Health Data Now!

It's well known that medical spending is highly variable but so are medical outcomes.  Here is Begley and Interlandi in Newsweek:

After we interviewed dozens of oncologists, pored over published papers, and obtained outcomes data that cancer centers have never before made public, it became clear that for these cancers there are indeed significant outcome differences depending where you are treated.

Five years after surgery for prostate cancer, for instance, 72 percent of men treated at leading hospitals are alive, compared with 62 percent of those treated elsewhere. Scrutinizing data from specific cancer centers reveals even greater gaps. Five-year survival for stage IV prostate cancer is 71 percent at Fox Chase, for instance, but 38 percent nationally. For stage IV breast cancer, the respective figures are 28 percent and 19 percent–an almost 50 percent edge. For stage IV cervical cancer, five-year survival is 33 percent at the Cleveland Clinic vs. 16 percent nationally.

Some of this is probably due to differences in patient characteristics but it could go either way – the better hospitals often get the hardest to treat cases.

Many hospitals hide this data (or "fail" to collect it which amounts to much the same thing) but there are some good rules of thumb such as looking for hospitals that specialize in certain procedures and thus perform many of them (there are large economies of scale in quality).  Patients can also find information about which hospitals closely follow best practices (kudos to Medicare for this data and see here for a mashup with Google maps) although the measures used are probably the ones that are easiest to collect and not the ones that correlate best with mortality.

Nevertheless, providing information does seem to drive change if only from the shame that a hospital receives when it is found not to be following best practices.  It's true that report cards can cause problems when the drive to get a better score causes hospitals to be more reluctant to treat sicker patients but better data on patient characteristics (stage of cancer etc.) and better process/treatment information can alleviate this problem. In fact, all hospitals should be required to provide standardized information for all patients on patient characteristics, treatments and outcomes.  Only by making outcome information public will hospitals have the incentive and researchers have the ability to develop more accurate report cards.  In short, I cannot think of a simpler change that would improve health care to as great an extent as freeing the data.

Comments

Another huge benefit is that the data can be used to identify best practices that can then be disseminated. Unfortunately, it's rarely simply a case of "freeing the data". It's more often a case of forcibly capturing it and making it speak.

This means requiring the data to be collected, standardized and reported. As you point out, hospitals don't necessarily want to share this information so the free market won't generate it without a great deal of help and prodding. The VA and Medicare are out in front on this, and improvements in IT will make it much easier and more effective to do this universally.

If you follow the argument that physicians do not follow best practices what you are really claiming is that medical schools are failing in their mission.

Do we need a Federal takeover of medical schools?

The best practices argument is overstated. While the average physician has a hard time keeping up with the knowledge in every field, that is not because physicians refuse to share information. It is just hard to do. Of course the Obama plan is to find super human physicians who are generalist who know everything, or at least will do what a centralized bureaucracy dictates.

Medicine is a science with a lot of variation. Look at medicaid reimbursements for drugs. The state has decided that research shows that one drug is very effective in a treatment of a disease. You have a patient that doesn't respond. Sometimes your DNA will make one drug more effective then another. Your physician wants to try a different drug because sometimes a small subset of the population responds. Then prepare to argue with a state employee on the other end of the phone. Because they will tell you that you may not use the other drug because general trials have not shown it to be cost effective on the general population or testing has not been done on the subset of the population you treat. i.e. it is not cost effective to treat people because outcome studies show that most people don't respond. Bad luck that you are not like most people. And the state things your physician is unable to make an objective decision. I guess most doctors are just poorly trained over paid plumbers

BTW

On the link that showed Chicago hospitals, I think you will find a strong correlation with the outcomes and the quality of the nursing staff. Hospitals that have a hard time recruiting and retaining nursing staff are the same hospitals that have the lowest scores.

Some of those low scoring hospitals serve poor communities. Communities that most nurses are reluctant to drive through never mind work in. (And pay isn't always that different. I think Cook County and University of Chicago have the highest paid nursing staff.)

In addition some of the other hospitals while not in poor communities have, I am told, difficulty with their nursing staff

Based on that link it would seem that nursing staff has a much bigger impact on outcomes at hospitals then physicians. (Although top physicians also tend to avoid these hospitals.)

Another BTW

Their is a smaller community hospital about 60 miles from the Cleveland Clinic. They brag about the outstanding outcomes of their cardiac unit. What they fail to mention is that complex cases are routinely referred the the Cleveland Clinic that has one of the better cardiac units in the world.

The data from the community hospital probably looks like more effective low cost care, but they are free riding on the talent at another hospital.

If you stand still, others will change. It is interesting to watch those who opposed parts of the healthcare bill which fund studies of what is effective now realize that this can lead to better outcomes.

Indeed, beginning to pay for outcomes, rather than procedures, is a way to have the market work to introduce best practices and control costs. They need not be mutually exclusive.

There have been a number of studies which show that what determines a doctor's treatment of an individual varies based on such factors as when the doctor was trained, with whom he/she was trained, whether the doctor is part of a multi-practice specialty group, and whether the doctor is employed or is in private practice (the latter factor influencing the ability of the organization to have influence over the practioner).

Development of science based medicine, studies of effectiveness of alternatives practices, procedures and products, are all public goods, or at least goods that if discovered, need to be costlessly diffused to other practioners, and therefore deserve public expenditures to subsidize additional production or capacity over what would be privately produced.

This is a huge peeve of mine.

I'm a geek, I admit it. When I make a major purchase I research the living daylights out of it.

When I was searching for a hospital for my wife and I to deliver our baby at this year, the lack of quality data astounded me.

I understand the arguments against, such as selection bias, but it seems to me that releasing this data in a normalized manner should be a number 1 priority in public health

This is pretty well documented in the medical literature; especially for complicated procedures (AF node ablation, heart transplants, etc.) it is very clear that the more procedures the doctor/hospital has performed, the better the outcomes.

Alex, in all services, spending is highly variable and so are outcomes. For another example, read
http://www.thefrisky.com/post/246-money-honeys-the-economics-of-prostitution/

Bill: "beginning to pay for outcomes, rather than procedures, is a way to have the market work to introduce best practices and control costs."

I don't know, Bill. I think the result suggested by DrYes 80 seconds earlier is more likely:

DrYes: "If you're a physician that takes high risk patients when no one else does, and you are penalized by such outcome measures, odds are you will not take the chance to treat someone who might otherwise not survive. For that 10-20% of patients who do 'recover' if treated, that's a death sentence."

Research in 2003 by Y. Shen of Boston University revealed that:

"Under performance-based contracting, the likelihood of a participant in the program being in the most severely ill group decreased (P 0.01), suggesting that adverse selection was occurring in response to the financial incentive."

If spending and outcomes are both highly variable, the question that springs immediately to my mind is whether they're correlated. Should be easy enough to figure out - does anyone know if this analysis exists? I suspect they're not that highly correlated.

The power of transparency has been shown time and again to improve the effectiveness of organizations by forcing them to make changes. In a health care system where insurers have near monopolies and hospitals are businesses, this transparency is all the more important. An annual national report card on hospitals would likely go a long way in pushing for efficiencies.

@Bill,
how exactly do you adjust for that risk? It seems to me that it would be very very easy to fudge for the smaller players.

@anonymous coward,

Re risk adjustment for outcomes. I know that Mayo Clinic and an associated organization I believe called the Insititute for Quality Improvement sponsored by Mayo and health plans have such measurements when they do comparative studies of the effectiveness of treatment in order to normalize what goes into their assessment. Will see if I can find some cites.

"The challenge, then, is to design incentives with the intended goal in mind."

A typical academic and consultant garbage sentence. Of course that's the challenge.

bill: "Most physicians and hospitals are paid the same regardless of the quality of the health care they provide, producing no financial incentives for quality and, in some cases, disincentives."

Most physicians and hospitals are paid the same regardless of the genetic endowments, life choices, and environments of their patients. And by that I mean the life choices and environments both before and after treatment. Considering the thousands of varied medical treatments and the millions of external factors which affect medical treatment outcomes, it seems to me an impossible task to "design incentives with the intended goal in mind" and to "pay for outcomes ... on a risk adjusted basis".

I have no problem with transparency. I do have a problem with private or public sector bureaucrats who believe they can accomplish impossible tasks but who are not the ones who suffer - perhaps die - when those bureaucrats fail at the impossible task. As DrYes pointed out, pay for outcomes leads to adverse selection which, for some, leads to death.

There's no incentive to collect this sort of data because there's no incentive for the employer-insured to be concerned much with prices.

And there's also less concern about quality when you're not paying. Just check out the quality of the food at a free hotel breakfast.

Yes mulp as the post says "all hospitals should be required" to post this information. As a number of commentators have pointed out our current system doesn't provide strong incentives to provide this information.

But Alex misses a big part of the Obama plan, they save costs by reducing access to specialists to save money. But specialists give you the best outcomes.

haha...this is laughably wrong. there are literally books filled with research papers out there pointing out that this is not always true. about the only thing a specialist is consistently better is costing more money.

Bk, MD

I am very sorry that you are a quack who was trained at a medical school that, for some reason, refused to train you in evidence based medicine. Where is this medical school and how do we close it? Or where are these medical schools that didn't get the text?

Or do you know physicians who are quacks? Who either slept through medical training or refuse to stay current. Have you reported any of these negligent physicians to your state medical board? If so how many. If they are endangering the public don't you have a moral obligation to stop them?

So what percentage of physicians do you consider ignorant? 98%, 75%, What percentage of physicians have best outcomes? You and two others.

Is medicine evolving. Yes. And at a much faster rate then we can expect a government bureaucracy to adapt. Of course that is what we need, a government bureaucracy deciding what are best practices and then requiring physicians, if they expect to be paid, to follow those central dictates.

If you think building a consensus about best practices is difficult under the current system, and such issues should be debated, why do you think that a centrally controlled government bureaucracy will be better.

And if I have a complicated issue, I will seek out a board certified specialist. But then you must think the whole issue of boarding is a waste of time.

The blinding arrogance of some physicians is amazing.

@Bill

I agree that the system we have now has absurd incentives. I'd like to see the system free-marketized. Right now, as far as I can tell the best method to do this is HSA's.

Most people don't have the ability to research the complex issues involved in treatment decisions. Your doctor should do his best to inform you but it should not be an adversarial relationship.

And some doctors will be better at doing this than others. How do we find which doctors are bad at it?

The sad truth is that this industry has been stealing from the poor and vulnerable in this country since its inception. We need to reign in the crooked CEO's and the most efficient way to do that is to nationalize this industry.

But I liked very much ..

The best practices argument is overstated. While the average physician has a hard time keeping up with the knowledge in every field, that is not because physicians refuse to share information. It is just hard to do. Of course the Obama plan is to find super human physicians who are generalist who know everything, or at least will do what a centralized bureaucracy dictates.HribarWiersteinerKerwoodRidgebearDahlstedtRewenkoBroermann

It just proves quality of health care is a factor in outcome. We can't though just put our total trust in the health care system and have to do our part our part to in maintaining our health with a healthy diet and regular exercise program. www.perfectpilates.com

It is common knowledge that every domain has its own superstars and then the random representatives. In medical care, things stay pretty much the same. Those leading medical centers are leading for some reason, I guess. They do a tremendous job. Funny how the medical field also acts as a competitive market. In the rehab field as well, Narconon drug rehab program and others alike gained popularity due to their excellent results.

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