Ted Audio Collective Hi everyone, you're listening to HBS After Hours.
I'm here tonight with Neheer and Felix.
How are you guys doing tonight?
Good, I love you. Good to be here.
Here at HBS, we are nearing the end of the school year.
Felix, you're so in touch with our MBA students, the ones that are about to graduate.
What's the vibe? The vibe is amazing.
So, you know, you go back maybe three, four weeks, everybody's nervous.
What's the summer internship that I'm going to get?
What's the permanent job that I will take after graduation?
These are the sweetest moments in the program when people know what they're going to do.
And it's lots of excitement, lots of enthusiasm.
It's a really nice period.
I'm always surprised by how nostalgia sets in sometimes.
So quickly, right? Before graduation, everyone's like, oh my god, you know, I have to leave.
And it's a fantastic thing.
It's incredible how much bonding takes place in such a short period of time.
I mean, it's only two years, but after two years, they just seem devastated to be leaving each other.
It's really something.
And when you hear a two -year MBA and then your individual experience here is, oh my god, this went by, it's two minutes of your life.
And so that's, I think...
And then you get a crush of students coming to see you in your office before they graduate.
And it's shocking to me every year how many of them said, if I could just do one more year.
And I'm thinking, it's time to go.
Go back to the real world.
So, here, you brought something you want to talk about today?
Yeah. I didn't think we were doing enough controversial things.
So I thought we could do the gender pay gap and solve it.
Oh, okay. Yeah, two minutes.
Yeah, it should take us a couple of minutes to solve the gender pay gap.
Yeah, that'd be great.
Terrific. All right.
I also brought a topic I want us to talk about.
It has to do with retail medicine, and I'll explain what that term means.
So, all right, let's get going then.
So, Mihir, why don't you get us started?
Yeah. So, I mean, the gender pay gap I think is just an incredibly interesting phenomenon.
And it bridges social concerns as well.
What we've seen recently is a couple of things.
One, some really innovative measures to try to address it in the UK and Iceland.
So, the UK has just really, I think, launched one of the most aggressive things, which they're making data transparent.
And they're really relying on transparency.
So, there has a website where you can see by firm what wage gaps are between men and women.
And it's crude. But it's required.
It's required. And it's not for larger entities.
Sorry, larger entities.
It's not tenure adjusted.
It's not all the things you'd want to do in a regression, but it's interesting.
And there's some big numbers.
You know, I think Goldman's number came out to be very large.
50 percent less. 50 percent plus.
Or something like that.
But now, of course, that can be about heterogeneity in titles.
Iceland has gone further.
And for firms larger than 25, they've mandated.
You have to show that you are paying women, you know, more equally.
So, I'm curious what your thoughts are about those two specific measures.
And then, to think more broadly about what we should be doing about the gender pay gap, what do you make of transparency, which is the UK version?
And what do you make of mandating, which is, I think, the Iceland side?
And what do you think about what we're doing in the U .S.?
And what are we doing in the U .S.?
Well, that's a great question.
We're muddling along.
So, Felix, what do you think?
When I think about the issue, I would often start thinking, so what's the gold standard?
Like, what do I really want to see?
In the end, what I really want to see is that people get paid very close to their levels of productivity.
And one reason why I think this is really important is if we have to pay them more as a result of regulation, then firms are going to be unlikely to hire whoever benefits from being overpaid.
If we pay them less, people don't make the kinds of investments in their careers that they should be making in order to be productive for the firm that they're working for, but society as a whole.
And so thinking about this gold standard, I'm actually much more comfortable with Iceland than with the U .K.
measure, because what Iceland basically has done is that you need payroll certification.
That means someone who's trained, someone who actually understands how do I create comparables across genders, but you can also imagine across age groups, across foreigners and people who live in Iceland, whatever fairness measure seems important at any point in time, there are skilled people who come
out and will tell you, okay, so this firm is doing a good job, and then the certification, you have the certification for three years.
My big concern with the U .K.
is that we get these quite shocking numbers.
Oh my God, women are underpaid by 50 % if you work at Goldman Sachs.
That has to be a reflection of women and men at Goldman do very different things in the firm.
And then you can think about ways in which this is helpful.
So for instance, if Goldman has fewer female top executives, one way to improve on the statistic is, oh, now you're going out and you're hiring talented women who could serve as top executives.
But it's a measure and sort of a source of reputational concerns that I think in many ways falls short of just recognizing that there are lots of differences why some people are not as productive as others and there should be differences in how much they get paid.
So I guess I would agree with you, Felix.
I mean, first of all, let me say, anything to move is in a better direction, I'm in favor of.
So even the most incremental thing I'm in favor of.
Is it sufficient? Not even close.
Neither one of these.
Neither one, I think, is sufficient.
And I think they sort of operate through this notion of shame, particularly the UK one.
The UK one for sure.
Yeah. I think they're underestimating how shameless companies can be on this dimension when they have multiple ways to explain it away.
So to your point, Felix, is in many ways a reflection of the fact that there are just fewer women in senior positions in a lot of these firms.
So let me give you two counters on this.
First off, the UK measure has some things to say for it, which is you're right in a snapshot way, right?
But this data is going to exist longitudinally.
And if you don't close that gap, I think that's going to be a problem.
Yeah. And you give the employer more degrees of freedom about the way they do it.
And I think that's helpful.
I agree, it's not as fast as you want it to be, and it's not as current as we'd want it to be.
But my instinct is the soft touches.
If you go too hard touch on this, you might get backlash in a way that's not great.
I don't know. So my instinct is that the transparency way is the way to go.
Look, if the US were to do what the UK is doing, I would be in favor of that.
Let me just be clear.
That would be a step in the right direction.
Is it sufficient? Absolutely not.
If you think about all of the different things that can be done, so for example, forbidding, asking about salary history, creating flexible work schedules, creating more generous leave policies.
I mean, there's so many things that can move us in the right direction.
But at the end of the day, I think until companies develop the will to recruit women into senior positions with much more energy, we're just not going to see movement on this.
So every company out there say, oh, we really try to recruit senior women, but we just can't.
There's a dearth of senior women.
It's just not true that they really try, because if they really try, what you would see is that even though there are very few women at the most senior positions, they would get so much more highly compensated because the market rate for these few people would just skyrocket.
If you're a qualified woman, you would be getting inundated with offers and people would be bidding for your services.
And so what you would see is that there would be a small cadre of women that would be in many ways dramatically overpaid as a result of market demand, which would then create theoretically a lot more incentive for women to begin to chase these positions.
You don't see that dynamic.
And the reason is, I think the effort that a lot of professional firms go to, to recruit senior women, is a really half -hearted go through the motions sort of effort.
I don't either think the UK thing is sufficient.
And you're absolutely right, which is these highly capable women, we should see wages skyrocketing.
And they're not, which is a problem for the reason you said.
So say we paint the future in which we roughly have gender balance across all the functions and seniority in the firm.
I think what that presumes is that people's lives and people's plans are quite similar across the genders.
What I find particularly interesting about the research that we have from the sources of pay differences is that so much depends on when families decide to have their kids.
So you have kids relatively early on, and there's minimal impact on pay differences.
You have kids late, which is typically true for highly qualified people.
You know, have a good chunk of their professional careers behind them by the time they have kids.
You don't see a pay difference.
It really makes a dramatic difference, and it remains a difference over time.
So you have, if you have your kids roughly between 25 and 35.
And the context in which I'm nervous about this idea that we should have roughly the same number of women, roughly the same number of men in each of these positions is I don't want to live in a world where you can't really make these choices.
Or if people make these choices, you put enormous pressure on companies to then somehow have a recruiting policy that gets us roughly to parity.
If that's what people choose to do, I would love to live in an economy where people get to do this and where if people choose to do this, there isn't an enormous amount of pressure for firms to make up for these choices.
So believe it or not, Felix, I agree with you.
No, I do agree with you.
So in a perfect world where we had perfect equilibrium, I don't know if the natural equilibrium would be 50 -50.
And to impose it on companies I think doesn't necessarily make sense.
But here's the thing.
We don't know what the natural equilibrium is.
We don't. So right now it's distorted because the incentives are so perverse.
So if you're a woman and you take time out to have kids, your incentives to go back to work are really deflated as a result of all of these different market dynamics.
So all I'm saying is companies should be doing whatever they can to create environments that are maximally attractive to everyone, where everyone can thrive equally.
And I don't believe that's happening right now, and I think in particular it penalizes women.
And until we get to that point, we're not going to know what the natural equilibrium is.
Let me give you what will sound like a retrograde idea, because I'm interested in your reactions to it, and this is going to be so self -aggrandizing.
Part of me feels like the answer is paternity leave.
You know, if you could force men to take six months, I know this is a weird policy, but certainly you can make it more easy and associate with less stigma.
And I know that sounds like, well, why does it that the men need to break?
I understand that, but in a way, you're putting them on a little bit more of a common footing, that you're out of the workforce and you have to kind of bear the burden in the household in a different way.
But it's not the six months.
It's being out for two years.
Yeah, you're right.
But I feel like at least that would help a little bit, because I think it's, there's this general equilibrium problem that in a way men are the answer to, which is they have to do things differently in order to allow women to do things differently.
You know, they have to pick up the slack.
They have to do certain things.
They have to bear certain burdens.
And only when that happens and when that changes, is it conceivable that other things will change?
I find your argument really interesting.
And the analogy that came to mind is, is study abroad.
You know how, it's not really like getting to know the world, but even just that tiny bit of experience that things can be radically different.
Somehow it changes people.
It changes people's mindset.
So I agree that the real long -term wage impact, you're not going to see if you force fathers to be at home for six months.
But I think it's one of these things where you don't really know, do you have a preference for being at home?
Well, that's true. I don't really know, because I never did.
Oh yeah, it would be really great to be at home.
But I don't really know, because I've never really done it.
So just as a tool to discover preferences, and then maybe have a little bit more understanding what it is to have been away for a little while.
I'm glad that the two men on the show have decided that men need more time.
That's the real answer.
Thanks guys. So with our remaining time, guys, I want to ask you about retail medicine.
And by retail medicine, I mean it's increasingly possible to get a range of medical care in a retail setting.
So the most prominent manifestation of this is where I live.
There are probably three or four urgent care clinics that you can just walk into and get care for a whole bunch of things.
If you look closely, what you'll see is retailers are now getting into the game as well as mass -merchantized retailers.
So CVS, Walmart, sometimes in partnership with health insurance providers.
But clearly moving to this vision where one day you can just in a retail environment and be seen, usually not by a doctor, by a nurse practitioner or a physician's assistant, for a whole range of things ranging from if you have a fever, if you've hurt yourself, if you're feeling dizzy, whatever it is.
The backdrop for this is the fact that in this country, the front line of medical care has always been primary care physicians, and their numbers are in decline.
And so there are fewer and fewer primary care physicians out there to see you first, and it's harder to get an appointment.
And so now what you're seeing is the emergence of this new front line.
My question is, if you had a loved one that was not feeling well, maybe fever, vomiting, something, would you say, hey, we're going to go to the Walmart and get you checked out?
So kind of answer for myself before I'm thinking about the loved one, I would totally do this.
And I think my intuition is sort of guided by two kinds of experiences.
I find when I go to different primary care physicians that I've experienced over my lifetime, I find there are enormous differences in the quality of care that I get.
Some of them seem to be really fantastic, fabulous, and others, you're not so sure how much they actually contributed.
And in many settings, I find that nurse practitioners really are doing the bulk of their work.
I'm in there for 20 minutes, and then I get to shake the hand of the real person who's responsible for my care.
And it's not obvious what it adds.
And so I think it's one of these where so much of the variation is just person to person.
And I would expect the same in a retail setting.
But this is one of those cases where how you experience the care might not be a reflection of the quality of the care.
So your nurse practitioner, he or she, might make you feel great and give you a lot of attention and make you feel like you're getting great quality care.
But you don't actually know.
Meanwhile, you might have a really impatient, rude, primary care physician that doesn't make you feel like you're getting great care, but is actually paying attention to some things and is less likely to miss some stuff that a nurse practitioner might.
So I mean, in situations where you don't feel well, I think my experience is when you talk to the nurse practitioner and you ask, oh, what's wrong?
What should I do? What do you think it is?
And then when you hear the verdict from the person who has an extra 500 years of training, there isn't a big difference.
Yeah. Well, I mean, so I have to say, we all bring our own baggage.
And in this case, I married into a medical family.
And so I think we fetishize that 500 years of experience.
And the reason why, of course, is because we're preoccupied with the low probability events.
Right? So this is all about low probability events, I think.
So that when you go in with the fever, it's not a fever.
It's like some bad problem you have that it's this is just the tip of the iceberg of that problem.
And you worry that that nurse practitioner may consider it something that's more like an average experience as opposed to the low probability event.
And in a way, what doctors do in part is, certainly specialists, is they think about low probability events.
And part of what we pay for is that.
And so I think that's a little bit of my inclination.
You wouldn't go. I think I'd have a hard time.
I think the more general issue though, I think is what I think is really interesting is these clinics.
But then there's also this thing that's going on with CVS and Aetna and Walmart and Humana.
And that is, I think, just much, in some sense, more transformative.
Like if somebody had told you, you know, 10 years ago, CVS was going to buy Aetna.
And there's going to be like medical clinics and CVS, just your mind would explode.
And there, I think what's happening is several things.
I don't know entirely.
It would be interesting to know what your perspective is.
But I think these, you know, these PBMs that are embedded in CVS and they're embedded in express scripts, they're like incredibly profitable.
Like crazy profitable because they are - pharmacy benefits, managers.
Exactly. And they obscure price discovery in the animal.
There's a lot of profits locked up in them.
And my understanding is that the insurers are interested in that business because that's like where the money is.
And so they're setting up their own PBMs.
And then on top of that, you know, the CVS answer I think is, well, we will be with Aetna and then we'll also give you the touch points so that you kind of come in our door for actual medical care.
So it just feels like a whole ton of integration.
And then I think that gets interesting from a system -wide perspective.
I agree with you, but here's the thing.
So I'm one of these people that complains all the time about the inefficiency in our healthcare system.
And so when I put my business hat on and I look at the CVS Aetna thing, I actually think it's intriguing for all the reasons that you describe.
And so much depends on the execution, but you can imagine some real efficiencies coming out of this.
And so you would think I'd be super excited about it.
But what it's going to mean in everyday terms is that that front line, that point of triage, because that's really what it is.
And I'm surprised by how nervous that makes me.
So let me give you another example.
I think that to me is interesting to think about.
So this is your big flu epidemic.
So you read in the paper, you have to be careful, it could be dangerous, you don't quite know, and so on and so on.
I have to flu. What does it mean for me to go to my primary care physician?
I have to make an appointment, it's during the day, it's like inconvenient in 15 different ways.
And so in the end, you know, I survived somehow and I didn't see anyone.
If I had a retail clinic just around the corner, I would have swung by, I would have said, this is now day three, I still have high fever, is that normal?
Is that what you're seeing?
Right now, because the primary care physician setup that I typically have is a complicated one, and so I don't go.
And so in a way, if I was in charge of building this business for CBS, I think building on the intuition, I would make sure I would have a first -class referral system that the people in the retail clinic are super clear about when it is that they don't know and that they make the referral at that point
in time. And I think what's gonna end up happening here is there's convenience issues and there's trust issues.
And they're gonna be able to do the convenience issues.
I don't know if they want to play the trust game.
I think it may be a more expensive game.
And the other thing I'll say is this also just strikes me as so emblematic of what's happening in all kinds of parts of society, but particularly in healthcare, right?
So the other thing is concierge medicine.
So the other retail aspect that's going on here is, young me, don't worry, you're gonna like have your personal concierge doctor that's retail in its own way, and the rest of us are gonna be schlepping over to CVS.
That's a side point, but it strikes me as representative of something more general.
I don't think it's a side point at all.
It feels like we're at this moment where the idea of fixing our healthcare system from the ground up just seems like an impossible, impossible thing.
So instead what you see is solutions popping up, potential solutions around the edges of the thing.
And so I think this is one manifestation.
I think concierge medicine is another, but what you're gonna get is even further fragmentation of our healthcare system and further sort of self -selection into different paths.
And I think there are gonna be some folks just so much better served by some of the new things that are emerging than others.
And then at the retail end, when you think about the trust issues right now, you don't really have a personal relationship with anyone at CVS.
So that is to me one of the most fascinating management questions around this move.
Do you want to be that way where you never know who's there, you never know who's gonna take your...
Completely transactional.
Completely transactional.
Or do you use this as a way to then say, no, actually there is someone you have a relationship with.
And this person is also going to look over your shoulder, what food you buy, and so on, and so on.
So it becomes like a total wellness thing or something like that.
Yeah. Yeah. So where they really manage much of the sort of non -medical, non -emergency care in a way that maybe because it is so...
When you think about how many wellness issues are really hospital issues, not that many, the really dramatic ones.
And everything else, I think, is a space where we could use lots of investment.
But I can't imagine you're gonna end up with personal relationships with your CVS representative.
I mean, that's gonna be expensive as hell to do that at scale.
I mean, you don't have a personal relationship when you go into the genius bar.
You don't have a personal...
That is a very high bar in a retail environment, right?
Maybe a very different idea as to what it means to be personal.
It's personal the way the bartender can sometimes be personal.
Right. So my conclusion from this conversation is that we can go in either one of two ways.
One, we end up with an increasingly fragmented front end of our healthcare system where anybody with means is going to concierge care and everybody else gets shunted to these hugely transactional...
Don't say shunted. Okay.
Felix wants to go there.
Or we end up with Felix's vision of the neighborhood nurse practitioner or a physician's assistant who gets deeply involved into the day -to -day, your day -to -day wellness.
I like my vision. Well, okay.
So we'll have to see.
Okay. So did you guys bring in pics tonight?
Yes, absolutely. I mean, every week.
Every week. It's one of my favorite parts.
I know. Okay. Felix, what's your pic tonight?
So one of my favorite travel destinations is Turkey and Istanbul.
Istanbul, in particular, I just think, is such an interesting place, deeply problematic, but also historical, super interesting.
And challenging to navigate, Meheren.
Exactly. That's what I'm looking for.
Difficulties. Sorry to disappoint, they have five -star hotels.
No, you could possibly want...
I never said I didn't want to stay in a five -star hotel.
Just a quick... Gotta be a little complicated.
But so I'm reading a book called Snow by this writer called Pamuk.
And the bulk of the book takes place in this small, small, small town all the way on the east side.
And the town has this interesting history where sometimes it's part of Turkey and sometimes it's part of Azerbaijan.
And you really have the sense of just how fluid history is in a way.
And the setting is one in which Islamist ideology becomes more important in this town.
And that creates a friction between the people who are not so religious and everyone who seems to be getting more religious over time.
It was fascinating to me when I think Turkey, I think Istanbul, and I think what is really a much more westernized part of Turkey.
And then you get the sense of a sweeping history.
And a really fun and interesting story on top of that.
That is, oh my God, this is like a different universe.
And we sometimes see it show up in Turkish politics in really interesting ways.
So quickly, can I ask a question?
So do the autocratic policies in Turkey make you less willing to go?
No. It doesn't influence your tourism decisions?
So my general intuition, I sometimes get it because I often go to China, I sometimes get it, you know, now with Xi Jinping, are you?
So it's versions of that question.
And my sense is engagement with the outside world is all the more important if you have interdependencies that you have in Turkey, Eastern Europe, China, lots of lots of places now.
Interesting. All right.
Me here. Yes. So I have a book.
It's called Kids These Days.
It's by Malcolm Harris.
And it's actually a book about millennials, of which I know nothing.
Other than you spend most of your teaching days with.
And that's precisely why I know I know nothing.
So it's a really interesting book.
It's the first full -throated defense of the millennial generation against all the stereotypes that I've heard.
He basically makes the argument that the behaviors that we non -millennials might find particularly objectionable are actually the outcome of a whole set of things that have happened to that generation.
In particular, one of the core things about his argument that I find really interesting is he basically makes the point that this is the first generation which views themselves as investments.
And that the language of investments is how they think about their development.
And so that leads them to think about their human capital in a different way.
That leads them to think about their jobs in a different way.
And it's all about yourself as an investment.
So give an example.
Like what's an example that stuck with you?
Think about how much time gets spent with these kids.
And think about what that does to a kid's mentality as they grow up.
This is the burden of being paid attention to as a child.
Yeah, in a way. I'm being serious.
Yeah. Anyway, so just in terms of understanding millennials, it's a short book.
I think it's really fascinating.
All right. So my recommendation this week is a product.
So the older I get, the more I find myself trying to hack my sleep.
You just do different things to try to ensure that you get good sleep.
So I recently had an opportunity to try a gravity blanket.
Have you heard of this?
No, I don't know what this is.
A gravity blanket is essentially a really, really heavy blanket.
You can get them in different weights.
You can get a 15 pounder, a 20 pounder.
I think you can even get a 25 pounder.
I had read about them, and I had heard that they're remarkably effective for certain kinds of people who have trouble sleeping and also for children who have trouble settling down.
So I had an opportunity to try one, and I think I had the best sleep of my life.
I think I slept for 10 hours.
It's like being back in the womb.
First of all, they're really heavy to the point where it's hard to move, but your nervous system just centers itself.
It's crazy. Wow. Is it claustrophobic?
It wasn't for me. Honestly, I fell asleep so quickly and so deeply that I don't remember much else than that, but it's such an awesome.
It's a fascinating product.
Do you have a name you want to recommend or a product specifically?
It's called a gravity blanket.
I'm sure there are other brands out there, but the one I tried was the gravity blanket.
There you go. Thank you.
Thank you. All right.
Thanks for listening everyone.
This is HBS After Hours.
You guys got to try that.
I got to try that. That's a real...
Did I try that? You tried one night or...
