Coss Effective » Tom Coss

On Unconditional Tolerance

Tom Coss — Mon, 24 May 2010 22:13:52 +0000

If your poor enough you will get sick. If you’re sick long enough, you will be poor. Economics and healthcare are pretty much two sides to the same coin. After all the nonsense spoken about on the healthcare front, some of which is discussed here, I took a month off to gather some thoughts around a broader set of behaviors in play.

Societies, and the economies that support them, are just a set or rules under which people have agreed to live, work and interact. Some economies are seem to do a better job than others, typically that is because the rules are clear and evenly applied there by reduce confusion and risk. America is one such economy. Like looking out the windows of a busy airport to the dance of activity below, our economy may appear messy, certainly disorderly, but in the end it works amazingly well. The dance of capitalism is quite wonderful to watch. Occasionally things lip, and companies fall, but in the end the music continues and we do pretty well.

America has been goofing around with the rules a great deal over the past two years, which will for certain produce effects. We hope these will be good, but from this perspective we don’t know for certain. Clearly based upon historical precedence, there is every reason to be fearful. What we know for certain is that those experimenting with these rules will not be the only ones affected by them, typically they’re not affected at all, hence I offer this.

One simple perspective in less than 800 words. I hope you enjoy

Tom

Ben Nelson Gets His Price

Tom Coss — Sun, 20 Dec 2009 00:23:30 +0000

From the perspective of a representative “playing their position” and looking out for their own constituents, Ben Nelson has done a wonderful job. As for the rest of the US, we’re asked to pick up the entire Medicaid bill for an entire state, for eternity. How wonderful is that?

What this means is that Nebraska will not have an incentive to mind the store as closely as they would had they had to participate in paying for it. Put another way, this is like going away to college with your parents credit card. Perhaps of all states Nebraska poses the smallest financial risk exposure to the American taxpayer, they are after all a hard working lot, still should this go through, Medicaid spending for Nebraska will certainly outpace that of the other states.

If you doubt this, consider what would happen if you put two piles of firewood on your front lawn, on one a sign that says “$50.00 a cord, and the other put a sign that reads “Free”.

Which one will go first?

Tom

Free Market Medicine – You’ll Like What You See.

Tom Coss — Mon, 23 Nov 2009 17:30:22 +0000

Imagine that you do the same job year over year, and in each year you get paid less. This is the condition in which most physicians find themselves. It may be difficult for some to have sympathy for physicians because many believe that they make lots of money, though some do. Still, physicians spent most of their 20′s and some of their early 30′s getting the training to provide services for which they are now get paid less and less to provide.

A few weeks ago I had reason to visit an Orthopedic Surgeon for a wrist injury. Upon making the appointment I learned that this practice has done something that I believe few physicians can do, but many more will; he quit taking insurance. As one with a strong free market bias, I had to learn more. A few days after my initial visit I called just to discuss his decision and what it required of him and his practice.

He admitted that his income had initially fallen, but that it is slowly on the return. He reduce his office staff by one half, and restructure his practice. Though he continues to provide orthopedic services, he expanded his scope of offerings to include services for which insurance companies will not pay, and patients would; he add longevity services for older patients seeking to avoid disease. These services are largely unsupported by insurance, still people willingly pay for services they believe to be valuable, and indeed this is.

Additionally, he freely admits that had he been younger with medical school debt and kids aiming for college, he wouldn’t have been able to make this move. But with both of those behind him, he guided his business offerings to a new audience, and one who would pay cash he loves his work as do his patients.

There is no better example of free-market medicine than what has been going on in the area of Dermatology. With the introduction of Botox to remove wrinkles, and a new host of dermal fillers and lasers, some dermatologists have evolved their practice, in part or completely, into cosmetic or aesthetic medicine for which it’s patients pay cash.

Cosmetic medicine, is an area of healthcare where third party players have little or no influence because neither patient or practitioner expect a third party organization to pay for the services. These are not life saving service, they are life enhancing services. This is free market medicine at its finest, but it’s not new. Dentists and most veterinarians have similar transaction relationships with their customers, neither are heavily influenced by insurance companies, and they seem to be doing just fine, even arguably better than classic medicine.

So what are we to make of this.

Have you ever tried picking up mercury with your fingers? That’s precisely how the economy works; human beings are amazingly adept at improving their lot in life through new and innovative means. In healthcare we are already seeing changes in the physician/patient relationship and its interaction. Quickly disappearing is the paternalistic relationship that had dominated physician/patient relationships in the past. The new relationship is more adult to adult; one in which the physician clearly directs care, but also one in which the patient is also part customer. For healthcare, this is exceptionally healthy. The patient rather than the payer or insurance company has a customer like relationship with the physician, or private medical services distributor.

For some physicians with whom I’ve shared this perspective, this is troubling until they realize that a more provider-customer relationship actually produces more revenue. This we know: physicians are smart people and know how to do math, they will certainly evolve their care practices in creative ways from which we all will benefit. Free market medicine will grow in the future, and some innovative companies have begun to figure it out

Thomas A. Coss, RN

Health Care Reform From A Patient Level Perspective

Tom Coss — Fri, 13 Mar 2009 01:19:47 +0000

In Ohio there are many small roads that go under train trestles. At the time train tracks were being laid, it was cheaper to simply dig down and have the road go under the train tracks, rather than building bridges over them. The challenge is, many of these roads were built when cars were much smaller, as were delivery trucks much smaller.

As a child I read a story in My Weekly Reader, about one large semi truck that was going down a small road under a train trestle and got stuck; I mean really stuck. As the story went on, there was a great deal of activity around the stuck truck as to how to get it dislodged; police, fire and train engineers all looking at the truct. A little boy happened upon the scene on the way home from school, and stopped to observe the commotion. After a while the boy had an idea.

The boy mustered up the courage to come up to a man with a white coat and hardhat. Pulling on the mans jacket, he said “I have a way you can get the truck free” . ”Look son”, the man said “we have lots of people here and engineers with a lot of experience; we can figure this out. Why don’t you just move on”. The boy stood around for a while, and again came up to the engineer, “Sir?” the engineer looked down, “son, you need to move along, we have this under control”. ”But sir”, the boy shouted “If you’ll just let some of the air out of the tires, you an drive it out”. The engineer was stunned and did precisely that.

The engineer saw the problem from his perspective, looking at the trestle and the top of the truck, and the little boy viewed the same problem from his 4 foot 3 inch perspective, and ultimately arrived at a better solution.

What we are seeing in the world of healthcare reform are lots of smart people in white coats looking at the top of the problem, and missing the simpler solutions. Every hospital I’ve been, and consulted with, is full of highly educated, well meaning and committed individuals. The challenge hospitals face is that besides all the commotion of running a modern healthcare facility, there are patients to care for. People like you, and me and family and friends. And then there are the nurses, techs and support staff that are around 23/7. These are the individuals who despite what happens around them, need to take care of people in need of care; very simple, while very complex.

We ought not forget those who interact with the technologies intended to improve their efficiency and the outcomes they produce..

One Reason Why Economies Improve

Tom Coss — Wed, 11 Mar 2009 03:58:05 +0000

What doesn’t stop or even slow down during an recession? Depreciation. Regardless of what we hear on TV in regard to the slowing economy, depreciation still continues. Car breaks and tires ware out, computers break, even educations depreciate as new innovations develop and new skills are required; and yes, even parts of people fall into disrepair and need mending.

The January manufacturers inventory index declined at 0.7% on top of an adjusted 1.5% in December. In healthcare this is more of a challenge in that we don’t “inventory” procedures, this is good news and bad. In healthcare services are both produced and consumed at the same time. Replacing some of these parts can occasionally be delayed, but not forever. Consider replacing an Aortic Valve, delaying that procedure has consequences, often more expensive. The challenge hospitals and some industries face, is that there are no “inventories” upon which to depend as a cushion when needs abruptly change. In healthcare one is limited in the ability to quickly “tool up” to meet clinical needs

Hospital’s and healthcare systems, need to be focusing on the fiew out the windshield and prepair accordingly. This is no time to deprive ones self the talent required to meet demands that can improve so very quickly. It’s time to turn positive

Tom

First $19 Billion and Then A Miracle Occurs

Tom Coss — Sat, 28 Feb 2009 18:13:00 +0000

Nothing quite describes the realities behind healthcare reform than this little cartoon. Most people when asked about their health care are relatively satisfied, only in general and often abstract areas is healthcare a problem. Is it expensive? Indeed it is, but compared to what? Healthcare is expensive because there are choices today that simply did not exist thirty years ago. The 50′s singer Bobby Darin wouldn’t have died at his young age, had he been born just ten years later. Today, heart valve replacements are bordering on trivial.

Now we re focused on the much needed improvement in information technologies in healthcare to do for healthcare what information technology did for manufacturing. However in the case of healthcare things are a bit more complex. There is a lot of talk about the Electronic Medical Record (EMR), but the big challenge remains: how?

We know the technolocy, and we’re pretty certain of the value in improving outcomes as well as population studies, but in the middle is actually getting it implemented and used part. In this space there are a lot of non technical issues such as culture, ease of use, understanding how the information is going to be used, security and many more. The implementation process, the part where people need to get engaged and participant, is the often overlooked stage, step 2 as the cartoon suggests. With $19 billion now headed into the healthcare information technology market, just how are we positioned with the implementation resources required for success. If healthcare IT companies aren’t scarfing up talent now, they will soon regret the delay.

Here is more on Capital Investment in Healthcare

Health Information Technology for Economic and Clinical Health Act – HITECH Act

Tom Coss — Wed, 11 Feb 2009 18:47:00 +0000

The Stimulus package passing through the Senate yesterday left untouched the nearly 136 pages of proposed legislation for Health Information Technology, over 18% of the immense 752 page document. To be more specific where specifics are rare, I’m referring to the ‘‘Health Information Technology for Economic and Clinical Health Act” or HITECH Act and its various components.

To net this out, the government is, as you know, big time into healthcare and growing bigger. Principally the legislation focuses upon the Electronic Health Record which many believe to be a critical element in reducing errors, saving time and improving outcomes. The legislation seems to be aware that there are many many moving parts to enabling the effective and confidential management of personal health information. Governing and standards committees will be formed and there are provisions for Comparative Effectiveness Research adding $400 Million to the effort.

This is probably the right legislation at the right time, still I’ll be keeping a diligent eye out as to unintended consequences, and you should to. I’ll be going through this in detail over the next few days, so check back and comment.

Tom

American Recovery and Reinvestment Act of 2009

Tom Coss — Tue, 10 Feb 2009 21:04:03 +0000

Farmers have known for centuries that if you want to harvest wheat in October, you need to be planting in the spring. If one is otherwise preoccupied and doesn’t get around to it until August, the wheat doesn’t care. It won’t all of a sudden work extra hard to meet an October deadline. In effect, you’re stuck. Planning to late, the error is on the throw, not the catch.

House Bill 1, now working it’s way through congress has highly specific provisions for the promotion and adoption of Electronic Health Records. Included in this package (Sec. 3412) are direct subsidies to hospitals who implement qualified EHR’s for their facilities. According to the House version of the bill, these subsidies range from $2 million to about $6.37 million with payments beginning in 2011. This is where the harvesting story comes to play, it takes time to get these initiatives under way, and the time to start is now.

There are a great deal of challenges in rolling out an EHR, regardless of the size of the organization, still this train is leaving the station. No time to waste.

Thomas A. Coss

All The Pleasure of One Hand Clapping

Tom Coss — Fri, 26 Dec 2008 01:56:22 +0000

Earlier this month the California Health Care Foundation published Equipped for Efficiency: Improving Nursing Care Through Technology, and in so doing, misses the largest point. The piece provides valuable information in regards to opportunities for improving healthcare efficiency, but doesn’t address the bigger problem: How?

How can these or any technology aimed at making healthcare more efficient be funded? What are the criteria? It’s difficult to utilize financial tools like Internal Rate of Return, Net Present Value or even simple Return on Investment models, in large part because it doesn’t matter. That is, life will continue with or without these technologies and the standard mechanisms of competition are so greatly blunted by the fact that medicine continues to be driven by the preferences of physicians.

All the recommendations in this report are legitimate, but where is the business model and how is it validated. That is where the intellectual heavy lifting lies. We need to build the business case that is measureable, transferrable and trustworthy.

A Quick Note on the Economey

Tom Coss — Mon, 15 Dec 2008 04:49:31 +0000

If you’re poor enough, you will eventually have health paroblems; conversely, if you are sick enough, you will be poor. With that in mind, the economy and ones health are effectively two sids of the same coin.

Here are my comments on BusinessWeek