Friday, March 18, 2011

In their boats . . .

There is an old joke about a university with a certain ethnic background (mine) that decides to set up a rowing team. After months of practice, the crew arrives at the Head of the Charles Regatta to compete. They are demolished -- recording by far the worst time of any 8-person boat.

Discouraged, the coach sends out the captain of the team to visit with other college teams to figure out how to get better at the sport. Hours later, Sam comes back and says, "Coach, I figured out the secret of their success!"

"What is it?" asks the coach.

"In their boats, eight people row and only one person talks!"

Apropos of that, please see the photo below of a sculpture from Jaffa, Israel, which seems to exemplify the lesson:

Those who have worked in hospitals already see the relevance of this story, but I present it more to provide a warning of what I see happening in the Massachusetts state government.

You may recall a post from a few months ago in which I set forth great hope about the usefulness of an all-payer claims database. Here's an excerpt:

Over the coming months, in accordance with an act passed last summer, the Division [of Health Care Finance and Policy] will be constructing an all-payer claims database (APCD). It will comprise medical claims, dental claims, pharmacy claims, and information from member eligibility files, provider files, and product files. It will include fully-insured, self-insured, Medicare, and Medicaid data. It will also include clear definitions of insurance coverage (covered services, group size, premiums, co-pays, deductibles) and carrier-supplied provider directories.

The Commissioner noted that the result will be "a dataset that allows a broad understanding of health care spending and utilization across organizations, population demographics, and geography." In my view, it will be a moving force in rationalizing payments to providers across the state....

One of the things then-Commissioner David Morales promised was that the database would be widely accessible, so that independent researchers, policy analysts, advocates, market participants, and others would be able to manipulate it to test hypotheses and assumptions. Well, the Commissioner has since announced he is leaving his post, and it already has become evident that there is no one in the government who is steering the boat along the lines he so clearly presented. Instead, there appears to be the classic bureaucratic situation: Too many people involved, none with authority, and certainly no one exercising the leadership needed to make this incredibly useful tool available to the public.

It is time for one person in the Executive branch to talk, and for the others to row, to make sure the Legislature's intent with regard to the transparent presentation of these claims data occurs in a timely and useful fashion.


e-Patient Dave said...

Even more, I'd say there's a growing consumer/patient movement who wants that transparency regarding not just the claims data (which is important, as you say) but about safety: full disclosure of which providers are three times more likely than average to make mistakes, and which are three times LESS likely to make mistakes.

It was quite an education for me to participate in the patient activist summit at the IHI Forum in December, and hear, quite painfully, the stories of so many people who watched family members be maimed or killed. Rarely in the news we hear of a worst-case doctor or hospital, and recently we saw a list of the hospitals least likely to commit errors; but on what grounds do they withhold the whole spectrum of performance? On what grounds are we not allowed to see which hospitals are more and less likely to hurt our family?

Do they think it's none of our business?

Anonymous said...

I know nothing about politics in Boston, but one wonders if there is not some furious lobbying going on behind the scenes by stakeholders who do not want this data to be publicly available, particularly in the present moment when your state seems to be poised to address its methods of provider payment.

I used to scoff at conspiracy theorists, but now believe in those who say, 'follow the money.'

All the more reason, Dave, for patient stakeholders to organize and become a potent voice themselves.


Anonymous said...

What incredible evidence of a picture being worth a thousand words.

e-Patient Dave said...

Nonlocal, don't forget that although you're a doc, the time will come when you or yours will be in the crucible. My speeches often say "Patient is not a third person word" - nor is it second person. (Grin? Not sure.)

btw, Paul, what's with the *keys* in the boat? The image conveys the chaos and lack of direction you cite, but why keys?

Paul Levy said...


How on earth would I know? It's the Middle East!

Anonymous said...

How about everyone working together is a "key" to success in getting somewhere


Anonymous said...

Perhaps the keys suggest unused capacity, in this case for cooperation. There are few incentives to move this boat forward, and many, many risks for the incumbents.

Demands for transparency may need to approach from another door.
Public health and patient safety advocates should follow the real money to seek cooperation. Larger employers could leverage insurance contracts by demanding answers to questions concerning variation in specific risk of hospital care. Retrospective and prospective surveys contracted with human resource departments can tap into a broader population of 'patients' by asking employees if they have ever experienced or had experience with poor care (and probe more in the highest risk categories). The data would lack precision from the medical side, but the goal would be to describe variation in healthcare from the patient side.

If providers or insurers will not ask, employers who pay so much to the system, should. And academic contracts could insure that aggregated pools of data are public.

Providers now would be in the position of having to produce data defending their quality and credibility - data which they could have had some control over had they stepped up to the public plate. (We should remember that for the most part, this data is not collected, except for limited regulatory demands). Given this option, perhaps they would agree to cooperate in aggregated databases in which their data was more precise and one among many, instead of a few.

The patient-safety movement would benefit by having a larger database (subpopulation employee surveys of harm) and constituency (increased awareness by healthy employees and employers). And insurance companies would have to pay as much attention to the employer side of the contract as the provider side.

Just an idea.

Paul Levy said...

Brian Rosman, over at Health care for All, posted this comment yesterday:

"This afternoon, acting DHCFP Commissioner Seena Carrington responded in effect in a post on the state’s Commonwealth Conversations blog.

Carrington writes that the state continues to convene daily calls on the technical issues (summarized on their website), and will be holding open forums in April to get wide public input on the project. She reaffirms the Division’s commitment to public availability of the data, which is not yet in the state’s hands.

The conversation highlights the value of our fast social media world in learning and discussing the issues."

e-Patient Dave said...

Here's an honest, naive question: are those daily calls getting anything done, or are they eight people talking and nobody rowing?

I just don't know how to construe that comment... but I remember a case in another industry where the regular calls weren't needed once a *decision* is made, and people got to work doing it.