Coss Effective » Efficiency

Medical Practice and 20% of Income from Cash

Tom — Sat, 03 Apr 2010 18:22:24 +0000

In regard to portability and ease-of-use, competing with a pen and piece of paper is difficult. We all know how a pen works, paper is lite and is easily moved about – there is no “down time” or “learning curve”; in addition, pharmaceutical and medical device companies will gladly give you all the pen’s you might desire.

The downside of pen and paper is that the information contained on paper doesn’t aggregate well. You can’t look back through it easily to assess what works and what does not. In earlier days when a family physician took care of you from cradle to grave, it wasn’t a problem; as long as the physician stayed alive, he or she was a biologic historical database of what went on in a patients life. Today, however, with highly specialized and fictionalized care, it’s a problem. So why not the sluggish acceptance of EHR’s in the private sector.

To the casual observer the perception is that costs are real, and benefits vague. These excuses are self-damaging and weak minded. Time to get busy.

In this piece regarding Electronic Health Records and Clinical Trials from Chris Thorman of Software Advice speaks to one legitimate benefit often talked about, but seldom realized. True, the use of practice data in clinical trials is limited, but it’s not zero, and it grows over time. Identifying subtle changes in treatments over time, or simply identifying patients for whom detailed clinical studies are appropriate, will contribute to improving efficiency of bringing new drugs and treatments to market. In so doing, a faster path to market results in a longer period under patent protection, and higher product lifetime valuation with lower costs.

In the end it looks like this: the medical practice of the future needs to begin now to design itself toward increasing its efficient and percent of total annual revenue from cash. This means providing services for which patients will pay cash along with discovering new means by which practices can contribute value and receive compensation outside the existing constraints of third party payment. This includes EHR’s, but also means a way patients can create appointments on their own schedule 24/7, along with a means by which medical practices can keep in closer communication with their patients.

There is no stability or efficiency in health care without successful and vibrant medical practices. It’s time for every practice to find an EHR that works for them and put it to use, along with systems and processesto build and manage closer relationships with their patients.

Commentariolus Medicus

garrett — Mon, 14 Dec 2009 02:43:24 +0000

As legend has it, while being arrested for his believes (based upon evidence) that the Sun, rather than the Earth, was the center of the universe; Nicholas Copernicus said of his captors: “I cannot admire enough those who accepted the heliocentric (earth as the center of the universe) doctrine despite the evidence of their senses.”

The difference between this statement of 5 centuries ago and today is simply the issue to which it is applied, and the date. For Copernicus it was aimed to those who held on to the notion that the Earth was the center of the universe, today the same could be applied to the notion that government ownership, specifically health care will produce efficiency. If this past century has taught us anything, its that governments don’t do healthcare well, still despite the evidence of our senses, our congress seem committed to its treacherous course.

Based upon the evidence of your own senses, what remains true, self-evident, observable and non-controversial is that no one else but you does your healing for you, or your dying for you. Only you live with the results of medical practice, good or not. There is no outsourcing, no cost-shifting, or possible means by which you can personally enjoy the benefits of healthcare while pushing the risk of its individual consequences on to someone else. You own it.

This makes the current healthcare debate personal. It would take a delusion of universal magnitude to believe for one minute, that a greater involvement of the government into our personal healthcare is in any way be an improvement. Of course, you are free to believe that government healthcare is better, but that would be foolish and you would be wrong. What is being proposed is about a few people feeling good about doing something they hope may be good, knowing in the end, they personally can no’t bear the full cost of any decisions they have made.

There are many more simple though less glamorous reforms that would be so much more effective, but they lack the flamboyant appeal of what is being proposed today. Lowering the deduct-ability threshold for out-of-pocket healthcare expenses, interstate purchasing of healthcare insurance and personal savings accounts that roll forward and accumulate over time allowing individuals to claim higher deductibles, and in so doing enjoy lower insurance premiums. But this is about theater, not reason.

Thomas A. Coss, RN

Repricing in America

Tom — Sat, 03 Oct 2009 22:31:16 +0000

I’ve been bothered in the best possible way by a comment made by Richard Davis, President and Chief Executive Officer of U.S. Bancorp. In almost a throw away fashion Richard told an audience of business executives in Orange County California, that the economy is going through a process of “repricing ” downward.

Clearly we know this to be the case in the housing industry, as those of us with houses have seen about 25% or more of the assessed value of the house disappear. As troublesome as this has been for many people, it has not stopped there. Just look around and you’re seeing it in the automotive business, grocery stores, and restaurants offering significant discounts. In the labor market, those getting new jobs are doing so at often dramatically lower salaries. Everything it seems is ratcheting down, finding a new market clearing level.

This deflation, or to be more positive, repricing, has consequences which favor highly efficient, low fixed overhead companies over those with large superstructures of bureaucracies. As we’ve seen, some companies can relieve some pressure by laying off labor, but those companies (I’m thinking GM) with lots of large buildings and large fixed expenses, can’t adjust sufficiently and quickly enough. For these large companies, it is exceptionally difficult to accommodate to downward price adjustments, hence they fail.

Companies which do succeed in these environments are new ones. These companies benefit by being new and not around so long as to have large fixed expenses, these are the entrepreneurs. The best way to grow our economy is for the US to have a brisk entrepreneurial bias in its policy decisions. In this Economy, as serial entrepreneur Ken Forbes, CEO of AppointYou in Aliso Viejo, California told me, it is easier to create a job than get one. This is the best time for the creative among us to leverage their comparative advantage of being lean, to get their products and services into the economy and make wonderful things happen for us all.

Thomas A. Coss

Public Option: Do You Feel Lucky?

Tom — Wed, 09 Sep 2009 22:31:58 +0000

Here’s the facts:

Not all hospitals, clinics and physicians are equally talented and knowledgeable in the delivery of healthcare services; here are some which are simply better than others, and experience matters.
It’s actually pretty difficult to kill someone. The human body is amazing in its ability to adjust to changes, whether it is the loss of a limb due to trauma, or the loss of the function of a kidney or part of one’s heart due to a heart attack. We adapt very well, but sometimes it’s not pretty.

For example, the difference in one’s quality of life when their heart is functioning at 50% capacity verses 20% capacity is astounding, as is the effect of the loss of function of both kidney’s rather than just one. In both cases, the effect upon the individuals quality of life is non-linear.

The challenge with healthcare is that neither the payer nor provider of services have to live with the results, that is solely left to the patient and their loved ones.

So then, what do we have with the current healthcare reform? Well it pretty much looks like this:

It may provide coverage to more people (but we don’t know this for sure nor does it mean that you can go anywhere you want for care).
It won’t save money (virtually no one believes otherwise).
It doesn’t address the means by which we will have enough physicians and nurses to go around.
It will not improve effieincy in the delivery of care delivery.
It won’t address the cost of defensive medicine (which is huge).
It won’t make you better off.
It will lead to more taxes.

Is there anything I missed?

Thomas A. Coss, RN

Improving Labor Efficiency in Healthcare

Tom — Sat, 05 Sep 2009 22:59:01 +0000

This site is focused upon efficiency as a contributing solution to the cost of providing healthcare services. Efficiency alone won’t carry all the water needed to address the cost of healthcare, but it will make a profound difference in the scope and amount of services provided per dollar spent. Last year I began a study based up some data going back over two centuries. In the early 19th century, over 80% of the US population was involved in agriculture…. they were farmers. By the beginning of the 20th century, that percent fell to 40%, and by the beginning of this century it fell to below 2%. This astounding increase in per worker productivity freed people to go into manufacturing at the beginning of the 20th century, leading to an amazingly robust century of innovation and improvements in the quality of life.

In 2008 I began looking into capital investment in heatlhcare as compared to other industries and found some interesting results. As expensive as healthcare has become, investments into improving the efficiency of the labor that provides those services has been poor. Per worker capital investment in healthcare is about 35% lower than it is in general manufacturing. How can we hope to lower the cost and expand the availability of healthcare if we insist on providing those services the same way they’ve always been done?

A more detailed explanation is available here until I hear: Improving Labor Efficiency in Healthcare.

Texting and Efficiency – This is Just The Beginning

Tom — Thu, 09 Jul 2009 02:14:51 +0000

“This message of twenty four words and 138 total characters takes you less than five seconds to consume, that is why texting is popular.”

According to a University of Pennsylvania study, the speed with which we consume information from our eyes to the visual cortex in the brain is approximately 10 megabytes per second, we hear at roughly one tenth that speed or a rate of about 102 kilobytes per second.

Just think how drastically communication has changed over the past 35 years. The first email went out in 1971, still it would take nearly 30 years before email became pervasive in society. In the mid 1990′s business still depended heavily upon voice mail, a slow and often annoying means of sharing information with colleagues in a time shifted manner. The annoying part came when people, seeking to gain favor with superiors, would copy everyone on the message. That copying continues today in email but in that there is hope.

In December of 1992 the first text message was sent via SMS or Simple Messaging Services. During the second quarter of 2008, AT&T reported that more text messages were sent from cell phones than actual calls. Texting is becoming a preferred means of communicating short messages from person to person. On June 9 of this year the US Senate held hearings from the major telephone operators in regard to pricing of texting services offered customers, and it is from those hearings that this story unfolds.

Though providers charge 20 cents per text when the individual has not chosen a texting plan, those people represent less than 1% of users. The average price per text is around a penny. The cost of providing that text is estimated to be about 0.0325 cents per text, providing the carriers with a very handsome gross margin of nearly 70%. Still, what really matters is that texting is growing at a rate approaching 50% per month and that texting is seen as fast and efficient.

This past 4th of July weekend I spent some valuable time with my daughter (16) and five of her friends. For a few minutes I was able to discuss with them their texting behavior, preferences and general insights into text messaging. Texting, it turns out, has a lot of benefits besides being efficient or quick to consume. It’s private for one, often more priviate than email, and it can be consumed discretely “even during church” according to one of the girls I interviewed. Texting has perseverence, it stays on ones handset and can be accessed at a later time. This is an added value to texting not commonly considered and from a marketing perspective, holds great promise.

The point of all this is that texting is more than the electronic version of sending notes among young kids in high school. Texting is important because it is succinct and so very quickly consumed. Character length constrictions force a succinctness that is greatly needed in communication, while also improving upon the speed by which the message is consumed. That same message above could be re-written:

“This msg of 24 wds & 138 characters takes u less than 5 secs to consume, thats y txtng is popular”

This version is now down to 21 words and 95 characters, a character reduction of 32%, while still clearly conveying the same message, only instead of taking you 5 seconds to consume, you consumed it in about 3. With the abundance of information thrown at us on a daily basis, anything that eases its consumption is good news indeed.

First What then Who, Managing Personal Healthcare

Tom — Mon, 24 Nov 2008 16:13:23 +0000

It’s been some time now, though the drama has long since passed a valuable story remains. It’s a story about healthcare, our future, and choice. I try to avoid the personal on this blog, but our current situation requires more courage and candor.

At the age of 48 I was diagnosed with Prostate Cancer. As you might imagine I was stunned as anyone would be, but not by in large concerned. As an RN who has treated patients with this condition, I knew it was caught early and that my prognosis was excellent. It was what happened after the diagnosis that I found compelling.

First was the matter of treatment choices of which there are many. Thankfully I wasn’t in a great hurry to treat the problem based upon a very low Gleason score, (a scoring system designed to stratify rick based cancer cell morphology) . The ”what” part of the decision process ( i.e. what treatment choice) took about 6 months for me to work through and in the end I decide on minimally invasive surgery. Then the challenging decision, who.

Based off of over 15 years experience as a Critical Care RN, I knew that the “who” decision is the most important decision affecting outcomes. Certainly the treatment form plays a role, but the individual who performs and manages the treatment is the big variable. Hence the problem, how do I find the individual who would provide me the likelihood of the best possible outcome?

When I was actively working as an RN, this would be an easy decision. I had a pool of resources across numerous facilities and I knew who to go to for the best possible care and outcomes. The problem I was facing is that I left nursing over ten years ago, and with that lost my “inside” advantage. I had to do some calling around, and I did.

My research has led me to plan on going to Henry Ford Hospital in Michigan who had, at the time of my surgery, over 200 Prostatectomey’s with the DaVinci Robot. I had followed the outcomes literature and had planned to fly from Southern California to Michigan for the surgery. Fortunate for me, I also found another equally successful program utilizing the same approach in Orange County and ended up having my procedure there. I was in and out of the hospital in 26 hours, one week of home limited activity recuperation and was back at work, and in the air, in about 14 days. My outcome has been excellent and I am very grateful for the candor and skill of the surgeon.

The reason for this story has to do with choices. If I were restricted in my choices in any manner, I would have had a much poorer outcome. Having discussed my situation with guys older, and younger than I, my outcome is astonishingly better. But what if I did not have the ability to choose “who”, what if I had to go to the surgeon based upon his or her seniority or availability, what then?

As we look for “fixing” healthcare, consider this story as not at all unique. Hearing politicians use the first person proclamations: “I’ll let you choose your own plan”, or “I’ll let you go to the physician of your choosing”, are frightening. Just the notion that the government has the power, presumed or otherwise, to dictate the choices who’s outcomes I have to live with, is unacceptable.

Know this: in the end, it is the patient who does the healing and it is the patient who does the dying, health care professionals are at best, participants, coordinators, supporters and facilitators. Neither we nor the Government will ever change that. The value of the internet doesn’t stop at providing information in the form of content, it is also a tool to find and take advantage of expertise well outside your local area. A national healthcare plan that encumbers one’s freedom to choose, is no plan at all.

Happy Thanksgiving.

Tom

Details on the Healthcare Labor Force

Tom Coss — Mon, 17 Nov 2008 02:26:36 +0000

Since my last post some time ago, I’ve been working on a piece that I hope will better explain what is happening in the healthcare labor economy and its contrast to what is going on outside healthcare.

Certainly much has changed in the general economy over the past six months, and more recently some exceptionally dramatic and unprecedented changes. I’ve been keeping a keen eye out for any evidence that what I’ve written about in this blog has change, and I’m delightfully pleased that with regard to healthcare, the picture remains good or labor. Still this doesn’t mean that all is well. Health care remains exceptionally inefficient and something needs to happen.

This piece explains in greater detail the nature of the health care labor market over time and in comparison to other labor markets of which we are all familiar. In addition, I tried to provide some insight into what individual health care facilities and organizations can do to improve efficiency, lower costs and improve outcomes.

Now this sounds like a tall order which in aggregate it might be, still in small decisions and actions, it is not.

Capital Investment for Improving Labor Efficiency in Healthcare

Three Things All Nurses Should Know

Tom Coss — Sun, 18 May 2008 04:10:35 +0000

This blog began around the compelling evidence mounting around the shortage of RN’s. The graph below is another view the result of a National Institute of Health publication of 2004, showing the demand for nurses (green line) against the supply based upon various assumptions on increasing supply of graduates. Still this isn’t the story, but rather the result of a story.

As I’ve been looking into this issue, I find on the net, no shortage of articles, I’ll be it sparsely published, describing the size of the problem, but few focused, as we are here, on what to do about it. One choice might be to simply ignore it. The assumption here might be that it is simply to big a problem of multiple causes so why bother. Another might be that some form of technology will likely come to the rescue and eventually mitigate the problem all together. Frankly, either choice is likely as reasonable as the other because the chooser can move on and no longer bothered by the issue. But if curiosity won’t allow that, then additional thought is required, so for a moment, consider this. Why is it so difficult to create an RN?

I started out as a Hospital Corpsman in the Navy, a course that took about 12 weeks of training, 8 hours a day, 5 days a week. It was legitimately challenging, and highly rewarding. As a result of that training and subsequent hospital work, I was able to “challenge” the Licensed Vocational Nurse exam.

As a civilian I returned back to college and now able to work part time as an LVN. Later became an RN while finishing my undergraduate degree in Economics.

I recall being struck by how little the RN training provided me in incremental education relative to the work required. Sure, the core sciences of physics, chemistry and biology were important, but for an experienced LVN, the nursing training was remedial. For one term I was taking calculus at the university in the morning, and nursing math (a licensing requirement) at the nursing school in the afternoon. There was no way to take advantage of predicate, outside the nursing program training, and because I really did want to become an RN, I just sucked it up and showed up. Still I regret the waste of time and requirements to license that produced dubious marginal value.

Having become an RN, I finished the BA in Economics, I stayed around an additional year studying the labor economics of nursing. Here are some things I think you should know. You may not like it, but here it is.

Nursing is a technical job, not a “profession”. This doesn’t mean that nursing doesn’t have professional ethics or objectives, or is any less important or “prestigious”, just that it doesn’t posses the necessary attributes of autonomy to be classified as a classical Profession; nurses do not practice independently. Now it’s important to get comfortable with this in order to move on in assessing nursing as a career choice. The focus on nursing as a profession avoids the real issues of compensation and competing in the market place of skilled labor.
Nurses have a relatively flat wage-experience curve. This, fits with #1 and explains part of why we have so few nurses in the field. What this means is that a nurses wage does not grow dramatically with experience and compete effectively with other labor choices. Typically nursing wages flatten out within two to three years after receiving a license, this means that in order to accelerate earning, one has to leave. There is a lot more behind this which I hope to address at a later time. You’ll like the story thought it might anger you at first. Perhaps another time, remind me.
Caring is not enough. I’ve heard the adds from Johnson & Johnson in support of attracting people into nursing and I applaud them for their effort and investment, but its more than caring. If you care about me as a patient, but have no idea what your doing and as a result my condition worsens, it matters to me little that you cared. What matters is that you are aware of my condition, know what to do and can intervene if things go poorly.

As the single largest providers of healthcare in the world, nurses are valuable because what they do is valuable, necessary and effective.

Institute of Medicine Report on Heatlh Care Workforce

Tom Coss — Sun, 04 May 2008 21:44:36 +0000

Discussed in earlier posts, is a growing concern over the increasing demand for healthcare services, and shrinking number of providers. On April 14th of 2008, the Institute of Medicine published an exceptional report entitled “Retooling for an Aging America: Building the Health Care Workforce”.


Retooling for an Aging America: …

Read this FREE online! Full Book \| PDF Summary

Aside for validating this blog, the report outlines in greater detail the changing needs of the healthcare system in regard to treating older patients. Included in the report is an estimate that perhaps 32,000 qualified applicants annually are denied entry into nursing programs due to the lack of space and available faculty. In addition, physicians are not particularly interested in geriatric medicine which in general competes poorly with other sub-specialties like Dermatology.

The net of all this is, as stated here before, is that we lacking the labor needed to support the current and future demand for healthcare services.