The problem in the financial crisis is that not enough peopled asked themselves (with the possible exception of Morgan Stanley), what if their assumptions are wrong?  What if we’re missing something?  What might be the effect, and is it something we can can survive?  Simple questions underlying rick management, and not being asked on behalf of this legislation.

This legislation could produce the same effect upon our economy as Smoot-Hawley Tariff act did in the summer of 1930 with a higher probability than anyone has yet discussed.

It is indeed possible to make things wore. Primum non nocere: Above all do no harm.

Tom

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

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

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

I’m not suggesting that the democrats are knowingly inflicting harm, though they are, but the reward to them in passing this legislation without full regard to its impact, is suspicious.  They are so looking forward to the signature parade at the White House, that they can’t see past the process.  In the legislative sense, this is MSP at its worse.

The U.S. jobless rate for October  jumped up 0.4 percentage point to 10.2%, the highest level since April 1983. The government’s broader measure of unemployment shot up even more, rising half a point to 17.5%, still with this in front of them, the democrats insist on pushing through their vision of reality.  The democrats are driving this train past all the alarms and warning of dangers ahead, and we’re stuck facing the results of the inevitable derailment.

This future is sad, easily predictable, guaranteed to get worse and fundamentally unnecessary. Perhaps  this will help:

Presume for a moment that you have a headache because someone is beating you on the head with a stick; you can: a) take medication for the headache or b) take away the stick. The government chose “a” (pass a huge healthcare bill and taxes to support it); I recommend “b” (lower the tax burden, don’t add to it, and free up capital investment in healthcare by reductions in capital gains.) By no means should the government be messing around in an industry of which they understand little, that was responsible for 56% of US job growth from 2002 to 2006, and an industry in which America has a strong comparative advantage that doesn’t outsource well.

Healthcare is complicated, as an RN, I can assure that is true beyond anyone’s imagination.  Should the House and Senate bill come into law in any fashion as currently seen, we are in grave condition indeed.  We all need to begin doing all we can to stay as healthy as possible, because should you get sick, the last thing you will want is healthcare.

Tom

BarackObama Tomorrow will mark a year since our historic victory. Do you have a favorite 2008 Election Day memory? Share your stories via #Nov4 21 minutes ago from web . 

 I “friended” the President to keep up on what he or his staff  feels to be important.  Frankly, I thought it might be a great way for the new administration to send out succinct (perhaps that’s the problem) messages to the electorate on what they might want us to know.  As it turns out all it’s used for is campaign stuff, support specific legislative items, send letters, stuff like that.  Still, perhaps that’s ok, who knows the proper use of twitter in a standing administration; it’s a question that very likely never came up before.  Just maybe this makes as good sense as any other use of twitter; then there was this post by the Obama staff. 

I’m struggling with this.  Of all that is going on, just why is it of interest to anyone to take a little trip down memory lane and share favorite story of a “historic” election?  Surely he could have easily said: “It’s been a year folks, how am I doing”?  Or perhaps something more contrite like: “Gees, who knew.  Now they want results?”  So ask yourself this, if you could send a statement to over 2.5 million people, what would you say.  Could you in your wildest imagination ask people to share their memories of you?   

 This is nothing less than inward focusing narcicism, straight up; as sad as it is tragic.

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

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

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