Monday, October 16, 2006

Not Transparency

Several months ago, the state of Massachusetts started a website (click on the box in the lower right of the home page that says Health Care Quality and Cost Information, and then click "physicians") with data on the volume of certain procedures done by individual surgeons at hospitals in the state. There are several problems with this website.

First, the state is using administrative datasets (i.e., billing information) to generate the numbers. Those datasets only allow for a certain number of "operators" to be listed as part of an admission. So, for a person who has multiple operations during the same hospital admission, not all of the procedures will be captured.

Second, the coding logic that the state uses has some oversights. Mass General Hospital and Boston Medical Center, for example, note that the category of abdominal aortic aneurysms (AAA) does not include endovascular repairs, which represent a significant portion of those types of surgeries. MGH points out, "The conventional surgery involves a major incision and the AAA is repaired by the surgeon sewing in an artificial aorta. The stent graft (or minimally invasive operation) achieves the same goal (eradication of the AA) by working up through the arteries in the groin. In the past year the percentage of AAA repaired with the minimally invasive approach has grown to 70% at the MGH." BMC states, "The ... definition allows us to report only on the volume of direct aortic aneurysm repairs. At Boston Medical Center, we do both endovascular aortic aneurysm repairs as well as direct repairs; adding the endovascular cases would more than double the volume reported for FY04."

Third, the numbers are out of date and do not represent the latest volume of surgeries carried out by doctors. I have suggested to people in the state and to insurance companies that it would be very, very easy to have real-time information on these topics: The state could set up a website and give password access to each hospital, and we could update the website from our own databases virtually every day of the year. We all keep track of our doctors' clinical volumes.

To keep us from "cheating" -- as if we would! -- the data submitted by us could be printed in italics and listed as unaudited until the state actually caught up with the figures in its own reports. At that point, the font could switch over to plain type.

And, finally, to persist with one of my favorite topics (see below), why doesn't the website include solid organ transplant surgical volumes? These are easily counted and reported. Wouldn't you want to know these figures if you needed a new liver or kidney?

We all appreciate the steps the state is taking, but if we are going to be serious about transparency, let's improve what is posted so consumers have up-to-date and accurate information.


Anonymous said...

The use of imperfect billing data is a challenge in both external and internal data analysis. Externally, almost every publicly available benchmark is based on billing data - from the cumbersome Medicare datasets to the more highly touted AHRQ Quality Indicators (which is used for public reporting in Massachusetts), the datasource for demographic, diagnosis, and procedure data is almost universally the UB92 billing form. Does the billing form provide the most accurate picture? Clearly not - since the standard for QI research continues to be the old fashioned medical record audit. But billing data does have advantages over hospital self-reporting: namely the uniformity of data (one definition for transplant wether its a good one or not means you can compare apples to apples) and the ease of collection (BI and MGH may have robust operational databases and the resources to prepare submissions to *yet another* quality agency - but little Winchester Hospital may find this a much a greater feat)

Anonymous said...

Sorry, Monica, but I cannot believe that all doctors and hospitals do not or could not keep track of how many AAAs each surgeon does, how many kidney transplants, and the like. The state website does not even attempt to provide mortality or morbidity quality measures, where I can understand the desire to have some risk adjustment factor. It simply offers the public a numerical count of procedures.

But, if a hospital chose not to count for itself, then it could ask the state to use the billing data as a surrogate -- knowing it was likely to have undercounting. As long as the website made the source of the data clear to the public, things would be fine.

I don't want to compare apples to apples if many of the apples were "drops" and were left on the ground to rot away. Let's pick the ones off the tree while they are still ripe and tasty.

Anonymous said...

Someone wrote in to say that the link I had posted was not longer functioning. Sorry about that. I have tried to fix it. Try the new one. If all else fails, go to and following the instructions I gave in the posting.

Anonymous said...

Seeing that you are so interested in transparency and hospital quality, I wanted to let you know about a local MA company, UCompareHealthCare. At health care consumers can get free comprehensive quality reports on hospitals. New data is being added all the time for cost and quality measures. There is also a professional tool at, which allows an even more in depth analysis of the hospital data and is affordable for any size hospital. It is refreshing to see executives like yourself that are on the side on transparency. It is going to take a significant effort by many people to continue to remove the barriers that are preventing the public from seeing the information they deserve to see. After all, it is their lives and wallets at stake.

Anonymous said...

In posting Jeff's comment, I make no representation about the services offered by the company he mentioned. I am just including it for people's interest.

Anonymous said...

Your ideas all sound very sensible. What are the state's objections?

Anonymous said...

Paul, I just wanted to point you to a webportal I developed over three years ago to create REAL PRICE TRANPARENCY in healthcare - We are a FREE site where doctors, hospitals and healthcare professionals can FREELY CREATE A WEBPAGE TO POST THEIR OWN PRICES for consumers to access FOR FREE. We were the first website to allow doctors and hospitals to do such. We are not a DATA mining operation or a site where doctors or hospitals were posted with out their direct participation. The internet has to many services that just LIST hospitals and doctors. What America needs are directories of doctors and hospitals who are truely committed to FAIR PRICING FOR ALL!

If you are TRUELY COMMITTED TO price transparency, you would join in our effort by creating a profile for youR HOSPITAL and the posting of prices where consumers can understand the benefits offered by your hospital.

Feel free to contact me any time

Rob Stehlin - Founder

Anonymous said...

As always, by posting a comment like the above, I am not implying an endorsement of the service offered. I include the comment just for people's information.

On the particular point, maybe I was not clear. We are not permitted to post the prices we charge to the insurance companies. It would take some kind of state legislative or regulatory action to allow that.

Anonymous said...

To reply to BC, I have not ever received a real explanation for the state's objections. There is a new body created by state law that is supposed to be looking into all this. Perhpas they will consider the suggestion.