CossEffective

Repeal HIPAA Now.

Tom — Tue, 31 Jan 2012 23:26:09 +0000

Back in 1996 when the Health Insurance Portability and Accountability Act (HIPAA) was signed into law there were approximately 20 million internet users, AOL was the most visited site and the average amount of time spent on line was about 2 hours a month. Today there are over 245 million internet users, no one talks about AOL and we spend about 27 hours per month on the net. Since the 90′s we have the arrival of Google, YouTube, facebook, internet banking and much more, yet we still have HIPAA.

If ever there is a piece of legislation in need of repeal it is HIPAA, and this dog needs to go. Despite creating an industry over night for consulting services, this legislation as produced nothing more than costs which are real, with benefits that are not.

Observing that a dinner tray, now cold, was in front of a patient of hers with bad vision, a nurse placed a small note above the bed alerting the nurses aids that the patient had muscular degeneration, later that day she was “counseled” that that was a HIPAA violation; the patient was 86. In effect it was somehow more important for this administrator to protect this patient’s civil liberties against discrimination than for her to receive a warm meal. Really? Is that where this has now gone?

The individual who reported this story to me was so afraid that she asked me not to mention her in this piece. So what’s this about, and why the paranoia?

Simply stated, there is no reason for the paranoia because the legislation itself is silly, creating nothing more than a portal for litigation absent damages. It is simply time for hospitals and healthcare professionals to stop this nonsense and tell the government that enough is enough. No one will ever confuse a hospital with a Bowling Alley, if a person is in the hospital, it’s likely because they are sick and not to improve their handicap, there is no confusion here.

In today’s social media, reality TV world the whole notion of what is private is changing. Surely there are those for whom privacy on some matters is important, I get that, still this legislation is taking a sledge hammer to an ant, HIPAA needs to go.

Graduate degree required? Not so fast.

Tom — Mon, 12 Dec 2011 05:20:54 +0000

Last week I received an interesting call from a recruiter seeking to fill a Midwest hospital position in Clinical Informatics. Though personally uninterested in relocating, I spent some time discussing the position just to see what hospitals are looking for in candidates. Little surprised me in regard to experience or technical knowledge, still there was one surprise, the hospital insisted that the candidate had a graduate degree.

As it turned out, this recruiter had been struggling with this facility and others in their desire for graduate degrees as a necessary condition for various position. The challenge with this approach is that there is no evidence that a graduate degree, though certainly wonderful to have, is a necessary condition for success. That is, there are no outcomes studies connecting graduate education to improved performance and outcomes, so why the requirement? By this criteria alone, people like Steve Jobs, Bill Gates, Jane Goodall all of whom have successful, highly innovative careers and none with even an undergraduate degree, would have no place in healthcare. Today we have Richard Davis, the highly successful President and CEO of US Bank with a BA in Economics, and Clay Shirky, Professor of New Media at Hunter College and now at New York University with his BA in Fine Arts; just how is that possible?

It’s difficult to imagine a robust industry of innovation if hospitals insist on outsourcing their hiring decisions to university admissions departments. Stunning as it is, an industry priding itself upon the rigor of science place upon itself entirely untested requirements in filling important position. Forward thinking hospitals desiring to be innovative, quickly need to be thinking differently about the getting the talent they need for success.

Re-admission Rate Statistic, Not so Fast

Tom — Sun, 06 Nov 2011 21:31:41 +0000

Being exceptionally fond of statistics, and even more so, aware of their limitations, I’m often delighted with when those limitations are discovered.

In this article by the Journal of the American Medical Association on Risk Prediction Models for Hospital Readmission the authors looked at a large group of studies and tested for their predictive statistical significance with interesting results.

This remains yet another indication of our limitations in treating “populations” rather than patients. Despite how exquisitely educated we may be or think we are, the incredible complexity of human biology and spirit requires that humility be practiced, as well as science.

RAND discovers the downward sloping demand curve.

Tom — Fri, 25 Mar 2011 23:26:27 +0000

In a startling find, a study from the RAND corporation found that higher deductables result in lower consumption of healthcare services.

“Studying more than 800,000 families from across the United States, researchers found that when people shifted into health insurance plans with deductibles of at least $1,000 per person, their health spending dropped an average of 14 percent when compared to families in health plans with lower deductibles“

It is believed that this discovery is found to be consistent with other items in the economy such as houses and cars. Sources say that it appears that there are fewer people looking for very expensive houses over $10 million than those looking for houses under $200 thousand. Similarly, fewer cars over $200,000 are purchased relative to those costing $10,000.

What are we to make of this incredible observation?

The Current Nursing Labor Market

Tom — Thu, 06 Jan 2011 04:41:53 +0000

I’ve come across comments on various nursing websites highlighting difficulties for new grads finding jobs and thought some economic perspective might be helpful.

First, the demand for RN’s will continue to grow at an average 2.2% per year, with supply of RN’s short of demand through 2018. Given that the mean age of all nurses is in the low 50′s, while baby-boomers are just now hitting the retirement age at the rate of 10,000 people per day, the gap between RN’s willing to work and the demand for their services will continue to diverge, i.e. stay healthy, you may be on your own. For certain, how RN’s are treated today can dictate how profitable institutions will be five years from now.

What you may not know is that nursing is part of what Jacob Mincer, Labor Economist of the 1950′s identified as part of the “secondary labor force”. This labor force, according to Mincer, tends to provide secondary income to the household where there is another income producer providing the largest income. Nursing, being part of the secondary labor force, tends to run countercyclical to the general economy. When things are good, the secondary labor force is relatively quiet, nurses work less hours or perhaps not at all, while asserting muted demands for attracting their highest marginal wage. When the economy slows down resulting in lay-off’s of primary income producers, the secondary labor market becomes more robust. People return to the labor force, work longer hours, and begin seeking higher wages.

This latter response to a downturn in the economy can produce an illusion that shortages have gone away, when it certainly has not, that is, it’s a head fake. A second wave problem happens when employers of nursing services fail to recognize the fragility of their current situation. This secondary labor force can quickly return to lower participation rates as soon as household income needs are met, and do so much faster than any hospital can possibly hope to manage. The second wave effect includes students who also misread the market and choosing not to pursue nursing fearing an absence of work when they are finished. Times like these present a tremendous opportunity for hospitals and healthcare organizations, or can set them up for future disasters if they handle these times poorly.

This is a time for healthcare organizations to be as accommodating and supportive as they can be in attracting new and experienced talent. Hospitals can gain a ton of good will, as well as an exceptionally deep and loyal bench of RN talent for the future, if they take advantage of these times and build solid relationships with returning RN’s as well as warmly embracing new grads. Failure to engage nurses now will result in profound shortages and an explosion of expense in the future, and there is absolutely nothing a hospital will be able to do to reverse the damage.

Questions?

Tom

Theft or Money Laundering

Tom — Thu, 16 Dec 2010 16:36:49 +0000

If I steal from you it’s theft, but what if I purchase lots of stuff on your credit card for which I expect you pay, is that any different? Oh I know, it’s for a good cause, still if I do not have your permission is it still OK?

What if you give me money that you can deduct from your income tax, and later I arrange for you to receive money and it happens to be very much the same amount, does that sound right?

This spending bill stinks.

Behavior Unbecoming a Physician

Tom — Mon, 13 Dec 2010 17:24:33 +0000

Physicians need to begin asking themselves why they depend upon government “officials” like HHS Secretary Kathleen Sebelius for their wellbeing. Today there is yet another plea for government not to cut physician reimbursement beginning January 2, 2010. Surely you must be asking yourself if this is why you spent all that time in post undergraduate education. Just how much professional autonomy are you willing to surrender?

Here is an objective worthy of adoption:

Five years from today my practice will be receive 50% of total annual revenue from cash.

Write it down, paste it in front of your desk so that you see it each morning, and begin making it happen. Physicians must reduce the capricious effects of government in their practice by making the government less relevant to their future.

World Health Over Time

Tom Coss — Sat, 11 Dec 2010 23:07:53 +0000

Through Gapminder one can see an amazing view of the improvements in the health of countries over time in association with the wealth of those companies. On this site you’ll see an incredible view of progress and some failures over the past two centuries, one standout being China.

The size of each dot represents the population size of the country, and because of this it is easy to point out China. Closely following China’s growth in terms of mean age of the population and their average wealth, it’s surprising to see such a dramatic change that occurred from 1958 through 1962. (This event is quick and deep on playback in the graphic, so you have to slow things down to see it) During this period the median age of the population fell precipitously from about 50 to below 30, while over 36 million people did of starvation.

The Economist F. A. Hayek said that it’s “The curious task of Economics is to demonstrate to men how little they really know about what they imagine they can design.” The truth behind this statement is less often recognized by those who profess to be “smart”, while commonly appreciated among those who happened to be experienced. All the smart people in the late 1950′s China were convinced they knew best for all concerned. With enthusiasm (and a fair amount of coersion) an experiment in design forced already poor peasants to trade high valued resources (labor and food) and turn them into low value goods (metal), most of which was poor in quality and useless. Imagine starving to death because someone had an idea based in an ideology, not reality – tragically many did, and still do today in North Korea.

Now, nearly 5 decades later a bunch of smart people think they can top-down design an infinitely more complex healthcare system to work more efficiently. These people know little about healthcare or medicine, but are absolutely confident that they know best simple because of who they are. They won’t be around when it fails, won’t see those who endure long waits for services or the damages that result, so does that make them smart or just shrewed?

Information = Freedom

Tom — Sun, 28 Nov 2010 18:56:13 +0000

In a 1985 report for the Electronic Fronter Foundation, Dr. Curtiss Priest makes a compelling three step observation into the intrinsic relationship between information and freedom.

Step A. Information affects the range of choices available to the individual.

You cannot choose among things you do not know exists. A person in need of repairing a broken wrist, for example, can seek out specialized individuals in order to gain information on choices to be made, and get it fixed. Just 100 years ago, among those choices would have been amputation, rarely would this be considered now; today we have lots of choices.

Step B. Freedom is a lack of restriction on choice.

Lacking external constraint by government on where one may go for help with a broken wrist, we have freedom to seek the best possible help we need for the best possible outcome. The freedom of acquiring proper information produces yet another freedom, the freedom that comes with a properly functioning wrist for the rest of one’s life; a nice freedom to have.

But what if a person on whom we depend to know of all possible choices, are themselves deprived of information? When conditions are more complicated than a fractured wrist such a cancer or rare diseases, choices can find themselves limited arbitrarily by the person to whom one turns for help. If you’re sick, does it really matter to you how or from whom your physician learned of a potential cure? Does it matter if that information comes from a colleague, professor or even sales representative as long as it works?

Step C. Thus information leads to greater freedom.

So here we are, if “A” is correct, and “B” is correct than one must agree that “C” is correct. There is an intrinsic link between information and freedom that can not be denied. Information leads to greater freedom by exposing choices, and choices properly acted upon, improve outcomes. Conversely, freedom enhances the value of information in that without the ability to act upon choices (go where you wish to get help), information doesn’t much help, and this brings us to healthcare reform.

The law recently struck down in Vermont, restricting the use of pharmaceutical prescription data, was passed in the name of “consumer protection”, also restrict choices and freedom. At an academic, legislative level such restrictions on information may seem perfectly harmless, but there can be no doubt that someone somewhere will be hurt. The notion that anyone has perfect knowledge into all the possible ramifications related to restricting information is naive, frightening and generally absurd.

As government continues to meddle in healthcare, acts like that undertaken by Vermont will become more common and dangerous.

Court Saves Vermont from Themselves

Tom — Sun, 28 Nov 2010 00:40:33 +0000

A striking piece of news last week regarding the use of medical sales data. On November 23rd, US federal applet court ruled unconstitutional a Vermont law prohibiting the use of prescription drug information that identifies prescribers and patients for commercial marketing purposes. (Judgment Here)

This is incredibly good news because had that law stood, or should this ruling be overturned at a higher level, we will all be poorer for it. Medicine is highly dependent upon unintended surprises which by definition are difficult to see, and impossible to predict. We need the ability to report on pharmaceutical sales data for commercial as well as clinical surveillance reasons, the challenge is that we don’t know when one will result in the other.

Prenatal Folic Acid is a great example of a medical recommendation which resulted from meta-analysis of multiple studies, along with their clinical results. The impact this modest, and remarkably inexpensive addition to the prenatal diet has been simply astounding, resulting in an over 50% reduction of significant neurological birth defects. No drug company would have focused upon this research because it’s is nearly impossible to make money at it.

Legislatures ought not play with things about which they do not understand. I’m losing my patients with half-witted interventions into a complicated healthcare system I will likely need in the future.

See other responses.

T. A. Coss, RN