Translucency with Turbid Clouds

Did you ever read a seemingly inconsequential sentence somewhere and it then just refused to leave your mind for days on end, triggering avalanches of thoughts way beyond the original intent, if there even was one? It just happened to me a few days ago when I read one more industry article about the recent Medicare data dump. The following remark was attributed to a primary care doctor: “The U.S. is entering an era of more accountability and transparency in all aspects of people's personal and professional lives and “medicine cannot be excluded,” he said”.  Back in 1996 a science fiction author by the name of David Brin, published an article in Wired Magazine, where he too prophetically argued that the era of transparency is no longer preventable. Ignoring an entire branch of physics, Mr. Brin suggested that the only antidote to the floodlights shining on each individual consists of a “flashlight” we can use to point at the elites running the lightshows. But Mr. Brin forgot another time honored use of flashlights: we can start pointing them at each other, no doubt to the great amusement of floodlight operators. This has the twofold benefit of keeping us from staring at the floodlights overhead, and of illuminating any subatomic particles that may have eluded the big lights. And there is no better, or more entertaining, place to begin playing with flashlights than medicine.

I won’t belabor personal transparency, since it is tantamount to invasion of privacy, which should be illegal, but it is not. Invasion of privacy in the U.S. is becoming a business model and a method of governance. If you missed the 60 Minutes segment on data brokers on April 9th, here is a link. In the now customary incestuous relationship between big business and government, the Institute of Medicine (IOM) is proposing to help data brokers clean up the dossiers they are compiling on people. Utilizing the Meaningful Use program lever, the IOM will be delegating this task to physicians, so a doctor visit will include detailed interrogation regarding such things as the ethnic/racial composition of the neighborhood you live in (geocodable, of course), sexual practices, exposure to fire arms, employment, country of origin, previous incarceration, and all sorts of important stuff for the Internet business. It will also help employers do a much better job with hiring good people since your doctor will have to note now if you are a conscientious, optimistic fellow, or alternatively a stressed out hostile, angry and dissatisfied individual. The IOM would have liked to add more of these hard to get data points, but they couldn’t find the faintest indication that those things have anything to do with medicine at this time. I’m sure they eventually will.

Professional transparency on the other hand, is a much more complicated issue. If you offer to sell a service or a product, you should expect some scrutiny of the value you provide for the buyer, unless of course, you have the means by which to force people to purchase your service or product. Legal systems have always endeavored to create moral frameworks for protecting buyers from unsavory sellers, and vice versa. The best buyer protection is full disclosure, or transparency, regarding the service or product being sold, coupled with legal accountability for negligent and intentionally fraudulent practices. With this in mind, shouldn’t it be the government’s responsibility, indeed its duty, to provide the public with as much information as possible regarding services provided by physicians? Particularly since medical services are most often not elective, and one could argue that the medical profession, as a whole, has the ability to force people into buying its services under duress. Let’s assume for a moment that the answer to this question is affirmative, and move on to a couple of more specific questions.

First, what is it that people buy from doctors? Roughly two types of things: expert advice or skilled repairs. When you are considering the purchase of these services, it would be very helpful to have an independent assessment of the level of expertise and proficiency at repairing items similar to yours. And of course, you would want to know how much the service is going to cost. In the pre-transparency era, we did our best to infer the level of physician expertise or skills by asking very simple questions: Where did he go to school? How long has she been in practice? What do my friends think about this doctor? Is he “affiliated” with the shiniest academic center in town? Are his other patients smart, educated people, or maybe even doctors themselves? We didn’t ask about cost, but more often we did ask if the doctor accepts our insurance, because doctor fees were a sunk cost for most people with health insurance.

You don’t have to have a Masters in Health Administration to see that even if we managed to obtain answers to all our questions, the dataset would be incomplete and fraught with inconclusive and even misleading subjective information. The Internet made it easier to both ask and get answers to some of our questions, but hasn’t done a thing to improve the quality of information available to us, and maybe the opposite is true, seeing how we are all perfectly willing to take advice from anonymous strangers who have nothing better to do other than to rate things online (when is the last time you rated something on a vendor site?). If the government is to step in and help us pick doctors, it would have to do much better than facilitate availability of social media gossip about this or that physician.

For example, what type of information could assist young parents with picking a pediatrician? Let’s be honest and admit that in addition to simple facts, such as education, years in practice, location, hospital affiliation, you would want to know what other parents think about this doctor, and what other doctors think about her as well. But in order to provide context to these opinions, you would need some objective measures. Do I get the doctor on the phone if I call with a concern, or do I get someone else? Will she always see my kid, or will we have to deal with a bunch of random people? Does she offer well-child appointments that fit my work schedule?  How difficult it is to get an appointment? If my child needs hospitalization, will she be there, or will I be on my own? How good are the physicians that cover for her? How good are the specialists she usually refers to? How often does she refer and for what reasons? How much time will she spend with my child?

And here are the things we wouldn’t need to know, not because these things are not important, but because they are largely implied and too granular to be indicative of substance. How many kids is she testing for pharyngitis and is she properly treating them? How many kids get weighted and have their height measured? How many are asked about smoking or whether they are depressed? How many girls are screened for Chlamydia and how many kids in her practice got all their shots?  And yet, the government is in full swing to deliver exactly this nitty-gritty information, and absolutely none of the answers most people seek, not because the answers we want are not available, or impossible to generate, but because keeping everybody busy looking at the trees may just be enough to detract our attention from the massive forest being erected in our health care backyard. 

You can easily extrapolate this example to adult primary care and specialty care of all types, including tertiary care. How about prices though? Since health insurance has evolved into indemnity insurance for errors in lifestyle, doctor fees are no longer a sunk cost for the majority of Americans.  Most everybody now, has to pay full price or at the very least a percentage of physicians’ fees in addition to insurance premiums. Our young parents may want to factor the cost of seeing a pediatrician into their decision making process for a variety of good reasons, not just because they are looking to care for their baby on the cheap. And here is where the most absurd facet of our health care system makes its appearance. The prices for seeing a doctor are meticulously defined and used by insurers, but doctors are prohibited from divulging them, and the government is doing absolutely nothing to change that.

What the parents in our example need is a simple table with rows listing all the pediatricians they are considering, and columns across, listing what each insurance plan in their area has decided that parents will have to pay each doctor, at least for the most common services (including facility fees, if any). Using this and similar tables for their own health care needs, our little family could make an informed decision not only about which doctors to see, but also which insurance plan they should enroll in. Unfortunately for them, and for their doctors, and for us all, such tables are detrimental to the moneyed interests of big health care businesses, and therefore will not be forthcoming anytime soon. Instead, the government is throwing out bunches of dollar numbers that have nothing to do with anything, implying that there is great wisdom to be found in partial truths, and that we should get busy trying to find the secret keys to said wisdom. 

Armed with irrelevant quality measures about their doctors and deliberately misrepresented price information, patients recently turned consumers are expected to take on the medical industrial complex, very much like mice are expected to attack the cat amusing itself before dinner. Transparency, we are told is a very powerful tool for an enlightened citizenry, and it is. Translucency by design, and turbidity by negligence, which is what we are being served here, are very powerful tools too. Different objectives though….