터졌거나 안터진 뇌동맥류 환자군 전체를 묶어서 연구한 결과이다.  또한 65세 이상의 환자만을 연구햇다.  따라서 지금 케이스에 딱 들어맞진 않지만 1500여명의 많은 환자군을 연구하였고 연구방법도 신뢰성이 높기 때문에 가져왔다...그만큼 확실한 연구가 아직까지 나오지 않았다는 얘기이기도 하다)


http://stroke.ahajournals.org/content/early/2013/05/16/STROKEAHA.113.001524.short (2013.3)



  내가 그에게 해줄말이라고는 고작 아직 실망하기는 매우 이르며, 6개월 ~ 1년이상을 기다려야 확실히 할 수 있고 많은 경우 환자들의 상태가 만족할만한 수준으로 좋아지리라는 것이다.  93%에서 1년 후 좋은 결과가 나오고(할머니, 할아버지들 얘기지만...젊으니까 더 상태가 좋아질 거라고 추론할 수는 있다) 또한 수술보다 시술을 선택한 것은 좋은 선택이었다...(최소한 머리를 여는 것까지 감수할 정도로 수술이 좋은 건 아니니까.)  수술후 큰 합병증이 없는 것만도 다행이다...하지만 약 20% 에서 재수술이 필요할 수 있다...정도 얘기해 줄 수 있었다.  이걸로 충분할리는 없을 것이다...많이 발병하는 질환도 아닌데 젊은 나이에 벌써 큰 시술을 겪은 그의 어머니가 안쓰러웠다. 그에게 1년간은 특히 어머님 잘 모셔야한다고 당부했다.  어머님의 일은 남의 일처럼 느껴지지 않는다...필자도 어머니의 건강이 안좋아지셨던 적이 몇번 있어서 그런지도 모른다.  그의 엄마가 어서 쾌차해서 건강해지시길 빈다. 이 글을 읽고 있는 환자의 가족분들께도, 힘든 시기를 겪어나갈 사랑하는 사람이 어서 건강해지시길 바란다.



Posted by JsPark21
의료2013. 11. 4. 11:30

다큐 '얀겔의 위대한 실험'은 친인간적인 건축에 관한 이야기다. 건축가 얀겔은 자동차의 효율성에 맞춰 도시를 설계했던 과거를 비판하고 도시에 사는 사람들이 살기 좋은 도시를 만들어야 한다고 주장한다. 빠르게 불어나야만 했던 도시들은 이제 비인간적인 도시로 여겨지는게 사실이다.  서울만 해도 2호선 지옥철이 큰 문제 아닌가.  게다가 도시 안의 나쁜공기는 또 어떻고...도10차선 도로 옆을 수많은 사람들이 지나가는데 꼭 그렇게 공해 많은 길로 사람들 다니게 했어야 했을까 싶다.  고층들 때문에 파란하늘을 보려면 고개를 한껏 뒤로 젖혀야 한다. 사람들은 놀 공간이 없다...

 

다큐에선 덴마크의 코펜하겐을 이상적인 도시로 꼽는다.  자동차보다 자전거로 이동하는 사람들이 많은 도시.  전 도시에 고층빌딩을 눈을 씻어야 찾아볼 수 있는 도시.  상가가 줄어든 대신 사람들이 모일 수 있는 공간이 널려있는 도시가 코펜하겐이다.  자동차가 아니라 사람을 위한 도시다.





아래 사진은 방글라데시의 다카라는 곳이다...엄청난 교통체증이 보인다... 가장 빠르게 인구가 늘어나는 도시중 하나임을 감안해도...여긴 정말 엉망이다.  차선 구분도 없으며 대로 양옆으로 차를 세로로 대놔서 도로가 더 좁아지고 정말 살곳이 못되는 도시라는 생각이 든다.


  

한국은 빠르게 발전해온 나라다.  내 생각엔 병원 역시 빠르게 인구가 늘던 그 시절에 맞게 설계된 것이 아닌가 싶기도 하다.  과연 병원은 환자중심으로 설계되었는가?  어떻게든 최대한 효율적으로 몰려드는 많은 인원을 소화하기 위해 설계된 것은 아닌가? 초음파는 꼭 초음파실로 환자를 보내야만 찍어야 하나...초음파기기가 환자들은 방문하는 건 어떤가?  환자를 위한 쉴곳은 충분한가?  환자는 병원 안에서 사육되고 있는가 살아가고 있는가?  이제까지 해왔던 것의 한계를 뛰어넘는 환자 친화적인 병원설계 역시 의료계 관계자라면 염두에 두어야 하겠다.





Posted by JsPark21
뉴스풀이2013. 10. 7. 15:17

파괴적 혁신이론으로 유명한 클레이튼 크레이텐센 교수의 컨설팅업계에도 파괴적 혁신이 진행되고 있다고 주장이 실린 기사입니다.  좀 긴데요^^ 차라리 홈페이지에 링크된 팟캐스트를 듣는게 좋을 것 같습니다.  느려서 듣기 편하네요.

작은 기업 컨설팅 시장에서 파괴적 혁신은 시작된 것일까요?


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Clay Christensen and Dominic Barton on Consulting’s Disruption


AMY BERNSTEIN: Welcome to the HBR IdeaCast from Harvard Business Review. I’m Amy Bernstein, and I’m here today with Clayton Christensen, professor of Business Administration at Harvard Business School, and co-author of Consultants on the Cusp of Disruption, a feature in the October issue of HBR. Joining us on the phone is Dominic Barton, Global Managing Director of McKinsey and Company. Dom, Clay, thanks for being here today.

CLAYTON CHRISTENSEN: Delighted to be with you

DOMINIC BARTON: Great to be here.

AMY BERNSTEIN: Clay, you’ve documented the phenomenon of disruption for years across numerous industries, probably most famously in the steel business. What are you seeing in the world of general management consulting?

CLAYTON CHRISTENSEN: Well, I will say that I see disruption occurring there, but everybody needs to know that we’re not pointing the finger at everyone else, that the process of disruption is occurring against the Harvard Business School itself. So this is not just a targeted shot at any one. But you do see it happen, and disruption always occurs in ways that it emerges in parts of the market where you wouldn’t even think to ask.

And in this case, what disrupts any business is somebody takes a piece of business that is not attractive to the leaders, and because it’s not attractive in the pursuit of profit, they go to bigger and bigger, and nicer and nicer pieces of business. And then the disruptor starts at the bottom and moves up. And what’s attractive in the consulting business is big clients who have big problems. And the more they can have more of those kinds of clients, the more profitable they become.

And what they leave behind are small pieces of business– small companies; tangible, immediate projects that they do and then you leave. And those are the kinds of disruptive innovators in consulting that are taking root. And then they move up, going after bigger and bigger pieces of business.

AMY BERNSTEIN: Does this differ in any way from what you saw in manufacturing, and what you see in other industries?

CLAYTON CHRISTENSEN: Yeah. Really, disruption is a process. The theory itself is in evolution over time. So at the beginning, we thought that the vertical axis in the disruptive diagram was the quality of the product.

And then we realized that, no, that’s just what customers are more profitable versus less profitable. And when we understood that, just everything fell into place. So for example, if you think of the airline industry as being disrupted, what’s the vertical axis on that diagram? I mean, once you have economy and first class, how do you go up market from first class? It just doesn’t make sense.

But then we realized, oh my gosh, it’s the length of the route. Long routes are more profitable than short roots. And so the big majors are getting out of short routes, and turning that over to regional jet providers so that they can go into longer and longer international routes where the margins are. And once you understood that, it’s happening.

AMY BERNSTEIN: So that’s your point about bigger problems, bigger clients? That’s the top of the y-axis?

CLAYTON CHRISTENSEN: That’s exactly right.

AMY BERNSTEIN: Dom, when did you know the world of consulting was changing, and that McKinsey had to change, as well?

DOMINIC BARTON: Well, first of all, I think I’d say that the consulting has been changing. For the last, I think, 20 or so years, there have been changes. And I think what was, if you will, an inflection point was– for me, at least– was in 2009, when I took on this role, I had some work done, which we recommend. We typically have our clients do when a new CEO comes in– which was just, how’s the global context shifting? And it was a work called global forces, which are, what are some of the core shifts over the next 15 to 20 years as far as we can see out, recognizing that could be a difficult thing to do?

And to cut a long story short, that work kind of said to me that we are in a time for some significant change in the world, and why should we think that we’re immune to that? I try to see– Amy, as you know– two CEOs a day, and one of the things that always came through was technology’s moving five times faster than management. I don’t know whether to be paranoid or excited. I’m typically both, with sort of a comment– this shift towards Asia and Africa, resource scarcity. Just a lot of big issues, and it just made me think, well, maybe we better think about what is that we’re doing.

And so as a result of that, we’ve launched a kind of an internal strategy review, which basically was an 18 month process, again, where we took our own medicine, and spent a lot of time talking with our clients, and also with people we don’t work with– clients we would like to serve, but companies that we’ve never served, talking to people outside the industry, observers and so forth. And it suggested that, as Clay has written in the article, that change is afoot in many dimensions.

AMY BERNSTEIN: Can you talk a little bit about what you were hearing specifically from CEOs that made you think you needed to go back and challenge the orthodoxies of McKenzie?

DOMINIC BARTON: Yes, there were a number of things. I think one was, why does every issue or opportunity or problem take a project manager plus two associates three months to solve it? Surely, there are other ways, more efficient ways. Surely, sometimes we may just want data. If you guys had collected information on how hospitals work, and you had a large number of them, and looked at how often an operating table was used and so forth, and collected data like that, we may just want the data, not the people, if you will.

So there was a notion of be more flexible. What we really value is x versus y. Sometimes, you go into far too much analytical detail. We only need to go 60% of the way to be able to get it.

We value the judgment, not so much the analytics. And this obviously varied by situation and type of client. But there were a lot of questions on– or suggestions on– you could be a lot more flexible in terms of how you work with us– the type of people, the amount of time, and so forth.

AMY BERNSTEIN: Anything about this strike you, Clay?

CLAYTON CHRISTENSEN: Actually, no. McKinsey is doing all of the right things. And yet, by doing the right things, it sets in place the process of disruption, which you then have to account for. And so the descriptions of the work that they’re doing– unbelievably foresighted work about complicated problems– is what we would call sustaining innovations. It’s hard to do, and that’s why they do it so well.

And then, when they take low-value adding activity, and outsource that to somebody, if you listen to the people in that company about what do they do next and next and next, they will try to do more and more high-value adding work relative to where they started out. And so the process is– he’s described it exactly right. And dealing with that is the big innovator’s dilemma.

AMY BERNSTEIN: So Dom, talk a little bit about McKinsey Solutions, if you would, if you could describe it. And tell us about the internal re-think that led to it.

DOMINIC BARTON: Sure. Well, as I mentioned, we did this– we called it a firm strategy review, which isn’t a very exciting name, but that was the 2010 effort we launched where, again, we talked to a whole range of clients and non-clients and third parties, if you will, and also alumni; and in that, a number of ideas for how we could work differently with clients, and what we work on or put forward. And one of them was actually an idea that had already been lurking in the background. It had come in in 2007, which was around taking data, if you will. And we sort of stumbled into it, and I’ll give an example.

One was around Chinese consumer insights. We found– when I was living in China, we couldn’t rely on a lot of the publicly available data, and what consumers were doing. So it just wasn’t reliable or it wasn’t accurate, so we started to develop our own. And we built a very large database of the Chinese consumer– the middle class consumer who’s changing at a very rapid rate, far more rapidly than we’ve ever seen before.

And I won’t bore you with all the detail of it, but we built that. And then what we found was that that database was something that actually clients wanted, and they wanted that– was the prime thing they wanted, as opposed to the McKinsey people around it, if you know what I mean. They said, we would actually like that data, and you’ve been collecting it, and we’ll pay for that. We don’t really need a team.

And so, that was one of the early McKinsey Solutions. There were some things in health care and a number of other areas. And we were experimenting with this, but the firm strategy review really kind of popped that out. And people said, boy, if you had that type of thing, we’d be very interested in that sort of information, and a new way of working with people, and so forth.

So that was the genesis of it. There had kind of been glimpses of it, or it was lurking in the organization. We weren’t really aware of what we had. It was brought more to life through this review.

And then, what I did on that one was put one of the most experienced senior people in the firm– actually, Michael Patsalos-Fox, who is a very close friend, and has been in the firm for 30 years. He used to run our Americas group. I had him lead our McKinsey Solutions.

And it was a bit of New Ventures Group, but McKinsey Solutions was a big part of it, because I knew he would stimulate it and he’d protect it, because one of the things– I’d be interested in Clay’s view– but when you try new things, it’s amazing the number of people and antibodies that are in the organization that try and kill it, because it’s different, and it’s why are we doing this? And we’re cannibalizing something, this isn’t right– all that sort of stuff.

So we needed a very strong leader to protect it, if you will, and nourish it. And he did. And he took that from kind of having– I guess there were three of them, to I think we now have 18. And it really was to help develop the model.

By the way, some of them have not worked. We’ve had to shut them down. But fortunately, the vast number of them are working, but it meant we had to change our people processes, right? A person who is running a McKinsey solution, which is more like a piece of software. So that’s sort of a bit of an overview.

AMY BERNSTEIN: It’s really interesting. And Clay’s been taking notes. I wonder what you think of what Dom’s been describing.

CLAYTON CHRISTENSEN: So you’re doing everything right that I can imagine you would do. And as a result of that, I worry about you. My wife said that she describes me as the Jewish mother of business, in that it doesn’t matter everything that is going right, a Jewish mother always worries about what’s not going right.

So just by analogy, disruption occurred in the traditional department store business. In the early ’60s, there were over 300 department stores. There are now only eight remaining. Macy’s is the largest.

And they were disrupted by discount retailers like Walmart and Target and Kmart. And the way the traditional department stores made their money is they generated gross margins of 40%. They turned their inventory over three times a year. So they got 40% times 3 equals 120% return on capital invested in inventory every year. And that’s the way they measured things.

When the disruptive retailers came in, they generated gross margins of 20%, and they turned their inventory over 6 times a year. So 20% times 6 equals 120% return on capital invested in inventory. And so their profitability– the bottom line was the same, but the method by which they generated that result was different. And that was the killer.

And so, the challenge– which will be a perpetual challenge– is that imagine that McKinsey Solutions in fact becomes very profitable. And its bottom line is the same. The formula by which they generate the profitability will be different.

And so every day, somebody’s going to come in to senior management saying, that doesn’t make sense, because from their perspective, it doesn’t make sense. And I wish I could say from my studies that that will go away, but it’s just smart people in the core business trying to improve their profitability when they see resources being spent on something that, from their perspective, doesn’t make sense in their belief that they’re helping McKinsey [? treasury ?] to stop doing what disruption says you should do. And so it’s a long way of saying congratulations, and oh my gosh, be careful.

DOMINIC BARTON: I think that’s very good caution.

AMY BERNSTEIN: So Dom, how do you deal with those antibodies, the ones that you referred to, that Clay just described?

CLAYTON CHRISTENSEN: And they’re not bad antibodies.

DOMINIC BARTON: No.

CLAYTON CHRISTENSEN: Isn’t it they exist in the pursuit of profitability, but they’re antibodies nonetheless.

DOMINIC BARTON: Yeah. And also, I think it’s the– we don’t measure profitability like a department store in that sense where I know where it is. But it’s also tradition, right? It’s kind of we’re here to work in a particular way. We’re not a software house. I mean what is this? There’s that element that comes in, too.

One of the things I found, by the way, is history is just a good thing to look at in your own institution as to what’s worked and what hasn’t worked. And so one, believe it or not– this sounds very trite– was when we decided to move to Europe from the US in 1959. There was a huge debate about it. I think the partnership with split as to whether this was a good idea or not to do it.

Another incident that I looked at was when we established the Global Institute, right? This was a research body that was actually set up purposely to do nothing to do with client work, if you will. It was a micro view of macro issues so as to help advance the state of management. But it explicitly could have not a direct link to clients.

And I thank God every day that we’ve got that Institute up and running, but I know that there were so many people that tried to kill that thing for probably 8, 9 years in McKinsey. We’re not a think tank. Why are we wasting this money? How much are we paying these people? Blah, blah, blah.

So in a minor way, I’m fearful of the antibodies, because I’ve seen them, and I know that just from some of the things we did do, it took extraordinary leadership of some of the people in those places to kind of– they’ve probably got a lot of scars on their back to keep it going. So I think also relating that a bit to the organization is important, to say, you know, we actually have done some things differently.

One other story. I remember when we set up our operations practice. And I sometimes tease people about this in McKinsey. It was in, like, 1990, I think, is when that started. And this is how to do lean, and how to take costs out of procurement and so forth.

And there was quite a raging debate in McKinsey about going into this. And this isn’t, again, so much an innovation in how we work, but certainly wasn’t what we work, because we were seen as a strategy firm. And there were literally comments from some senior people in McKinsey, saying, we don’t want to do that type of work. That’s the work that knuckle-draggers do. I mean, really sort of rude statements were made to this group of partners that wanted to build this practice.

And again, I think there were some lessons learned from us, and why that practice was able to grow and be successful, even though they did things in quite different ways. We hired quite different people because of how they worked with the organization, what they stood for, how committed they were, all this sort of stuff. So those are things that are going on.

But I’m trying desperately to look as much as we can for wherever we’ve had some innovation, to try and drive it, and then kind of relate that to people and say, you know what, guys, I know this may seem strange to you in where it is, but we have done this. My only worry is I think that the speed and pace of change that we’re going to have to go through is going to go faster, and be bigger given these global forces. And that’s where I think Clay’s Jewish mother analogy is a good one. A bit paranoid about that.

CLAYTON CHRISTENSEN: Good for you. It is so exciting for me that I can’t stop jumping up and down here.

DOMINIC BARTON: One other thing, Amy. I was going to ask Clay this. To what extent do you think it’s normal– I’m struck by that some of the changes that you need to go through are actually lying around in the organization, but we don’t recognize them. So sometimes I wonder, maybe we don’t know what we have, if you know what I mean, that could help us.

CLAYTON CHRISTENSEN: It’s a great observation. And what you can predict is that all of these things are bubbling up, and the organization itself will only identify those things that help the organization make more money in the way it’s structured to make money. And if there’s an idea that is proven at a small level, if it doesn’t fit the way the organization makes its money, it will either languish, or the organization will force it to conform itself to the way it makes money.

And so you have kind of two strikes against it in that it won’t come up to the top as an interesting idea if the organization can’t use it. And then b, even if they see it, they will make it conform itself to the way they make money. And to have something that truly is disruptive– and in this case, that deep understanding of how an area or an industry works– and use that in the context of McKinsey Solutions, which would be a disruption in disruption, is really hard to do. And if you could pull it off, my gosh, congratulations It just is really hard.

AMY BERNSTEIN: So this last question is to both of you. Where is the consulting industry going? What’s it going to look like in the next 10 to 20 years?

CLAYTON CHRISTENSEN: So I would bet that the existing leaders are going to be very vibrant 20 from now. And what they’re going to be increasingly known for and good at are the complicated problems for which there is no standard solution, and that there are projects that they can bill at higher prices for the world’s largest corporations.

AMY BERNSTEIN: So scale is an important factor in this complexity?

CLAYTON CHRISTENSEN: That’s right. That’s right. But on the other hand, there will be new companies that begin to be more and more important. And things that today seem out of the ordinary, unique, judgment-filled, a generation from now these will be standardized and outsource-able.

And it’s those that hit the outsourcing balls from McKinsey. They then start doing the low-value adding stuff. And then always the next question is– next year, how can we provide more and more value adding? And so, my bet is that 20 years from now, there will be people who today aren’t significant now start to become more and more significant.

And I think we can predict that. And it’s not because I wouldn’t ever attribute anything to McKinsey doing anything wrong. It’s doing things right that makes it hard.

AMY BERNSTEIN: So from where you sit, Dom, does that seem to be where the industry is going?

DOMINIC BARTON: Yeah, I think I would agree with Clay in the sense that I think there will be some new players. I’m biased. I’m determined that we’re going to be around and be leaders come hell or high water. But I think the way what we do and how we work will, I think, have changed pretty significantly.

And what I mean by that is if I– again, I go back to the kind of 70% of our work was in strategy, organization. Corporate finance is now 30%. I think we’re going to see at minimum that kind of a shift in terms of what we’re working on, but more importantly– as Clay said– is how we’re working on it.

And I think there will be any elements that can be disaggregated or outsourced will be out. And just to put a personal example on it, I remember one of the very first projects I did in McKinsey. This was in 1986, was a consumer goods project we were trying to figure out.

It was for a fast food company, and what the size of a particular meal should be– how many pieces of chicken should be in the order, and so forth. And I think it took six months to come up with a recommendation. I think with today’s technology– the search technology, the amount of data that’s available– I’d be surprised if that project wouldn’t take two weeks, if you will.

CLAYTON CHRISTENSEN: Absolutely.

DOMINIC BARTON: And the last thing that sort of goes through my mind is the work that Foster did on looking at the average lifetime of an S&P 500 company. And that one, if I had anything that’s over my office wall, that’s one– you know the average. I think the average lifetime was something like 90 years in the mid 1930s, and now it’s somewhere in the order of 18 years. And so I just think we have to have an assumption, a bit of a paranoid view of where we have no God given right to be here, so we better be spending some certain amount of resources or experiments going on.

CLAYTON CHRISTENSEN: Amy, can I just add one other thing?

AMY BERNSTEIN: Of course.

CLAYTON CHRISTENSEN: I think in many ways, the business of the Harvard Business School is to develop useful theories about management that can be used. And in many ways, McKinsey and its competitors in the consulting business are a distribution channel for our ideas. And if they aren’t vibrant, then we don’t have a way of getting our ideas to individual– individual people can read the Harvard Business Review. But for an idea to impact a company, we don’t have in academia a channel for that idea. It has to be people like McKinsey, who– I’m sure that you won’t be happy with my referring to you as a value adding reseller.

DOMINIC BARTON: No.

CLAYTON CHRISTENSEN: You take an idea, you value add it, and you send it. And it’s just very important to us that we have a great relationship with you. And if I were going to be a Jewish mother for the Harvard Business School, I would say, ladies and gentleman, have you noticed that McKinsey is pulling in-house the development of the next generation business ideas?

And when you see that happening, as the provider of the ideas, we got to say, we need to just look at the mirror in a very, very thoughtful way.

AMY BERNSTEIN: Well, thank you both. That was Harvard Business School professor Clayton Christensen and McKinsey Global Managing Director Dominick Barton. For more on this, go to hbr.org.

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