posts-cache.json

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  {
    "id": "23b1f0c8-5973-81d5-91bd-c9279b5a40a6",
    "title": "Part 4: From 1 Year to 1 Month: A Proposal for Better VBC Contracts",
    "slug": "proposal-for-better-vbc-contracts",
    "excerpt": "Value-based care contracts are challenging due to lengthy negotiations, strict and evolving security demands (especially post-Change Healthcare), and rigid terms that hinder innovation. These issues create financial strain for startups, making value-based care primarily accessible to large, established healthcare entities. In a world rapidly changing due to AI and at the policy level, we should set a target of contracts taking 1 month rather than 1 year. My recommendation is for contract standardization and data sharing processes that are either centralized or fully open-sourced.",
    "coverImage": "image1.jpg",
    "date": "2025-07-30",
    "content": "\nValue-based care contracts are brutal. They take years to negotiate. Security requirements are intense, taking months or years to implement, and then the contracts are inflexible as the business changes. Still, they are the first step to doing value-based care: improving quality and cutting costs.\n\n\nThis post will explain these contracts and propose how to make them faster and better for all parties. In a time of rapid change at the federal level, multi-year contracts are at a severe disadvantage and I worry they could put our goal of improving outcomes and reducing cost even further out of reach.\n\n\n## Value based contracting today\n\n\nWorking at Cityblock Health and Firsthand Cares, I've seen about 10 of these contracts. They are complex agreements that shift focus from the number of services (fee-for-service) to quality and cost-effectiveness (value-based care). These agreements aim to incentivize holistic, preventative, and efficient healthcare for complex patient populations, mainly those on Medicaid or dually eligible for Medicare. They also include commercial plans from employers or purchased independently.\n\n\nThe main point of a value-based contract is to deliver value-based care. The insurance company wants to buy outcomes, not services. To do this, the value-based care (VBC) company \"buys lives\" from an insurance company. This means the VBC company gets a set price for the future medical costs of those people, expecting to profit by lowering costs or increasing revenue.\n\n\nValue-based care involves two main parties:\n\n1. Insurance company: A risk-averse, publicly traded company obligated to provide predictable value to shareholders.\n2. Value-based care company: A smaller, risk-tolerant, venture-backed startup. Its main job is to return 5x+ the invested dollars to its shareholders over 5-10 years.\n\nAlso, LoL (lots of lawyers)\n\n\nThe key parts of these 100+ page value-based contracts are:\n\n1. **Patient Attribution**: This clause defines the specific patient group the provider is responsible for. It sets the method for assigning members, clarifying whose costs and outcomes are measured. This usually includes high-need individuals with multiple chronic conditions, behavioral health needs, and social barriers to health.\n2. **Scope of Services:** The contract details the services the provider must deliver. This can include behavioral health, substance use disorder treatment, and social support like housing and food security.\n3. **Quality and Performance Metrics:** Metrics are set to measure the provider's success in improving patient health and managing costs. These focus heavily on outcomes and require significant effort to track and report. Key performance indicators (KPIs) in a contract would likely include:\n    1. **Fewer Hospitalizations and Emergency Department (ED) Visits:** A main goal is proactive, community-based care to prevent costly acute episodes.\n    2. **Better Management of Chronic Conditions:** Metrics track control of conditions like diabetes (e.g., HbA1c), hypertension (e.g., blood pressure), and asthma, usually using specific HEDIS measures.\n    3. **More Patient Engagement:** Measured by frequency of contact, adherence to care plans, and patient satisfaction.\n    4. **Behavioral Health and Substance Use Outcomes:** Metrics might include follow-up rates after mental illness hospitalization or initiation and engagement in addiction treatment.\n    5. **Preventative Care Measures:** Tracking rates of cancer screenings, immunizations, and annual wellness visits.\n4. **Financial Terms and Risk Arrangement:** This section outlines the financial structure. It details the capitated payment rate and shared savings or risk arrangement. This includes the formula for calculating total cost of care, the benchmark for performance, and the percentage of savings or losses the provider is responsible for.\n5. **Data Sharing and Reporting Requirements:** Transparent data exchange is crucial for the value-based model. The contract specifies data types to be shared between the insurance company and provider, including claims data and patient-reported outcomes. It also defines reporting frequency and format.\n6. **Care Coordination and Collaboration:** The agreement sets expectations for how the provider will coordinate care with other healthcare entities, including specialists, hospitals, and community-based organizations—many of which the insurance company may own.\n\nA value-based contract aligns both parties' goals: improving population health while managing healthcare resources.\n\n\nConsider a patient who recently had expensive surgery. Will they keep having expensive healthcare, or will costs regress to the mean? The answer depends on the surgery type, their history, and demographics.\n\n\nAs a value-based care business, your main customer is a large insurance company. Their problem areas are high-cost or highly variable healthcare costs. These make it harder to deliver predictable returns for their shareholders.\n\n\nContract negotiations take about 1-2 years and involve many specialized consultants, lawyers, CEOs, and board members. Single lines in the 100+ page contract can change the company's financial viability. Each contract differs significantly, and every insurance company considers its method \"standard.\" It might be 5 separate documents signed individually to keep the process moving, or one large document.\n\n\nThe first challenge to examine is how this process creates significant financial problems for the value-based care company.\n\n\n## Contracting challenges: The J curve\n\n\nStartups need money and time. Insurance companies have seemingly unlimited money and are slow. Not a good match.\n\n\nA startup needs to know:\n\n- How long will contract signing take?\n- When will the contract start?\n- How long will the contract last?\n- How long from contract start until that operation profits?\n\nAnswering these questions is almost impossible.\n\n\n**The bottom of the J curve**\n\n\nDue to the large investment in just getting the contract, you start in a hole of roughly 30-60 \"person months,\" whatever that costs, before your team performs as expected.\n\n\nHere is a rough estimate of contract-specific resources (likely very wrong):\n\n\n| <u>Team Name</u>                          | <u>Month count low</u> | <u>Month count high</u> |\n| ----------------------------------------- | ---------------------- | ----------------------- |\n| Sales and growth                          | 12                     | 24                      |\n| Lawyers                                   | 6                      | 12                      |\n| Data and IT Support                       | 3                      | 6                       |\n| Implementation and training team          | 1                      | 3                       |\n| Time performing below target productivity | 2                      | 6                       |\n| <u>TOTAL</u>                              | 24                     | 51                      |\n\n\n### The line must go up\n\n\nValue capture is complex. You don't do something and get paid for it immediately. There are various important dates and payment tranches. For example:\n\n- HEDIS and other quality measures are finalized once a year.\n- Monthly capitation payment or PMPM fee is based on active patient enrollment.\n- Quarterly performance-based incentives exist.\n- Annual shared savings reconciliation occurs.\n\nThis payment uncertainty creates significant financial uncertainty that a value-based care company must factor in when raising capital. This, along with many unanswered questions, often starts these contracts deep in the red financially.\n\n\nPredicting these payments is hard because insurance claims data is at least 3 months old. Due to this timing, you are essentially fronting the insurance company 3+ months of work before getting paid.\n\n\n### Deploying Venture dollars\n\n\nVenture capital is high-risk, high-reward money for innovation.\n\n\nWith external constraints like the time to sign a contract, set up a market, and get paid, capital takes a long time to be used. It often sits frozen in the company, only becoming active once a new contract is signed.\n\n\nFor the startup, timing your J curve around these contracts, revenue, and when to raise venture funding is extremely difficult.\n\n\nLarge, billion-dollar+ companies simply run many of these processes concurrently, so all teams are maximally utilized, and uncertainty matters less. For smaller companies with less cash, this time uncertainty is existential.\n\n\n## Contracting challenges: Every contract is their own special flower\n\n\nAll this makes it very hard to build a consistent, measurable, and scalable business. After major breaches like Change Healthcare in 2024, insurance companies are more reluctant to share data. They have all developed vastly different standards:\n\n- Different patient populations (more medically complex, more urban or rural).\n- Different security requirements (Firsthand, only a few years in, needed both HITRUST R2 and SOC 2 type 2).\n- Different data formats for insurance claims and patient contact information.\n    - Some insurance companies send paid amounts, others don't.\n    - Variable coverage for the designated patient population (60-80%).\n    - Different insurance claims formats (no consistent standard).\n    - Different data exchange methods, usually manual SFTP file uploads at a set time, with formats that can change monthly.\n- Custom files for opt-outs, exclusions, mobile/telemed, updating contact info.\n- Custom integrations with providers owned by the insurance company or state Medicaid programs.\n\n## Contracting challenges: Data security post-Change Healthcare\n\n\nIn 2024, Change Healthcare, a UnitedHealth Group subsidiary, suffered the most significant cyber incident in US healthcare history. Attackers are believed to have taken a huge amount of sensitive data; estimates suggest personal and health information for one in three Americans may have been compromised. UnitedHealth Group reported the attack would cost over a billion dollars in 2024 alone, including ransom, system restoration, and financial aid to affected providers.\n\n\nThis attack shocked the healthcare insurance industry and drastically changed data exchange standards—a key part of value-based contracts. More recently, insurance companies have blocked downstream vendors from using AI on their insurance claims—tools they likely use internally.\n\n\nBefore Change Healthcare, the contracts I worked on had a relatively small security exhibit. Even the most demanding contracts might require completing a security standard in two years. Today, however, Firsthand, a small team, must be compliant with both HITRUST R2 and SOC 2 Type 2 before it can even receive data to evaluate if a contract could work.\n\n\nThere is no official certification for HIPAA compliance, so frameworks like HITRUST and SOC have emerged.\n\n\n**What is HITRUST?**\n\n\n**“HITRUST is the Health Information Trust Alliance…healthcare acronyms like to be on the nose. HITRUST is a more healthcare specific security framework and takes the greatest hits from the many different security standards that healthcare companies will typically encounter like HIPAA, NIST, ISO 27001, PCI, and other capitalized letters that sound like loud noises.” -** [**Nikhil**](https://www.outofpocket.health/p/what-goes-into-soc-2-and-hitrust-with-vanta)\n\n\nHITRUST changed significantly from version 9 to version 11, adding hundreds of controls for cloud security that were previously minimal. The certification process takes two years and involves hundreds of individual \"controls.\"\n\n\nTo achieve HITRUST, a company must provide three things for each control: a policy, a procedure, and sample evidence.\n\n\nFor example, for the control, \"The leadership team is trained on their roles and responsibilities,\" the first step is to write a policy about the type and frequency of training. Then, create a \"procedure\" document specifying what training applies to which people. Finally, to prove implementation, provide sample records showing that the required people received the training outlined in the policy and procedure. This process repeats for over 300 controls.\n\n\n## Contracting challenges: What do words mean anymore?\n\n\nIt's unclear who \"the leadership team\" refers to: technical leadership, the board, or the C-suite? Interpret it wrong and you might be on a corrective action plan, which must be disclosed to all existing payer partners.\n\n\nThe controls are often short, generally worded sentences. Our head of L&D, a former English teacher, found them…deeply problematic.\n\n\nDebating data security questions can be confusing. Here's an example from an exchange (PC refers to the \"Professional Corporation,\" a clinician-run entity legally able to provide healthcare services with an arrangement with the startup):\n\n> Q: We receive some data from the insurance company and augment it with information gathered while caring for patients. Does the data transmission security requirement in the agreement apply to that augmented data?\n>\n> _Lawyers: We analyzed the data flow from a HIPAA perspective. Our view is that the data the non-PC entity receives for Engaged Members is shared in its capacity as a business associate of the PC (a covered entity with a patient-provider relationship with the Engaged Member). This differs fundamentally from a HIPAA perspective when data is shared with the PC about non-Engaged Members, where the non-PC is a business associate to [Insurance Company]._\n>\n>\n> _For Engaged Member data, from a HIPAA perspective, it's equivalent to data being shared with the PC, which then shares it with the non-PC to support the PC's performance of services under the Provider Agreement. The parties will simply skip sharing Engaged Member data directly with the PC since the non-PC is its authorized business associate. Consequently, the [Contract document] would not govern the transmission of data about Engaged Members to the non-PC because it falls under the Provider Agreement's covered entity pathway._\n>\n>\n> If you understand that, you might have a future in the healthcare business.\n>\n>\n\nHere is a security requirement I struggled to interpret. I asked five CTO/CSOs, and received ten different answers on how to set up systems to conform to it:\n\n> \"Logical controls, virtual machine zoning, virtualization security, and segregation must be in place to help prevent attacks and exposure in multi-tenancy environments. This may be accomplished with tenant isolation, data isolation patterns, database per tenant, or application instances.”\n\nIt's a real challenge.\n\n\n## Contracting challenges: Inflexibility\n\n\n<figure><img src=\"/images/image1.jpg\" /></figure>\n\n\nOne less discussed challenge with healthcare contracting is its inflexibility.\n\n\nIn Part 3, we've shown how insurance companies and value-based care operate with limited information. It is difficult to know what is truly happening before signing the contract, so new information emerges as you iterate. However, the contract often remains fixed, sometimes based on what the insurance company promised the state in its RFP to operate Medicare and Medicaid.\n\n\nAt a recent company, we developed a more efficient care model. However, the specifics of our old model were in both the contract with the insurance company and their agreement with the state for Medicaid. This meant we could not switch to the new model until the insurance company re-bid Medicaid in that state.\n\n\nYour care model can change, but the contract often cannot.\n\n\n## Who does this well?\n\n\nIf value-based contracting is to continue, contracts must be signed in one month, not twelve. What would that require?\n\n\nEfficiency usually comes from fully opening something up or fully centralizing it. Currently, we have neither; it is both opaque and distributed. This needs to change.\n\n\nA centralized approach would involve creating a sanctioned VBC contact broker. This broker would act as a middleman, providing standard terms to both sides, with blanks for exact cohort definition and financial terms. Crucially, this broker would host all required data in an isolated, compliant warehouse. Insurance companies would upload files, and VBC companies could read those files via an API without copying the underlying data, reducing risk. This could also be a federal initiative.\n\n\nAnother approach would be to fully open source both the contract and the data interchange formats. Contracts are currently confidential, but I wonder if they could be opened and standardized at the federal level. Data exchange is finally getting the benefits of open-source through [The Tuva Project](https://thetuvaproject.com/), which aims to open source the data transformations needed to parse insurance claims. Currently, every insurance company handles their claims differently, and every VBC company implements these transformations on their own with no real reference. Both the contract and data interchange process could be much more efficient.\n\n\nI believe payers primarily care about favorable terms and data protection which is satisfied in both. Either of these directions would advance the industry. I don’t know if these changes would get us to 1 month, but it would be much less than 12.\n\n\n# What could the future hold\n\n\nToday, in 2025, value-based contracts are largely only accessible to extremely large players in healthcare due to challenges with financing, consistency, and data security. By the time a value-based contract is secured, the care model is essentially set in stone – blocking the iteration that makes startups successful.\n\n\nWith millions of people losing Medicaid coverage and hospitals still bearing the cost of their care, hospitals could contract with value-based care providers to reduce losses on that population. I am concerned that these contracts take too long to adapt to policy changes from Washington, which disadvantages all of us.\n\n",
    "section": "VBC",
    "author": "Brennan Moore"
  },
  {
    "id": "23b1f0c8-5973-81c3-a56b-ec8186ab8233",
    "title": "Part 3: Why Your Health Data is a Mess",
    "slug": "why-your-health-data-is-a-mess",
    "excerpt": "Your official health record is a useless mess, fragmented across different doctors and insurers. I argue that advertisers at companies like Google and Amazon know more about your daily life and habits than your own physician. Because this foundational data is so broken, new healthcare models like value-based care are failing, and simply applying AI won't fix the problem until the data itself is fixed.",
    "coverImage": "IMG_0096.png",
    "date": "2025-07-29",
    "content": "\nWorking in healthcare can feel like navigating a maze in a fog. Doctors are skilled problem solvers, but their maps are often 100 page faxes pieced together from four different electronic health record systems. While the tech world warns that not using AI means falling behind, doctors need to help patients now, with only about 12 minutes for each visit.\n\n\nThe real world is messy. Decisions are made with limited data and time. In an era of highly targeted mobile advertising and wearable supercomputers – the dissidence between data in healthcare and data used to sell you shoes is LOUD.\n\n\nThis post explains specific healthcare data challenges to show a core problem with value based care. By partnering with insurance companies that have poor information, value based care has followed money instead of data. I believe building a foundation on reliable ground truth data, not lagging insurance claims, offers a path to higher quality, data informed care at a lower cost.\n\n\n<figure><img src=\"/images/IMG_0096.png\" /></figure>\n\n\n# What is a health record?\n\n\nPeople talk a lot about protecting health records, but what is a health record? Unclear.\n\n\nAt a minimum, it is your name connected to a health facility. That simple combination is protected by laws like HIPAA and security frameworks like HITRUST & SOC 2. A complete health record would ideally contain all your health information like demographics, a full medical history, a list of medications and allergies, and notes from your care team. Hopefully it would also have detailed documents like test results, treatment plans, immunization records, and consent forms.\n\n\nHowever, <u>that document doesn’t exist</u>.\n\n\n**Health records in the real world**\n\n\nYour actual 'health record' is more like Marvel's Infinity Stones, scattered across the galaxy, and guarded by different villains.\n\n- <u>Insurance company asteroid field</u>: Where your past health services go to live, but only for the time you were with them. Think of it as a series of tiny, isolated islands but if you leave the island, the island is destroyed.\n- <u>Primary care planet:</u> Full of notes and forms, but good luck if you ever switch doctors!\n- <u>Prescriptions planet:</u> An actually high functioning planet since Surescripts has an up to date and comprehensive list of your medications. However, the planet is protected by the CVS space force which seems to be dispensing medications for the first time every time you go.\n- <u>Hospital planet</u>: Robust data on surgeries and test results run by that hospital but with strong gravitational pull so that data can come in but never leave.\n- <u>Self-care planet:</u> Where your personal wellbeing battles it out with your Strava KOMs (for all you fitness buffs out there!)\n\nGetting data to travel between these planets is like trying to send a fax to the moon – expensive, slow, and…probably impossible. The financial cost of this lack of interoperability is immense and a whole separate issue from this post. \n\n> I personally love [watching tortured healthcare engineers try to help each other on the r/healthIT subreddit](https://www.reddit.com/r/healthIT/comments/1mcilzz/how_do_you_handle_inbound_hl7_adt_messages/). Highly recommend!\n\nYour insurance company doesn't have access to the notes from your primary care doctor's visit. If your primary care doctor refers you to the hospital, the hospital will get your records by requesting a fax. None of these people have any idea about your mental health, data from your Apple Watch, or your ability to pay for different treatments.\n\n\n**The real gap in your health record**\n\n\nThe thing I think is missing the most about your health is the GOOD in your life. <u>It's like your health record is only interested in your bad days, not your triumphs</u>. This makes it very difficult for providers to connect with patients — they are medical fire fighters rather than trusted partners.\n\n\nA close family member of mine recently completed a substance recovery program and is doing very well. Their transformation is truly inspiring. They are making huge health progress with their diet and exercise. But, I asked and they have not seen their primary care doctor in years. This is a perfect time to provide support and maintain momentum, but the healthcare system is unaware.\n\n\n<figure><img src=\"/images/IMG_0093.png\" /></figure>\n\n\n# My own (inaccurate) health record\n\n\nIt is illuminating trying to build your own <u>accurate</u> medical record.\n\n\nWhile living in New York City, I have visited four different health systems. As I wrote this, I requested my medical records from all four. Each facility had a different list of medications. None had documented my family medical history or a complete list of my vaccinations. None had records of my childhood surgeries or a surgery from 2012. There was no data on my mental health, living environment, or my current physical therapy.\n\n\nI've also had four different insurance plans in NYC. Since these companies don't share data, each one only has a small piece of my health history.\n\n\nA third group, the clinical data exchange networks, also has pieces of my health data. These include Health Information Exchanges that send event notifications, Surescripts for medications, and networks like Commonwell and Carequality that allow providers to request records from eachother. Epic's Care Everywhere network allows sharing between providers, but only if the patient has linked those providers in MyChart. Unfortunately, I wasn’t able to request my records from any of these sources.\n\n\nEven with all the talk about making health data work together, my health record is still wrong. <u>The data we're sharing is garbage</u>. This was my experience at companies like Firsthand and Cityblock. We would find out that patients were taking completely different medications and had different health conditions than we thought. A big part of what we did was just correcting their records.\n\n\n**The missing data**\n\n\nIn 15 years in NYC, I’ve been to 5 primary care appointments which — is low! — but isn’t far from average. Data on checkups varies, but studies suggest that a most people do not see a primary care physician every year. This creates huge gaps in time with no data!\n\n\nEven when you do see a doctor, a lot of information gets left out. I told my doctor about my knee pain and some of the vitamins I take, but I didn't mention everything. This is normal. Studies show that 60-80% of people don't tell their doctors everything. They might forget, be embarrassed, or just not want to be a difficult patient.\n\n\nMy doctor seemed rushed. After the appointment, I opened Instagram and saw an ad for something I wanted to buy.\n\n\nDo you know who has more real time data about how I’m doing? Google, Facebook, Amazon.\n\n\n<figure><img src=\"/images/868ffee7-bf10-44f5-b563-b8ea13053659.png\" /></figure>\n\n\n# Sell me healthcare\n\n\nIt sounds crazy, but combining advertising data with medical records could transform healthcare.\n\n\nAdvertisers know your age, where you live, your job, and your interests. They have your location history and know what you like based on what you read and follow online.\n\n\nUnlike health data, which is scattered and incomplete, the advertising industry has detailed profiles on most Americans, sometimes going back decades. Google knows what you're interested in, Meta knows your social connections, and Amazon knows what you buy.\n\n\nYour doctor and health researchers don't have access to any of this information. Combining these datasets could help us understand if medications and surgeries are actually working from how people’s behavior online changes after treatment.\n\n\nWhile there are major privacy concerns for more centralized systems, our current system is doing a terrible job of protecting our health data. In 2024 alone, patient records for ~276 million Americans were breached ([ref](https://www.hipaajournal.com/healthcare-data-breach-statistics/)). The dark web may have more accurate health data for me than my doctor.\n\n\nThe fragmentation of our health system is itself a security risk. Regular business operations require transmitting data between countless parties using data security standards customized for each one. It is a complex issue perhaps for another blog post.\n\n\n<figure><img src=\"/images/IMG_0090.png\" /></figure>\n\n\n# In a perfect world\n\n\nSuccess in value-based care depends on good data. The goal for a VBC company is to give the right treatment to the right person at the right time. Value-based care companies try to do this by specializing in certain conditions, like diabetes.\n\n\nThe process is supposed to be simple:\n\n1. Partner with an insurance plan.\n2. Select a group of people with a specific health condition.\n3. Group them by location.\n4. Assign them to local care teams.\n5. Prioritize them based on need.\n6. Engage them and provide care.\n\nBut it's almost impossible to get accurate, up-to-date health data. Just identifying people with diabetes is a huge challenge.\n\n\n# **The problem with claims data**\n\n\nIt is impossible to find the patients who need help the most when they need it.\n\n\nAt my previous companies, we had major problems with insurance claims data\n\n- Missing or low insurance claims for <u>30-50% of the identified population</u>\n- <u>Cost information</u> had been stripped from the claims (paid amounts)\n- Claims arrive monthly and include data that is <u>at least 3 months old</u>\n- More than 30% of the people on the list would change insurance plans each year.\n\nEven when claims data is good, it only shows what happened under that one insurance plan. Information from when you had a different job or insurer is missing. Details about your mental health, housing, or food situation are not included.\n\n\nA value-based care company can get more records if they meet the patient and get them to sign a consent form. But by then, they've already committed to caring for that person, even if they've moved, are sicker than expected, or are in jail.\n\n\nWe once had an insurance partner tell us that two different patients were actually the same person and that one of them had died. We called the family to offer our condolences, but it turned out they weren't the same person. We then had to fix the merged medical records and apologize to the family. In 2025, value-based care companies are still being assigned patients who are dead or in jail!\n\n\n<figure><img src=\"/images/a21cm3.jpg\" /></figure>\n\n\n## Who does this well?\n\n\nE-commerce companies have spent billions of dollars building systems to track customers and their purchases. With AI, they're getting even better at predicting what people will buy, how much they will pay and when they will buy it.\n\n\n<u>The healthcare industry never paid those big data billions</u>, so we don't know what happens to patients after they leave the doctor's office. AI can't fix this because the data is too flawed to be reliable. We can't tell if an AI is right or just making things up. Our health data is missing basic information like demographics, interests, fitness data, and the patient's own view of their health. The data that does exist is often both inaccurate and incomplete as it was for me.\n\n\nNo one in healthcare can answer these simple questions:\n\n- Did you go to the specialist I referred you to?\n- Do you feel like your health is getting better or worse?\n- Did you take your medication today?\n- Are you in jail?\n- Are you still eligible for your health insurance?\n- What are your parents' medical conditions?\n- Do you have any mental health or substance use issues?\n- Do you have a stable income and place to live?\n- Have you had any big life events recently?\n- Have you filled out our consent form?\n\nHere's the wild part: <u>Someone trying to sell you shoes could answer more of those questions than your own doctor</u>!\n\n\n# Gravity always wins\n\n\nToday, value based care companies primarily partner with insurance companies. Gravity is dollar savings in the form of reduced medical spend & increased reimbursement. It pulls all value based care into its orbit.\n\n\nIn an AI world, ‘data is the new gravity’ and will drive the next wave of healthcare innovation. <u>Healthcare has spent many billions trying to squeeze water out of the rock that is insurance claims data.</u>\n\n\nIt turns out, we've been looking for the princess in the wrong castle all along. She's not with the insurance companies; she's chilling out at Epic (or maybe even Google or Facebook). <u>The future of value based care will be built around companies with rich data and a real information asymmetry to existing players and to insurance companies.</u>\n\n\nHealthcare should <u>keep patients at the center</u>. Most data sharing efforts have put companies before consumers, focusing on reducing the risk of getting sued or fined instead of improving the customer experience.\n\n\nContacting a mother to offer condolences for their dead son when their son is not actually dead is not a great patient experience! If the U.S. wants to control healthcare costs, it needs a universal system with accurate, complete information.\n\n\n### Main takeaways\n\n- Current health data is often inaccurate and was created for billing, not for creating a complete patient record.\n- Health records are missing key information about a person's life that could improve their care. The missing data is from inconsistent PCP visits, lack of social determinants & mental health data as well as not tracking positive factors of someone’s well-being.\n- Data from sources like someone’s online presence and advertisers could provide better and more timely information about a person's well-being.\n\n## I am hopeful about the future\n\n\nFor value-based care to finally follow the data, a few things need to change. While pressure can come from different directions, meaningful progress likely starts with a new foundation built on better policy.\n\n\nMeaningful change starts with **policy**. If the government creates a unified patient ID and enforces modern data-sharing agreements like TEFCA, could push toward a single source of truth for every patient. This foundational layer would make it possible for real innovation to happen, rather than creating even more competing data sources.\n\n\nOnce that foundation is in place, other players can start to build on it:\n\n- **Patients, empowered by their own data,** could use new AI tools to navigate the health system. I am particularly optimistic here since consumers could be motivated to improve the accuracy of their health record by the promise of higher quality, most integrated care.\n- **Big Tech** companies like Apple or Google could re-enter the space, using this new data infrastructure to create a truly useful health record for their users. By combining clinical data with information from their own platforms (like wearable data), they could sell access to value-based care companies, creating a new market based on rich, real-time information.\n- **Hospitals and Accountable Care Organizations (ACOs)** could more easily partner with value-based care companies. With access to better data from EHRs, VBC companies could more effectively deploy preventative care and care management. Financial pressures, like reduced Medicaid eligibility, may motivate Hospitals and ACOs to find proactive solutions for keeping people healthy and out of the emergency room. Data standards could lower the integration cost with the myriad of partners required.\n\nMy main worry is that the healthcare industry is rushing to use AI without first fixing the data. This could lead to people being denied the care they need because of an incomplete and inaccurate health record.\n\n\nWhile this is a lot! It is just one of post my attempt to share some things I’ve learned.\n\n\nIn the next post, we'll dive into value-based contracting, so stay tuned!\n\n\nRecommended reading\n\n- [If Air Travel Worked Like Healthcare](https://www.youtube.com/watch?v=5J67xJKpB6c&ab_channel=TheNewAltons): A 15 year old video that could have been made yesterday\n- [CMS's Health Tech Bombshell by Brendan Keeler](https://healthapiguy.substack.com/p/cmss-health-tech-bombshell): A deep dive into some recent movement at CMS\n- [Empowering Patient Choice with Payer and Provider Data By Ron Urwongse](https://defacto.health/2025/01/28/empowering-patient-choice-with-payer-and-provider-data/): A great read if you are interested in more specifics on exactly what we can do to improve the quality of health data (I’ve intentionally simplified a lot in this post). While practical, I think the proposed solutions are not compelling enough and too incremental. Self scheduling and provider directories are nice but it still sucks to visit 3-5 facilities to get anything done. I do think this is where VBC’s care managers provide great consumer experiences for discrete populations but a more significant reorganization would be required at national scale.\n- [Kill the Clipboard! A Federal Policy and Industry Roadmap to Accelerate Innovation and Cut Administrative Waste](https://leavittpartners.com/wp-content/uploads/2025/07/NEW-Ideas-for-the-Trump-Department-of-HHS_FINAL.pdf) A further deep dive on some of the recommendations underlying what is coming out of CMS\n",
    "section": "VBC",
    "author": "Brennan Moore"
  },
  {
    "id": "23b1f0c8-5973-8185-8d09-dc69516e02a9",
    "title": "Part 2: What is Value-Based Care?",
    "slug": "what-is-value-based-care",
    "excerpt": "This post explains that value-based care is a model that pays providers to keep patients healthy, contrasting it with the traditional fee-for-service system. I argue that while the goal is simple, implementing it is \"harder than rocket science.\" Drawing from my experience, the post details the extreme difficulties involved, including navigating multi-year contract negotiations with insurers, building a massive and complex operational system before seeing a single patient, and the immense challenge of aligning internal teams who often have conflicting goals. I argue that this operational gridlock makes it nearly impossible to create a scalable, efficient, and truly patient-centered system.",
    "coverImage": "IMG_0087.png",
    "date": "2025-07-28",
    "content": "\nThe book “[The American Healthcare Paradox](https://bioethics.hms.harvard.edu/journal/healthcareparadox-review)” uses a simple question to explain a problem in US healthcare. Who pays for a shoe? Imagine a homeless person gets a foot infection that leads to an amputation. The hospital and insurance company handle the expensive surgery, but the person is now disabled and still homeless. This outcome is bad for everyone.\n\n\nValue-based care aims to fix this by focusing on prevention. The idea is to \"pay for the shoe\" to avoid the much higher cost of an amputation later. I saw how this works at firsthand and Cityblock Health. Investing in social and behavioral support helped people in underserved communities avoid preventable health problems and take more control of their lives.\n\n\n<figure><img src=\"/images/815e54ae-c5cc-4cb3-8a17-8d222588334e.png\" /></figure>\n\n\n# Why is Value-Based Care important to me?\n\n\nMy mom's experience as a physical therapist inspired my interest in value-based care. Growing up, she built incredible relationships with her patients, who were often nearing the end of their lives. My two brothers and I were given at least 3 cats and 5 dogs from her patients, entirely due to the deep relationships she built with her patients who were no longer able to care for their pets.\n\n\nNow, her work is different. She spends nights and early mornings on documentation. Her patient visits are a strict 45 minutes, which is often too long for a simple check-in but too short for someone with serious issues.\n\n\nThe fee-for-service model requires this machine-like approach to get the most payment in the least time. I wanted to help change healthcare from a transactional system to one focused on genuine health.\n\n\n<figure><img src=\"/images/IMG_0087.png\" /></figure>\n\n\n# What is Value-Based Care?\n\n\nMost people think of healthcare in **Fee-for-Service (FFS)** terms.  where Doctors and insurers negotiate a fee per service provided to a patient. The prices aren't particularly transparent resulting in lots of surprise medical bills but it’s basically paying for a service with a little haggling there in the middle.\n\n\nValue-based care takes a longer-term view of your health. It pays providers to keep you healthy and manage chronic conditions to prevent emergency room visits. There are a few common models:\n\n\nWith _shared savings_, if a team of doctors keeps their patients healthy and reduces overall costs, they get a portion of the savings.\n\n\n_Bundled payments_ use a single fixed price for an entire medical event, like a hip replacement. This encourages all providers involved to work together efficiently.\n\n\n_Capitated payments_ are like a subscription. Providers get a fixed monthly payment for each patient, regardless of how many services they need. This creates a strong incentive to invest in preventive care.\n\n\nThe main idea is to shift financial risk from the insurer to the provider. This encourages them to focus on high-quality, efficient care because it affects their finances. For patients, this should mean more coordinated care with a focus on wellness.\n\n\n<figure><img src=\"/images/image4.jpg\" /></figure>\n\n\n# My experience with Value-Based Care\n\n\nI have spent eight years working for companies that aim to use the ‘capitated’ VBC model. However, the reality of value-based contracting is much messier than the theory.\n\n\nAs a small startup, you begin with just a team of pretty smart folks with some idea for how to provide better care at lower cost. After raising funds, your first job is to get a value based contract with an insurance company so you can start seeing patients.\n\n\n<figure><img src=\"/images/IMG_8381.jpeg\" /></figure>\n\n\n**Value based contracting**\n\n\nWhen we brought on the CEO of Cityblock Health, we had his 90 day goal to ‘land a contract with an insurance company’. Little did we know, that takes about 1-2 years.\n\n\nDuring that 1-2 year contracting process, the company needs to get ready so they can launch the moment the ink is dry. The sales team is feeding information back to the product team about what aspects of the care model are appealing to the insurance company. The finance team is figuring out what kind of money is available for operations. The team develops its offering by writing policies and procedures, designing a staffing model and setting up software – without seeing a patient or being able to test anything — for years.\n\n\nThe contracts themselves are often secret and legally complex, covering everything from financials to AI to data security. All of this effort is just to set up a pilot program. This high risk and capital intensive start tends to favors only founders with extensive industry experience – this isn’t the territory for fresh college grads.\n\n\nTerms of the deal may include:\n\n- Performance incentives for things like: Completing quality measures (e.g., A1c checks for diabetics), risk adjustment (updating diagnoses to increase insurer payments from Medicare/Medicaid) and steerage to designated providers.\n- Control cohort definition for benchmarking.\n- A per-patient-per-month management fee.\n- Fee-for-service billing arrangement for some services.\n- Carve outs for patients and for services that are out of scope\n\nOver my time at Cityblock and firsthand, I’ve seen about 10 or so of these contracts get signed and every single one of them is different. The payment terms, performance metrics, data formats and reports are different every single time. \n\n\nIn theory, to scale a business you need to have some kind of operational consistency and shared tools that make you more efficient than 10 completely independent companies. In practice, consistency gets pushed to the side to sign the deal since the dollars are so enormous. If a national insurance company will to pay you to do something, you do it.\n\n\n<figure><img src=\"/images/IMG_8380.jpeg\" /></figure>\n\n\n**The race to see your first patient**\n\n\nIt is easy to bemoan the long contracting process, but it ends up feeling like a year long sprint. Every week is a blessing as given the immense number of components to spin up before you see your first patient.\n\n\nAt Cityblock, about a week before launching our first clinic, we were testing out our system. One of our providers asked us how to schedule an appointment. Well, we never built scheduling. After years of going through the list of required features with focus groups, experienced providers and our leadership team who have run large systems — no one brought up scheduling. In about a week we built scheduling for our clinic on top of Google Calendar and it actually worked quite well for many years. It is easy to say ‘how did you miss something so obvious’ but the list of needs is so incredibly long. Table stakes features like scheduling are less differentiating in the market than AI enabled decision support.\n\n\nFor a bit more detailed look, here are a few things you need before standing up your first VBC clinic:\n\n\n<div className=\"column\"><div>\n    \n<u>**Data Platform**</u>\n\n\n**Data Ingestion**\n\n\nCan we reliably ingest data?\n\n- _think:_ Claims, Labs, Prior auth\n- _think:_ Surescripts, Commonwell, ADTs\n- _think:_ Health Gorilla, Ribbon, Zus Health\n\n**Enterprise Data Management** \n\n\nCan we normalize data for internal use?\n\n- _think:_ Unified data models for medical records and claims\n- _think:_ Summary tables\n\n**Self Service BI** \n\n\nCan managers reliably oversee operations?\n\n- _think:_ Performance dashboards\n- _think:_ Partner reporting\n- _think:_ Looker, Tableau\n- _think_: Cotiviti, Inovalon\n</div><div>\n    \n<u>**Delivery Model**</u>\n\n\n**Member Record of Truth**\n\n\nDo care teams have accurate, reliable & comprehensive data\n\n- _think:_ Summarization\n- _think:_ Centralized health data + timeline\n\n**Clinical Care Delivery**\n\n\nDo we have smooth workflows for common tasks (AI is big here)?\n\n- _think:_ Documentation, orders, RX\n- _think:_ Decision support\n- _think:_ Structured assessments like PHQ-9\n\n**Pop Health & Signals**\n\n\nCan we segment and prioritize patients based on need and $$$?\n\n- _think:_ Acuity, Impactability\n- _think:_ Dx Gaps, Quality Gaps\n\n**Practice Management** \n\n\nCan we run our offices?\n\n- _think:_ Scheduling\n- _think:_ Hub operations\n- _think:_ Empanelment\n</div><div>\n    \n<u>**Patient Front Door**</u>\n\n\n**Omni-Channel Comms** \n\n\nCan we seamlessly communicate with members?\n\n- _think:_ SMS, Call, Video\n- _think:_ 24/7 on demand\n- _think:_ unify CRM + EHR data\n\n**Outreach & Engagement** Can we drive real engagement and frequent interaction?\n\n- _think:_ Integrated marketing\n- _think:_ Bulk campaigns\n- _think:_ Consents\n\n**Member Portal** \n\n\nCan patients drive their own actions?\n\n- _think:_ Self scheduling\n- _think:_ Self assessment\n- _think:_ Remote monitoring\n</div></div>\n\n\n<figure><img src=\"/images/Gemini_Generated_Image_ekvonxekvonxekvo.png\" /></figure>\n\n\n**Value-based operations**\n\n\nOnce you are seeing patients, the hard part has truly only just begun. One of the main aspects of healthcare business is that they tend to have many independent components that are actually pretty interdependent. Everyone needs to be both good at their job and good at collaborating with a wide array of very different people with very different goals.\n\n\nThis means lots of meetings with 10-15 ‘decision makers’. A simplified cross functional team might include a couple people from each of these teams:\n\n- **Growth**: Making sure the deal is actually something the company can do and the financial terms make sense. Team up with finance and actuarial scientists\n- **Account management**: After the deal is signed, it is handed to a team that manages the ongoing relationship and newer requests and reports.\n- **Data integrations**: Ingesting the data from the insurance company q/a-ing it each time the files come in every month.\n- **Implementation**: Setting up physical clinics and hiring teams for those clinics\n- **Data science**: Predictive Analytics and Risk Stratification using sophisticated algorithms, this team identifies patients at high risk of developing chronic conditions or experiencing adverse health events. This allows for early intervention and targeted care management.\n- **Compliance**: Make sure all the providers are credentialed and everyone has had the requisite training, policies are effective and enforced.\n- **Operations**: This department is focused on measuring and enhancing the quality of care delivered and making sure it is delivered in a financially sustainable way.\n- **Engagement and outreach**: Team to contact and get people enrolled in your program\n- **Clinical quality:** They track key clinical outcomes, patient safety, and patient satisfaction. Their responsibilities include implementing evidence-based best practices, conducting audits, and preparing for quality reporting to insurance companies and regulatory bodies.\n- **Learning and development**: Are teams able to perform our care model and use the software we have built and/or purchased?\n- **Billing**: Value based care companies still have to file claims and negotiate with payers. These teams often have their own totally independent stack of tools.\n- Oh and some tech stuff in there ;)\n\n<figure><img src=\"/images/Screenshot_2025-08-02_at_21.05.36.png\" /></figure>\n\n\nEach of these teams is essential, but each is so different the company ends up looking like a Frankenstein acropolis with Tuscan, Doric, Ionic, Corinthian, and Composite columns all mixed in. It is difficult to get these teams aligned. Operators in the field want to solve problems locally, while engineers want to build solutions that scale. Business managers try to optimize minutes, while clinicians might spend days helping a single patient. It is almost impossible to get these teams moving in the same direction to build a strong, scalable business.\n\n\nI asked Google’s Gemini AI to try to help me make light of the challenges in VBC, but now I may need to go cry in the shower.\n\n\n<figure><img src=\"/images/Screenshot_2025-08-01_at_11.37.24.png\" /></figure>\n\n\n## What about fee-for-service?\n\n\nFee-for-service may seem simpler right? But these practices also face a huge administrative burden. Their payments can be adjusted based on quality measures that require extensive documentation. Providers must not only do the right thing but legally prove they did it.\n\n\nIf you run a FFS facility, your job is to extract maximum revenue from each room. Facilities increase profit by boosting service volume and complexity, shortening visits and hiring staff to maximize billing. Optimizing the facility and staff performance requires many similar components to running a value based care business.\n\n\nFrom a high level, value-based care also seems simple. Insurance companies pay more for better health outcomes. Yet defining \"better\" is subjective and proving results is a real challenge.\n\n\nIn either system, providers are frustrated by conflicting demands. They can do everything for the patient in front of them, but that delays other visits and increases costs. They can keep all visits the same length, but that means spending less time with patients who have complex problems. They can complete all their documentation to get a bonus, but that means less face-to-face time with patients.\n\n\n<figure><img src=\"/images/IMG_0084.png\" /></figure>\n\n\n# Healthcare is hard\n\n\nI say value-based care is harder than rocket science because we have spent far more money on healthcare reform than NASA spent on the moon landing, with much less success. The people in healthcare are skilled and well-funded, yet American health outcomes are worse and more expensive than in any other developed country.\n\n\nBoth fee-for-service and value-based care have their own administrative burdens and contradictions. The struggle to balance quality, cost, and access is what makes improving healthcare such a complex puzzle.\n\n\nIn many ways, data is oil in healthcare. Many of the problems facing healthcare are issues with capturing accurate data and then taking the correct course of action based on data.\n\n\nIn the next post in the series, I’m going to go into why healthcare data is especially difficult oil to refine. Check it out [here](https://www.zamiang.com/writing/why-your-health-data-is-a-mess).\n\n",
    "section": "VBC",
    "author": "Brennan Moore"
  },
  {
    "id": "23b1f0c8-5973-8009-832d-e9878a5f0cb6",
    "title": "Part 1: What is “healthcare” in the US",
    "slug": "what-is-us-healthcare",
    "excerpt": "An introduction to the U.S. healthcare system as \"harder than rocket science\" because it's a massively expensive and underperforming system plagued by \"consolidated fragmentation.\" Despite enormous spending, outcomes lag behind other developed nations. The core issue is that the major players—insurers, hospitals, and providers—have grown into powerful, competing silos. This creates a gridlock that stifles innovation and prevents them from working together effectively to improve patient health, as each entity focuses on its own financial advantage.",
    "coverImage": "IMG_0079.png",
    "date": "2025-07-27",
    "content": "\nMy grandfather, an engineer on NASA's Apollo missions, often joked that rocket science was simple: you just point the rocket in the right direction and light it. The real challenge was all the engineering required to make that simple act possible. American healthcare presents a similar paradox. The goal of pointing a patient toward the right treatment should be straightforward. But, it is often tangled in the complexity of byzantine data systems, misaligned business contracts, and fragmented healthcare organizations. My aim with these posts is to untangle that web, and explore the what makes American healthcare feel harder than rocket science.\n\n\n\n<figure><img src=\"/images/IMG_0080.png\" /></figure>\n\n\nAs a technology leader at forward thinking healthcare companies like [Cityblock Health](https://www.cityblock.com/) and [Firsthand](https://www.firsthandcares.com/), I built platforms that delivered preventative care to tens of thousands of our system's most underserved individuals. We proved that new models could simultaneously improve outcomes and reduce costs. But, the landscape continues to change. The strategies that powered those successes are no longer sufficient in an era defined by AI and the market dominance of a few healthcare giants. I believe we need to take a new approach to healthcare data, business contracts, and health organizations.\n\n\n## **Let's get started: Where are we now?**\n\n\n_This first part gives an overview of the business of US healthcare in 2025. You can likely skip it if you already work in the industry._\n\n\nHealthcare is a massive industry and the largest employer in the United States, with over 22 million workers. It makes up 17.7% of the nation's total economic output (GDP) and is expected to reach 20% by 2032.\n\n\nThe growth in healthcare costs has far outpaced other industries. From 1996 to 2024, health insurance premiums increased by 339%, while average wages grew by only 126%. During that time, over half of the average employee's pay increase was absorbed by health insurance costs. As a result, the take-home pay for many Americans has not changed much in 30 years, despite major gains in productivity from new technology.\n\n\nThis huge and uneven growth in healthcare costs is one of the reasons most Americans feel so frustrated. \n\n\nSee [here](https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time/#Annual) for a much deeper dive: \n\n\n<figure><img src=\"/images/924aac10-20e9-4e0f-a48c-3a9df4a6d3f9.png\" /></figure>\n\n\n## **Healthcare in the US vs the UK**\n\n\nYou'd hope that all that money spent would mean the U.S. has the best healthcare in the world. Well, that's not true for everyone.\n\n\nA good way to see this is by looking at maternal mortality, which is how many women die during or after childbirth. It's often seen as a good way to tell how healthy a society is overall. Let's compare the U.S. rates with the UK. I'm not saying the UK system is perfect, just that it's a similar country to the U.S. and is more different than Canada.\n\n\nIn 2022, the US had 22 maternal deaths for every 100,000 live births. The UK had only 5.5. The UK achieves this while spending 10% of its GDP on healthcare, compared to the 17.7% spent in the US.\n\n\nHowever, It is misleading to talk about a single \"US healthcare system.\" A person's health is best predicted by the [the zip code you were born](https://hsph.harvard.edu/news/zip-code-better-predictor-of-health-than-genetic-code/). There are vast differences between states. For example, California's maternal death rate is half the national average at 10.5. Louisiana's rate is 37.3, which is similar to that of developing nations like Cuba or Mongolia. These wide gaps in health outcomes make it difficult to agree on national policies.\n\n\n<figure><img src=\"/images/f565ebab-737b-4532-8b52-fbc67eb29fb0.png\" /></figure>\n\n\n# The big players\n\n\n<figure><img src=\"/images/IMG_0079.png\" /></figure>\n\n\n## **The basics**\n\n\nIn short there are 5 may groups at play in American healthcare:\n\n- **Patients/Consumers:** The people who need healthcare.\n- **Providers (Doctors, Hospitals, Clinics):** Deliver the actual care.\n- **Payers (Insurance Companies, Government Programs like Medicare/Medicaid):** Pay for the care.\n- **Pharmaceutical Companies/Medical Device Manufacturers:** Develop and sell drugs and equipment.\n- **Employers:** Often facilitate insurance for employees and purchase healthcare products for them.\n\n## **The big Players: Payers / Insurance companies**\n\n\nPayers, or insurance companies, are the most powerful group. All the money flows through them. Over the last 20 years, they have shifted from simply paying bills to actively managing care. They can deny treatments and reduce payments to providers they consider poor-performing.\n\n\nInsurance company revenues are staggering: UnitedHealth Group at $400 billion, CVS Health at $372 billion, and Cigna at $241 billion, and the list goes on. However, their profit margins (how much money they actually keep) are quite low and are similar to a restaurant, ranging from 1.5% to 3.8%. This is partly because they invest a lot in growth and research. \n\n\nGrowth has also come from **Managed Medicaid** and **Medicare Advantage**. These \"managed\" programs are where private insurance companies handle government-sponsored health benefits. This means that some of the $1.8 trillion spent on these government programs to flow through them. These programs connect patients with a network of doctors and hospitals, as an alternative to the traditional government system where every service is paid for separately. While these plans might reduce costs for people on these plans, they can also lead to higher costs for taxpayers, and it's not always clear if they actually save money in the long run.\n\n\n<figure><img src=\"/images/image8.png\" /></figure>\n\n\n<figure><img src=\"/images/image1.png\" /></figure>\n\n\n## **The big players: Hospitals**\n\n\nHospitals have also grown into powerful economic engines through consolidation. For example, HCA Healthcare, the country's largest hospital system, had more revenue in 2023 than Netflix, Uber, and Starbucks combined. Key problems with hospitals are a lack of price transparency and a heavy focus on tasks related to billing. Patient information is often not shared between hospitals, doctors, and insurers, which makes coordinated care difficult.\n\n\nEven though prices are now more transparent due to recent legislation, the costs vary wildly. For example in NYC, a C section at one hospital may cost you 20 times as much as at a different one down the street.\n\n\n<figure><img src=\"/images/20138a2f-15e0-43ad-bc88-3db576edc11b.png\" /></figure>\n\n\n## **The big players: Providers**\n\n\nProviders like doctors have also seen major changes. Most physicians, around 75%, are now employed by hospitals or corporations, whereas 20 years ago they were almost all independent. Many have joined larger groups called Accountable Care Organizations (ACOs) to help coordinate care and meet performance goals. Practices now employ more support staff to handle the documentation required by electronic health records and complex payment models.\n\n\nThese larger groups help with better coordination of care among their doctors and can support each other in meeting \"value-based care\" goals, like **Clinical Quality Measures**. These measures look at things like how well doctors follow guidelines for preventive care (like vaccination rates or cancer screenings) and how well they manage long-term illnesses (like controlling blood pressure for patients with high blood pressure or A1c levels for diabetic patients).\n\n\n<figure><img src=\"/images/53961c24-c866-4a11-a01c-04b5c3e18c66.png\" /></figure>\n\n\nThe second big change for healthcare practices is the number and type of people who support each doctor. Currently, practices have about 4.79 support staff for every doctor. This ratio of support staff to doctors is a big topic and has changed quite a bit over the past 20-30 years. This is due to more documentation needed for electronic health records (EHRs), the need to report data to calculate all the performance measures mentioned above, and the shift toward doing more \"care management,\" which is often called a **Patient-Centered Medical Home (PCMH)**.\n\n\n<figure><img src=\"/images/e0f17b8e-decf-405a-a28e-d0d28e746685.png\" /></figure>\n\n\n<figure><img src=\"/images/image7.png\" /></figure>\n\n\n# Today: Consolidated fragmentation\n\n\n<figure><img src=\"/images/IMG_0083.png\" /></figure>\n\n\nOver the last decade, every part of the healthcare system has consolidated. Insurers, hospitals, and provider groups have each grown into powerful, separate entities.\n\n\nI call this \"consolidated fragmentation.\"\n\n\nFrom their own fortresses, these groups argue over <u>who pays when things go wrong</u>, <u>who gets rewarded when things go right</u>, who controls patient data, and who pays for shared technology.\n\n\nThis structure creates gridlock. While new technology like AI should make innovation easier, the most logical financial move for each group is to seek an advantage over the others. This comes at the expense of working together for patient health.\n\n\nAs a consumer, I want all these companies trying to innovate to find lowest cost and highest value ways to keep me as healthy as possible – the science of health.\n\n\nIn the next post, we will look at why a more integrated approach called \"value-based care\" might be the solution. Check it out [here](https://www.zamiang.com/writing/what-is-value-based-care).\n\n\nRecommended reading:\n\n- [<u>https://www.nytimes.com/interactive/2025/07/03/business/economy/healthcare-jobs.html</u>](https://www.nytimes.com/interactive/2025/07/03/business/economy/healthcare-jobs.html)\n- [<u>https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time/#Annual percent change in total national health expenditures per capita and personal consumption expenditure price index, 1980-2023</u>](https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time/#Annual%20percent%20change%20in%20total%20national%20health%20expenditures%20per%20capita%20and%20personal%20consumption%20expenditure%20price%20index,%201980-2023)\n- [<u>https://bioethics.hms.harvard.edu/journal/healthcareparadox-review</u>](https://bioethics.hms.harvard.edu/journal/healthcareparadox-review)\n",
    "section": "VBC",
    "author": "Brennan Moore"
  },
  {
    "id": "48bf9070-3e34-40c3-8d50-280910e7b7d1",
    "title": "An introduction to building software for value-based care",
    "slug": "value-based-care-intro",
    "excerpt": "This post argues that building successful software for value-based care (VBC) requires a shift in mindset: create a Customer Relationship Management (CRM) tool, not just a better Electronic Health Record (EHR). VBC realigns healthcare incentives around long-term patient outcomes, succeeding through proactive, relationship-based care rather than transactional services. Technology's role is to support this relationship by helping care teams orchestrate interventions effectively. The most valuable tools are often simple and pragmatic, focusing on the unique, core needs of the care model and enabling proactive management of patient health.",
    "coverImage": "Screen_Shot_2022-06-25_at_09.21.21.png",
    "date": "2022-07-02",
    "content": "\nI attended a talk on 'The Future of the EHR' and noticed a significant gap between the presented capabilities and what I observed driving great care at Cityblock. At Cityblock, our ideal electronic health record (EHR) resembled a customer relationship management (CRM) tool with a side of EHR. Given this disparity, I wanted to reflect on my journey as the first engineer and head of engineering for Cityblock Health. What did we do that mattered and why?\n\n\nOur aim at Cityblock was to improve the lives of people in underserved communities. However, our engineering and product team primarily consisted of professionals from non-healthcare backgrounds with innovative ideas for supporting our staff. Some concepts included voice/dictation capabilities, radically simplifying tasks/collaboration, a command line interface, and automating care plan management. Interestingly, our most successful projects were relatively modest builds, such as:\n\n- UI, policies, and procedures for care workers to text patients\n- Real-time integrations with health information exchanges (HIEs) that drove immediate in-person interventions, primarily around hospital admissions\n- Spreadsheet import/export functionality for matching providers and patients and rebalancing care teams\n\nWhy did these seemingly simple features matter, while many others didn't? Let's explore what value-based care is fundamentally about.\n\n\n<figure><img src=\"/images/Screen_Shot_2022-07-02_at_16.51.25.png\" /></figure>\n\n\n### Value-Based Care\n\n\nValue-based care is about putting patients first in everything we do - that is the singular core value. The patient is our customer, and our complete focus is providing excellent service to our customers over the long term.\n\n\nHowever, as software builders who don't directly see patients, how do we effectively \"put patients first\"?\n\n\nWe put patients first by helping care workers implement appropriate interventions. We orchestrate the right people, in the right place, with the right information, at the right time.\n\n\n> I use \"appropriate\" here instead of \"right,\" \"correct,\" or \"ideal\" intentionally.   \n> The tech team builds trust through making and keeping promises with our staff and patients. Within the scope of value-based care, the most effective path is to provide consistent, easy-to-understand, and dependable solutions across all challenges the staff face.\n\n\n<figure><img src=\"/images/qtq80-CxRwk9.jpeg\" /></figure>\n\n\n### What is Value-Based Care?\n\n\nValue-based care (VBC) is a relatively new approach to healthcare payment. It generally means that medical professionals assume financial responsibility or \"risk\" for the quality of care they provide. This differs significantly from fee-for-service (FFS), where providers focus on performing discrete tasks well. In FFS, providers manage their reputation, but they receive the same payment regardless of readmissions or complications in the care they provide. They also rarely address issues beyond the medical scope, such as transportation, housing, or mental health.\n\n\nThere are numerous value-based care financial models. Most commonly, they take the form of combining many services into one \"bundled payment\" (such as combining preparation, surgery, and follow-ups for a knee replacement), shared savings, or partial and then full risk (sometimes called \"capitation\"). Risk approaches are unique since the provider organization can lose money if a patient's costs exceed their estimate. When calculating cost in a risk agreement, medical providers and insurance companies negotiate whether to include the costs of physicians, specialists, emergency visits, and pharmacy.\n\n\nOne challenge with shared savings and risk contracts is that they incentivize providers to lower costs - which could potentially lead to (illegally) denying or discouraging services in the short term. To counteract this incentive, most value-based contracts span 3+ years, which would penalize such behavior if it increased costs later. In practice, most value-based care providers focus on reducing emergency room utilization in favor of more frequent and longer primary care or social needs-focused visits. An ED admission costs approximately $2,200 in NYC (Gottlieb et al., 2018), and those resources could fund many hours of specialized in-home services.\n\n\n> Quality measures are another way the health system ensures baseline care. These quality measures might include requirements such as \"[ensure each patient diagnosed with diabetes gets their A1c level checked every 12 months](https://mdinteractive.com/mips_quality_measure/2021-mips-quality-measure-001).\" Quality measures are updated annually to prevent providers from gaming the system. However, [their effectiveness remains unclear](https://chqpr.org/downloads/Why_Quality_Measures_Do_Not_Measure_Quality.pdf).\n\n\n**Why Not Fee for Service?**\n\n\nA relatively healthy individual we cared for at Cityblock averaged 15-20 emergency visits per month (one every other day) and had not seen a primary care doctor in many years. On the other end of the utilization spectrum, I recently scheduled an appointment with my primary care physician, and the next available slot was three months out. On the day of the visit, I took approximately two hours off work to see the doctor for about 8 minutes and pay a $75 copay.\n\n\nMost readers may not frequently visit the emergency room, but many relatively healthy people do. The ER effectively functions as an as-needed, accessible medical service. People who cannot take time off work, wait months for an appointment, or afford copays rationally use the ER when they need medical attention or are concerned about a health issue.\n\n\nValue-based care attempts to better meet people's needs and align incentives among patients, providers, and insurance companies. I believe this is best achieved when providers develop deep relationships with their patients and act proactively rather than reactively.\n\n\n### The Value Journey\n\n\nVBC tools support several key stages of the patient-provider relationship. In simplest terms, a provider reaches out to patients, actively listens to them, and then helps them achieve their goals. The process typically includes:\n\n- **Outreach**: How can we identify and initiate conversations with our patients?\n- **Knowledge and Trust Building**: How can we learn more about the actual challenges this patient faces? How can we deepen our relationship to establish two-way communication?\n- **Population Management:** What interventions can we implement today to reduce the likelihood of more intensive interventions later? What is the most critical intervention for the person who needs it most?\n\nA patient will move between these three areas of focus, sometimes in reverse order, such as when a first visit doesn't go well and the provider needs to try another approach to build trust.\n\n\n### The People Doing the Work\n\n\nUnderstanding the people caring for patients and their responsibilities is essential before considering technological solutions. People first.\n\n\nA significant insight of the value-based care model is that complex care management requires establishing a trusted contact with the patient separate from individual medical or behavioral specialists. A trusted non-medical contact can provide extended, meaningful visits and higher-quality care at lower costs by serving as the \"quarterback\" of a broader team of experts.\n\n\nThe \"quarterback\" of the care team (a group collaborating to care for an individual patient) can be a community member who manages the relationship with the patient. They provide trusted referrals to and seek guidance from a team of specialists and a network of community organizations. These specialists may participate in a care team that meets daily. The medical and social needs specialists may co-lead a daily care team meeting or \"huddle,\" but at the patient level, they are typically brought in to address specific issues and/or co-develop a forward-looking care plan with the \"quarterback.\"\n\n\nIn terms of relative scale, the \"quarterback\" may focus on approximately 20 patients, while a specialist like a social worker may serve around 100 patients (NOTE: there is considerable variance here - sometimes the quarterback may manage 100+ patients).\n\n\n**Brief Role Descriptions:**\n\n\n<u>Community Health Partner / Quarterback</u>\n\n- Foster lasting relationships as the face of the team and key point of contact\n- Help patients achieve their goals, identify new needs, and coordinate care\n- Collaboratively manage care for a population living with complex medical and behavioral health needs\n\n<u>NP/PA, RN, and PCP</u> (NOTE: These are very different roles but all focus on medical operations)\n\n- Co-manage a panel of complex patients in a value-based care environment\n- PA/NP: Provide comprehensive care management, chronic disease management, urgent home-based and community-based primary care visits, preventative care, and wellness. Work with relevant providers regarding behavioral health and other specialties\n- PCP: Diagnosis, treatment, counseling, medication management, acute triage, and follow-up care\n\n<u>Social Worker / Behavioral Health / LCSW</u>\n\n- Coordinate treatment plans, perform psychotherapy, support medication management, etc.\n\nOther team members may include lawyers, transportation specialists, benefits specialists, and more.\n\n\nBeyond the care team, broader management roles exist, such as Medical Directors and Care Management leaders who oversee multiple care teams to ensure quality, compliance, and consistent care models. On the business side, Market Operations professionals analyze entire geographic areas and think strategically about staffing levels, patient populations, community partnerships, and physical resources like clinics or equipment.\n\n\n<figure><img src=\"/images/Screen_Shot_2022-07-02_at_16.48.16.png\" /></figure>\n\n\n**Tech Fluency of Staff**\n\n\nWe've briefly examined roles and responsibilities, but it's important to note that healthcare professionals typically use very different tools than office workers. Regarding technological experience, it's generally safe to assume these professionals:\n\n- Are adept at using various complex tools and finding workarounds\n- Don't prefer using iPads for work (a note to every digital health startup)\n- Share tips and tricks with each other verbally\n- Have limited experience with Slack/Teams/Discord\n- Have limited experience with GSuite for documents or calendar management (most medical professionals have administrative staff manage their calendars)\n- Are comfortable with email but follow different communication norms\n- Are comfortable with texting or messaging applications\n\n> Organizations can hire for technological proficiency, but this doesn't necessarily correlate with job performance at scale. However, when starting small, this approach can help establish initial operations.\n\n\n### The Role of Technology\n\n\nTechnology's primary role is to put the patient first. Tech teams in this domain must rigorously manage resources and focus to provide care across multiple dimensions and address countless edge cases. They must also help the overall business iterate quickly toward a proven effective model.\n\n\nI'll discuss the extensive range of functionality in a future post, but generally, the business needs far exceed the team's capabilities, at least initially. This leads to numerous discussions about whether to build, buy, integrate, or outsource solutions.\n\n\nAs a general principle, you should build solutions that are unique to your company and core to your model - areas where you'll need to iterate most frequently. Everything else can be outsourced, purchased, or obtained through partnerships. However, if you cannot find a partner that meets your quality and speed requirements, it may make sense to bring that capability in-house.\n\n\nHere is a diagram illustrating this approach:\n\n\n<figure><img src=\"/images/Screen_Shot_2022-07-02_at_18.22.10.png\" /></figure>\n\n\nIn software design, I often emphasize \"optimizing for flexibility\" and building systems that are easy to modify safely. Ease of modification is far more important than code execution speed. Business realities change continuously. Areas that were not core may become essential, and unique aspects may become less distinctive as the competitive (and political) landscape evolves.\n\n\nWhile tech teams must creatively address all business needs, in-house teams should focus on areas that are both unique and core to the business; otherwise, your attention will be spread too thin to provide differential value and meaningful innovation.\n\n\nThose <u>unique and core</u> tools may include:\n\n- Solutions for selecting, prioritizing, and matching patients with providers (\"Which patients can we help?\" \"Which providers should see them and how often?\")\n- Tools providers use in the field (mobile apps/websites)\n- Tools that management uses to make informed market-level decisions (reporting dashboards)\n\nAreas that are <u>core but less unique</u> might include:\n\n- Identifying quality gaps\n- Scheduling - though the quality of external tools may be insufficient\n\nAreas that are <u>not core but unique</u> might include:\n\n- Reports for external partners\n\n# The Future of Value-Based Care Tools\n\n\n<figure><img src=\"/images/Screen_Shot_2022-06-25_at_09.21.21.png\" /></figure>\n\n\nValue-based care demands a great deal from providers, who urgently need new tools in this environment.\n\n\nI believe the future of EHRs will involve a bifurcation between teams focused on volume and those concerned with value. This is illustrated in the chart above, where providers assuming risk require more sophisticated tools for data collection, analysis, and planning compared to those handling fee-for-service.\n\n\nBeyond performing their jobs effectively, value-focused teams must anticipate future needs and actively engage patients (rather than waiting for them to schedule appointments). Value-based care tools should help care teams manage relationships with their patients and plan proactively to maintain trust and reduce the risk of adverse outcomes.\n\n\nFrom this perspective, the ideal solution begins to resemble a sophisticated CRM platform like Zendesk or Salesforce rather than a traditional EHR.\n\n",
    "section": "All",
    "author": "Brennan Moore"
  },
  {
    "id": "1e249a3d-5355-4382-aa8f-b51fc940ab2e",
    "title": "Learnings from building Kelp: Getting people the information they need when they need it is hard!",
    "slug": "learning-from-kelp",
    "excerpt": "Reflections on pausing the contextual recommendation tool, Kelp, concluding that its goal—getting people the right information at the right time—is nearly impossible for a third-party app to achieve. The core problem is technical: without deep, OS-level access to user data and behavioral signals, recommendations remain mediocre. True contextual help must be built into the operating system itself. The key business takeaway was the need to solve a highly specific, paying use case for a narrow audience before attempting a broad, cross-platform solution.",
    "coverImage": "Screen_Shot_2021-12-27_at_22.17.12.png",
    "date": "2022-04-30",
    "content": "\nI've decided to temporarily halt progress on Kelp and take [a job](https://www.akitasoftware.com/blog-posts/joining-akita-to-build-the-observability-solution-i-wish-i-had). Why? What did I learn?\n\n\nMy goal with Kelp was to build a tool that \"gets people the information they need when they need it.\" Hitting that goal proved more difficult than anticipated!\n\n\nWhy? Recommendations are a multi-sided challenge. Kelp needs three things:\n\n1. Access to the information to be recommended\n2. Signals for when to recommend information\n3. A UI for presenting recommendations\n\nFor step one, we need to cross boundaries from native apps (like Chrome, Safari, or Messages) and API-driven tools (like Gsuite or MS Teams). Even with modern APIs, there are gaps in this data, leaving an \"uncanny valley\" of recommendations.\n\n> At best, Kelp can combine \"meh\" information with \"meh\" signals into a fantastic UI.   \n> Meh times meh is still meh.\n\nFor example, Kelp cannot compete with features like Safari's recommendations that pull from Messages. Kelp does not have access to links from Messages and cannot present recommendations on both mobile and desktop browsers on iOS.\n\n\n<figure><img src=\"/images/Screen_Shot_2021-12-27_at_22.17.12.png\" /></figure>\n\n\nFor my users, Kelp was always missing some integration or they had a unique workflow that I didn't handle.\n\n\nAs a solo-preneur, I found myself iterating more on integrations than on the core product.\n\n\n## What does the future hold?\n\n\nI believe there is still space for a tool that provides contextual recommendations. We need less focus on helping people buy things they don't need and more on helping people be their best selves.\n\n\nHowever, with advertising dollars so close, contextual recommendations haven't yet had \"big tech\" dollars thrown their way. There are no tools that actively help us maintain relationships with friends ([clay.earth](https://clay.earth/) is perhaps the closest), prepare for work meetings, or find things based on context clues instead of keywords (e.g., \"what was that book Nicki sent me?\").\n\n\nI'm not sure what the future holds, but I do want to reassess Kelp's optimal location (browser, desktop, or mobile) and how to best package it as a product (including questions around privacy importance).\n\n\n## How might Kelp fit in with other tools?\n\n\nKelp does not exist in isolation. It's part of a broader ecosystem of \"personal information management\" tools. Looking at the space overall is helpful for understanding potential positioning.\n\n\nNOTE: Similar to Kelp, these tools suffer from limitations of upstream APIs.\n\n\n### Digital personal assistants\n\n\nDigital personal assistants have finally escaped the legacy of Clippy—only to run headfirst into the briar patch of call centers and support chatbots. As a result, consumer-facing digital personal assistants don't feel like an enjoyable \"premium\" experience.\n\n\nSome digital personal assistant startups targeted meeting scheduling (e.g., [x.ai](http://x.ai/)). Today we have Doodle, Calendly, and native functionality in mail/calendar apps that provide better UX around this messy transaction. It turns out that's all we really needed.\n\n\nWhat about voice-based personal assistants? Even with massive technological achievements, Alexa, Google Assistant, and Siri still remain [far behind](https://twitter.com/klivdahl/status/1475220450598924297) the prickly assistant in the [Knowledge Navigator demo](https://youtu.be/9bjve67p33E).\n\n\nThe major issue they face is that the UX for a digital assistant is not clear or easily discoverable. A good product clearly sets expectations and then meets (or exceeds) those expectations. Digital personal assistants struggle to clearly indicate their possible behaviors, and as a result, people use them for a few narrow use cases they discover during initial usage. [[ref](https://mashable.com/article/amazon-alexa-usage-drop)]\n\n\nI believe the future of digital personal assistants lies in helping us navigate messy transactions. For example, in healthcare, chat UIs are meaningfully less frustrating than trying to actually visit your PCP. As a result, within that narrow scope, human-augmented chatbots are performing quite well for many digital health businesses.\n\n\n### The 'command line' for your life\n\n\nThere is significant hype in the \"command line\" space, but none have achieved mainstream adoption yet. Many will remember [Greplin](https://techcrunch.com/2013/10/02/cue-greplin/), and now we have [Raycast](https://www.raycast.com/) and [Searchable.ai](https://www.searchable.ai/). Similar concepts with different implementations.\n\n\nMy hypothesis is that, similar to voice UIs, the interface for a command line is not easily discoverable. People will do some exploration when they first use the tool but rarely explore further. As a result, these will primarily serve the \"optimizer\" crowd. However, this audience is growing and has purchasing power. Expert tools can be viable businesses today.\n\n\nHowever, I believe the optimal UI for most tasks is direct manipulation—accurate and immediate. Command line tools sacrifice directness for the efficiency of hotkeys. For most people, correctness and control are more important than efficiency.\n\n\n### End user programming\n\n\nEnd user programming is the concept that users should be able to write programs to perform simple repetitive tasks. Apple and Google smart home apps are probably the widest distribution of this idea. People can create rules such as turning off lights when they leave the house.\n\n\nThis space faces challenges since it's easier than ever to simply learn to code. The segment of people who both have a problem that programming could solve but don't want to learn to code is relatively small. While \"if this then that\" has entered common parlance, spreadsheet-like solutions remain dominant, and \"no code\" solutions are evolving around narrower verticals (like smart homes).\n\n\nAs a result, there is no mass-adopted solution for programming behaviors across all apps ([Apple Shortcuts](https://nick.comer.io/post/ios-shortcuts) might be the closest), and perhaps that's acceptable.\n\n\n### \"Desktop 2.0\" (or 3.0?)\n\n\n<figure><img src=\"/images/obsidian.png\" /></figure>\n\n\nThe \"networked thought\" model popularized by Roam Research and Obsidian promotes linking information not by \"app\" or \"folder\" but by [keyword]. What if this approach could extend to our entire desktop? Our files, web pages, and emails would be linked together like in Roam/Obsidian (minus all the [braces] and pound signs).\n\n\nWhile this solution might interest some users, it omits most social interactions and information that is passively rather than actively tagged by users.\n\n\nMy hypothesis is that the next iteration of the desktop will center on people instead of apps. This new OS would extract data from apps (mobile) and files (desktop) via a global identity platform.\n\n\nAs Meta moves to capture a higher percentage of people's time while navigating around Apple's ad blockers, I anticipate this becoming a major battleground in the next decade.\n\n\n### Summary: The future is contextual recommendations\n\n\nI believe contextual recommendations need to be built seamlessly at the OS level to be effective, but as an independent developer, I lack the influence to effect this change.\n\n\n## What did I learn from a business perspective?\n\n\nFind a small use case that people will pay for first.\n\n\nI should have conducted more thorough diligence on identifying specific customers with very specific needs. My target user group—people managers and individual contributors at startups with too many meetings—was too broad. Each individual uses their own set of tools (Gsuite, Notion, MS Office, etc.), and teams share information differently.\n\n\nI wanted to create a cross-tool solution, but there's value in a more focused approach like \"we make Google Docs more efficient\" rather than \"we help you manage your team's information.\"\n\n\nI also learned that it's practically impossible to monetize Google Chrome extensions, so I should have abandoned that approach sooner.\n\n\n## Last but not least: Open sourcing Kelp!\n\n\nI hope the tool proves useful to future innovators in this space. You can [check it out on Github](https://github.com/zamiang/kelp).\n\n",
    "section": "All",
    "author": "Brennan Moore"
  },
  {
    "id": "adf01aca-d32c-48d9-8fca-50d5e6f137b3",
    "title": "Learning from a Hyper-Growth Startup",
    "slug": "learning-from-hyper-growth",
    "excerpt": "This reflection on leadership in a hyper-growth startup argues that self-management is the most crucial skill. Management in such a chaotic environment is inherently reactive and emotionally draining, not strategic and proactive. The key to effectiveness is to abandon \"ruinous empathy\"—the futile attempt to please everyone—and instead fiercely conserve personal energy for high-impact moments. This is achieved by accepting failure and tradeoffs as constant, communicating them transparently, and focusing on maximizing success in key areas rather than fighting every fire.",
    "coverImage": "textures.jpg",
    "date": "2021-10-25",
    "content": "\nI was the first engineer and 3rd employee at a company that grew from a problem statement to a team of [over 550 people with a $1.3B valuation in 3 years](https://cityblockhealth.medium.com/investing-in-health-justice-734a62ba0129). Over that time, I moved from being the only engineer to managing managers and leading a team of ~22. What did I learn?\n\n\nIt surprised me how challenging it was to maintain my identity amid the pressures of hyper-growth. Today, I'm \"battle-hardened\" and want to share some lessons in striving to be my best self in that chaotic environment. I learned about the power of strong relationships with teammates and how to ask effective questions to diagnose problems across teams. But first and critically, I learned about managing yourself.\n\n\nThese insights are difficult to deliver in a narrative format, so I've divided this post into several sections:\n\n- [Managing yourself](/adf01acad32c48d98fca50d5e6f137b3)\n- [Managing the team](/adf01acad32c48d98fca50d5e6f137b3)\n- [References](/adf01acad32c48d98fca50d5e6f137b3)\n\n<figure><img src=\"/images/_DSC0134.jpg\" /></figure>\n\n\n# Staying in Your Manager Mindset\n\n\nFew individual tasks as a manager are difficult on their own. However, there are numerous areas requiring focus, and you need to conserve your energy for tasks that carry a heavy burden.\n\n\nManagers are humans placed in positions of power, and they often struggle with how to use that power [[ref](https://twitter.com/polotek/status/1447345526408577024)]. Teammates, also human, become frustrated by organizational issues affecting their happiness, such as career growth and compensation. They are uncertain how to address these frustrations and consequently direct them toward their manager. Resolving structural issues takes quarters or even years—time that direct reports don't feel they have. As a result, managers end up expending much of their energy setting expectations and managing frustrations. This leaves little capacity for addressing systemic issues or leading major initiatives.\n\n\nFor me, the dissonance between what I wanted to accomplish and what I was actually doing made it difficult to fully focus on the task at hand. The emotional and personal challenges were substantial. I recall a low point where I hadn't slept for days and resorted to drinking half a bottle of NyQuil. Still sleepless, I went to the gym for an hour and then continued working a full day. Regular exercise and peer networks like [Orbital NYC](https://orbital.nyc/) were invaluable during recovery.\n\n\nI envisioned management as a series of deliberate actions toward accomplishing significant objectives. In reality, the opposite often occurs. Management is frequently reactive, and major decisions carry substantial emotional weight. At a high-growth company like Cityblock Health (where in year two, staff increased from ~20 to ~140), management constantly lags behind, and emotions run high.\n\n\nSeveral critical practices helped me maintain the manager mindset:\n\n- Align your expectations with reality. Expect change [[ref](https://www.zamiang.com/writing/theory-of-change)].\n- Confront failure and performance issues directly.\n- Manage your energy. Do not work if you lack the necessary focus. You cannot easily reverse management mistakes.\n- Prioritize sleep. The challenges will remain tomorrow, but you'll be better equipped to address them.\n\n### 💣 Confront Failure\n\n\nClearly communicate what you can or cannot accomplish and help others do the same.\n\n\nDiscussing failure is emotionally challenging for achievement-driven individuals (and for most people). It becomes easier once you recognize that everyone experiences failure. Failure is the environment we all navigate. We make tradeoffs, and every tradeoff disappoints someone somewhere—identify where and plan accordingly or communicate about it openly.\n\n\nI attempted to minimize the number of people I disappointed, but this approach took a significant toll (['ruinous empathy'](https://www.radicalcandor.com/stop-ruinous-empathy/)). I often arrived at compromise solutions that left everyone somewhat dissatisfied.\n\n\nNow, rather than treating tradeoffs as harm mitigation problems, I concentrate resources in areas that are working well to maximize success. Success isn't about trying to win every battle but setting early expectations about which battles you expect to win and communicating those priorities clearly. I like to say that \"we are always experiencing failures but never a failure.\"\n\n\nLater in this post, I discuss goals. Helping your direct reports become comfortable discussing their near-term objectives and supporting them when they fall short is essential. When you model the practice of discussing your goals and failures in team settings, those same conversations with your direct reports become more natural.\n\n\n### 🍃 Energy Conservation\n\n\nI initially thought that when people encounter difficult problems, they would read, research, and thoroughly discuss potential solutions. However, the reality is that you often have just three minutes in a meeting before needing to move on.\n\n\nSmall, quick wins accumulated day after day are how you build something great. Managing your energy so you can fully engage during those critical three-minute windows is essential.\n\n\nAn effective manager of managers can have a substantial impact with minimal energy expenditure. This requires quickly mapping prior experiences to new challenges. For me, writing this post (and others) helps ensure these lessons remain accessible, allowing me to retrieve them efficiently even during low-energy periods.\n\n\n<figure><img src=\"/images/_DSC0015.jpg\" /></figure>\n\n> \"I have yet to see any problem, however complicated, which, when you looked at it in the right way, did not become still more complicated.\" [[ref](https://quoteinvestigator.com/2015/06/15/complicated/)]\n\n# Helping the Team\n\n\nLong ago, I learned that my job as a manager is to help others accomplish \"the right work.\" I've tried numerous approaches to bring the right people together, adjusted meeting cadences, and refined approval processes to provide teams with necessary information and business drivers. Yet I often wondered if anything was working.\n\n\nA significant aspect of managing across multiple teams is the ability to quickly assess long-term projects and the personal dynamics within them. With accurate information, finding solutions is often straightforward. However, obtaining accurate information is simultaneously simple and extraordinarily difficult.\n\n\nUnderstanding teams and active projects requires asking uncomfortably basic questions. Ideally, ask as someone who genuinely wants to help (building trust and psychological safety are key) rather than as a leadership figure conducting an interrogation that prompts defensive or inaccurate responses. It also requires persistence in ensuring work aligns with business objectives and that technological investments are strategic rather than \"promotion-driven\" [[ref](https://twitter.com/gergelyorosz/status/1442162670753431559?lang=en)].\n\n\nRegarding what questions to ask, I find these factors for effective collaboration from [Camille Fournier](https://twitter.com/skamille/status/1304889995040362496?ref_src=twsrc%5Etfw%7Ctwcamp%5Etweetembed&ref_url=notion%3A%2F%2Fwww.notion.so%2Fbrennanmoore%2FSpinning-Learning-from-hyper-growth-c3cf6a1f6f96440bb87c8c47e0f88d83) valuable for evaluating teams and projects:\n\n- Are you communicating effectively with one another?\n- Do you know where you are going?\n- Do you know how you are getting there?\n- Do you know how to determine if you are making progress?\n- Have you done the work to ensure your team can actually accomplish their tasks?\n\n### ⚽️ Goals\n\n\nTo gain a higher-level perspective on organizational activities, many companies establish formal goals. Until recently, I had never worked in an organization with a formal goal-setting process. Previous companies focused more on delivering specific deliverables by specific dates. Goals require more nuance.\n\n\nThe process I recommend is to spend a few minutes in 1:1 meetings writing 2-3 objectives you plan to accomplish in the next 30 days. Begin by \"working backward\" from the impact of the work. Ask, \"What impact do you want this project to have, and how will you measure that impact?\" Set the impact as the deliverable rather than the feature itself, and agree on a target date. After several impact-driven meetings, you can introduce the SMART framework to evaluate whether each goal is:\n\n- Specific – targeting a specific area for improvement.\n- Measurable – quantifying or at least suggesting an indicator of progress.\n- Achievable – possible to accomplish within the timeframe.\n- Realistic – stating what results can realistically be achieved given available resources.\n- Time-related – specifying when the result(s) can be achieved.\n\nI prefer maintaining a somewhat informal approach, mentally referencing the SMART methodology while helping team members set ambitious but achievable goals.\n\n\nAlthough my team members and I often fell short of our goals, this process enhanced our ability to anticipate obstacles and enabled us to prioritize projects that addressed those obstacles. Additionally, it provided quick performance feedback that we could promptly deliver to team members\n\n\n# References\n\n\n## 🧘 My Personal Practices\n\n- Develop a hobby or personal practice completely disconnected from work.\n- Build a network of peers you can consult for advice (and whom you support in return). [[ref](https://www.get-merit.com/)]\n- Identify memorable principles to ground you.\n- Expect to encounter significant pressure. That is normal. Practice pushing back by listening and asking questions, not by being negative or defeatist.\n- Read management literature but recognize that reality is messier than theory. Consult peers at your company rather than relying solely on internet advice. This will help you better understand their leadership style.\n- Build psychological safety and allow space for venting, but then guide teammates toward constructive action [[ref](https://larahogan.me/blog/bring-solutions-not-problems/)].\n- Identify aspects of your work that bring you satisfaction and fulfillment.\n- Leadership involves creating a compelling narrative that engages people. Validating team members' experiences, demonstrating vulnerability, and maintaining transparency are valuable but insufficient for leadership.\n\n## 🗝 My Core Values\n\n- The two things that matter are people and performance—in that order. [[ref](https://fs.blog/knowledge-podcast/doug-conant/)]\n- Lead through positivity.\n- Be a source of unwavering consistency.\n- Relationships are long-term investments; projects are short-term endeavors.\n- Make myself redundant and create opportunities for others.\n\n## 📚 Resources\n\n- [The Manager's Path](https://www.goodreads.com/book/show/33369254-the-manager-s-path)\n- [The Making of a Manager](https://www.goodreads.com/en/book/show/38821039-the-making-of-a-manager)\n- [Accelerate](https://www.goodreads.com/book/show/35747076-accelerate?ac=1&from_search=true&qid=CdR41Ztymq&rank=5)\n- [The Art of Leadership: Small Things Done Well](https://www.goodreads.com/book/show/50083106-the-art-of-leadership?ac=1&from_search=true&qid=xomeEQMhqN&rank=1)\n- [The Manager's Handbook](https://themanagershandbook.com/)\n- [A curated list of articles and tips](/7a4ed588ece991c92b1ffafc26aa772f)\n- A CTO job description written in [simple affirmative statements](https://stanete.com/my-CTO-job-description)\n- Hypertext 1:1 questions [[ref](https://hypercontext.com/)]\n",
    "section": "All",
    "author": "Brennan Moore"
  },
  {
    "id": "7475049c-49b3-4068-814e-a5aaf37a5e78",
    "title": "Is Buying in Brooklyn Worth It?",
    "slug": "is-buying-worth-it",
    "excerpt": "Brooklyn homeownership is not \"worth it\" as a financial investment. After accounting for renovation costs, high transaction fees, and the opportunity cost of not investing in the stock market, my profitable-on-paper sale was actually a financial loss. The true costs were the non-financial headaches: months of living in construction dust, battling city bureaucracy over permits, and fixing bank errors over property liens. I conclude that you buy a home not for the return, but for the control and satisfaction of making a space your own.",
    "coverImage": "Screen_Shot_2021-10-19_at_15.43.47.png",
    "date": "2021-09-29",
    "content": "\nThe stories I've read about apartment ownership were either crude financial analysis or clean NYT real estate fluff. My story is neither. In reality, no matter how nice and clean your apartment is, buying and selling an apartment is MESSY.\n\n\nI bought an apartment in Park Slope for $700K, renovated it, and sold it for $815K three years later. With $175K down, I made a 60% return. But, including the renovation costs, lawyers, permits, and agent fees, was it 'worth it'?\n\n\n## How did the renovation go?\n\n\nI don't want to detail the whole renovation process, but it was both stressful and satisfying. Before on the left; after on the right.\n\n\n<figure><img src=\"/images/Screen_Shot_2021-10-19_at_15.43.47.png\" /></figure>\n\n\n## Home ownership and sale costs (rounded)\n\n\nIf you are curious about the various costs that come into play, below is a summary of the major expenses for buying, owning, and selling an apartment.\n\n\n## Rent vs. buy calculation\n\n\nBelow you can see that renting was $38,000 more expensive than buying. However, if I had invested my down payment and renovation money in the stock market, renting would have been $100K cheaper!\n\n\nOwning property has tax benefits, but they are complex. You can deduct [mortgage interest](https://www.rocketmortgage.com/learn/mortgage-interest-deduction) from your federal taxes. If your existing deductions already push you into using the itemized deduction, this can be beneficial on your federal tax return. However, if you have few deductions and use the standard deduction, the mortgage deduction is less beneficial since the standard deduction is already quite high. You can technically also deduct property taxes, but if you can afford property in NYC, [you probably can't](https://yoreevo.com/blog/how-badly-will-tax-reform-impact-nyc-real-estate) deduct property taxes in NY. If you are curious about tax savings, consult with a CPA.\n\n\nIn my case, I received about $20K of tax savings from owning property.\n\n\n# The price of money\n\n\nThe S&P returned 56% over the term of my mortgage. That would have turned my $175,000 down payment into $273,000. After 20% capital gains tax, I would have made $78,000. That profit would have covered renting an apartment twice the price of a comparable rental.\n\n\nWhen people discuss why home ownership may not be the best investment, they refer to the 'opportunity cost of capital.' In this instance, while buying was about $38,000 cheaper than renting a comparable apartment, I missed out on significant stock market gains. The opportunity cost only increases when you incorporate other upfront costs like the cash required for renovations or place some value on your time.\n\n\nAs you can see in the real estate agent fees and the flip tax above, the transaction costs for selling an apartment are high. In addition to those fees, selling takes time. The current estimate is 5 months from listing to closing and receiving funds from the sale.\n\n\nUnfortunately, the opportunity cost was not the only expense I incurred.\n\n\n## Non-financial costs: Dust\n\n\nFor at least 6 months out of the 3 years, I was living in a construction site.\n\n\nThere were three major projects: initial renovation, replacing the stairs, and replacing the heater cover.\n\n\nWith each project, there was preparation for construction, the actual construction, and then attempting to remove as much dust as possible. You live with construction for much longer than the construction actually takes. In a large house, you might have an extra room or outdoor space for using power tools. In NYC, if you can afford an extra unused room, you can probably afford to live somewhere else while the construction is ongoing.\n\n\nSince we were not able to do much ourselves, we saved costs by doing the finishing work (sanding, painting, and staining).\n\n\nIt is difficult to quantify the cost of being surrounded by dust and construction for 6 months, but it is an inconvenience that would be unusual in a rental.\n\n\n## Non-financial costs: Permit me not\n\n\nWhen I moved in, there was an electrical box in the apartment from 1986. Today, it is considered a fire hazard, so I hired an electrician to replace it. They replaced the box for $2,200 and permitted the job with the DOB (Department of Buildings)... but then they passed away (very sad) before closing the permit. Importantly, I could not sell my apartment with an open permit.\n\n\nThus began an epic quest to close the permit!\n\n\nI'll spare you all the details, but I went from contacting an 'expeditor' (a great job title!), navigating the \"DOB: Now\" and \"DOB: Now Inspections\" websites, to finally going into the belly of the DOB to obtain a piece of paper with an email address that I used to schedule an inspection. Unfortunately, I didn't pass the inspection and had to pay an electrician another couple thousand dollars to replace the electrical box (again), issue a permit (again), and be present for another inspection.\n\n\nOriginal work: $2,200\nFixes: $900\n2nd permit: $1,500\n\n\nTotal cost: $4,600 (and a full day navigating the DOB) to replace an electrical box—a job that takes an electrician less than 2 hours.\n\n\n## Non-financial costs: Lien on me\n\n\nOne particularly challenging issue that increased costs was discovering I had two liens on the apartment. In my mind, a 'lien' was a beverage I had heard about and would probably sip in moderation if the opportunity presented itself. In banking terms, having two liens means I owed my apartment to two banks simultaneously.\n\n\nIf I were planning financial disruption, promising my apartment to as many banks as possible and then having them fight over it would be an effective strategy for destabilizing an industry. Unfortunately, my modest $500K mortgage was not enough to destabilize the trillion-dollar banking industry.\n\n\nFor a timeline of events: I obtained a mortgage through Bank of America in 2017. During the subsequent years of low mortgage rates, I unsuccessfully tried to get them to lower my rate. Instead, in November 2020, I paid approximately $5,000 to refinance and reduce my rate from 3.75% to 2.8%, which lowered my monthly payment by $500. The second bank then sold my mortgage to a third bank after just one month.\n\n\nDuring the weeks before closing on the sale of my apartment, my lawyer conducted a 'lien search' and discovered I had two liens on the apartment. One was from Bank of America and was made out to two people—Brennan Moore and Brennan Harold Moore. I later had to prove these were the same person in a rather bizarre conversation with the bank. The second lien was to the bank I refinanced with, not the bank the mortgage was later transferred to (and to whom I made monthly payments). My lawyer was understandably confused.\n\n\nUnfortunately, I bore the consequences of this confusion, as it takes FORTY-FIVE DAYS to close a lien. This delayed the closing by a month.\n\n\nMy favorite moment was when a BofA customer service representative asked if I had a fax machine. Not thinking of e-fax services, I said 'no.' They responded, \"Oh... well, in that case, we will have to email you the documents. The email takes 3 days to arrive.\"\n\n\n## Takeaways\n\n- Be extremely cautious about permitting anything.\n- Conduct regular permit searches for your apartment.\n- Perform a lien search after refinancing to ensure the process completed correctly.\n- The real estate industry needs more efficient property transfer processes.\n\n# So... was it worth it?\n\n> I really feel it is disingenuous to call home ownership a good investment for most people.\n\nA home is illiquid (selling took 5 months!) and does not provide returns comparable to the stock market at any risk tolerance. While I owned my apartment for only 3 years, my parents purchased their home for approximately $90K in the late 80s and, after significant renovations, sold it for approximately $150K in 2018. While the value of their home grew 60%, $90K invested in the S&P in 1988 would be worth over $1.8 million today. Even a much lower-risk portfolio would have more than paid for a fantastic rental.\n\n\nIn buying a home, you are purchasing control and forcing yourself to save. The renovations I completed were dramatic. As an owner, you can undertake large renovations to accommodate working from home or fix those small annoying issues present in every rental.\n\n\nOverall, I'm satisfied with my three-year ownership experience. I learned a great deal and was able, with helpful advice from many friends and loved ones, to create a space I was truly proud of.\n\n\nYesterday, I was venting to my girlfriend about yet another fee and declared I would never own again. She stopped me and said, \"You enjoy tinkering and fixing things. Don't kid yourself that you want to rent someone else's apartment forever. You are an owner at heart.\"\n\n\n<figure><img src=\"/images/Screenshot_2025-07-22_at_22.21.45.png\" /></figure>\n\n",
    "section": "All",
    "author": "Brennan Moore"
  },
  {
    "id": "5b8c0dc9-1688-4843-ad22-c6548ed65d68",
    "title": "How to Build Trust and Foster High-Impact Teams",
    "slug": "phases-of-impactful-small-teams",
    "excerpt": "This post argues that as startups grow, the initial high-trust environment often collapses into chaos. The common leadership mistake is to push for more speed; the real solution is to slow down and rebuild trust through predictability. The author outlines a four-stage journey where a team matures by making and keeping progressively more abstract promises: evolving from committing to specific tasks (via ticketing systems), to achieving monthly goals, and ultimately, to delivering business impact measured by KPIs. This entire process is driven by retrospectives, which help a team understand its current level of trust and take the next step.",
    "coverImage": "Screen_Shot_2021-08-08_at_16.11.19.png",
    "date": "2021-08-16",
    "content": "\nThis post explores the critical component of a 'strong' team: trust. I believe building a strong team means listening for the level of trust through frequent retrospectives. The team improves by incrementally adopting practices that either build trust or leverage the team's existing trust.\n\n\nI have not joined a company that had a clear roadmap for how a team progresses from 'new' to 'strong'. Without this vision, conversations about team practices were often frustrating and left newer teams feeling attacked.\n\n\nWith a vision for how a team builds trust, we can help teams advance to the next level rather than applying uniform standards to teams at different stages of development.\n\n\n<figure><img src=\"/images/Screen_Shot_2021-08-08_at_16.11.19.png\" /></figure>\n\n\n# How Trust Is Broken\n\n\n## In the beginning…\n\n\nEarly on in a startup, you are bound together with risk-takers making a singular abstract promise - find product-market fit! For me, this is the ideal team environment, and I thrive in this kind of work. However, I have struggled to maintain this creative, high-trust environment as the startup achieves success.\n\n\n<figure><img src=\"/images/Screen_Shot_2021-08-08_at_16.09.14.png\" /></figure>\n\n\n## The fall…in velocity\n\n\nIf the startup succeeds, the team will quickly transition into an environment with minimal trust.\n\n\nNew teams with new stakeholders, new team members, and shifting business needs all work to erode trust. The team has plummeted from the best kind of team to the most challenging kind of team.\n\n\nThe team was soaring, shipping at the speed of light. Now, the team is climbing the Rocky Mountains with people they barely know from Zoom meetings.\n\n\nThe team has lost trust. Teams can no longer agree on what to promise, who to make promises to, or why they are making promises in the first place.\n\n\nLeaders mistakenly push these dysfunctional teams to move faster, but at this stage, you need to slow down. Instead of focusing on 'iteration speed' or 'quality', the first challenge is to build trust between stakeholders, leads, and collaborators.\n\n\nTrust is about predictability and **not** velocity.\n\n\n<figure><img src=\"/images/Screen_Shot_2021-08-08_at_16.09.54.png\" /></figure>\n\n\n# How to Build Trust on Teams\n\n\nWe build trust to handle bigger challenges. To collaborate effectively, teams make promises to other teams and then keep those promises. Making and keeping promises allows groups of people to depend on one another.\n\n\nAs a team matures, it can evolve from making specific promises (e.g., \"we will build you this exact API endpoint by next sprint\") to more general promises (e.g., \"we will help you solve your data access problem this quarter\"). More general promises can have greater impact at lower cost by allowing the team more creative freedom and encouraging deeper collaboration (i.e., understanding the business need).\n\n\nWe build trust to handle bigger challenges.\n\n\nThis trust-building process is broken into four stages. In each stage, the team makes incrementally more abstract 'promises' to the business (and each other) and then builds trust by delivering on those promises. The four stages of trust are:\n\n1. No trust: Functional chaos\n2. Some trust: Measurement and ticketing _(think: Jira and burn-down charts)_\n3. Strong trust: Goals _(think: multi-month projects delivered on time-ish)_\n4. Deep trust: Impact _(think: KPIs and quarter-level projects moving business metrics)_\n\n## Kickoff: Retrospectives\n\n\nBefore starting out, the team must arrive at a shared understanding of the present reality and then align expectations about what will happen in the future. This is where the 4 stages of trust come in.\n\n\nMuch like setting off on the Oregon Trail, take stock of the team and resources, plan for the challenges ahead (dysentery!), and then embark on a journey toward a known destination.\n\n\nThe team should be able to start the journey knowing they are on the same page as leadership.\n\n\nRunning great retrospectives shouldn't hold you back from running retrospectives at all. You can't learn if you don't share. In general, retrospectives should capture what went well, what didn't go well, and other notable events. It helps to have someone who can energize the event to maintain high participation. Once things are going well, I highly recommend occasionally inviting stakeholders to see how you work.\n\n\nIf you would like to learn more about running retrospectives, here are a few resources I found helpful:\n\n- [Growing our team with retrospectives](https://plaid.com/blog/growing-our-team-with-retrospectives/)\n- [Running effective retros](http://werve.net/articles/running-effective-retrospectives)\n- I highly recommend using [EasyRetro](https://easyretro.io/) to facilitate the process\n\n<figure><img src=\"/images/Screen_Shot_2021-08-08_at_21.25.48.png\" /></figure>\n\n\n## 1 - No trust: Functional Chaos\n\n\nA lot of work is happening, but the promised work rarely gets done. It is unclear if the work being done is the 'right' work or whether it is having any impact.\n\n\nI had a new manager join the team who said, \"this is not a lean team, this is an emaciated team.\" She was right. Each team member individually managed multiple pieces of infrastructure and had no real metrics for success. Sprints were difficult to predict since the scope was too large and the number of stakeholders was staggering. The team was highly motivated to get things working, but that left team members scrambling to put out fires, rarely documenting work or making their efforts visible to the PM or their manager. Engineers thought they were working at peak efficiency, while stakeholders thought nothing was getting done—a terrible situation.\n\n\n**What do team meetings look like?**\n\n\nStandup feels like a waste of time since the day's plans are never realized.\n\n\n**What does success look like?**\n\n\nSuccess is being able to plan forward day over day and then week over week.\n\n\n**What are common retro topics?**\n\n\nThe team is probably not having retrospectives. If there are retrospectives, there are likely a few dominant voices expressing frustrations without seeing results.\n\n\n**What should you be doing to get to the next phase?**\n\n\nStop. Just stop.\n\n\nThe leaders need to get buy-in from the company/partners to temporarily slow the team's work. Stop hiring. Do NOT bring in external consultants or additional headcount to a team in this phase.\n\n\nThe team should have an offsite or much longer retrospective to get people talking and healing. Then, begin bi-weekly retrospectives. Bring in stakeholders to help them understand the team if they can engage productively. Ideally, the team's stakeholders can be part of the solution by finding ways to limit work in progress.\n\n\nThis is where a leader (you?) can present a more hopeful future. As mentioned above, the most important (and most difficult) challenge for the leader is to share their views with the team and then together with the team, arrive at a shared understanding of reality. Once you have that shared understanding, the team can share experiences working on 'dream teams' and the leader can help articulate that north star. Then, together, chart the path toward that north star.\n\n\nI deeply believe that the next step to repair trust between both team members and the company is the methodical practice of measurement and acting based on data.\n\n\n## 2 - Some trust: Measurement\n\n\nPeople find they cannot trust what others say, so they find a tool they can trust instead. The tool serves as an intermediary for all work.\n\n\nThis is when the team makes serious use of a planning tool like Jira (or one of the many alternatives) with estimates. User stories are added ahead of time and broken down into small units of work (tasks), and then each task is assigned and estimated.\n\n\nAs a manager on a team like this, your job is to find fun and creativity despite the rigid structure. This phase involves significant change as the team decides what to embrace and measures the impact of those changes. Those changes might include:\n\n- Get people excited about measurement by trying out a new tool ([Clickup](https://clickup.com/), or [Linear](https://linear.app/))\n- Kanban vs sprints\n- 1, 2, or 3-week sprints\n- Story points or time tracking\n- Trying a tagging system and altering the ticket structure\n- Using Slack bots and GitHub integrations to make work less monotonous\n\nStandup should be daily and conducted around the board. Before starting work, the team must break down user stories into tasks, estimate each task, and then determine what amount of work can be completed in a given timeframe. You can't fix what you can't measure.\n\n\n**What do team meetings look like?**\n\n\nTeam meetings are 90% about tickets and unanticipated blockers. People rarely reference the big-picture quarterly goals or business needs.\n\n\n**What does success look like?**\n\n\nThe team anticipates roadblocks and delivers on timelines accurately.\n\n\nIn my experience, the big 'win' at this phase is being able to successfully add people to the team. The process work is dull, but adding new energy to the team often helps this phase be more engaging.\n\n\n**What are common attributes?**\n\n\nThe team usually starts with longer sprints (3 weeks), and team planning meetings are conducted synchronously. PMs are often involved in the 'who' and the 'how' of work items as they do not yet fully trust the Technical Lead.\n\n\n**What are common retro topics?**\n\n- Unanticipated technical debt issues\n- Lack of understanding of business goals\n- Team members are brought a solution rather than a problem\n- Engineers are not effectively raising blockers or sharing setbacks in standup\n\n**What should you be doing to get to the next phase?**\n\n\nThe measurement phase is when you build the team fundamentals—the foundations of trust.\n\n- <u>Communication</u>\nEach team member needs to practice communicating in retrospectives and effectively use standup and messaging to share unanticipated changes in a productive, non-inflammatory way. Team leaders need to develop skills to be both active listeners and swift problem solvers to address unanticipated setbacks.\n- <u>Stability</u>\nIf bugs are regularly introduced or the system crashes, no one will trust the engineers who built it. Prioritize tracking system reliability metrics like 'mean time to restore' and 'change failure rate' (see: [Accelerate](https://www.amazon.com/gp/product/B07B9F83WM/ref=ppx_yo_dt_b_d_asin_title_o01?ie=UTF8&psc=1)) to prevent system stability issues from eroding trust.\n- <u>Address Technical Debt</u>\nIn addition to improving system health, the team should improve its 'internal health' by addressing factors that slow progress or add unpredictability (e.g., a flaky test suite or a stakeholder who intervenes inappropriately).\n- <u>Value each team member's time</u>\nAs the team becomes more consistent in hitting its goals, diligent estimation may not be the best use of engineer time. The team can gradually stop breaking down and estimating every individual task as a group and have engineers estimate individually as best suits their level of experience. Engineers should be able to help each other plan in less formal settings such as chat or quick pairing sessions.\n- <u>Morale</u> \nCelebrate wins as widely as possible, such as at larger department or company-wide meetings. Share progress and learnings in retrospectives—smart failures are progress, and progress builds morale.\nCelebrate 'heroes' but do not depend on them. Ensure no work done by team members goes unrecognized. If people need to go above and beyond or take on unplanned work, make sure to acknowledge it but not incentivize it (a delicate balance!).\n\n## 3 - Strong trust: Goals\n\n\nAt this point, your team should have strong fundamentals. The PM and tech lead need to excel at communicating the business context, user stories, and/or project documents in whatever form works best for the team (tickets, slide deck, documents). Individual contributors should be skilled at asking questions and flagging blockers. The team should collaborate using 'blame-free' and supportive language. The infrastructure and tooling should be reliable enough to support frequent deployments and have sufficient test coverage and/or monitoring so that developers can build reliable software.\n\n\nWith those fundamentals in place, the work can become more creative. Rather than building to a specification and breaking down all tickets far in advance, the team is trying to address a user story or business need. The team should have the trust to ship experiments or small tests to see what will address the need and will likely start using feature flagging or versioned interfaces.\n\n\nPMs and stakeholders will become less involved in the 'how' and more focused on the 'what', the 'why', and metrics around 'how we will know if we hit our goal'.\n\n> _Note: This phase is easiest to achieve for teams doing 'feature work' as feature work is a notch bigger than a 'sprint'. Data teams or infrastructure teams may have many smaller projects on the order of days and then larger quarter-level initiatives. This means there isn't a clear next step up. I believe it requires a technical leader to help break these quarter-level projects down into milestones that can be 'goals', or a PM to group a set of smaller asks into a larger month+ 'launch' as a 'goal', but even so, it is challenging._\n\n**What do team meetings look like?**\n\n\nTeam meetings are 20% about tickets and 80% focused on discussion of goals, questions about different implementation tradeoffs, upcoming blockers, and improving system/usage metrics.\n\n\n**What does success look like?**\n\n\nWork should feel much more engaging. Engineers are able to think longer-term and move at higher velocity due to less ticketing overhead. PMs spend less time with engineers on the 'who' and 'how' of tickets and more time with stakeholders, socializing the next initiatives.\n\n\n**What are common attributes?**\n\n- ~2 week sprints or effective kanban\n- Less 'overhead' to running sprints (fewer group meetings and/or shorter team meetings)\n- Smaller meetings, such as a TL and PM planning the sprint\n- PMs not involved in the 'who' and the 'how' of work items but deeply involved in the 'what', 'why', and 'when'. PMs spend more time bringing engineers along.\n- TL and ICs on the team collaborate to break down work with less involvement from the PM.\n- ICs can pull from a general pool of work.\n\n**What are common retro topics?**\n\n- Our goal was not well articulated, or a shared understanding of the goal was not achieved\n- Too many meetings / meetings are too large\n- Isolation from other teams\n\n**What should you be doing to get to the next phase?**\n\n\nThis is when you start looking beyond your team. By this time, you are likely one of the stronger teams in your organization. You are delivering value quickly, but you are often still being told what problems to solve and when to solve them. You may struggle to understand how your work helps the business.\n\n\nThere is an even better way of working ahead. But it requires the business to change.\n\n\n## 4 - Deep trust: Impact\n\n\nThe major difference between this and the prior phase is that work is connected to a longer-term strategy. In each phase, the team makes progressively more abstract 'promises' to the business. To move beyond user stories, you need the business to leverage KPIs or some system that can give you direction, autonomy, and a way to measure your success. Depending on the company's stage, that may simply not be possible.\n\n\nThe KPIs need to be communicated repeatedly and remain consistent for at least a quarter so that teams understand what other teams are doing at a high level. The team alone can't make this happen; the business needs to be willing to focus on specific drivers without major distraction for an extended period. The business needs to trust the team to deliver without imposing rigid timelines.\n\n\nIn my experience, this is the hardest phase to achieve when the team is relatively close to the business. At Cityblock, one team built software for doctors who then cared for patients. If the insurance company's total cost for those patients was lower this year than last year, Cityblock made money. The time horizon and indirection make it difficult to tie success or failure to the software used by the doctors. A team that is closer to the business, like an e-commerce checkout team, or further from the business, like an infrastructure team, can have an easier time here (though they often have challenges in the 'goals' phase).\n\n\n**What do team meetings look like?**\n\n\nLarge team meetings have 0% focus on tickets, with approximately 50% focus on goals and 50% on moving metrics. There are still discussions about features, but there are more debates on how to test whether they will have the anticipated impact.\n\n\n**What does success look like?**\n\n\nKey business metrics improve significantly. Team members are involved in decision-making.\n\n\n**What are common retro topics?**\n\n- Too many meetings / meetings are too large\n- Team isn't handling tactical requests effectively\n- Metrics may not be correctly aligned with goals\n\n**What should you be doing to get to the next phase?**\n\n\nI don't have a definitive answer. I have never been able to maintain this phase for long. Often, personnel changes or shifts in business strategy reset the team to 'phase 1'.\n\n\n---\n\n\n# In Summary\n\n\nThe type of process you employ on your team is a function of the trust between team members. As a leader, you can run a more effective team that derives satisfaction from their work by meeting them where they are and working with the team to adjust processes as the level of trust changes. You can maximize your team's potential by working with them to improve trust among team members and between the team and the business.\n\n\nThe journey to rebuild trust—from 'functional chaos' to an 'impact-driven' team—is lengthy and will encounter challenges. At a high level, the journey will look something like this:\n\n1. Start regular retrospectives with a more extensive retrospective to kick things off.\n2. The team works together to predict the tasks they will complete.\n3. Team leads measure the team's delivery rate, failure rate, and track issues that block or slow progress (like technical or process debt).\n4. Reduce focus on task-level prediction and increase focus on delivering larger projects or hitting goals.\n5. Reduce focus on work delivery and increase focus on the impact of work.\n6. If the team changes significantly... return to step 1.\n\n### Key Points\n\n- Early teams commit to tasks or features, while mature teams commit to abstract concepts.\n- Rapid growth necessarily disrupts early trust patterns. ([ref](https://jchyip.medium.com/why-its-difficult-to-build-teams-in-high-growth-organisations-e1aee8446337))\n- To rebuild trust, focus on predictability, not speed.\n- The journey to rebuild trust begins with the team developing a shared understanding of the current reality and then aligning expectations about future developments. This is where the vision for effective teams comes in.\n- Grow gradually. Similar to an individual progressing from a new engineer to a team lead, the team will incrementally handle work with increasing levels of uncertainty.\n- Return to the measurement phase if the team changes significantly to reinforce fundamentals.\n    - 'Significant change' means a substantial team size change or a new leader like a TL or PM.\n    - While traditions from being a more mature team should persist and help the team quickly return to its previous state, new team members have not built the same fundamentals as the rest of the team.\n\n## References\n\n- [Tuckman's stages: Forming, Storming, Norming, Performing](https://www.mindtools.com/pages/article/newLDR_86.htm)\n- [Accelerate: The Science of Lean Software and DevOps: Building and Scaling High Performing Technology Organizations](https://www.amazon.com/gp/product/B07B9F83WM/ref=ppx_yo_dt_b_d_asin_title_o01?ie=UTF8&psc=1)\n- [Why it's difficult to build teams in high growth organizations](https://jchyip.medium.com/why-its-difficult-to-build-teams-in-high-growth-organisations-e1aee8446337)\n",
    "section": "All",
    "author": "Brennan Moore"
  },
  {
    "id": "33eb72a7-04fa-4dd0-9671-8abd450e39c4",
    "title": "What Does Working at a Successful Startup Look Like Financially?",
    "slug": "working-at-a-successful-startup-look-like-financially",
    "excerpt": "An engineer at a successful startup sold $x million in shares to diversify my wealth, only to discover afterward that they were just two months shy of qualifying for the QSBS tax exemption. This \"hidden rule\" would have eliminated their entire federal tax bill. The post serves as a cautionary tale about the immense financial cost of navigating the complex and often obscure tax laws surrounding startup equity without specialized knowledge.",
    "coverImage": "IMG_3160.jpg",
    "date": "2021-07-16",
    "content": "\n_or…how it cost me $1,000,000 to sell startup shares on the secondary market._\n\n\nAfter joining 3 startups, I was fortunate enough to help found a company that grew from 0 to single-digit billions in valuation in just 4 years. My role during much of that time was leading the engineering team. While I don't know the exact percentage of the company I originally owned, my current shares amount to approximately 0.002% of the company, worth about $X,000,000. The million-dollar question is: when converted to cash, how much money do I actually receive?\n\n\n<figure><img src=\"/images/IMG_3160.jpg\" /></figure>\n\n\n## Why Sell Some Shares?\n\n\n$X,000,000 is an unfathomable sum for someone who never really imagined making $100K/year. I grew up in a relatively modest rural area to well-educated parents. I attended public school without tutors or extensive extracurricular activities. Sundays were spent cutting coupons from the newspaper, and it took years after college to feel comfortable ordering an appetizer at a restaurant. I feel extremely fortunate about my upbringing and the resources I had access to. However, my world growing up differs significantly from NYC in 2021.\n\n\nI chose to sell a portion of my shares because the money would be transformative. I also believe having 95%+ of my net worth in a single company represents significant risk.\n\n\n## What Happens When Selling Shares on the Secondary Market?\n\n\nSelling shares on the secondary market is quite involved. End-to-end, it took 16 weeks from contacting the secondary sales company to receiving funds.\n\n\nAfter leaving the startup I helped found, I contacted my long-time tax advisor about potentially selling some shares of the company I had worked at for the past 4.5 years. I asked whether there were any tax implications I needed to be aware of when selling shares on the secondary market. He confirmed that since I had early exercised and completed an [83(b) election](https://www.investopedia.com/terms/1/83b-election.asp), the shares would qualify for long-term capital gains. Great!\n\n\nOn April 15th, I signed agreements to sell a portion of my shares totaling $2,000,000 on the secondary market (Note: this is not the actual amount). I believed this approach would preserve significant upside potential while immediately helping me live more flexibly and assist my mother in retiring. (This was [pre-tomato plants](https://twitter.com/sweatystartup/status/1405205780329078793?lang=en))\n\n\nFor transactions of my size, the facilitators take their maximum fee of 5%, which in this case is $100,000. Here is how I calculated my anticipated net proceeds:\n\n\n```html\n2,000,000 - 100,000 \nTotal after placement fee = $1,900,000\n\n1,900,000 * 0.2 (federal long term capital gains) + 1,900,000 * 0.12 (NYC state + local)\nTotal taxes = $608,000\n\n1,900,000 - 608,000\nTotal take home = $1,292,000\n\n(608,000 + 100,000) / 2,000,000\nTaxes and fees as a percent of takehome: 35%\n```\n\n\nOn April 28th, President Biden announced a tax plan where capital gains over $1,000,000 would be taxed as ordinary income, with the changes retroactive to April 28th, 2021. Unfortunately for me, the taxable event date for my sale is not when I signed the transfer agreement (April 15th) but when I receive the funds. This means my transaction, despite being initiated without knowledge of this potential policy change, would be subject to this new tax rate. With this new rate, my total taxes and fees would be:\n\n\n```html\n2,000,000 - 100,000\nTotal after placement fee = $1,900,000 \n\n1,000,000 * 0.2 (federal) + 900,000 * 0.4 (federal under Biden plan) + 1,900,000 * 0.12 (state)\nTotal taxes = $788,000 \n\n1,900,000 - 788,000 \nTotal take home = $1,112,000\n\n(788,000 + 100,000) / 2,000,000 \nTaxes and fees as a percent of takehome: 44%\n```\n\n\nThis reduces the net proceeds on a sale of $2,000,000 in stock to $1,112,000. 44% of the total is consumed by taxes and fees. However, there was nothing I could do, so the process continued.\n\n\nIn mid-July, approximately 14 weeks after signing the transfer agreements with the buyer, the funds from the secondary sale arrived in my account. This transfer occurred 4 years and 10 months after the options were initially granted to me, which I had early exercised with the [83(b) election](https://www.investopedia.com/terms/1/83b-election.asp). After the sale was complete, the company voided my prior stock grants and issued me a new grant with my remaining shares.\n\n\nMinor note: The cost basis of my shares was $0.01, so my calculations rounded down to $0.00 for calculating capital gains. State taxes are also deductible on your federal taxes up to a maximum of $10,000. Both of these factors would provide a few thousand dollars in savings.\n\n\nNote 2: I am validating these calculations with multiple CPAs.\n\n\n## Exemption!\n\n\nAround this time, a financial advisor from a large investment bank reached out via LinkedIn about helping startup employees manage their new wealth. I responded, and they informed me that my shares might be eligible for a '[QSBS tax exemption](https://www.brownadvisory.com/us/theadvisory/qsbs-tax-exemption-valuable-benefit-startup-founders-and-builders)'. Despite having researched extensively about taxes relating to startup shares and consulting my tax advisor prior to the sale, I had never heard of a 'qualified small business' tax exemption.\n\n\nThe QSBS exemption means that if you owned shares of a 'qualified small business' while the business had less than $50 million in assets and held those shares for 5 years, then up to $10,000,000 in profits are <u>completely exempt from federal taxes</u>.\n\n\nThe concept that there are additional tax exemptions beyond long-term capital gains was astonishing to me. I never anticipated the federal government would create a 100% tax exemption, so I never investigated this possibility.\n\n\nWhile the QSBS exemption benefits early-stage employees/founders, it is particularly advantageous for early-stage startup investors. It also allows individuals to [roll funds](https://www.brownadvisory.com/us/theadvisory/qsbs-tax-exemption-valuable-benefit-startup-founders-and-builders) into other investments before the 5-year mark and maintain tax exemption. For example, if you invest in an early-stage startup and sell those shares after 3 years, you can invest your money in another early-stage startup within 6 months and sell after 2 years (5 years total invested in a QSBS). These investments now avoid any federal taxes on profits up to $10,000,000 per year, allowing you to stagger sales to further minimize taxes.\n\n\nNote: There are apparently also more [controversial](https://www.propublica.org/article/lord-of-the-roths-how-tech-mogul-peter-thiel-turned-a-retirement-account-for-the-middle-class-into-a-5-billion-dollar-tax-free-piggy-bank) tax saving methods where you purchase shares with your [ROTH IRA](https://www.irafinancialgroup.com/learn-more/financial-success/start-up-founder-stock-in-a-roth-ira/).\n\n\n## How Does QSBS Apply to My Situation?\n\n\nAfter conducting research, I found that the startup appears to qualify as a 'qualified small business' and that approximately half of my shares were vested while the company had less than $50 million in assets. However, given that I sold some shares, complications arise.\n\n- If I sold half of my shares, did I sell the first half (those that would qualify for QSBS in the future) or the last half? How would I determine this?\n- Given that I now have a completely new stock grant with a new date, can any of my shares be considered as having been held while the company had < $50 million in assets?\n\nMy current understanding is that one or both of these factors disqualify me. This means none of the shares I currently own will be eligible for the QSBS exemption in the future.\n\n\n## A Stacked Game\n\n\nIn summary, I made one decision that cost me either $X00,000 (at the current tax rate) or $1,000,000+ (under proposed capital gains changes) in taxes. Given that none of my shares qualify for QSBS in the future and that taxes on my shares are 35%-44% of $X,000,000, that cost equates to approximately 1/4-1/3 of my personal wealth.\n\n\nHow does that feel? I have mixed emotions—I'm doing well financially yet feeling somewhat disappointed. It reminds me of playing a board game with someone who didn't explain all the rules beforehand. They suddenly announce, \"boom, I win; game over,\" revealing some previously unmentioned rule. Had I known about this hidden rule, I would have adopted a different strategy, but the moves have already been made.\n\n\nWith one move, I simultaneously encountered two hidden rules—a retroactive tax change and an obscure tax exemption. Had I known about either one, I would have waited or sold fewer shares.\n\n\n## What's Next?\n\n\nI was relatively advantaged in this situation and still experienced significant financial impact. I've worked at many startups and learned about the [AMT exemption](https://www.investopedia.com/terms/a/alternativeminimumtax.asp) and the [83(b)](https://www.investopedia.com/terms/1/83b-election.asp) election, which few startup employees both know about and can afford. The 83(b) election requires paying to exercise options covering 4 years within 30 days of starting a new job. In most cases, this costs tens of thousands of dollars. Even fewer understand how the AMT exemption applies to exercising startup options (consult your CPA about this). By early exercising all my shares when their value was $0.01, I was able to \"hold\" my shares as long as possible and get closer to the QSBS exemption.\n\n\nIs all this fair? I'm not certain. Many individuals have accumulated significantly more wealth by utilizing AMT, QSBS, and their ROTH IRAs in ways few understand. Complexity inherently benefits those with knowledge and resources.\n\n\nWhat I do know is that I now have both more knowledge and more financial resources than before.\n\n",
    "section": "All",
    "author": "Brennan Moore"
  },
  {
    "id": "1367e1bb-741c-4799-8297-5e82810b897d",
    "title": "Guide to Engineering Ladder Communication",
    "slug": "engineering-ladder-communication",
    "excerpt": "Creating a successful engineering ladder isn't about perfect documentation—it's about building trust and psychological safety. The best ladders are actively used by teams and trusted across the organization because they're built on a foundation of \"trust but verify\" principles and open communication. Treat your ladder like a business relationship with SLAs, acknowledge potential failure modes, and remember that its success hinges on whether both engineers and management share a common understanding of its terms. ",
    "coverImage": "_DSC7129.jpg",
    "date": "2021-05-26",
    "content": "\n_Why your engineering ladder doesn't really matter, but team buy-in does._\n\n\n<figure><img src=\"/images/_DSC7109.jpg\" /></figure>\n\n\nI've been involved in numerous engineering ladder revamps throughout my career. I've witnessed excellent frameworks fail and simplistic ladders succeed. A good ladder isn't necessarily one with perfect documentation or comprehensive edge-case coverage, but rather one that is actively used by your team and trusted across the organization. The ladders pictured above don't look impressive, yet they're vital to our fishing industry. How do you ensure your ladder gains widespread adoption and organizational support?\n\n\n## **What is a ladder?**\n\n\nAt its core, a ladder is a framework to categorize people into groups and compensate them accordingly. However, it can be much more. A well-designed ladder can empower engineers to accurately self-evaluate and advocate for their growth path. It can be used to appropriately place new hires in the right role. At the team level, it can serve as a framework to equitably evaluate performance, which informs compensation and title decisions.\n\n\nFirst, the ladder needs firm ground to stand on.\n\n\n<figure><img src=\"/images/_DSC7129.jpg\" /></figure>\n\n\n## The ladder foundation\n\n\nManagers often emphasize the benefits of ladders without addressing the uncomfortable core function: segmenting people and paying them differently. This presents challenges at both individual and team levels.\n\n\nAt the individual level, people typically struggle with acknowledging their own gaps or celebrating their successes. Both highlighting your achievements and sharing insecurities can be extremely uncomfortable in an unsupportive environment. This discomfort can cause people to behave differently than they would in normal work settings, creating challenging situations for managers. Even individuals who accurately assess their own performance may question whether others are evaluated with the same level of scrutiny.\n\n\nAt the team level, performance is more collaborative than many companies acknowledge. Managers are responsible for providing appropriate opportunities and fostering a high-performance environment with motivated collaborators. Ladders often fail to address performance within the context of challenging working conditions, such as opportunity gaps or interpersonal issues that can impede advancement. This asymmetry—where the company evaluates individuals without reciprocal evaluation—can generate conflict.\n\n\nBased on these experiences, I believe ladders require a foundation built on two key elements:\n\n1. <u>Trust of the organization</u> so that employees believe their investment in the ladder will yield results.\n2. <u>Psychological safety between managers and direct reports</u> so they can discuss performance gaps, seek appropriate opportunities, and resolve interpersonal issues.\n\nBefore implementing a ladder, you must ensure that this foundation of organizational trust and psychological safety is robust, or your ladder will collapse.\n\n\n### 1. Organizational trust\n\n\nFirst, you should <u>not</u> simply ask team members to trust the organization. Instead, encourage them to build a relationship based on 'trust but verify.' An engineer wouldn't blindly trust an API that merely claimed to 'work well.' For a critical service, you would expect metrics like average response time, throughput limits, and uptime guarantees in a Service Level Agreement (SLA) incorporated into a business contract.\n\n\nAn effective exercise to build trust is to establish SLAs for this 'career advancement service.' Begin by discussing anticipated failure modes and your strategies for addressing them.\n\n\n**Examples of anticipated failures:**\n\n- Categorizing people into a limited number of groups will inevitably result in some misplacements.\n- People at the upper or lower bounds of levels may experience frustration due to either struggling with broader scope responsibilities or being close to higher compensation.\n- Due to fundraising cycles or other company-wide events, promotion cycles may not occur as scheduled.\n- Evaluation inconsistencies may exist between different managers.\n\n**Based on these failure modes, we could establish SLAs such as:**\n\n- Failure rate (frequency of mis-leveling)\n- Mean time to restore (how quickly mis-leveling is corrected once identified)\n- Response time (adherence to performance review schedules)\n- A qualitative metric such as \"Do you believe you and your peers are evaluated fairly?\"\n\nThe most critical aspect is demonstrating awareness of potential failures and your commitment to addressing them when they occur. This approach builds trust. Additionally, if you provide a mechanism for the team to verify that the ladder is being properly implemented, they can contribute more productively to improvements. For example, if candidates are frequently interviewed at incorrect levels (high 'failure rate'), you can target that specific issue rather than discarding the entire ladder system.\n\n\n### 2. Psychological safety\n\n\nThe foundation of a learning culture is psychological safety—mutual respect and the ability to take risks without fear of negative consequences. When teams have psychological safety, they're more willing to acknowledge their mistakes and develop preventative measures. They're also more comfortable raising concerns and exploring innovative solutions.\n\n\nThe ladder implementation process presents an excellent opportunity to build psychological safety by demonstrating vulnerability to your team. [Recent research](https://www.strategy-business.com/article/Building-a-culture-of-learning-at-work) suggests that sharing past experiences regarding feedback reception and discussing current development goals in a group setting contributes positively to team psychological safety.\n\n\nIf you're comfortable sharing in a group setting, tell your team about a time when you benefited from constructive criticism and identify areas where you're currently focusing your development efforts. This can initiate a valuable process where you openly discuss your improvement areas and welcome (and receive!) their assistance.\n\n\nIn more extensive one-on-one settings, I have utilized [this list](https://randsinrepose.com/archives/your-mid-year-leadership-check-in/) of questions by [@rands](https://twitter.com/rands) to gain deeper insights. I share my responses with team members during one-on-ones to establish rapport and invite them to share theirs.\n\n\n## Stabilize the foundation\n\n\nWith a relatively safe and trusting environment established, you can articulate why the ladder is important. This helps make the ladder less intimidating, particularly for newer team members.\n\n\n### How to talk about the importance of the ladder\n\n\nIn the past, I insufficiently emphasized the business aspects of the ladder. Upon reflection, I would discuss the ladder in business terms, as I believe it fundamentally establishes a business relationship—and it would be disingenuous to suggest otherwise. A ladder is an arrangement where the business compensates individuals who can provide services the organization anticipates needing in the future.\n\n\nA ladder helps define the parameters of that business relationship. Both the capabilities that a business requires and individuals' competencies evolve over time. The ladder and broader performance process provide an opportunity to reassess and adjust the terms of that relationship. For example, when an employee develops and can deliver more value or better services that the business needs, their compensation should increase accordingly.\n\n\n### How does the ladder work?\n\n\nLadder placement involves gathering data from three sources:\n\n- External information such as certifications, years of experience, or educational background to gain insight into life experiences that may help the company anticipate challenges.\n- Peer assessments of demonstrated skills. Independence exemplifies this well. While solitary work is generally not ideal, the ability to deliver substantial features independently enables contributions to new project initiation. Thus, an engineer who demonstrates independence may provide greater value to a company than someone who cannot work autonomously.\n- Self-assessment.\n\nAbove all, remember that a ladder is not personal—you are not defined by your work. This is business.\n\n\n# What's next?\n\n\nA ladder's success isn't determined by its ability to articulate career levels, but by whether both the team and management trust it and share a common understanding of its terminology. Can the team trust that fulfilling the ladder requirements will lead to timely promotion? Can managers trust that the team actually uses it? Can both parties trust that people are leveled consistently across teams, regardless of gender, race, or company tenure?\n\n\nContinue to ask these questions and pursue ongoing improvement.\n\n\n**Ladder references**\n\n\nA competency matrix/ladder should undergo continuous improvement. I recommend reviewing the ladder references below as potential starting points. You can then customize the ladder to meet your specific needs and update it as those needs evolve.\n\n- Open source ladders on [progressions.fyi](https://www.progression.fyi/), [this repo](https://github.com/bmoeskau/engineering-ladders), and [here](https://www.swyx.io/career-ladders/)\n- [Fog Creek Professional Ladder](http://joelonsoftware.com/articles/ladder.html)\n- [Programmer Competency Matrix](http://sijinjoseph.com/programmer-competency-matrix/)\n- [Dropbox Engineering Career Framework](https://dropbox.github.io/dbx-career-framework/ic1_software_engineer.html)\n",
    "section": "All",
    "author": "Brennan Moore"
  },
  {
    "id": "56dfd7bb-111f-4dd4-bbde-a1c2b941adf0",
    "title": "Learning from Artsy: How to hire awesome engineers",
    "slug": "hiring-awesome-engineers",
    "excerpt": "Finding smart, motivated people who work well together is virtually impossible. If Artsy has a secret sauce, it is how it hires. All else falls from the assumption that they have hired the best people who want to work together to achieve Artsy’s mission.",
    "coverImage": "IMG_3603.jpg",
    "date": "2016-08-01",
    "content": "\nThis is a key lesson I learned while directing the web engineering team at Artsy. Artsy's vision is that art can be as popular as music, and its mission is to bring all of the world's art online. It has now raised over [50MM](http://blogs.wsj.com/privateequity/2015/03/26/catterton-leads-25-million-funding-round-for-artsy/) and has made it to that in-between phase where it is ['not a startup not yet a company'](https://www.youtube.com/watch?v=IlV7RhT6zHs).\n\n\nBeing a part of that change was an incredible opportunity. While I was at Artsy, the company matured and grew from 15 to about 90 people. Since leaving, it has further matured and the staff count is over 100. Each of these people probably have their own list of things Artsy does right or wrong, but this series is my list. The hope is that this helps me (and maybe others) build on Artsy's success in future roles. My knowledge, and these lessons, reflect my experience within engineering team and not the company as a whole.\n\n\n<figure><img src=\"/images/IMG_3603.jpg\" /></figure>\n\n\n# Hiring awesome people\n\n\nFinding smart, motivated people who work well together is virtually impossible. If Artsy has a secret sauce, it is how it hires. All else falls from the assumption that they have hired the best people who want to work together to achieve Artsy’s mission.\n\n\n## Finding awesome people\n\n\nThe first step in hiring is defining the position. Artsy does this by crafting aspirational rather than clinical job descriptions. Within engineering, the job description focus on challenges, ownership, opportunities for growth and quality of team. In keeping with this high level approach, Artsy lists qualifications as fundamentals rather than 'x years doing y'.\n\n\nEven with a great job posting, reaching engineers is challenging. At a recent engineering event, a CEO was walking around interrupting conversations to ask people if they were developers, and if so, pitched his company. In contrast, Artsy values the unique knowledge and contributions of individual engineers. It demonstrates these values through contributing to open source, blogging, speaking and targeted press. During this process, engineers begin to understand Artsy, and Artsy understands individual engineers. Rather than yelling 'developers!, developers! developers!' in crowded room, Artsy uses this knowledge to vet and make dedicated offers to individual engineers.\n\n\nThe takeaway is that the key to finding great people is making the hiring process about people. Artsy's process is in direct contrast with my current role where engineering applicants create an account on our hiring portal and fill out a 12 page form before we can contact them. This severely limits our applicant pool. Artsy keeps the barriers to 'first contact' low through online contact via OSS/blogging and by inviting candidates to a casual team event or coffee.\n\n\n## Evaluating awesome people\n\n\nIf you could choose between an doing interview or doing references which would you pick?\n\n\nArtsy is very much in the 'references' camp but does continue to do interviews -- it just does them non-traditionally. Starting with a rigorous process for finding highly targeted people to interview enables a different interview process. Instead of a rigorous evaluation, Artsy uses the interview to answer questions about the candidates experience and then focuses on selling the candidate on the company.\n\n\nThis lack of focus on the interview, stems from the belief that it is impossible to tell good from great in an interview for creative or technical roles. The interview is a highly artificial environment that is unrelated to how the individual creates value day to day. While the environment is artificial, one-on-one are also reliable because they play on our biases. We often \"value intuition over historical data\" and \"value people who are similar to us\" much more than we should. We are also influenced by quick and superficial qualities such as attractiveness, race or background which have nothing to do with the candidate's ability to perform. Some companies change their interview process to fix all of these issues. Artsy solves this by acknowledging these biases, communicating them and focuses on references.\n\n\nArtsy's secret weapon in evaluating candidates is doing references in a thorough way. Artsy believes that 'references are not a defense against hiring poorly, they are a way to hire great people'. There are a variety of techniques for improving reference calls. In general, the goal is to see questions like \"What are your general thoughts on x's performance?\" and \"How was working with x?\" as warmup questions rather than the meat of the call. The call can focus on more substantive questions where you ask the reference to compare 'x' against other people. For example, 'Are they the best person you've worked with in that role?', 'Why are they not the best?'. Ask about what get the person excited and what makes them happy. Just like when seeking out individuals, reference calls are about understanding who they are as an individual and whether they will be able to perform at a high level in your organization.\n\n\nJust like interviews, references have many biases and issues. Consider the strength of the reference and the general strength of employees from that company. Ideally someone experienced in the industry, with has a wide network tied into many similar companies, should do the reference call. After doing many interviews and references, you will understand which organizations have consistently awesome people and which don't. You will also build up a network of people you can ask for a second opinion on a candidate.\n\n\n## Closing on hiring awesome people\n\n\nThe closing process is just as high touch as you've been all along. If you either make an offer or reject the candidate, do so thoughtfully by incorporating feedback from references and interviews so the individual can improve. Deciding whether to make an offer is always difficult but is really asking ['Is this someone you would actively seek to work with?'](http://www.quora.com/What-is-the-engineering-interview-process-like-at-Stripe)\n\n\nDuring the closing process, salary negotiations will come up. The negotiation is not an opportunity to try to get the most out of a person for the least amount of money. Salary negotiators are unfair and inconsistent with any organization that values actual human beings. As Artsy states, 'compensation is a function of the value of the candidate based on market rate, the value the company brings to the candidate and the market in between'. For figuring out market rate, dB., the CTO of Artsy, recommends [responding to recruiter spam](http://code.dblock.org/2015/01/09/how-to-make-recruiter-spam-useful-my-canned-response.html) to ask about comp. They have also published the comp framework [here](http://artsy.github.io/blog/2015/04/03/artsy-engineering-compensation-framework/).\n\n\nWhen closing, consider other factors that may go into them accepting the offer. Don't hesitate to bring in employees, references or investors to support making the hire. If they accept, send a something personalized and anything you think might generally interest the candidate errr… new hire - Congrats!\n\n\n# Takeaways\n\n\nAfter moving on to a different company, I've discovered just how challenging it is to enact a similar hiring process. You can't pick and choose various convenient or 'easy' parts of Artsy's hiring process, and just apply them. Each step builds on the previous one - such a with the closing process. During a thorough reference call, you often learn information that helps you make the hire when the time comes.\n\n\nAnother challenge with implementing this is making the time. It takes an extraordinary amount of effort to create a human centered hiring process. Creating a little hiring portal and posting on LinkedIn is easy but, it doesn't work. At my current company, we mostly race to do things that needed doing yesterday. We don't yet have a product process where we plan features (say, in sprints) and execute them. Without proper planning, it is near impossible to set aside time to [mine our network](http://firstround.com/review/Mine-Your-Network-for-Early-Stage-Hiring-Gold/), thoughtfully pursue and meet with the kind of people we want to hire.\n\n\nI've also gained a greater appreciation for the network effects of Artsy's hiring process. By actually understanding and caring about people, the process generates a lot of good will even when it doesn't work out. That good will pays off in terms of valuable referrals. Without this network, contacting people is more challenging. In my new role where we yet to develop this network, we also have yet to open source anything or create any kind of blog. This limits our exposure to engineers. In addition to these challenges online, we work in deep Sunset Park, Brooklyn. We are over an hour from anyone working in Manhattan and far from community events. While this may sound like a ton of challenges, by using this model, we at least have identified a clear goal and the problems in our way.\n\n\nIn summary, if you want to hire awesome engineers, put in the work. Demonstrate that you care about and understand the value engineers provide.\n\n",
    "section": "All",
    "author": "Brennan Moore"
  },
  {
    "id": "4b262608-91fa-459d-823e-2c9c99021927",
    "title": "Debugging a live Saturn V",
    "slug": "debugging-a-live-saturn-v",
    "excerpt": "We all have stories, as engineers, of fixing some crazy thing at the last minute right before the demo goes up. We have all encountered situations where we needed to fix something that was our fault and we needed to fix it now.",
    "coverImage": "sdim6232jpg_10385653373_o.jpeg",
    "date": "2015-01-11",
    "content": "\nWe all have stories, as engineers, of fixing some crazy thing at the last minute right before the demo goes up. We have all encountered situations where we needed to fix something that was our fault and we needed to fix it now.\n\n\nThis story is something that I think about in those times to remember to stay calm. No last minute fix could ever be this dramatic or important.\n\n\nMy grandfather passed away about a week ago. At the service, I was asked to say a few words and read from his memoirs. This was my choice.\n\n\n---\n\n\n<figure><img src=\"/images/sdim6232jpg_10385653373_o.jpeg\" /></figure>\n\n\n## RED TEAM 4 TO THE POD\n\n\n_The first unmanned launch of a Saturn V on November 9th. 1967. From the personal memoirs and the pen of William E. Moore January 28th. 1994._\n\n\nThere was five of us Rocket Scientists lounging around the ready room listening to the Apollo 4 Countdown on loud speakers and headsets. We were members of the Red Team Group and we were the Electrical Systems experts on all hardware interfaces between the firing room and the Saturn V vehicle three miles away. Our ears were now being drawn into a developing situation happening on the net. No response was received from an electrical circuit that controlled the separation of the S-II Stage from the S-1C Stage in flight.\n\n> \"That was one of my electrical circuits!\"\n\nIt just so happened that circuit is controlled by a series of relays located almost directly beneath that cold beast that was spewing out all kinds of funny colored, very cold gases -- the Saturn V rocket. We took a look at our blue prints and found the relay that must be the problem and called for a recycle in the countdown to a point where we could cycle the switch on the electrical networks console to see if the relay would pick up -- that was a \"no go\". Now things got serious. The NASA Test Conductor was talking 'scrub the launch' but our S-II Stage Test Conductor was talking 'go to the pad'.\n\n\nWell, the Red Phone rings.\n\n> \"Bill, how sure are you that this relay is the problem? Are we going to send people to the pad to rewire the rocket and not be able to launch because we guessed wrong?\" said \"AC\" Filbert C. Martin\n> \"It's worth a shot, the signal is not reaching the vehicle and that relay module is the only active component between the Firing Room Console and the Vehicle. You snap out the old Relay Module and snap in the new one and we will be able to tell if that was the problem a few seconds later.\"\n> \"Well, we are a little concerned about sending a team to the pad with a fully loaded vehicle. We thought your team would do a lot of blueprint trouble shooting -- I'm not sure we planned to actually send anybody out to a fueled vehicle\"\n> \"Just don't let them launch this mother till we are at least half way back from the pad -- OK!\"\n\nAbout thirty minutes later the five of us (Bob Kelso NRR Sr. Tech, Bill Moore; NAR Engineer/ Team Leader, the NASA Safety Engineer, the NRR Quality Control and the NASA Pad Leader) got the official word to head for the Launch Pad with our new Relay Pod. It was 11:30pm. It was a dark, slow, three mile trip. As we got closer to the Saturn V it was shrouded in a white cloud of venting gases which relieved the pressures building up inside the vehicle fuel tanks.\n\n\nOur goal was to enter this two level hermetically sealed, all welded steel coffin called the Mobil Launcher Base topped by a fully loaded 363 ft. high Saturn V, weighing 6.2 million pounds, and the permanently attached 380 ft. high Umbilical Tower, weighing 500k pounds. We finally stopped and left our van to walk up and into the second level of the Mobile Launcher Base. About this time, it came to my mind that during one of our training sessions we were told that one of the fully fueled prototype S-II rocket stages had been exploded out in the desert. The results showed that all buildings better be at least three miles from the launch pads - which they are. We were now within 25 feet of this 363ft tall bomb that sounded like it's giant fuse had been lit, and we were soon going to get much closer.\n\n\nThe Saturn V was more noisy and ghostly than I had ever expected and it had grown much taller and certainly more threatening since last week. The venting fuel made loud hissing sounds when relief valves popped or opened up suddenly. It was very easy to let your imagination infect your brain. This is a very dangerous place and everything seems to be moving in the heavy foggy mist. There was no way to talk to each other, heck, we could barely see each other and...we hadn't thought of this problem so we held onto each others yellow protective clothing like kindergartners crossing the street. We all wore safety helmets but they just did not make you feel like you were really safe.\n\n\nAs we climbed up the last step prior to opening the sealed submarine type entry door that led into the second level. We slowly opened the heavy steel hatch-type pressurized door it was like stepping into the jaws of a huge steaming dragon. The nitrogen fog, used to suppress fire, and the dim red glow from the emergency lights of level A made it look like a hollywood swamp scene. We started making our way through the 21 compartments to find our Relay Rack as the noise took on a more penetrating tone that seemed to bounce from wall to wall.\n\n\nThe smell became a mixture of kerosene with a mild touch of burnt paint and rubber. I was glad that the astronauts did not take this path to go aboard the Saturn V because my goosebumps were changing to a weird color of purple. With the realization that this was a much worse place to be trapped in, the team moved more rapidly to the relay rack. We replaced the old relay module and then had to cycle the switch on the firing room console. We then checked that the relay kicked in and that the signal was picked up on the vehicle. We resealed the cabinet, signed off on all the paperwork and got the out of there without any more sight seeing.\n\n\nThe drive back to the ready room very was fast and uneventful. The five of us were like stone figures, thinking about where we had been and what we had just accomplished. What could have happened and didn't. All of this without ever realizing that this experience was as close to being in the shoes of an Saturn V astronaut as any of us would ever be again.\n\n\n<figure><img src=\"/images/sdim6175jpg_10385398926_o.jpeg\" /></figure>\n\n\n---\n\n\nIn later letters, my grandfather mentions how fortunate he really was, having growing up a farm boy in West Virginia to have not just once in a lifetime experiences, but really once in many lifetimes experiences. The service was about celebrating his life, and this seems like one of those incredibly unique events that really does celebrate his life, both in terms of how he handled a mind bogglingly stressful situation and how he tells it the comfortably detailed and slyly humorous ease that was so characteristic of how he spoke.\n\n\nA really incredible man who really contributed a lot to the world around him and meant a lot to those close to him, he will be sorely missed.\n\n\nWe all have stories, as engineers, of fixing some crazy thing at the last minute right before the demo goes up. We have all encountered situations where we needed to fix something that was our fault and we needed to fix it now.\n\n\nThis story is something that I think about in those times to remember to stay calm. No last minute fix could ever be this dramatic or important.\n\n\nWe all have stories, as engineers, of fixing some crazy thing at the last minute right before the demo goes up. We have all encountered situations where we needed to fix something that was our fault and we needed to fix it now.\n\n\nThis story is something that I think about in those times to remember to stay calm. No last minute fix could ever be this dramatic or important.\n\n\nWe all have stories, as engineers, of fixing some crazy thing at the last minute right before the demo goes up. We have all encountered situations where we needed to fix something that was our fault and we needed to fix it now.\n\n\nThis story is something that I think about in those times to remember to stay calm. No last minute fix could ever be this dramatic or important.\n\n",
    "section": "All",
    "author": "Brennan Moore"
  }
]