Why Transparency Doesn’t Work.

The Cleveland Clinic is by far the best provider of cardiac care in the nation. If you have cancer there is no better place to be than Texas. Johns Hopkins is the greatest hospital in the America.

Why? Because US News and World Report suggests as much in its hospital rankings.

But which doctors at the Cleveland Clinic have the highest success rates in aortic valve repair surgeries? What are the standardized mortality rates due to cancer at University of Texas MD Anderson Cancer Center? Why exactly is Johns Hopkins the best?

We don’t have answers to these types of questions because in the United States, unlike in the United Kingdom, data is not readily available to healthcare consumers.

The truth is, the rankings with which most patients are familiar provide users with little. Instead, hospitals are evaluated largely by “reputation” while details that would actually be useful to patients seeking to maximize their healthcare experiences are omitted.

Of course, the lack of data available about US healthcare is not US News and World Report’s fault – it is indicative of a much larger issue. Lacking a centralized healthcare system, patients, news sources, and policy makers are left without the information necessary for proper decision-making.

While the United Kingdom’s National Health Service may have its own issues, one benefit of a system overseen by a single governmental entity is proper data gathering and reporting. If you’re a patient in the United Kingdom, you can look up everything from waiting times for both diagnostic procedures and referral-to-treatment all the way to mortality and outcome data by individual physician.

This is juxtaposed to the US healthcare system, where the best sources of data rely on voluntary reporting of information from one private entity to another.

Besides being riddled with issues, including a lack of standardization and oversight, the availability of data to patients becomes limited, manifesting itself in profit-driven endeavors like US News and World Report or initiatives like The Leap Frog Group that are far less well-known and contain too few indicators to be of real use.

The availability of data in the United Kingdom pays dividends. For example, greater understanding of performance has allowed policy makers to consolidate care centers that perform well and close those that hemorrhage money, cutting costs while improving outcomes.  Even at the individual hospital level, the availability of patient data keeps groups on their toes.

Hospitals constantly monitor their outcomes at the procedural level, and if problems do arise they are quick to seek solutions, lest patients make use of the easily accessible data and choose to seek care elsewhere. I know the power that freely available data has to encourage healthcare providers to increase quality of care firsthand, as it is part of the reason I was brought in to consult at one hospital in particular.

In the United Kingdom, the gathering and reporting of data is easy due to the centralization and public nature of the healthcare system, but the United States faces significant barriers to achieving such a free flow of information. For example, private hospitals currently at the top of the arbitrary rankings have little incentive to report detailed outcome data. On a related note, without the larger players taking part, smaller or less prestigious entities trying to prove their worth have nothing to which to compare their own work for the public.

Of course, some private entities and actors in the United States would surely fight against greater oversight, regardless how reasonable oversight by empowered patients may be.

A lack of centrality in US healthcare also leads to issues with standardized reporting. For example, the Mayo Clinic is likely to see much more extreme cases than is a hospital in a small town in Minnesota. Without one body ensuring that all cases are coded according to a standard protocol, there is no way to take into account factors such as severity of illnesses when creating the figures to report to the public.

As such, even if each individual hospital did currently report data on all of its physicians’ outcomes, it might not be comparable across institutions, limiting the usefulness of the exercise.

Private entities and actors within US healthcare claim to have little excitement about government involvement in the system, suggesting it will ultimately create waste and reduce competition in the sector. However, specifically concerning data availability, a look at the United Kingdom would suggest that more centralized oversight does just the opposite while continuing to empower patients.

Whether run through a more robust and better-publicized private initiative or more centralized public entity, the United States can benefit from better monitoring and reporting initiatives in the healthcare sector. Hopefully we are not far away from patients being able to act on more objective data to determine the best hospitals and even the best doctors for their needs.

Alexander Chaitoff is a 2013 Marshall Scholar pursuing his Master of Public Health at the University of Sheffield. He will begin as a first year medical student at the Cleveland Clinic Lerner College of Medicine in the fall of 2014.

16 replies »

  1. Government involvement is only part of the answer. It comes down the culture change that comes from the public (and public awareness as well. In Australia there are three different companies from http://www.gmhba.com.au/ to http://www.frankhealthinsurance.com.au/ to http://www.medicareaustralia.gov.au. Each has shown their own approach based on market conditions mixed with government regulation with some providing all the data customers could want while others are more limited with the belief to only provide limited information they actually need.

  2. Price and quality transparency will be key to empowering new health care consumers. As they spend more of their own money for health care services, there will be an increased demand for price transparency tools.

  3. You’re very right- we do have incomplete information, and Leapfrog is far from the only one that feels this pain. Patients, providers, and purchasers across the US would see huge benefit we had the kind of data NHS has access to.

  4. @ leapfrog

    I wouldn’t take the title too literally. After reading this post, I think its clear that the author is arguing transparency does work and is important and is in fact. something we should be working for. The problem is that we have incomplete information, particularly on the patient side. I imagine access to an NHS-like treasure trove of data would give the organization like the Leapfrog group even more to work with …

  5. Just wanted to clear one thing up, which is that I actually agree – I think transparency can be quite important. I think there might have been a bit of a miscommunication with the title in regard to that. Regardless, I appreciate the information.

  6. It’s interesting that the title of this piece is “Why Transparency Doesn’t Work”, yet the article focuses on the UK’s health system and the great deal of transparency they offer to their patients. In my opinion, transparency is one of the best opportunities to improve our broken healthcare system here in the US; only through transparency will we see real change and improvement. I’ll be transparent and admit that I’m an employee of The Leapfrog Group, so clearly I disagree with your assessment of Leapfrog not being of real use. I’d like to share one example with you. Since Leapfrog began publicly reporting on rates of early elective deliveries several years ago – the first organization to do so nationally by hospital – we’ve seen incredible improvement by hospitals across the country, with the national average of early elective deliveries decreasing each year and many hospitals dropping their rates to near zero. This is an issue that matters greatly to consumers, and is impacting the hundreds of thousands of babies that are now being delivered more safely and not winding up in the NICU. Reducing early elective deliveries had been on ACOG’s agenda for nearly 30 years, but real change only came when the push for transparency resulted in public reporting of early elective delivery rates. Transparency does work, Mr. Chaitoff, and I hope your continuing medical education will teach you as much.

  7. There is a lot of modification of guidelines–and there are often several guidelines for the same condition–such that this, together with lots of artistic variation in medicine and lots of comorbidity–people can have many different conditions at the same time–keeps standardization of descriptors and language of the EHR from being very tight. After all, you can’t do RDBCTs on, say, one variable if the control arm of the trial has a mixture of normals , diabetics, metabolic syndrome folks, and people with the acute phase reaction from some inflammatory problem.

  8. “9 out of 10 doctors surveyed recommend statistics for their patients who understand statistics”

    “There are 3 kinds of statistics:
    – lies
    – damned lies
    – statistics”

    I do believe in statistics, but statistics are definitely amenable to manipulation. Beware

  9. “While the United Kingdom’s National Health Service may have its own issues, one benefit of a system overseen by a single governmental entity is proper data gathering and reporting” I was having a really bad day untill I read the preceeding in quote. Good luck in medical school. I would love to follow you thru your career and watch how your opinion changes as you start actually practicing medicine.

  10. Opacity = Margin

    A cardinal implication of Efficient Markets Hypothesis 101.The most “efficient” market, being the most transparent, also yields the lowest margin.

  11. It’s worth noting that under ObamaCare, insurers can no longer profit by dumping or denying coverage to those with pre-existing conditions. Raising yearly deductibles and narrowing provider networks are now their two primary means of making a profit. So, it doesn’t do much good for healthcare customers to try to seek out the best doctors and hospitals when they are confined to provider networks that are becoming increasingly narrow.

  12. How does one study data that is not generated?…or doctors who don’t generate it? …the appendicitis patients without typical symptoms who get sent home? … the untreated depressives or rheumatoid arthritics? .. or the sickle cell trait cases? or the rare mediterranean- fever patients?

  13. What you propose is very reasonable, however given the performance of Healthcare.gov, I sincerely doubt the ability of the government to carry this out effectively.