Data follies and naked doctors


The Medicare data dump was cheered by many--me included--as the powerful grip the public needed to rip the shroud off of healthcare prices. For years now, the healthcare industry has done everything it could to keep prices a secret in order to veil their pricing manipulations and prevent patients from making price comparisons. But now that information is public and hospitals and doctors feel naked in the spotlight. While their private pricing bits are dangling in public view, we are still only seeing one side and that's dangerous to providers and patients alike. Welcome to the Data Follies…

We now know more about healthcare pricing, but what about correlations and analysis between pricing and quality of care? Are higher prices buying better quality patient care or not? Do cheaper prices equate to poor health outcomes or not? Do higher prices mean waste is rampant and lower prices mean waste is eradicated or is the opposite true? Obviously this analysis needs to be done before we have the means to evaluate the costs we're now counting in the Medicare data dump. Context matters, in other words.

Consider this from Lisa Rosenbaum's post in The New Yorker:

"The calls for price transparency, as a means of bringing down health-care costs, have certainly gained momentum in the past year. In this latest chapter, the hope is that members of the public will be empowered by their access to payments data, and will use this information to identify doctors who are behaving badly, helping to end fraud and profit-driven overuse. In fact, Medicare already conducts internal audits, and the two highest billers in 2012, an ophthalmologist and a cardiologist, both from Florida, were already under federal review. But the third-highest biller, a pathologist, directs a diagnostic company that performs tests for twenty-six other pathologists, which are all billed under his name. Similarly, an oncologist from Newport Beach, California, who billed nine million dollars, explained that all the billing at his practice, which includes five physicians, was under his name, and much of it was directed toward expensive chemotherapy drugs. (One such drug, for advanced melanoma, called ipilimumab, costs about a hundred thousand dollars for four treatments.)"

Further, Rosenbaum goes on to explain:

"An analysis by the Washington Post found that Medicare paid sixty-four billion dollars to doctors in 2012, of which forty-three per cent went to office overhead, forty-one per cent went to doctor compensation, and thirteen per cent went to drug costs. Even within the Medicare system, these data provide an incomplete picture, as the reimbursements do not include payments within hospital systems (which fall under Medicare Part A) or various Medicare Advantage plans, which cover many seniors but are not included in these numbers.

Despite these caveats, members of the public were encouraged to use these data to make more informed decisions about where to seek care. Indeed, in a press briefing on Wednesday, Jonathan Blum, an administrator at the Centers for Medicare & Medicaid Services, said, 'We look forward to making this important, new information available so that consumers, Medicare and other payers can get the best value for their health-care dollar.' The suggestion that these data can allow you truly to comparison-shop, however, is misleading. These data do not tell us anything about the value of care."

The bad news for doctors and healthcare institutions is that now we need you to turn around so we can see the entirety of your nakedness. We will need more data, specifically on patient outcome and the reasons why you chose the tests and treatments that you did at the time. This shouldn't be too awkward an exercise given the health insurance companies have pretty much done this to you already. They're just hoarding the results of their analysis. But that's ok. Most of their analysis was aimed at hiking their own profits and not in improving patient outcome. I can't imagine that analysis would be very useful to anyone else except maybe in stripping health insurance companies naked and putting them under a public spotlight too. That of course is why they're not in a data sharing mood.

The bad news for data crunchers is even if and when we get this additional data from providers, some context will still be missing. I hate to break it to you, but medicine is as much an art as it is a science. Too often diseases and ailments share the same symptoms and doctors are forced to find the correct diagnosis through a process of elimination. This by its very nature creates waste. Doctors with great instincts will likely produce less waste in the process but even they cannot eliminate waste entirely.

Add to that the fact that healthcare providers treat every patient with the same illness in exactly the same way. The problem with that is that individual patients react differently to those treatments necessitating even more trial and error to find what works for them. Alternative approaches, chiefly personalized medicine and genetic-based treatments but others too, are being perfected as we speak. But they're not in wide use yet and they certainly weren't in 2012--the timeframe the data in the Medicare dump was collected.

If you want to know more about personalized medicine and pharmacogenomics, see my post "The Great 'We vs Me' Personalized Medicine Debate" in GenomeAlberta. 

Further, health insurance companies require a ridiculous amount of testing and treatments in an ongoing effort to avoid paying for more expensive surgeries and treatments. For years, they have forced doctors to do things doctors think are totally unnecessary. But doctors do those things anyway so that they can get paid and so that their patients don't get stiffed with the entire bill because the insurance company weaseled out on a technicality.

It is blatantly unfair to judge doctors on the waste in tests and treatments insurance companies forced them to do. Why didn't the doctors say something about this problem earlier, you might ask? Because health insurance companies routinely include a gag order in their contracts. If doctors do speak out, even if only to a patient in the privacy of an exam room, the health insurance company can sue them right out of business.

So, yes, the Medicare data dump is useful--but only to a degree. We need more data to get out of the data follies we are now in. In short, we must strip and examine every single player in the healthcare space if we are to truly arrive at the information we need to control healthcare costs. But we will always have to temper our analysis with the acknowledgement that fraud is only one foul element at play here, information manipulations abound and we have to weed those out.

Sticking all the blame on doctors is what the healthcare industry would prefer we do as that distracts our attention from other foul practices. It's time for data practitioners to expose everything--human lives hang on the balance of our work. - Pam