Alameda Hospital cannot pay its bills. The budget presented to the Board in June was essentially a fantasy with only small chance of succeeding. The majority of the Board and management refuse to plan for the future.
Although Krugman's quote below explains a lot about the delusion, deception, and disconnect from reality that Hospital supporters engage in, there is another element in play. They think they do not have to worry about the problems because the acquisition of more sub-acute and SNF beds will save the day. I am a skeptic, but I will lay out the context so that others can judge. As you may or may not know, the District already operates a SNF at South Shore. One advantage to a hospital operating SNF beds is that these beds are considered "distinct part nursing facilities". The names come from the fact that they are part of an acute care hospital or hospital system, but operate as a "distinct part". In some rural hospitals, these may not be so distinct and may be "swing beds" going from one use to another based on the patient in the bed. The upshot is that these DP/NF beds are reimbursed by Medicaid (and I believe Medicare) at a rate higher than they would pay a non-affiliated facility. I can only speculate as to the policy reasons that this decision was made, but clearly it provides an incentive for hospitals who may have less choice over their patient population and may serve higher acuity patient than other SNF's. For example, if a placement from acute care cannot be found, the Hospital can discharge the patient to a DP/NF bed without suffering financially (or at least not too much). Also, this does provide a subsidy for multiple facilities who would not be able to survive without this increased reimbursement (Laguna Honda in SF or some rural hospitals).
The District proposes to take advantage of this rate element by leasing beds from existing SNF's within Alameda and then operating them as DP/NF beds. This is win-win. For the facility, they gain guaranteed income from the sublease, and, for the District, they gain contribution from the additional dollars from the DP/NF reimbursement rates. This is somewhat a gaming of the system, but as long as the various agencies approve it is legal.
Some problems with this strategy for me:
1. I'm not really ok from a policy position with the way that this strategy extracts additional tax dollars without adding any net beds.
2. The additional contribution does not cover the parcel tax so Alamedans are still on the hook.
3. What's worse, is that this strategy locks the District into operation of an acute care hospital for which there is no evidence (despite my repeated requests) that Alamedans benefit in terms of medical outcomes and is subject to closure as soon as OSHPD decides to actually enforce black and white regulations on its books.
4. If the acute care hospital closes for any reason then the District is likely to be on the hook for the sublease amount even though the DP/NF dollars will be gone.
5. Finally, the DP/NF dollars could easily be cut by a state and federal government looking for places to trim the budget. Management does not think this is likely because of global effects across the state and the nation, but I can envision various models that would cut Alameda out, but leave larger more politically sensitive entities whole. Three right off the top of my head include: 1. Cap the number of DP/NF bed seligible for increased reimbursement at the license number as of 1/1/2011 or an average that reimbursement was received for the 2011 fiscal year. 2. Require a minimum percentage of all beds in the facility to be Medi-Cal occupied. (I don't know what the number is that preserves Alameda County's reimbursement or Laguna Honda's while cutting Alameda District, but there is one and I'm sure the state budget people, and politicians, know what it is.) 3. Require the beds to be co-located with the acute care beds or require the beds to be in a seismically retrofitted location (same difference).
Finally, why is this opportunity all of a sudden available now? Warren Buffet writes (I think he is quoting someone) "When you look around the poker table, and you can't tell who the patsy is, that's when you should stop playing." Perhaps the SNF operators know when the getting is good and see a patsy?
Wednesday, June 29, 2011
Tuesday, June 28, 2011
People who say it better than I can
From the inestimable Paul Krugman:
"I was originally going to end this post by saying something about stupidity, but that’s not right: the people atthe BIS [Alameda Hospital] aren’t stupid. What’s going on here is something different and worse: we’re seeing the desire for conventional respectability outweighing the lessons of history; we’re seeing vague prejudice (prejudice that just so happens to serve the interests of rentiers [the political clique that runs Alameda]) trumping analysis."
"I was originally going to end this post by saying something about stupidity, but that’s not right: the people at
Monday, June 27, 2011
Because it won't be on the front page of the paper
But it is still important. The headlines from the most recent finance packet.
This one is simple.
1. Alameda Hospital has lost 2.9 million dollars on an operational basis through the end of May and is projected to lose more in June. (Because of the 3rd party liability reversal, the net loss is 1.5 million through May.)
2. Alameda Hospital cannot pay its bills unless it uses an emergency line of credit. The District does not have the balance sheet or income statement to support such a loan.
3. Bank of Alameda is willing to lend money to a virtually insolvent institution because it can lay claim to the parcel tax revenues until the loan is paid off even if the District discontinues all services to the people of Alameda.
This one is simple.
1. Alameda Hospital has lost 2.9 million dollars on an operational basis through the end of May and is projected to lose more in June. (Because of the 3rd party liability reversal, the net loss is 1.5 million through May.)
2. Alameda Hospital cannot pay its bills unless it uses an emergency line of credit. The District does not have the balance sheet or income statement to support such a loan.
3. Bank of Alameda is willing to lend money to a virtually insolvent institution because it can lay claim to the parcel tax revenues until the loan is paid off even if the District discontinues all services to the people of Alameda.
Sunday, June 19, 2011
Why Alameda Hospital is Inferior
Here's the problem. Alameda Hospital is not a lousy hospital, but people think I am saying that. What I am saying is that Alameda Hospital is incapable of delivering consistently superior outcomes (or even adequate outcomes) in the acute care setting. Michael Jordan FAILED at becoming a baseball player which was his dream. He had all of that athleticism; all of that money; all of that desire and he FAILED.
Yet nobody would assess Jordan's career and focus on his failure unless he would have stubbornly insisted that he would not give up; that he was a great baseball player; and never deviated from that opinion. The Board majority is exactly that blind when it insists that no change is needed to emergency and acute care services at Alameda Hospital.
What makes a Hospital great:
1. Exceptional clinicians is one aspect. Although every single physician at Alameda Hospital is licensed and many/most are Board certified, they are not exceptional. None of them are tops in their field. Certainly the care is adequate, but nothing better than you will receive at Alta Bates (18-19 minutes away even without sirens), San Leandro or Eden (19 or 22 minutes away respectively), or Kaiser ( 16 minutes away) or Highland (13 minutes away). In fact, if you are having a neurological problem, the level of care available at Eden is much higher. If you are a trauma victim, then I don't care how scary Highland is, you want to go there. And if you are having a serious heart attack (what is known as a STEMI), then the EMT's better take you to Alta Bates-Summit.
2. Technology. More and more, care is dependent on technology. Alameda Hospital is in the process of upgrading its technology, but technology costs money and the Hospital is not capable of keeping up in this area because of its finances. In addition, because of its size, the costs - for the exact same equipment - are higher because Alameda Hospital is in a poor negotiating position with vendors. For example, Alameda Hospital paid between 5-6 thousand dollars for every mobile workstation (computers on wheels or COWs). This was significantly higher than other hosptials I am aware of. Other initiatives that are going to cost more and/or go slower are things like computer physician order entry, barcoding medications, and advanced imaging technology (even though the PACS is finally up, there are more advances, features, and modalities that Alameda will not have available to it full-time).
3. Resources. A Hospital that is not struggling is one that has the ability to respond to challenges like seismic retrofitting. Remember, Alameda Hospital has been out of compliance with sesimic requirements since 1/1/2002 and has no established plan to correct that deficiency much less the structural aspects of the seismic law which were originally due 1/1/2008 but have been extended multiple times. Also, morale, quality initiatives, and regular maintenace suffer when an organization is always, always struggling.
Next Board meeting, once again the Board majority will vote to impose a $298 per parcel tax on Alamedans that yields no benefit to the community as a whole in terms of better health. The only thing that will convince me otherwise is evidence (not anecdote). I have asked repeatedly for such evidence, but none has been forthcoming.
Yet nobody would assess Jordan's career and focus on his failure unless he would have stubbornly insisted that he would not give up; that he was a great baseball player; and never deviated from that opinion. The Board majority is exactly that blind when it insists that no change is needed to emergency and acute care services at Alameda Hospital.
What makes a Hospital great:
1. Exceptional clinicians is one aspect. Although every single physician at Alameda Hospital is licensed and many/most are Board certified, they are not exceptional. None of them are tops in their field. Certainly the care is adequate, but nothing better than you will receive at Alta Bates (18-19 minutes away even without sirens), San Leandro or Eden (19 or 22 minutes away respectively), or Kaiser ( 16 minutes away) or Highland (13 minutes away). In fact, if you are having a neurological problem, the level of care available at Eden is much higher. If you are a trauma victim, then I don't care how scary Highland is, you want to go there. And if you are having a serious heart attack (what is known as a STEMI), then the EMT's better take you to Alta Bates-Summit.
2. Technology. More and more, care is dependent on technology. Alameda Hospital is in the process of upgrading its technology, but technology costs money and the Hospital is not capable of keeping up in this area because of its finances. In addition, because of its size, the costs - for the exact same equipment - are higher because Alameda Hospital is in a poor negotiating position with vendors. For example, Alameda Hospital paid between 5-6 thousand dollars for every mobile workstation (computers on wheels or COWs). This was significantly higher than other hosptials I am aware of. Other initiatives that are going to cost more and/or go slower are things like computer physician order entry, barcoding medications, and advanced imaging technology (even though the PACS is finally up, there are more advances, features, and modalities that Alameda will not have available to it full-time).
3. Resources. A Hospital that is not struggling is one that has the ability to respond to challenges like seismic retrofitting. Remember, Alameda Hospital has been out of compliance with sesimic requirements since 1/1/2002 and has no established plan to correct that deficiency much less the structural aspects of the seismic law which were originally due 1/1/2008 but have been extended multiple times. Also, morale, quality initiatives, and regular maintenace suffer when an organization is always, always struggling.
Next Board meeting, once again the Board majority will vote to impose a $298 per parcel tax on Alamedans that yields no benefit to the community as a whole in terms of better health. The only thing that will convince me otherwise is evidence (not anecdote). I have asked repeatedly for such evidence, but none has been forthcoming.
Friday, June 10, 2011
I Want Some of What They Are Smoking
I cannot recount the last Board meeting on June 6. It was too long, surreal, and sad, but here are my top 5 "Alice through the looking glass" moments.
1. Jordan Battani declaring that the filter she applied was the voters telling her that they wanted to keep the Hospital open.
2. Michael McCormick suggesting that had I attended the Finance Committee meetings the inconsistencies and unrealistic assumptions of the budget would make sense to me.
3. Cannot recall exactly who said it, but I was told several times that healthcare accounting is strange and magical. Actually, no it isn't, at least not at the level that the Board considers the budget.
4. The idea that entering into new debt when you are in violation of the loan covenants exposing yourself to the loan being called and other negative consequences is no big deal and that I was "fixating" on that aspect of the budget.
5. The budget itself which projects a profit of over half a million dollars for the next fiscal year.
I suppose there ought to be six impossible things listed, but it all happened after breakfast.
1. Jordan Battani declaring that the filter she applied was the voters telling her that they wanted to keep the Hospital open.
2. Michael McCormick suggesting that had I attended the Finance Committee meetings the inconsistencies and unrealistic assumptions of the budget would make sense to me.
3. Cannot recall exactly who said it, but I was told several times that healthcare accounting is strange and magical. Actually, no it isn't, at least not at the level that the Board considers the budget.
4. The idea that entering into new debt when you are in violation of the loan covenants exposing yourself to the loan being called and other negative consequences is no big deal and that I was "fixating" on that aspect of the budget.
5. The budget itself which projects a profit of over half a million dollars for the next fiscal year.
I suppose there ought to be six impossible things listed, but it all happened after breakfast.
Tuesday, June 7, 2011
June 6, 2011 Board Meeting
An academic perspective:
Neurobiological Correlates of Social Conformity and Independence During Mental Rotation
A literary perspective:
2+2=5
Some questions that should have been answered last year about the current year's budget that would have saved me from last night. (It was after all my anger at the ridiculousness of last year's budget that caused me to run for the Board.)
1. What happens if we cannot achieve the 24.3% reimbursement rate? Now it may seem that this is not pertinent because, after all, the Hospital is projected to have a 24.1% rate, but each tenth of a percentage of gross revenues represents over a quarter of a million dollars.
2. What happens if the IGT funds are not as lucrative as in FY2010? The Hospital projected they would receive another 2.165 million dollars this year when, in fact, the number is closer to 760 thousand. There was even some hope that the original budget number was conservative and that the actual IGT funds would exceed FY2010's. Obviously that assumption worked out poorly.
3. What are the chances we can get financing for the seismic retrofit work and might it behoove us to forego spending over 1 million dollars when we may not be able to move forward? The answer I got from Director Battani was, essentially that the Board would address that issue when it arose. We all know how that worked out, but any reading of the financials could have concluded this, and, in fact, I sent maanagement and Director Battani a rough analysis demonstrating the impossibility of obtaining financing months before they revealed this in open session. Keep in mind, that I had no closed session information when I put together this analysis, yet the Board insisted in public session that it would be a challenge, but they were confident that they could deal with it.
4. What are our contingency plans on staffing levels if we do not achieve anticipated revenue?
5. What happens if the court order barring new reimbursement rates goes away? The answer turned out to be the Hospital was hit with a bill for over 600 thousand dollars.\
6. What will be the impact of a delay in opening the wound care center? Can we really locate offices, make lease improvements, hire personnel, and launch a new service in just six months? The wound care center is now projected to open midway in the fiscal year about one year late (if we keep to the schedule).
BUT I was asking too many questions last night and too detailed ones. Would that the previous Boards have asked some questions instead of always voting "Aye".
Neurobiological Correlates of Social Conformity and Independence During Mental Rotation
A literary perspective:
2+2=5
Some questions that should have been answered last year about the current year's budget that would have saved me from last night. (It was after all my anger at the ridiculousness of last year's budget that caused me to run for the Board.)
1. What happens if we cannot achieve the 24.3% reimbursement rate? Now it may seem that this is not pertinent because, after all, the Hospital is projected to have a 24.1% rate, but each tenth of a percentage of gross revenues represents over a quarter of a million dollars.
2. What happens if the IGT funds are not as lucrative as in FY2010? The Hospital projected they would receive another 2.165 million dollars this year when, in fact, the number is closer to 760 thousand. There was even some hope that the original budget number was conservative and that the actual IGT funds would exceed FY2010's. Obviously that assumption worked out poorly.
3. What are the chances we can get financing for the seismic retrofit work and might it behoove us to forego spending over 1 million dollars when we may not be able to move forward? The answer I got from Director Battani was, essentially that the Board would address that issue when it arose. We all know how that worked out, but any reading of the financials could have concluded this, and, in fact, I sent maanagement and Director Battani a rough analysis demonstrating the impossibility of obtaining financing months before they revealed this in open session. Keep in mind, that I had no closed session information when I put together this analysis, yet the Board insisted in public session that it would be a challenge, but they were confident that they could deal with it.
4. What are our contingency plans on staffing levels if we do not achieve anticipated revenue?
5. What happens if the court order barring new reimbursement rates goes away? The answer turned out to be the Hospital was hit with a bill for over 600 thousand dollars.\
6. What will be the impact of a delay in opening the wound care center? Can we really locate offices, make lease improvements, hire personnel, and launch a new service in just six months? The wound care center is now projected to open midway in the fiscal year about one year late (if we keep to the schedule).
BUT I was asking too many questions last night and too detailed ones. Would that the previous Boards have asked some questions instead of always voting "Aye".
Monday, June 6, 2011
Sunday, June 5, 2011
More Numbers
The budget calls for 1.25 million dollars to come from payment for services based on the charge master (that is the master list of all charges). This is equal to about 2% of net revenue so that means the % price increase X the percentage of charges this price increase applies to is equal to 2%. I am interested to know the component breakdown into each of those two variables and even the detail within the variables (such as any differential in the % price increase or if it was a single across the board increase). I'm going to start with a baseline assumption that the numbers are something like 10% price increase and 20% of the total net revenues this applies to, but that assumption is a total SWAG. The real numbers, I'm sure, will be revealed at the Board meeting.
Just numbers - Updated
So every year, management submits a budget and every year the Board dutifully approves it and every year management misses the numbers by a mile. Rinse, repeat except this year there will be at least one dissenting vote to this charade. (Even 2009/2010 was a miss of, I think of about 1 million dollars from budget, only mitigated by the IGT funds that became available at the last minute from an agency where, I believe, at least one Board member had inside connections to someone in a leadership position.)
2011/2012 projects a profit of 540k but a lot of that hope is built on cutting "Salaries and Agency" expense by 2.4 million dollars. The associated FTE decrease associated with this is 22.7 so doing the rudimentary math that works out to about 106k per FTE. Now the 106k is not fully loaded cost, but just the direct salary expense. The other expenses of FTEs (to total the fully loaded cost - things like benefits, space, etc) are captured in other line items on the budget. The only specific category of FTE's that this budget calls out is CNA's. In addition, some savings will be realized by closure of the lab draw station at "Alameda Town Center" (sic). I am almost certain that this does not average out to personnel receiving 106k per FTE. Never mind if the Hospital can hold the line at this level of staffing, a decrease of over 5% from 2011 (while forecasting overall volume increases). I need to understand how that 2.4 million number was derived because it does not work out with my assumptions so I must be mistaken in my assumptions.
Updated. John Knox White asked me for the updated numbers and these are them as near as I can tell from the archive
Total for the last 6 years:
FY Budget Actual Miss
2006 0? -60 60
2007 0? -3900 3900
2008 +20 -2400 2400
2009 +100 +250 -150
2010 +360 -350 700
2011 +490 -1500 2000
FY Budget Actual Miss
2006 0? -60 60
2007 0? -3900 3900
2008 +20 -2400 2400
2009 +100 +250 -150
2010 +360 -350 700
2011 +490 -1500 2000
Minimum of a 9 million dollar miss cumulative over the last 6 years.
Notes:
FY 2006: Did not locate budget in archives although anyone can request it from the District. Since the budget must be balanced I used 0 profit as the minimum budget.
FY 2007: Same as for 2006. I used 0 profit as the minimum budget.
FY 2009: I believe the audited numbers may have shown a better result than shown here, but it was the single year of actually meeting or exceeding the budget over the last 6 years.
FY2010: The 2.165 million of IGT funds was a game changer and unbudgeted. Wilma Chan led the agency that gave the money to the Hospital and I don't have any idea if that helped, but it certainly could not have hurt.
FY2011: Backed out 1.4 million in IGT funds that failed to materialize. Also 200 thousand of positive changes to reimbursement balanced against 640k of negative changes. Also, backed out the write-off of the Kaiser liability from 2006.2011/2012 projects a profit of 540k but a lot of that hope is built on cutting "Salaries and Agency" expense by 2.4 million dollars. The associated FTE decrease associated with this is 22.7 so doing the rudimentary math that works out to about 106k per FTE. Now the 106k is not fully loaded cost, but just the direct salary expense. The other expenses of FTEs (to total the fully loaded cost - things like benefits, space, etc) are captured in other line items on the budget. The only specific category of FTE's that this budget calls out is CNA's. In addition, some savings will be realized by closure of the lab draw station at "Alameda Town Center" (sic). I am almost certain that this does not average out to personnel receiving 106k per FTE. Never mind if the Hospital can hold the line at this level of staffing, a decrease of over 5% from 2011 (while forecasting overall volume increases). I need to understand how that 2.4 million number was derived because it does not work out with my assumptions so I must be mistaken in my assumptions.
Saturday, June 4, 2011
How Big A Hole is the Hospital In for 2011/2012?
This is all AFTER almost 6 million dollars provided as subsidy by the parcel tax.
1. 1.968 million projected loss for this year.
2. 1.452 million of non-cash revenue due to a write-off of a 2006 liability.
3. 2.1 million reduction in reimbursement as a result of AB97.
A total of 5.52 million dollars has to be made up just to break even in the next fiscal year. In addition, there are considerable capitalized costs which will impact cash flow even though they do not affect the income statement. In 2010/11, those costs totaled over 1 million dollars above and beyond depreciation expense (that > 1 million is the net cash flow impact). The question of capital vs. expense is often dictated, but sometimes it is a judgement call and the current management of Alameda Hospital has every incentive to skew their judgement towards capital vs. expense. (For example, I would have argued that some of the seismic work should have been expensed as soon as it became obvious that any construction would be delayed indefinitely. Also, the PACS and EMR implementations were heavily capitalized. This is not to say that management has done anything wrong; it reflects a difference of opinion of how the Hospital finances should best be presented to show their true nature.)
With this kind of unhealthy financial circumstance, the Hospital wants to engage in 2 major projects going forward based on projections which are likely, given the incentives, to be optimistic. The first is the wound care center requiring 900k of capital of which 3/4 will be borrowed from the Bank of Alameda under terms which the Hospital appears not to be able to meet. The second is acquisition of additional SNF beds based on a reimbursement structure that I don't believe can survive intact given the nature of both the California and federal budgets.
For 2010/2011, the previous Board (which consisted of a majority of its present members - Deutsch, Battani, and McCormick - approved a budget that projected a 540k profit for this fiscal year. That was projected without the benefit of the 2006 liability write-off. If we back out surprises from that projection (1.4 million shorted in IGT funds, benefit and cost from retroactive change in some rates, and the liability write-off) then the 2010/2011 projected results true up to a 1.5 million dollar loss or about a 2 million dollar miss. This is in addition to money spent on seismic retrofit work that had no immediate benefit, but was capitalized nonetheless. There may be some contentiousness at Monday night's meeting, but based on the numbers I have identified in this post, I will be sticking to my guns that the Hospital needs to present a better plan than they have to date.
1. 1.968 million projected loss for this year.
2. 1.452 million of non-cash revenue due to a write-off of a 2006 liability.
3. 2.1 million reduction in reimbursement as a result of AB97.
A total of 5.52 million dollars has to be made up just to break even in the next fiscal year. In addition, there are considerable capitalized costs which will impact cash flow even though they do not affect the income statement. In 2010/11, those costs totaled over 1 million dollars above and beyond depreciation expense (that > 1 million is the net cash flow impact). The question of capital vs. expense is often dictated, but sometimes it is a judgement call and the current management of Alameda Hospital has every incentive to skew their judgement towards capital vs. expense. (For example, I would have argued that some of the seismic work should have been expensed as soon as it became obvious that any construction would be delayed indefinitely. Also, the PACS and EMR implementations were heavily capitalized. This is not to say that management has done anything wrong; it reflects a difference of opinion of how the Hospital finances should best be presented to show their true nature.)
With this kind of unhealthy financial circumstance, the Hospital wants to engage in 2 major projects going forward based on projections which are likely, given the incentives, to be optimistic. The first is the wound care center requiring 900k of capital of which 3/4 will be borrowed from the Bank of Alameda under terms which the Hospital appears not to be able to meet. The second is acquisition of additional SNF beds based on a reimbursement structure that I don't believe can survive intact given the nature of both the California and federal budgets.
For 2010/2011, the previous Board (which consisted of a majority of its present members - Deutsch, Battani, and McCormick - approved a budget that projected a 540k profit for this fiscal year. That was projected without the benefit of the 2006 liability write-off. If we back out surprises from that projection (1.4 million shorted in IGT funds, benefit and cost from retroactive change in some rates, and the liability write-off) then the 2010/2011 projected results true up to a 1.5 million dollar loss or about a 2 million dollar miss. This is in addition to money spent on seismic retrofit work that had no immediate benefit, but was capitalized nonetheless. There may be some contentiousness at Monday night's meeting, but based on the numbers I have identified in this post, I will be sticking to my guns that the Hospital needs to present a better plan than they have to date.
Wednesday, June 1, 2011
Why is the Hospital so Important to my Fellow Board Members (navel gazing edition)
So given the terrible results projected for this year, why would anyone fight so hard to keep a small, heavily subsidized, not superior (and possibly inferior) hospital open? In the past, some of it could have been explained by a belief that "the will of the people" was being served, but that vote was over 10 years ago and circumstances have changed. In addition, in my opinion, that campaign was fraught with misleading messages from the pro side (I voted for the District). Also, political ambition has played a part (Lena Tam, Rob Bonta, Mary Ezzy-Ashcraft, and probably Leah Williams). I don't believe that any of my fellow Board members are looking to "upgrade" (?) to the City Council. Of course, we don't need an explanation for Dr. Deutsch; closing the Hospital would probably mean a forced retirement for him and his ego is intimately tied up with the Hospital (understandably so given how long he has been working there). For management, the answer seems obvious, but I think they also take cues from the Board as to what stance they will take. Debbi Stebbins and Kerri Easthope are, based on what I can tell, competent administrators. I assume they know this Hospital is essentially doomed in its present configuration.
I think the major reason that my fellow Board members don't want to see the obvious is groupthink. There is a rich literature in peer pressure regarding both the socially beneficial aspects (better teamwork, conformance to norms) and the costs (incorrect answers, lower self-esteem, lack of innovation). I'll continue to try to break this lock on their brains.
I think the major reason that my fellow Board members don't want to see the obvious is groupthink. There is a rich literature in peer pressure regarding both the socially beneficial aspects (better teamwork, conformance to norms) and the costs (incorrect answers, lower self-esteem, lack of innovation). I'll continue to try to break this lock on their brains.
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