Knocking the Palooza Out of the Data

Just back from the Health Datapalooza confab that took place last week – an event now in its 4th year hosted by the federal government. I had a few lingering thoughts to share. First, on the event name: I’m guessing it came out of my old business partner and current national CTO Todd Park’s experience in Washington, where trying to get any single distinct thought through “the interests” could knock the “palooza” out of a grown stallion.

You’d think the federal government would be the last ones to host a Datapalooza, but the fact is NO ONE ELSE has stepped up!

So they did.

And complain as I might about the G-men and G-women being industry conference conveners (makes me want to bathe with a wire brush) they pulled it off pretty darn well. The Department of Health & Human Services (HHS) attracted hundreds of serious entrepreneurs… and hundreds more wannabes (who real entrepreneurs desperately need in order to feel cool).

And boy were there some great bloopers…

Kaiser came blistering onto the scene with an open API—to the location and hours of operation of its facilities! Kinda sounds like Yelp to me…I’d be surprised if developers will come a runnin’ to that one. Kaiser’s CIO (a very cool guy whom they or anyone in health care would be lucky to get) broke this news in a two-minute keynote speech. Imagine President Obama announcing, in a State of the Union address, that the green vegetables in the White House cafeteria were now much crunchier!

HHS Secretary Kathleen Sebelius applied similarly excessive fanfare announcing the release of cost data for 30 ambulatory procedures. The whole idea that Toddy (Park) was trying to get going with this Palooza was not to release REPORTS on things but to release the SOURCE data so that anyone with proper security and privacy clearance could INVENT a million reports that no one had ever conceived before!

So here are my thoughts on all of this, some of which I shared at the conference in my way-longer-than-two-minute keynote:

1. Release the data!! Secretary Sebelius announcing the release of cost data for 30 ambulatory procedures during her keynote felt like the Secretary of Energy serving up a can of 10W30 to oil companies to drill into.

Her words were great. To wit: “The fact that this [unlocking the data] is growing by leaps and bounds is a good indication that we can leapfrog over years and decades of inaction into an exciting new future.” YES! GO GIRRRL!  OK, so…where’s the data?

Wait, you can’t mean the 30 procedures!  That’s a report; one possible report, out of the millions that will be run and discarded once the underlying data is available. Data on 30 procedures? That is nearly NOTHING. In a stroke of good fortune, just a few days before the “Federalpalooza” the original 1979 court case that has been the government’s primary reason for refusing to give paid claims data to HIPAA-covered, secure entities was overturned! NO MORE EXCUSES. The government is NOT supposed to play the game. They are supposed to make the rules and pinch the cheaters.

2. Let non-foxes apply to guard the henhouse. Right now only entities that are governed by at least 75% health care providers are allowed to apply to be an Accountable Care Organization (ACO)…and most of THEM are mostly controlled by hospitals. Any analysis of where we are overspending in health care shows that the long pole in the cost tent is the hospital. We have 45% more hospital capacity than we should. No hospital wants an ACO bonus that comes out of its own revenue! It’s just self-preservation.

Now there is some nuance: Cheaper and smaller hospitals that are close to full and can steal share from bigger systems, could profit. But the point is the kind of skill you’d need to run a good negotiation, process control/coordination, information management and so forth are NOT found in ANY hospitals!!

Uncle Sam needs a provision in the ACO law for an Independent Risk Management (IRM) company, which would allow non-caregiver entities who are capable of managing “risk” related data to do so. We’ve  been walking our proposal to make this happen around DC for months, and everyone we talk to loves it and agrees that empowering docs, not huge institutions, is the way to achieve real savings—but nobody with the power to change policy wants to stick his or her neck out to help make it happen. Don’t do it for me, do it for the nation!

3. Allow free market for health information exchange! Even once Uncle Sam releases the paid claims data, we won’t be close to where we need to be…because claims data is kinda lame! It’s been “coded” with payment in mind. What would be VERY cool is to get referrals and results/feedback between caregivers into electronic form.  It would eliminate the ABSURD amounts of “re-work” we do today both as caregivers and as patients.

Ever get a clipboard from a practice that should already know everything they are asking you? The way this works in every other sector is through “supply chain partnership.” Whoever needs information pays whoever has it, once it’s delivered electronically. This way the receiver can change their mind and can ensure proper delivery because the sender gets a benefit for paying attention and connecting effectively. But because of old anti-kickback laws, this is ILLEGAL in health care…and ONLY in healthcare.

It would not be that big a fix. Just let payments of less than $10 be excluded from coverage under the Stark Law.  What you are getting instead of this today is hospitals “employing” doctors in order to coordinate and kick back to them.  They employ the doctor for $200,000 (give or take) more than they make, they put them on the same computer system as the hospital, and they make it clear that this old system is to be used to pump referrals towards the core. Referrals would be better coordinated and kickback levels would be lower if this game was given a breath of fresh air and everyone came out of the closet.

Yes, I rant about government. I feel violated when they step into the market. But when I am honest with myself, I know that they are supposed to step in when a market is broken. That’s their role. Sooo, we must un-break the market in healthcare…then Uncle Sam will have no excuse but to back out.

Jonathan Bush is the co-founder, CEO and President of athenahealth, Inc.a leading provider of internet-based business services to physicians since 1997. Prior to joining athenahealth, he served as an EMT for the City of New Orleans, was trained as a medic in the U.S. Army, and worked as a management consultant with Booz Allen & Hamilton. He obtained a Bachelor of Arts in the College of Social Studies from Wesleyan University and an M.B.A. from Harvard Business School. Read more from Bush at the athenahealth blog.

16 replies »

  1. “You’d think the federal government would be the last ones to host a Datapalooza, but the fact is NO ONE ELSE has stepped up!”

    Jonathan, you are wrong.

    athenhealth was invited to participate in the coming revolution in healthcare March 10 2014

    vitaTrackr is a health data marketplace facilitating the movement of health data from point of creation to qualified destinations that value it. The vitaTrackr marketplace is an industry-wide utility benefiting all, but advantaging no individual sector or entity. vitaTrackr is an independent and agnostic to all market participants. The consumer, (data owner) authorizes data transfers.


  2. From Wikipedia: “Regulatory capture refers to the actions by interest groups when this imbalance of focused resources devoted to a particular policy outcome is successful at ‘capturing’ influence with the staff or commission members of the regulatory agency, so that the preferred policy outcomes of the special interest groups are implemented.”

    By this definition, virtually our entire federal government suffers from “regulatory capture”. The influence of various industries on the SEC, FDA, Interior, DoD, etc., is well documented and now accepted as an inherent function of our political system.

    The difference is that the mission of Monsanto, KBR, Lockheed and the like is simple and straightforward: maximize shareholder value. If healthcare organizations, even or especially those that are “non-profit” (snicker, cough, wheeze) also look to simply make as much money as possible, will the free market rectify that situation on behalf of healthcare consumers? Isn’t there a role here for government?

  3. I’d like to see some data on just what proportion of the Great Self-Made Health IT Genius Jonathan Bush’s meteoric athenahealth revenue rise across the past few years owes directly to the Meaningful Use program he otherwise routinely disses.

    Recall his video interview at HIMSS 2009, wherein he said that the ARRA/HITECH “Schtimulus was just gonna “schtimulate all these losers”? Thought he was quite pleased to take the federal money.

    He also once said that the RECs should get “a quick bullet. They won’t even know”

    A real class act.

  4. Go JB ! I have been writing for about 8 years on HIT, and the development of EMR, and HIX. Admittedly at times I have been unappreciative of what the U.S.. government in the form of HHS has done for healthcare.I thought my sarcasm was the finest on the interweb, but JB even exceeds my distorted sense of humor. It is said that sarcasm is based upon poorly disguised hostility. It has been said that HHS and CMS (like Starship Enterprise) go where no one has gone before, which becomes obvious as we approach the limits of Federated Space and encounter Romulans and Klingons awaiting to devour our health system.
    The comment written by someone earlier about the public sector that when the ‘market is broken’ government steps in to fix it. Hmm that seems to involve printing more money which we do not have. Why worry about Chinese cyber intrusions when they are loaning us all these funds to develop IT.

    Any time the federal government steps in you can be certain it is going to cost taxpayers dearly. The infusion of incentives, HITECH and the ARRA has created a new HIT bubble, which now must be sustained by the health system, from small MD offices to huge clinics and hospitals. In an era of the black hole of reimbursements adding this capital outlay and new allied health professionals in the form of HIT personel probably will do little to reduce costs or improve care and/or outcomes.

    Yes, there are some great minds, statisticians and algo designers in the health space.

    The Datapalooza is second only to the :Lalapalooza….Which originates in California where there is much ‘la la’

  5. I think I love you – giving data to PATIENTS is the gap most often left yawning in all the rah-rah I hear from health IT, be it developer or clinical user. Open systems, that can take *upload* (from my own health data collection, ie Fitbit/Fuel) as well as download, offers OpenNotes, and allows for 2-way comms with my healthcare team? NIR.VA.NA.

    Opening the system to patient input will give the system data that will really blow the doors off clinical care. Right now, we’re lucky if they call us back … and when they do, we’re still asked to use a freakin’ FAX machine to communicate.

  6. The theme of the Datapalooza is the value of information. But one thing is more valuable than data to health care providers and insurers: the patient him- or herself. Most of the jockeying around patient records and the supposedly anonymous, aggregated information sold from those records is a scheme to keep patients in the system that is deriving profit from them.

    It’s always an excellent and bracing jolt to hear Jonathan Bush, and he often shines opens up a whole new angle on debates that are agonizing the health care field.

    But I’d like to suggest that, if the industry sincerely adopts a focus on giving just the care needed to patients and no more (the motivation behind HITECH and Meaningful Use, of course) will drive us to more openness in EHRs and other data, and solve some of the problems Bush highlights.

    One of the big lessons from the datapalooza is that aggregated data becomes valuable when it is publicly available, so it can stimulate small and independent researchers and developers, not just established institutions with the millions to invest in proprietary data sets. If the goal is to make the system more efficient and squeeze out waste, rather than to maximize the revenue derived from each patient, organizations are motivated to open the data.

    The next step is to make all the software that handles and crunches the data open source. VistA, as well as several other EHR systems, are open source, and if US institutions determine they need something totally different, they can combine their resources to produce a flexible system to meet all needs cheaply. Open systems will remove all the license fees and other barriers to sharing among EHRs.

  7. I agree with many of Jonathan Bush’s points. I do take issue with a few, however.

    A review of the 89 ACOs approved to be in the Medicare Shared Savings Program last July shows that 57% (51 of 89) do not involve hospitals or hospitals employing ACO professionals, including the one in Connecticut of which I am the CEO. I have not crunched the figures for the Jan 2013 group of 106, but many in that group do not include hospitals, as well.

    Physician-led ACOs not tied to any hospital(s) should be in a much better position to be able to reduce ER visits, hospital admissions/readmissions, high cost imaging, etc. than those run by hospitals, assuming they can manage their data, quality reporting and care coordination well, as they have no financial responsibilities to any hospital.

    A fully free market for health information exchange should include pricing and payment information. However, most commercial insurers, and all the big ones, include strict confidentiality provisions with penalties for any disclosure of payment terms in their contract with providers.

    Many health insurers have spent the last few decades doing their best to disaggregate physicians for contracting and pricing, often using contracts on a “take it or leave it” basis (here’s your new fee schedule…not negotiable.). Being exempt from federal antitrust laws (McCarron-Ferguson Act of 1947) sure has given the big insurers the upper hand here. However, now the insurers are faced with the need to contract with organized groups of physicians who can coordinate care quality and care management as part of commercial ACO deals. Many of the insurers are still trying to “have their cake and eat it too” by still wanting to have individual physician contracts for pricing terms, but ACO contracts with physician organizations that don’t involve fee schedule negotiations, but have quality and shared savings provision in the aggregate.

  8. “Liberals object to corporate influence over government, and “crony capitalism” is much of what is wrong with the healthcare system so I’d suggest reserving judgement.”

    Yes, remove government and capitalists will play fair and regulate themselves for the benefit of the market.

    Why didn’t I think of that???

  9. I agree with Jonathan’s overall position – the feds are doing a good job under difficult circumstances. However, let’s look into his 3 suggestions from the patient’s perspective.

    1 – “Release the data!!” – I completely agree. This however is only half the picture. A patient needs to be able to use the released data for decision support in a specific situation.

    2 – “Let non-foxes apply to guard the henhouse.” – I completely agree. I call this “The Independent Purchase Decision Test” and you can read about it here: https://thehealthcareblog.com/blog/2013/05/30/the-independent-purchase-decision-support-test/

    3 – “Allow free market for health information exchange!” – Right-on. As you can see in my posting above, independent decision support aims to shine a light on the ordering doctor’s incentive to “pump referrals to the core”.

    The Stark Law exemptions are an institutional issue. The patient is not subject to Stark laws or kickbacks. The patient has a right to get independent pricing.

    However, for the sake of argument, let’s assume the EHR vendor deserves $10 to cover the costs of sending clean data to an independent decision support service acting as an agent of the patient. A patient with a typical $2,000 deductible and facing obvious risks from aggressive medicalization http://blogs.scientificamerican.com/guest-blog/2013/05/29/the-scientific-basis-for-choosing-to-be-a-patient-forearmed-is-forewarned/ would be well advised to spend 10 bucks and get personalized independent assessment of costs and risks for any order over $100 or so.

    Blue Button Plus can enable this kind of independent decision support. Will athenahealth be the first EHR vendor to offer real-time access to new orders via a Blue Button Plus portal for $10? If they do, how many athenahealth customers will enable this feature for their patients?

  10. Oops, I should have said economics isn’t entirely a science, some aspects of it have more solid evidence than other aspects.

    Also I’d suggest that many don’t fit along a straightforward “rightleft” perspective, nobel laureates like Friedman, Hayek and Buchanan weren’t conservatives. Hayek considered himself a “classical liberal” who didn’t approve of modern liberalism.

  11. re: “I love it. In this version of reality Jonathan Bush apparently has become a screaming leftie!”

    Liberals object to corporate influence over government, and “crony capitalism” is much of what is wrong with the healthcare system so I’d suggest reserving judgement.

    It isn’t a “version of reality”. Again everything on that site is well sourced, everything from nobel laureates like Stigler and Friedman and Coase and Hayek, to the AMA and AHA, data from the OECD, Federal Reserve, etc. I’d challenge you to find a logical or evidence hole in it. Unfortunately most people considering the healthcare issue either don’t know much about economics (many great business people don’t even if they think they do, it isn’t necessary for business success), or business (nobel laureate Ronald Coase recently wrote in the Harvard Business Review about the unfortunate disconnect many economists have from the real world of business and entrepreneurs), or simply don’t grasp the many factors involved since they focus on their little piece of the healthcare world and simply haven’t had reason to step back and examine the big picture.

    Obviously you may not agree with it, since economics and policy aren’t sciences and there are disputes over data so you may have other sources that differ from what is there. You may find what you consider data or logic flaws, but at least it might lead you to think through things. I’d suggest considering having an open mind.

  12. re: ” I know that they are supposed to step in when a market is broken. That’s their role. Sooo, we must un-break the market in healthcare…then Uncle Sam will have no excuse but to back out.”

    Unfortunately you have that backwards. Government broke the market badly and continues to break it.

    Nobel economics laureate George Stigler won his prize for regulatory capture theory, writing a few decades ago that “as a rule, regulation is acquired by the industry and is designed and operated primarily for its benefit”. Government stepped in to provide favors for various special interest groups in the healthcare world, limiting competition, e.g. through requiring “certificates of need” which are as silly an idea as letting taxi cartels prevent new entrants. They made a huge complex system which hides myriad favors for special interest groups throughout the system.

    The free market can’t unbreak the system without the government stopping those favors which prevent us from having anything remotely close to a free market in heathcare. If you tried to impose the equivalent of many of the sorts of “market fixes” government pushes on healthcare in say the consumer electronics sector, people would burst out laughing at how little sense they make except for special interest groups.

    There is a lot of money in healthcare so some entrepreneurs do step in to try to solve problems, but many of the best investors and business people instead seek out ideas in less regulated industries so innovation is a fraction of what it otherwise might be.

    Details, with numerous links to support all of this with data from places like Harvard and the AMA and AHA, etc, here:


  13. Take it from one who was there and has seen him plenty–this appearance was JB off the hook at his finest. Now we need athena fully on board with BlueButton just like HHS needs to get fully on board with releasing ALL the data. And watch for the video starring a very plaid green jacket!