Coss Effective » Healthcare

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.

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

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

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

Lessons from Timothy Treadwell for Healthcare Reform

Tom — Sat, 31 Oct 2009 21:20:26 +0000

Timothy Treadwell had his own vision of the world, particularly in regard to wild bears. An example of that vision can be seen in a video of Treadwell, sitting in a stream, reading to a bear he had come to know.

Few question the sincerity of Treadwell, also known as the Grizzly Man; he loved the out of doors, all its wildlife, and he surely loved bears. For over 13 years he followed them, filmed them, wrote about them, and as much as he could, lived among them. On Monday, October 6, 2003 the partial remains of Treadwell were discovered, he had been eaten by the bears.

I’m not making light of Treadwell or his cause; still this tragic little story was, inevitable. Treadwell’s vision of the world dramatically differed from reality, and in the end, reality prevailed. He couldn’t help himself in wanting to be closer and closer to the bears he loved, and slowly over time, he extended that vision to his own peril and that is the lesson.

This is a great example of where we find ourselves in the healthcare reform debate. It’s very comforting to think that there is a group of people, so smart and insightful as to be able to craft a plan to manage the healthcare of millions. We are, it seems, eager to abandon the evidence of our senses and believe that by some means not fully understood, a group of ordinary people who, having chosen to work for the government, will have morphed into something they previously were not. These individuals will somehow craft a workable healthcare system in a way no one has ever considered in the past. Within this system, diversity goals will have been met, procedures will be reduce, screening will go up, more people will be treated, innovation will thrive and costs fall.

I don’t question the sincerity, but outcomes are not bound to sincerity or good intentions, they are bound by actions; not what people think or wish, but by what people do. It is noteworthy that the end for Timothy Treadwell was also the end for his girlfriend (also eaten) and for the two bears suspected to have done the deed. All are gone. It seems that this congress is committed to a vision of the world around them, wholly unsupported by history or evidence, and that we the will have to suffer its consequences; how very sad and exceptionally unnecessary.

Thomas A. Coss, RN

A Case for Truth and Plain Speaking in Healthcare Reform

Tom — Thu, 15 Oct 2009 16:48:24 +0000

Suppose that a physician who is treating you for cancer, were to observed the same scruples regarding their use of language as we currently see from President Obama, and congressional leadership. Now lets say that this same physician were to tell you that your “cancer is cured”. How would you know if you should start that James Mitchner novel you’ve wanted to read, or dial 911?

Medicine, for all its flaws and inefficiencies, has an exceptionally high regard for truth and plain speaking. You would not find a physician willing to tell you “you’ll be fine” when he or she believes by knowledge and experience, that you will not; to do otherwise would be considered malpractice. Physicians may choose their time and place, but you’ll not find them mincing words when it counts.

If the president and congress is going to mess with healthcare, they need do so by the rules of medicine, not politics. They need to investigate and understand the problem completely, and then produce a clear, accurate and defensible diagnosis. They need to share that diagnosis with the patient and family ( in this case the entire US citizenry) discuss options, and define anticipated outcomes of each one. They need to answer all our questions, even if we repeat a few, and provide us the evidence they have in support of their diagnosis and treatment plan. And finally, nobody should be doing anything without our written permission.

We should not accept anything less out of the president and congress than we would of our Doctor.

Thomas A. Coss, RN

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.

Senate Committee on Healthcare Reform

garrett — Wed, 15 Jul 2009 23:07:13 +0000

Senate Committee sent out an incomplete healthcare reform bill today seeking approval by the entire Senate. This is the latest in a series of Potemkin Villages the president can view while bobbing along in his dingie propelled by two oars: self importance on one side and hubris on the other.

There was a time in our history when 9 out of 10 people in the US worked in agriculture and some how the government didn’t see a need to reform agriculture. Similary, general manufacturing peeked in the use peeked in 1958 with over 40% of the us labor force working in manufacturing, where was the crisis then? Now with healthcare involved in 17% of our GDP and less about 10% of the US labor force, somehow we need “reform”, I’m not buying it.

For this to work, you must first believe that when smart people enter into government services they somehow become infinately more intelligent, and therefore better positioned to make your medical decissions. If that is your beilef, please inform me of any situation in which that exists. I would love to see it.

Comparative Effectiveness in Healthcare

Tom — Sun, 15 Mar 2009 00:04:52 +0000

You’ve either seen, heard or perhaps been involved in a situation where a family member asks to borrow money, and later you find out they took a weekend vacation that the lender could not afford. It’s natural that when you lend money to someone, you have some interest into their spending choices. Look at what happened to the auto industry executives who flew into Washington on private jets asking for money. Or the Northern Trust Bank’s golf tournament in California that raised such a hoopla. I don’t have a position on the rightness or wrongness of either private jets or golf tournaments, just that when people receive funds from other people, those other people have a new found interest into what the receiver does .

The government is going to be putting lots of money into healthcare, and similarly, will have increasing interest into how that money is being spent. Comparative Effectiveness Analysis of drugs, and devices is such a response. From what I’ve read, comparative effectiveness likely makes sense, but being an American, it makes me a little uncomfortable as well.

Business already do a great deal of analysis on drugs and products to assure that they have a competitive advantage over existing treatment, and thus a market. The cartoon below applies here as well. There is a large “step 2″ to comparative effectiveness as to how and under what conditions it applies; that needs to be clarified. One big element, it seems, is that comparative analysis assumes information technologies are in place through which to acquire the information and process the results. One has to wonder about the operational possibilities. How’s the miracle going to occur.

The Wall Street Journal has a nice piece on Comparative Effectiveness .

Just so you know, at the time this piece was written a query of Google for “comparative effectiveness” and healthcare returned 127,000 citations