I think it’s fair to say Jonathan Gruber will not be offered the role of Pinocchio. Although intelligence agencies, in search of the truth serum, might have an interest in the ingredients of what he drinks.
Please put away the pitchforks. Gruber deserves credit for honesty and bipartisanship. Plus a complete rejection of Disneyland economics. If you’re looking for transparency, the other face of honesty, Gruber is ground zero.
‘Stupidity’, though, was an unfortunate choice of noun. And inaccurate. Gruber should have said ‘rational ignorance’ or ‘boundless optimism in technocracy,’ which describes most voters in any democracy.
‘Rational ignorance’ sounds smart. The cognoscenti know what you’re trying to get at. And the rationally ignorant, well they’re rationally ignorant. The term means something we do all the time: that is we can’t be bothered to seek information whether something is factually correct or not. It’s an information heuristic (mental short cut).
Imagine the information overload if we were presented itemized bills for everything we consumed in a restaurant. We’d know the costs of transporting that fine rack of lamb to the city, of its slaughter, of cleaning the abattoir after the slaughter. But to what avail is this information?
Unless you’re a payer hunting for pseudofraud, granularity is a nuisance. So that to avoid long term anhedonia from figuring CBO’s myriad calculations from magical Keynesian models we watch the Kardashians instead.
When you’re rationally ignorant you can be duped. Or rationally duped. But here is the key point: we choose what we allow ourselves to be duped about. No one can fool us twice without our consent.
Continue reading “Gruber’s Voters: Rational Ignorance”
Filed Under: THCB
Tagged: Gruber, Rational Ignorance, Transparency
Nov 17, 2014
Crowdsourcing is engaging a lot of news organizations today. While some journalists are nervous about crowdsourcing — “Yikes, we’d rather talk than listen, and what if they tell us something we don’t want to hear? Or something that we know isn’t true?” — we here at clearhealthcosts.com love crowdsourcing. We find, as journalists, that our communities are smart, energized, truthful and engaged, and happy to join hands in thinking, reporting and helping us make something that’s bigger than the sum of its parts. We learn great things by listening, so … now we’re going to to an experiment crowdsourcing coverage for our blog.
Our current project crowdsourcing health care prices in California, with KQED public radio in San Francisco and KPCC/Southern California public radio in Los Angeles, has been a great success, as was our previous project with WNYC public radio, and we’re looking forward to launching similar projects with other partners. Continue reading “It Cost What? Crowdsourcing Costs In An Evolving Healthcare System”
Filed Under: THCB
Tagged: Costs, Crowdsourcing, Journalism, pricing, Transparency, Wellness
Oct 12, 2014
Jeremy Hunt, secretary of state for health in Britain, recently toured the Virginia Mason Medical Center in Seattle. He said the visit was “inspirational” and announced plans to have the British National Health Service (NHS) sign up “heart and soul” to a similar culture of safety and transparency. Hunt wants doctors and nurses in NHS to “say sorry” for mistakes and improve openness among hospitals in disclosing safety events.
I had a similar reaction to my tour of Virginia Mason. The hospital appears impressive—and truly gets impressive results. My nonprofit, the Leapfrog Group, annually takes a cold, hard look at the hospital’s data and named Virginia Mason one of two “top hospitals of the decade” in 2010. Every year, it ranks near the top of our national ratings.
Virginia Mason’s success is rooted in its famous application of the principles of Japanese manufacturing to disrupt how it delivered care, partly at the behest of one of Seattle’s flagship employers, Boeing. There are numerous media stories and a book recounting the culture of innovation Virginia Mason deployed to achieve its great results, so I won’t belabor the point here. But at its essence is Virginia Mason’s unusual approach to transparency. Employees are encouraged to “stop the line” – that is, report when there’s a near miss or error. Just as Toyota assembly workers are encouraged to stop production if they spot an engineering or safety problem, Virginia Mason looks for every opportunity to publicly disclose and closely track performance.
It is not normal for a hospital to clamor for such transparency. Exhibit A: the Leapfrog Hospital Survey, my organization’s free, voluntary national survey that publicly reports performance by hospital on a variety of quality and safety indicators. More than half of U.S. hospitals refuse the invitation of their regional business community to participate in Leapfrog, suggesting that transparency isn’t at the top of their agenda. But for Virginia Mason and an elite group of other hospital systems, not only is the transparency of Leapfrog a welcome feature, but they challenge us to report even more data, faster.
Continue reading “A Hospital That Is a World Leader On Transparency”
Filed Under: THCB
Tagged: Leapfrog Group, Transparency, Virginia Mason
Aug 31, 2014
There is a growing group of articulate and engaged patients committed to getting access to all their medical information in order to be better positioned to work collaboratively with their clinical teams. Published studies like the OpenNotes project have consistently shown significant benefits and a lack of serious problems. Health care systems are slow to change and just beginning to understand both the need and value to this more transparent and collaborative approach.
My institution, for example, is not ready (or even interested) in anything approaching opening chart notes to patients. In fact, although our secure portal will be launched in the near future, there was some resistance to making even problem lists, medication lists, lab and x-rays available through the portal.
That need not prevent individuals from contributing to change. A few years ago I began providing every patient with a copy of their office visit note as they left the office after their visit. The intent was for us to do the assessment and plan collaboratively and make sure they have a copy of our (collaborative) plan. Patients have been very appreciative, and use it to share the assessment and plan with family and consultants, and as a reference. A few bring it back at the next visit with notes on it about what they did and what happened.
To the objectors who say that one cannot be honest in a note if the patient is going to see it, I say: balderdash. (Actually, what I say is much stronger…) For one thing (the smaller point) the patient is already allowed to see it if they but ask. More importantly, this argument depends entirely on the principle that the clinician knows best and needs to keep secrets in the interest of the patient. What I have experienced is a variation on the advice I got many years ago regarding relationships: if it’s important, then it’s important enough to be open about and deal with. If you aren’t willing to deal with it openly, you are not allowed to save it up and spring it on your partner (patient) later.
Continue reading “An Open Note to Open Notes Objectors”
Filed Under: Tech, THCB
Tagged: Charting, doctor/ patient relationship, Electronic Health Record, Open Notes, Peter Elias, Transparency
Jul 18, 2014
Recently the Centers for Medicare and Medicaid (CMS) made troves of data publically available. CMS released data on hospital charges, physician utilization, in addition to other data sets. Journalists and academics were excited to potentially confirm their theories on healthcare spending.
We at The Engelberg Center hosted an event, Hacking America’s Health where experts from the Brookings Institution and the government spoke to participants regarding the impacts of data transparency on the nation’s healthcare system. The purpose of the festival is to focus on “innovators from around the world and their transformative solutions to global challenges.”
Out of this discussion emerged a consensus that data transparency could spur disruptive innovation in the health sector but overcoming several key barriers was essential to maximizing the benefits to the public.
Benefits of Data Transparency
1. Help Consumers Make Informed Decisions
Open data offers numerous benefits to consumers. The CMS data unveils the enormous variation in the cost of different treatments. Enabling consumers to find high value care providers improves the efficiency of the market. Price transparency can also uncover providers that charge unusually high prices and puts pressure on them to lower those charges. Finally utilization can reveal if a doctor uses a rare treatment with regularity. All of these data empower health care consumers to choose wisely.
2. Identify Vulnerable Patients
CMS has used open data for numerous projects to help patients. One project involves collaboration with local and state governments. Using Medicare claims information they identified specific patients who could be in special danger in the aftermath of a natural disaster. Without electricity it’s impossible to operate a lifesaving device like a ventilator or nebulizer. The claims data allows emergency officials to notify such individuals about the locations of shelters.
3. Data Mashups
Combining together data sets could help identify bad actors in the health system. For example merging data from the Sunshine Act which describe payments and items given to physicians combined together with utilization data from CMS. This could identify doctors who were using a drug or procedure due to a financial relationship rather than best practice. Other data mashups could also uncover unexpected patterns.
Continue reading “Upgrading the Value of Data Transparency in the Health Sector”
Filed Under: Uncategorized
Tagged: CMS, Darshak Sanghavi, Hacking America, Health Data, Informed Decision Making, Joshua Bleiberg, Transparency
Jun 2, 2014
Many years before the creation of Healthcare.gov, President Obama embraced data analytics during his early years in the Senate.
In 2006, he and senator Tom Coburn (R-Okla.) successfully sponsored the Federal Funding Accountability and Transparency Act, which resulted in creation of usaspending .gov, “a significant tool that makes it much easier to hold elected officials accountable for the way taxpayer money is spent“.
A History of Failed Federal IT Projects
A considerable amount of taxpayer money is spent on federal IT projects, but in contrast to the aspirations of Obama in his early years in the Senate, it is not spent responsibly.
According to the Standish Group report, from 2003 to 2012 only 6% of the federal IT projects with over 10 million dollars of labor cost were successful.
52% of them were either delayed, went over budget or did not meet user expectations. The remaining 41% of the IT projects were abandoned or started from scratch. Perhaps most troubling is that healthcare.gov is just a one example among many.
Continue reading “Healthcare.gov and the History of Failed IT Projects”
Filed Under: Tech, THCB
Tagged: Accenture, CGI, Deloitte, federal contracting, Healthcare.gov, HIT, Niam Yaraghi, Transparency
Apr 3, 2014
The conversation has changed.
The old conversation: “You cost too much.”
“But we have these sunk costs, patients who can’t pay … ”
“OK, how about a little less then?”
The new conversation: “You cost too much. We will pay half, or a third, of what you are asking. Or we will take our business elsewhere. Starting now.”
“But … but … how?”
Exactly: How will you survive on a lot less money? What are the strategies that turn “impossible” to “not impossible”?
The old conversation arises from the classic U.S. health care model: a fully insured fee-for-service system with zero price transparency, where the true costs of any particular service are unknown even to the provider. The overwhelmingly massive congeries of disjointed pieces that we absurdly call our health care “system” rides on only the loosest general relationship between costs and reimbursements.
It’s a messy system littered with black boxes labeled “Something Happens Here,” full of little hand waves and “These are not the droids you’re looking for.”
With bundling, medical tourism, mandated transparency, consumer price shopping, and reference pricing by employers and health plans, we increasingly are being forced to name a price and compete on it. Suddenly, we must be orders of magnitude more precise about where our money comes from and where it goes: revenues and costs.
We must find ways to discover how each part of the strategy affects others. And we need some ability to forecast how outside forces (new competition, new payment strategies by employers and health plans, new customer handling technologies) will affect our strategy.
Key Strategy Questions
For decades, whenever some path to profit in health care has arisen (in vitro fertilization, urgent care, retail, wellness and the others) most hospitals have said as if by ritual, “That is not the business we are in.” As long as we got paid for waste, few health care organizations got serious about rooting it out.
And most have seemed content with business structures that put many costs and many sources of revenue beyond their control.
In the Next Health Care, the key strategy questions become:
Filed Under: THCB, The Business of Health Care
Tagged: consumer driven health, Costs, Employers, Healthcare organizations, Joe Flower, Reference-based pricing, the business of healthcare, Transparency
Mar 28, 2014
In a recent column, security expert Bruce Schneier proposed breaking up the NSA – handing its offensive capabilities work to US Cyber Command and its law enforcement work to the FBI, and terminating its programme of attacking internet security.
In place of this, Schneier proposed that “instead of working to deliberately weaken security for everyone, the NSA should work to improve security for everyone.” This is a profoundly good idea for reasons that may not be obvious at first blush.
People who worry about security and freedom on the internet have long struggled with the problem of communicating the urgent stakes to the wider public. We speak in jargon that’s a jumble of mixed metaphors – viruses, malware, trojans, zero days, exploits, vulnerabilities, RATs – that are the striated fossil remains of successive efforts to come to grips with the issue.
When we do manage to make people alarmed about the stakes, we have very little comfort to offer them, because Internet security isn’t something individuals can solve.
I remember well the day this all hit home for me. It was nearly exactly a year ago, and I was out on tour with my novel Homeland, which tells the story of a group of young people who come into possession of a large trove of government leaks that detail a series of illegal programmes through which supposedly democratic governments spy on people by compromising their computers.
I kicked the tour off at the gorgeous, daring Seattle Public Library main branch, in a hi-tech auditorium to an audience of 21st-century dwellers in one of the technology revolution’s hotspots, home of Microsoft and Starbucks (an unsung technology story – the coffee chain is basically an IT shop that uses technology to manage and deploy coffee around the world).
I explained the book’s premise, and then talked about how this stuff works in the real world. I laid out a parade of awfuls, including a demonstrated attack that hijacked implanted defibrillators from 10 metres’ distance and caused them to compromise other defibrillators that came into range, implanting an instruction to deliver lethal shocks at a certain time in the future.
Continue reading “Computer Security as an Exercise in Public Health”
Filed Under: THCB
Tagged: Computer Security, Hacking, Information-Sharing, NSA, public health, Transparency
Mar 17, 2014
It’s 8.30 am, just before clinic opens. It is 2010. Dr Byte* checks an online forum, and something catches his eye.
A female patient is complaining about a doctor. Her posting has led to strident reactions from other doctors. Patients are taking her side. It looks ugly.
It turns out that the patient had asked her family doctor whether she could use her smartphone to record the encounter. Her doctor was apparently taken aback and had paused to gather his thoughts. He asked the patient to put her smartphone away, saying that it was not the policy of the clinic to allow patients to take recordings.
The patient described how the mood of the meeting shifted. Initially jovial, the doctor had become defensive. She complied and turned off her smartphone.
The patient wrote that as soon as the smartphone was turned off the doctor raised his voice and berated her for making the request, saying that the use of a recording device would betray the fundamental trust that is the basis of a good patient-doctor relationship.
The patient wrote that she tried to reason, explaining that the recording would be useful to her and her family. But the doctor shouted at her, asking her to leave immediately and find another doctor.
Some participants on the online forum expressed disbelief. But the patient then went on to state that she could prove that this had actually happened, because she actually had a recording of the encounter. Although she had turned off her smartphone, she had a second recording device in her pocket, turned on, that had captured every word.
Continue reading “Patientgate: Why Patient Recordings Will Change Everything”
Filed Under: Tech, THCB, The Vault
Tagged: doctor/patient communication, Glyn Elwyn, Privacy, shared decision making, Transparency, UK Data Protection Act, Wellness
Mar 13, 2014
Since HIPAA entitles virtually all patients to obtain copies of their complete medical records at any time, it is always best to write notes with the assumption that patients may read them.
However, as electronic portals provide patients with easy access to their records, clinicians may feel new pressure to be more mindful about how they write their notes. They may alter their approach to or even omit sensitive information to avoid worrying patients unnecessarily. They may try to balance clinical and non-technical language to avoid confusing patients; they may feel they need more time to write notes that patients can read.
They may be concerned about how patients might choose to share their notes, including posting a clinician’s note on Facebook, medical forums, or other social media.
Most doctors in the OpenNotes study found that they generally didn’t need to change how they wrote their notes. Patients did not expect doctors to write notes aimed specifically at them and were grateful simply to have a window into their medical record.
However, a minority of doctors reported that they changed how they documented potentially sensitive topics. These included mental health, obesity, substance abuse, sexual history, elder, child or spousal abuse, driving privileges, or suspicions of life-threatening illness. These are not new dilemmas, but they gain urgency in an era of shared visit notes.
Unless you believe a conversation might harm your patient, a good rule of thumb is to write about things you discussed with your patients (and conversely, to talk about content you will write about). Many clinicians already follow this practice, and some choose to dictate notes with their patients present.
When documenting sensitive behavioral health issues, we recommend trying to describe behaviors descriptively, rather than labeling them or suggesting judgments. We also suggest highlighting the patient’s strengths and achievements alongside his/her clinical problems. This can help the patient gain a broader context within which to consider his or her illness and tackle difficult behavioral changes.
Continue reading “The Open Notes Toolkit: Writing Fully Transparent Notes”
Filed Under: Uncategorized
Tagged: OpenNotes, personal health records, RWJF, Transparency
Mar 10, 2014