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Strange Things in the Precious Metals
Issue #531, July 17, 2018

Buying Years of Retirement
Issue #530, July 09, 2018

Rent-A-Kid for Retirement
Issue #529, July 02, 2018

The Dark Side of Student Loans
Issue #528, June 25, 2018

The Cost of Out-sourcing Convenience
Issue #527, June 18, 2018

Social Security: 66 or 70?
Issue #526, June 11, 2018

Student Loans: There’s (Unfortunately) a Lot More!
Issue #525, June 04, 2018

Co-signing a Note
Issue #524A, May 31, 2018

The Knight Frank Luxury Index and Collectables
Issue #524, May 28, 2018

The Importance of Diversification: The Myth of Diversification
Issue #523, May 21, 2018

How to Save Thousands on Your Food Bill
Issue #522, May 14, 2018

MoviePass and Other Things
Issue #521A, May 10, 2018

Degree Inflation, Long Training Periods, and “Certification”  Part III
Issue #521, May 07, 2018

Degree Inflation, Long Training Periods, and Certification” Part II of III
Issue #520, April 30, 2018

Follow-up on Several Things
Issue #519A, April 25, 2018

Degree Inflation, Long Training Periods, and “Certification”: Part I of II
Issue #519, April 23, 2018

The Kids Birthday Party Hustle
Issue #518A, April 18, 2018

A Pension Question: Part II of II
Issue #518, April 16, 2018

A Physician is an Executive
Issue #517A, April 11, 2018

A Pension Question: Part I of II
Issue #517, April 09, 2018

Is the Correction Over?
Issue #516A, April 05, 2018

Used Car Dealers, Student Loans, the Chinese, and Uncle George’s Rule
Issue #516, April 02, 2018

Starter Homes
Issue #515, March 26, 2018

Redecorating: Beware!
Issue #514, March 19, 2018

NASDAQ Closes at Record High
Issue #513, March 12, 2018

A 40% Chance
Issue #512, March 05, 2018

Several Things
Issue #511, February 27, 2018

Human Capital, Education and Wealth
Issue #510, February 19, 2018

Another Stock Market Update
Issue #509A, February 18, 2018

Some Thoughts on Savings
Issue #509, February 12, 2018

A Stock Market Upfate
Issue #508S, February 10, 2018

Who Can You Trust? Part II of II
Issue #508, February 05, 2018

The Christmas Decoration Pre-worn Jeans Hustle
Issue #Interim Bulletin #507A, February 03, 2018

2018 Outlook for Financial Markets
Issue #507, January 29, 2018

Who Can You Trust? Part I of II
Issue #506, January 22, 2018

Life Insurance Settlements
Issue #505, January 15, 2018

Commodities and Buying the Breakout
Issue #504, January 08, 2018

Buffett Wins His Bet
Issue #503A, January 04, 2018

Practice Real Estate and Free Agency
Issue #503, January 01, 2018

Outlook for 2018: Part III: Stocks and Bonds
Issue #502, December 25, 2017

My Outlook for 2018: Part Ii: Precious Metals
Issue #501A, December 21, 2017

Outlook for 2018: Hard Assets: Part I of III
Issue #501, December 18, 2017

More Thoughts on Bitcoin
Issue #500A, December 14, 2017

Fees and Good Relations with Bankers
Issue #500, December 11, 2017

Salvator Mundi
Issue #499A, December 07, 2017

Should You Rent or Own a Home?
Issue #499, December 04, 2017

A Gift Subscription
Issue #Interim Bulletin #498A, December 02, 2017

Stocks vs Real Estate: Asset Allocation: Part II of II
Issue #498, November 27, 2017

When Good Enough is Fine
Issue #497A, November 22, 2017

Stocks vs Real Estate: Asset Allocation. Part I of II
Issue #497, November 20, 2017

The Saudi Arrests and the Perils of Foreign Investing
Issue #496, November 13, 2017

Gambling and Las Vegas
Issue #495, November 06, 2017

Some Tips on Auto Insurance
Issue #494, October 31, 2017

Bitcoin and the Digital (Crypto) Currencies
Issue #493, October 23, 2017

The Coming Bear Market: Part II How to Prepare
Issue #492, October 16, 2017

Some Observations on Cemeteries
Issue #Interim Bulletin #491A, October 12, 2017

The Coming Bear Market: Part I: The Myth of Buy and Hold Forever
Issue #491, October 09, 2017

The Market makes New Highs
Issue #490, October 02, 2017

The Importance of a New High
Issue #489, September 25, 2017

A Little Insurance: Wealth, War and Wisdom
Issue #488, September 18, 2017

Some Observations
Issue #487, September 11, 2017

How to be Successful in Your Career
Issue #486A, September 07, 2017

How NOT to Buy a Home
Issue #486, September 04, 2017

This Week in the Market
Issue #485, August 28, 2017

Is the “Trump Bump” Running Out of Gas?
Issue #484, August 21, 2017

Gold is on the Move
Issue #483, August 14, 2017

The Importance of Estimation
Issue #482, August 07, 2017

Buying Art and Collecting: Part II of II
Issue #481, July 31, 2017

Buying Art and Collecting in General, Part I of II
Issue #480, July 24, 2017

Physicians need to be More Forceful: Follow-up
Issue #479, July 17, 2017

Physicians need to be More Forceful
Issue #478, July 10, 2017

Your First “Real” Investment
Issue #477, July 03, 2017

Leasing a Watch: Don’t
Issue #476, June 26, 2017

The Importance of Your Children having a Job
Issue #475, June 16, 2017

The Problem with Medical Student Debt is—the Med Schools
Issue #474, June 12, 2017

Critters and Varmints in your Home and Yard
Issue #473A, June 07, 2017

Leveraged ETFs
Issue #472, May 29, 2017

Leasing a Vehicle: Don’t!
Issue #471, May 22, 2017

Issue #470, May 15, 2017

More on Buying Jewelry
Issue #469, May 08, 2017

Buying Jewelry: Gold, Diamonds and Pearls
Issue #468, April 30, 2017

Thomas Sowell: Part III of III
Issue #467, April 24, 2017

Thomas Sowell: Pat II of III
Issue #466, April 17, 2017

Live Close to Where You Work
Issue #465, April 10, 2017

Medtronic in Hospital Management
Issue #Interim Bulletin #464A, April 07, 2017

Thomas Sowell: Part I of II
Issue #464, April 03, 2017

A Political Contribution a an Investment: Part II of II
Issue #463, March 27, 2017

A Political Contribution as an Investment: Part I of II
Issue #462, March 20, 2017

Buffett Selling Vacation Home
Issue #461, March 13, 2017

Advanced Placement (AP) ourses
Issue #460, March 06, 2017

The Importance of a Credit History
Issue #459A, March 02, 2017

A Credit Card Scam
Issue #459, February 27, 2017

The Electronic Health Reord
Issue #458, February 20, 2017

Issue #457, February 13, 2017

Platinum and Palladium
Issue #456, February 06, 2017

Economic Outlook for 2017: Part II of II
Issue #455A, February 02, 2017

Economic Outlook for 2017: Part I of II
Issue #455, January 30, 2017

A Story From Vegas
Issue #454A, January 25, 2017

Land Donation Deals and the IRS
Issue #454, January 23, 2017

The Theory of Gambler’s Ruin
Issue #453, January 16, 2017


By Robert M. Doroghazi, M.D., F.A.C.C.

Medtronic in Hospital Management

Issue #Interim Bulletin #464A, April 07, 2017

    This is from the MedPage Today article on 3/30/17 “Bringing Device Makers into the Hospital: Good Business or Ethical Risk?” by Nicole Lou.
    UH Cleveland is the first hospital in the US to outsource the management and operation of their cath lab to medical device maker Medtronic (MDT). This business model has already met with success in Europe, saving the hospitals money and expanding MDTs business portfolio. It also raises questions about hospitals controlling their operations, and whether physicians can use devices from other manufacturers.
    MDT launched its Hospital Solutions business in 2011, and in 2014 purchased the Italian firm NGC, which already managed several cath labs. This began after a senior official said MDT “needs to switch from a medical device company to a healthcare company…if we want to be part of the solution of the delivery of healthcare”. Insourcing—bringing a company in to do a job onsite—is become more common across many industries. 
    Maastricht Med Center in the Netherlands saved $2.5M in one year from MDT health directives, including a new time-in, sign-out procedure, more best practice procedures, and staff development and educational programs. The results decreased cancelled procedures, increased efficiency, and boosted patient satisfaction. Imperial Healthcare in London also reports positive results.
    MDT says the goal at UH Cleveland is to “leverage functional expertise, such as inventory management, as well as consulting capabilities in various process improvement and change management methodologies, to identify opportunities to improve system capacity, cost efficiencies, and patient engagement (RMD comment: Vigyaz, Hungarian, “look out for danger”. That is corporate double-speak. It can mean anything)…The health system will maintain responsibilities for all activities requiring professional licensure and full discretion…to medical decision making and patient care, including decisions related to procurement and device selection”.
    Encouraging such arrangements is the focus of Medicare and Medicaid to bundle charges. Hospitals are looking to improve efficiency and reduce costs while MDT is looking to increase penetration. Such partnership also gives companies access to performance data (see my #2 comment below).
    Concerns among physicians include A) whether they will be pressured to use certain devices or products over others, esp. if they believe the products aren’t equal. B) If products of other companies will even be available.  C) They will be working alongside company employees. D) What happens if a different company is the first to come out with a new procedure or device not carried by MDT?
    RMD comment: Here’s what I see as some of the issues.
    1) This illustrates and reinforces what I see as the continued “corporatization” of Medicine. The government, huge insurance companies, huge publically-traded pharma and instrument-makers, with the ability to raise billions in the capital markets, and who spend millions on political lobbying, hospitals (whether profit or non-profit) run by huge corporations. Physicians have little power to stand up to this onslaught, and are continually being marginalized and losing influence.
    2): From above: gives manufacturers access to performance data. Say there are 5 interventional Cardiologists at a hospital. One is “weak” (has below-average results), 2 average, and 2 first-class. Will the administrators of the cath lab have the discretion to direct all procedures to the 2 stars, and put the other 3 out of business?
    3) Everyone should always try to improve efficiency and hold down costs. But it is safe to say that hospitals won’t, Heaven-forbid, share the savings by lowering charges to patients, or raising the salaries of nurses and other front-line employees. Rather, they will retain the savings to protect profits and pay the “Suits” their 6, 7, and 8-figure salaries.
    In support of this view, see my Commentaries:
    A) Negative Secular Trends in Medicine: High Hospital Profits. American Journal of Medicine. November, 2016.
    B) Negative Secular Trends in Medicine: High CEO Salaries. American Journal of Medicine. February, 2016.
    4) It is naïve in the extreme to believe that physicians won’t be pressured to use the in-house products. Does a wild bear…, is the Pope…is a frog’s heinie water-tight? Physicians employed by the hospital will have no choice: they must do what they are told, or they will lose their jobs.
    5) If things don’t work out well, how does a hospital extricate itself from the agreement? Agreement ends on December 31, on January 1, you must hire all new cath lab employees and stock hundreds of new products. Hard to imagine a smooth transition.
    6) Who has ultimate control of the lab and the employees? Is the Director responsible to their superiors at MDT or a hospital executive? Two guesses, and one doesn’t count. One person must have ultimate control. All I can say for sure is that it won’t be a physician.
    7) From the point of MDT, I find the idea innovative, and I don’t blame them for pursuing it. It is up to all participants—hospitals, physicians and MDT—to make sure the patient is best served.
    8) There would be far less concern if the insourcing was a management company whose expertise was to run cath labs, with no ties to an instrument maker.
    9) I’m sure the talking heads will have answers to all my questions. Be skeptical.
    I need to think about this a lot more, and need more information and insight. I would greatly appreciate any feedback (source will be held in confidence).

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