1. AIA Vitality Life Insurance
2. Data Driven Healthcare Quality Markets
3. Abu Dhabi Health Authority – Weqaya
Vitality Institute Commission – Recommendation 3 http://thevitalityinstitute.org/commission/create-markets-for-health/
https://hbr.org/2014/11/what-the-u-s-can-learn-from-india-and-brazil-about-preventive-health-care
media companies, automakers, clothing retailers, and other industries have for decades looked abroad to find ideas and innovations they can adapt for the US market. But in one of America’s largest, fastest growing, and sometimes most confounding sectors — healthcare — the situation is different.
Imports like aspirin (Germany) and the heart transplant (South Africa) have become almost as American as apple pie. But in preventive health — keeping people from getting sick, or helping them manage the conditions they do have — we adapt too few of the best foreign innovations and models that have proven to be effective and sustainable at scale.
The U.S. spends far more per capita on healthcare than any other nation. Clearly we need to adopt cost-effective prevention efforts where we can. And we have to do so in a way that fits our health care infrastructure, including reliance on the private sector — a mix of for-profit and non-profit payers and providers — as the bedrock of our system. Two tactics that do fit, and can both lower costs and improve patient care, include more expansive use of mobile technology and of lay health workers. Both can be supported by non-profit intermediaries. Scalable models for these interventions are in use and successful in emerging economies, and are particularly germane where it comes to preventing illness and disease in low-income or geographically or linguistically hard-to-reach patient populations.
India’s Telemedicine
Take telemedicine for example, an approach to getting information to remote populations at a fraction of the cost of circuit-riding physicians. In India, 70% of the population lives in rural areas, but only 3% of the country’s specialist physicians practice in those areas. A nonprofit called World Health Partners (WHP) is working to bridge the gap by identifying informal health providers at the village level and using live streaming over the internet to connect them to highly qualified specialists far away. These lay workers, compensated through consultation fees and a reasonable mark up on drugs sold, measure blood pressure, temperature, heart rate, respiratory rate, and can assess EKGs and transmit the results directly to the specialist physicians.
The University of California at Berkeley has studied the program and reported a dramatic increase in access to reproductive health services among six million villagers at a cost of $5.84 per adult for a couple of years protection from pregnancy. Perhaps the most important lesson for the U.S. in WHP’s telemedicine initiatives in India is its approach to scale. Rather than implementing a program and figuring out later how it might be brought to very large numbers of people, WHP is building scalability into the design through low-cost approaches, and a reliance on for-profit rural practitioners — effectively working with the private sector to build a new market for preventative health.
Brazil’s Integration of Lay Health Workers
More deeply integrating lay workers into our health system offers another path to lowering costs and broadening the reach of preventative health care. Most nations, including the U.S., make some use of lay or community health workers, but Brazil is notable for the scale at which it does this, and its success in integrating such workers into its larger healthcare system. A recent Johns Hopkins study notes that Brazil now deploys over 220,000 Community Health Agents (CHAs) to reach more than half of its 200 million residents. They work as members of health teams, including at least one doctor, one nurse, an assistant nurse and six CHAs to serve approximately 1,000 families. All the team members are salaried, full-time employees, and the CHAs must live in the communities they serve, promoting and delivering preventative health practices such as breastfeeding, prenatal care, immunizations, and screening for diseases including HIV and tuberculosis. In tandem with this approach, Brazil now has one of the most rapidly declining childhood mortality rates in the world, and has made striking gains in immunization coverage and other measures of preventive health addressed by the CHAs.
While the U.S., too, has some promising community health worker models, such as “health coaches” at AtlantiCare in Atlantic City, N.J., and “ promotoras” at Latino Health Access in Santa Ana, CA, Brazil’s experience offers us a path to scale, one that no longer views community health workers as “non-traditional,” but integrates them into the healthcare system, and, ultimately, pays for them in the same way that care in clinical settings is remunerated.
Mindset Before Model
The “market” for preventive services is almost nothing like the market for automobiles; we can’t rely on market forces alone to increase the flow of global preventive health innovations into the U.S. But we should recall that Japanese automakers had been innovating for a long time before American automakers got serious about exploring and adapting these innovations. The first change may need to be mindset: expanding our view of where we might find powerful models for improving preventive health in the U.S., expanding our idea of who should be involved in identifying, prototyping, and scaling these models, and thinking big — designing for scale — from the outset.
Nidhi Sahni is a Manager in the public health and global development practice with The Bridgespan Group, a nonprofit advisor to other nonprofits and philanthropy.
Michael Myers is Managing Director at The Rockefeller Foundationand leads its global health work.
http://thevitalityinstitute.org/news/focus-on-pharma-creating-a-market-for-disease-prevention/
SustainAbility Newsletter “Radar” | Oct 30, 2014
Should pharmaceutical companies be in the business of producing pills, or of making people well? The answer is both. Elvira Thissen argues that with diminishing returns in medicines it is time for pharma companies to move away from philosophical discussions on prevention and adapt to new realities instead.
[…]
The Business Case for Prevention
A recent report by The Vitality Institute – founded by South Africa’s largest health insurance company – estimates potential annual savings in the US of $217–303 billion on healthcare costs by 2023 if evidence-based approaches to NCD prevention are rolled out.
At an estimated global cost of illness of nearly US$1.4 trillion in 2010 for cardiovascular disease and diabetes alone, there is a market for prevention. In the UK, the NHS spends 10% of its budget on treating diabetes, 80% of which goes to managing (partly preventable) complications. Reducing disease incidence represents a considerable value to governments, insurance companies and employers.
Some sectors are already eyeing the value of this market.
[…]
For access to the full article and SustainAbility newsletter, click here.
Lecture 1: Why Do Doctors Fail?
Lecture 2: The Century of the System
Lecture 3: The Problem of Hubris
Lecture 4: The Idea of Wellbeing
http://www.bbc.co.uk/programmes/articles/6F2X8TpsxrJpnsq82hggHW/dr-atul-gawande-2014-reith-lectures
Atul Gawande, MD, MPH is a practicing surgeon at Brigham and Women’s Hospital and Professor at both the Harvard School of Public Health and Harvard Medical School.
In his lecture series, The Future of Medicine, Dr Atul Gawande will examine the nature of progress and failure in medicine, a field defined by what he calls ‘the messy intersection of science and human fallibility’.
Known for both his clear analysis and vivid storytelling, he will explore the growing importance of systems in medicine and argue that the future role of the medical profession in our lives should be bigger than simply assuring health and survival.
The first lecture, Why do Doctors Fail?, will explore the nature of imperfection in medicine. In particular, Gawande will examine how much of failure in medicine remains due to ignorance (lack of knowledge) and how much is due to ineptitude (failure to use existing knowledge) and what that means for where medical progress will come from in the future.
In the second lecture, The Century of the System, Gawande will focus on the impact that the development of systems has had – and should have in the future – on medicine and overcoming failures of ineptitude. He will dissect systems of all kinds, from simple checklists to complex mechanisms of many parts. And he will argue for how they can be better designed to transform care from the richest parts of the world to the poorest.
The third lecture, The Problem of Hubris, will examine the great unfixable problems in life and healthcare – aging and death. Gawande will argue that the reluctance of society and medical institutions to recognise the limits of what professionals can do is producing widespread suffering. But research is revealing how this can change.
The fourth and final lecture, The Idea of Wellbeing, will argue that medicine must shift from a focus on health and survival to a focus on wellbeing – on protecting, insofar as possible, people’s abilities to pursue their highest priorities in life. And, as he will suggest from the story of his father’s life and death from cancer, those priorities are nearly always more complex than simply to live longer.
Find out about Atul Gawande ahead of his 2014 Reith Lectures…
In 2010, Time Magazine named him as one of the world’s most influential thinkers.
His 2009 New Yorker article – The Cost Conundrum – made waves when it compared the health care of two towns in Texas and suggested that more expensive care is often worse care. Barack Obama cited the article during his attempt to get Obamacare passed by the US Congress.
Atul Gawande’s 2012 TED talk – How do we heal medicine? – has been watched over 1m times.
Atul Gawande has written three bestselling books: Complications, Better and The Checklist Manifesto.
The Checklist Manifesto is about the importance of having a process for whatever you are doing. Better focuses on the drive for better medicine and health care systems. Complications was based on his training as a surgeon.
In 2013, Atul launched Ariadne Labs – a new health care innovation lab aiming ‘to provide scalable solutions that produce better care at the most critical moments in people’s lives everywhere’.
Professor Guy Maddern’s tips on protecting yourself in surgery
1. If you are away from a major hospital, get yourself to one. A particular problem, Professor Maddern says, exists when rural patients resist transfers to major hospitals because they don’t want to leave their families.
2. Lose weight and don’t smoke.The proportion of deaths where obesity was a factor increased slightly this year. “An operation done on a thin person relative to a fat person can have a completely different outcome,” Professor Maddern says. This is particularly important for older people, who have the most operations.
3. Go to a hospital that performs a lot of the type of surgery you are going to have, particularly if it is complex. Remember, practice makes perfect.
http://www.canberratimes.com.au/national/health/one-in-10-surgery-deaths-due-to-flawed-care-or-injury-caused-by-treatment-20141203-11z5y1.html
Dangerous: Surgery risks can outweigh benefits. Photo: Nic Walker
More than one in 10 deaths during or after surgery involved flawed care or serious injury caused by the treatment, a national audit has found.
The Australian and New Zealand Audits of Surgical Mortality shows delays in treatment or decisions by surgeons to perform futile surgeries are still the most common problems linked to surgical deaths.
But surgery also appears to be getting a little safer, with the audit, which covers almost every surgery death in Australia, finding fewer faults with the medical care provided to patients than it has in the past.
Audit chair Guy Maddern said of the deaths where there were concerns, about 5 per cent involved serious adverse events that were likely to have contributed to the person’s death.
In about 8 per cent of cases, the audit found some area of care could have been delivered better.
“These are the sorts of deaths where it was a difficult surgery, and instead of going straight to an operation, maybe additional X-rays and imaging should have been pursued, or maybe the skill set of the team that was operating could have been more appropriate,” he said.
“Sometimes, of course, the result would have been exactly the same.”
Professor Maddern said some surgeons, particularly in general surgery, orthopaedics, and, to a lesser extent, neurosurgery, still needed to work on deciding not to proceed with surgeries where the risks outweighed the benefits.
“People are thinking a little bit longer and harder about whether an operation is really going to alter the outcome,” he said. “These are the types of cases where you know before you begin that it is not going to end well.”
However, in some areas with many patients with complex conditions, things were just more likely to go wrong.
The report, which includes data from nearly 18,600 deaths over five years, found in 2013 the decision to operate was the most common reason a death was reviewed.
Overall, delays in treatment, linked to issues such as patients needing to be transferred or surgeons delaying the decision to operate, were still the most common problem, and in about 26 per cent of the deaths no surgery was performed.
Between 2009 and 2013, the report shows a decrease in the proportion of patients who died with serious infection causing sepsis from 12 per cent to 9 per cent, while significant post-operative bleeding decreased from 12 per cent to 11 per cent. Serious adverse events halved from 6 per cent of deaths in 2009 to 3 per cent in 2013.
Every public hospital now participates in the audit, along with all private hospitals in every state except NSW. However, Professor Maddern said he was pleased NSW private hospitals had agreed to participate in future.
Doctors are now provided with regular case studies from the audit, in which de-identified information about the death is provided, so they can learn from any mistakes.
“What we are seeing is an overall decrease in deaths associated with surgical care, which may be due to many things, and we think the audit is helping,” he said. “It’s making people think twice.”
Professor Guy Maddern’s tips on protecting yourself in surgery
1. If you are away from a major hospital, get yourself to one. A particular problem, Professor Maddern says, exists when rural patients resist transfers to major hospitals because they don’t want to leave their families.
2. Lose weight and don’t smoke.The proportion of deaths where obesity was a factor increased slightly this year. “An operation done on a thin person relative to a fat person can have a completely different outcome,” Professor Maddern says. This is particularly important for older people, who have the most operations.
3. Go to a hospital that performs a lot of the type of surgery you are going to have, particularly if it is complex. Remember, practice makes perfect.
http://www.commonwealthfund.org/publications/blog/2014/dec/health-reform-foolish-courageous
The history of comprehensive health reform shows unequivocally that it’s a short-term political disaster. That’s why so many political leaders have either avoided the issue, or regretted engaging it. Franklin D. Roosevelt, arguably one of our most politically adept presidents, turned his back on national health insurance in 1934 when advisors argued for including it in the Social Security program. He continued to dodge it for most of his long presidency. Both Jimmy Carter and Bill Clinton paid heavy political prices for their proposed national health care programs.
Health reform’s political toxicity is all about math and voting. Even prior to the ACA, more than 80 percent of Americans under 65 had health insurance, and most were satisfied with their coverage and regular care. These are people—better educated, employed, with middle to higher incomes—who vote, especially in mid-terms. The elderly, of course, have Medicare and they too are generally satisfied with their insurance and care. The 20 percent who didn’t have insurance before the law was passed were—and are—much less likely to show up at the polls. They tend to be younger, less-educated, and less well-off.
Then there’s the nature of health care as an issue: highly personal, highly consequential, and incredibly complex and confusing. Health care is about people’s deepest hopes and fears, for themselves and for their loved ones. And the health care system has become a multi-layered maze of huge insurance chains, enormous and acquisitive provider organizations, government regulation, and constantly changing therapeutics.
This makes it easy for opponents of health reform to stir opposition by arguing—fairly or not—that any new program will make things worse for people who are satisfied with their insurance and their care. This is precisely why President Obama felt the need to promise, inaccurately as it turned out, that every American who liked their insurance plan would be able to keep it under the ACA.
And supporters of reform have difficulty explaining any new program and motivating its beneficiaries to take advantage of it. Witness the large numbers of uninsured Americans who remain unaware of the availability of subsidized insurance through the ACA marketplaces.
So, to put it crudely, why would any sane politician push a program likely to scare and confuse large numbers of people who vote, in order to help small numbers who don’t?
There are two possible responses. One is that it’s the right thing to do, since a lack of insurance is essentially a death sentence for millions of Americans. Doing the right thing, however, can be politically costly: when Lyndon Johnson pushed through the Civil Rights Act in 1965, he gave away the southern United States to the other party for a generation.
A second argument for braving health reform is practical: it simply has to be done to make our health system viable. The private health insurance industry in the United States, and our health system as a whole, have been in a downward spiral that threatens the interests of all Americans, including the now contentedly insured. Prior to the ACA’s enactment, more and more people were losing insurance, or being forced—because of huge premium increases—to purchase coverage that offers less and less protection.
For some years now, insured Americans have been the proverbial frog in the cooking pot, barely noticing as the water slowly approaches the boiling point. A health care system in which, year after year, the cost of insurancerises faster than workers’ wages is not sustainable for anyone.
Relatively little attention has been paid to ACA reforms that attempt to make the system sustainable by tackling fundamental problems with the health care delivery system and with the structure of the private insurance markets. The reason may be that insurance markets and delivery systems—their problems and solutions—are complex and much less interesting than the political battles surrounding covering uninsured Americans, and whether currently insured Americans may face cancellation of their plans. While the major long-term political gains to supporters of health reform may lie in these delivery system and insurance reforms, President Obama and many current congressmen and senators will likely be long gone when and if those gains materialize.
So ACA supporters have every right to be concerned about the politics of health reform. Each will have to decide for themselves whether health reform was foolish, courageous, or both.
In the meantime, millions of Americans now have health insurance who didn’t before, and the cost of health care is increasing at the lowest rate in 50 years.
http://blogs.crikey.com.au/croakey/2014/12/01/as-nutritionists-enable-health-washing-by-coca-cola-a-call-to-end-unhealthy-sponsorship/
It’s a question the Nutrition Society of Australia and its members might be pondering, after having Coca-Cola as a gold sponsor of their recent annual scientific meeting.
As the World Cancer Congress in Melbourne this week puts the spotlight on the implications of rising obesity rates for cancer, health advocate Todd Harper highlights the contribution of soft drinks to obesity, and argues that health organisations need to look for healthier funding sources.
***
Todd Harper, CEO of Cancer Council Victoria, writes:
No sporting club or health event would accept sponsorship from a tobacco company in Australia today, even if it was allowed.
We know that smoking kills, and so do everything possible to reduce its visibility to ensure younger people aren’t encouraged to take up the habit.
Obesity is also a known risk factor for many cancers, as well as other chronic diseases, yet organisations and events continue to accept sponsorship from the very companies peddling products that contribute to this significant health issue.
Despite this, some organisations focused on health, and particularly healthy kids, see little problem in holding their hands out for money from soft drink companies.
Our recent Cancer in Victoria: Statistics and Trends 2013 report revealed uterine cancer rates are steadily rising; a cancer for which obesity is a principal risk factor. Obesity is also a risk factor for breast, bowel, oesophageal, pancreas, uterine, kidney, gallbladder and thyroid cancers.
In fact, we recently learned from the World Health Organization (WHO) that nearly half a million new cancer cases around the world can be attributed to high Body Mass Index each year – including more than 7000 in Australia. (A new study by the International Agency for Research on Cancer found that nearly half a million new cancer cases per year can be attributed to high body mass index (BMI). The study was published on November 26 in The Lancet Oncology. Using its methodology, more than 7000 new cancer cases in Australia per year can be attributed to high BMI.)
The number of Victorians diagnosed with cancer is projected to double by 2024-2028 to more than 41,000 cases a year, with obesity considered a significant contributor to this. It’s a problem that we can’t ignore.
Many people are aware of the dangers of smoking, and the link between smoking and cancer – which is why we’ve seen such a rapid decline in smoking rates. At the same time we are seeing an equally rapid rise in the number of people who are overweight or obese. We need the same awareness about this as a risk factor if we are to stop more cancers before they start.
Drinking soft drinks contributes to higher kilojoule intake, weight gain and obesity. With one can of Coke containing 10 teaspoons of sugar, each can consumed increases the risk of being overweight.
The WHO recommends the consumption of sugary drinks should be restricted, as do Australia’s recently reviewed dietary guidelines, while the World Cancer Research Fund recommends consumption should be avoided entirely. Leaders in cancer control are meeting in Melbourne this week for the World Cancer Congress, and the challenges related to rising global obesity will be firmly on the agenda.
In the meantime, Coca-Cola continues to sugar-coat its image; fooling the community into believing it is part of the solution to the obesity epidemic.
Rather than being part of the solution like it claims, this multi-billion dollar company is trying to veil the impact of its products by positioning itself as a promoter of physical activity. This is merely a distraction from the fact that it continues to promote its sugary drinks as being part of a healthy diet.
Disturbingly, the company has aligned itself with organisations that encourage healthy active lifestyles, such as the Bicycle Network.
The decision by Bicycle Network to enter into a partnership with Coca-Cola attracted strong criticism from public health experts after a piece in Croakey a year ago, yet the partnership continues. This is especially problematic considering the ‘Happiness’ program is targeting teenagers, a group particularly susceptible to marketing and the highest consumers of these drinks.
Similarly, the Nutrition Society of Australia, the peak scientific nutrition group in the country, has Coca-Cola as a gold sponsor for its Annual Scientific Meeting underway in Tasmania.
This is disappointing on a number of levels, not least of all the fact that one of the themes for the conference is ‘Diet and cancer: what does the evidence show?’
Coca-Cola’s attempts to link itself with these organisations won’t reduce the consumption of sugary beverages and won’t make a gram of difference in reducing overweight and obesity.
Wouldn’t it be better to create alternative sponsorship sources for health-promoting organisations?
As was done with the banning of tobacco sponsorship and the creation of alternative funding sources through VicHealth, it’s time for some similarly creative thinking.
Creative thinking that will kick Coca-Cola out of sponsoring health-promoting activities, and create healthier options for organisations like the Nutrition Society and Bicycle Network.
My fear is that unless we take such action, we run the risk of limiting the impact of important health programs such as the Rethink Sugary Drinkcampaign, encouraging a switch to water and reduced-fat milk; and theLiveLighter campaign, which aims to help people make simple lifestyle choices to improve their overall health and cut their cancer risk.
These programs are vital yet are minnows in the campaign to win the healthy hearts and minds of the public when faced with the corporate might of the highly processed food and drink companies, but with some creative thinking and political will, the scales can be tipped in favour of a healthier way.
• Todd Harper is CEO of Cancer Council Victoria.
The Department of Health has nowhere near the strategic policy capability it needs. While it has a strong track record of delivery, overworked and unappreciated staff need a break.
The Department of Health is a long way from where it needs to be, according to its recent capability review, which found it in dire need of the capacity to produce an overall strategic policy for Australia’s federated health system. That doesn’t come as a surprise to people who understand how the department works.
The process of developing a white paper on reform of the federation, the likelihood of the current fiscally restrained environment continuing and the High Court’s decision on the legitimacy of federally funded school chaplains — which could have implications for hospitals — are all listed as factors that presage a need for a transformation of the department and its role. The reviewers say the federation reform process, which progressed on Friday with the release of an issues paper on roles and responsibilities in health, is “a significant opportunity for the department to exercise strategic influence on future health system thinking and strategy”.
The department has been highly dependable when it comes to delivering on complex reforms and projects it has been tasked with, but the Australian Public Service Commission’s review team says its “strong focus on tactical, transactional and reactive delivery distracts from the development of a proactive, long-term and system-wide strategy”.
Of the 10 capabilities assessed, two are in urgent need of attention: there is almost nothing in place to motivate Health’s overworked and unappreciated staff, and it lacks an overarching “outcome-focused strategy”. UNSW associate professor of medicine and health policy expert Dr Tom Keating, who has considerable experience working with the department, says the review is “a pretty substantial indictment of the organisation”, but also a valuable tool for its leaders.
“I think it’s a very, very useful review, which I hope the department takes on board and responds to,” he told The Mandarin. “I certainly think there is an issue there with overall strategic capacity. They need that, and they also need leadership from government. Government needs to be interested in and be prepared to develop an overall strategic perspective on where they want to take health, and they’re not there now. To be fair, the last government, after their first year, wouldn’t have been anywhere near it either and they put in place processes to get there.”
It was the National Health and Hospitals Reform Commission, in which the Health Department was just one contributor, that ushered in the more “well-integrated overall policy framework”. “For instance,” said Keating, “the primary care policy of the last government was very well articulated, put together on the basis of really substantial consultation with the sector, and was highly supported.” He suggests the Coalition’s current lack of a coherent federal health policy might make the task of reforming the department even trickier.
“I suspect these things are quite deep-seated and they’re endemic to the organisation in a way, but some of it may be related to the current situation as far as government is concerned, because the current government doesn’t have a coherent, overall health policy — it deliberately went to the last election without one — and now its initiatives are piecemeal, unrelated and pretty incoherent,” said Keating. “So in a way, it’s not surprising that the department might be the same, but I think the review, while it’s been done within the last 12 months, probably reflects some deeper things within the department; that it’s not well-geared to develop a coherent, overall policy framework.”
The review found a need to “better connect sources of evidence across the organisation to support the development of a high-level whole-of-health-system view … in an increasingly contested policy environment” and that despite the establishment of a Strategic Policy Unit, “policy discussions are largely constrained within work silos”. The reviewers comment:
“There is broad acknowledgement that the growing prevalence of chronic disease, continued disparity in health outcomes, increasing citizen expectations and unsustainable long-term rate of growth of government health expenditure are some of the many challenges facing the health system. However, notwithstanding the existence of a Corporate Plan 2014–17, the department has not engaged with its authorising environment to help develop a high-level strategy to seek to address these and other systemic issues.”
Until the review, Health was apparently unaware that government and stakeholders expected it to come up with such an overarching strategic policy:
“The department maintains the belief that policy strategy is not sought by stakeholders or the Government. This view is not supported by evidence gathered as part of this review.”
On motivation, the review found employees “intrinsically” motivated by their own interest in working at Health, but little else. A very strong track record of delivery has come at a cost. Employees described a “results over people” culture and there is a widespread belief among the various staff and stakeholders interviewed for the review that it can’t go on this way:
“Going forward, many employees and stakeholders commented that the requirement to deliver at all costs on all commitments is increasingly unsustainable in an environment of declining resources. Employees report that they work long hours and under immense pressure to deliver. This is a workplace health and safety risk.”
The immense respect commanded by former secretary Jane Halton came through in the process, but there was criticism of the “command and control” leadership style in the department she led for 12 years. Interviewees variously described senior leaders as “risk averse, outwardly defensive and internally siloed”. Keating says “you can see that reflected from the outside”. The review cautions:
“While this approach may be appropriate in responding to a crisis or national emergency … its application in day-to-day management has resulted in the disempowerment and poor use of its workforce, reinforced vertical silos, limited corporate ownership and potentially hampered innovation.”
The reviewers heard that SES staff work extremely long hours, duplicating each other’s work due to inefficient systems and processes. As a consequence, executive level staff are in no hurry to join them in the upper echelon. As well, the report states that “employees at all levels have overwhelmingly reported that the Executive Leadership Team had zero tolerance for bad news or failure”:
“Employees reported they are fearful of making a mistake or failing to deliver. They report that that this has encouraged a departmental culture of compliance and self-censorship, influencing avoidance behaviours such as the escalation of decisions and a reluctance to report ‘red lights’.”
“My experience of working with the department,” said Keating, “mainly on policy and program review related work, is that it’s populated by a large number of young, highly intelligent, well motivated people, who know next to nothing about health and who move around fairly quickly. Down through the body of the organisation, that’s the sort of profile, and then higher in the organisation you’ve got people who tend to have been there a very long period of time, and so can lose that critical perspective on the organisation.
“So I think that there might be some organisational characteristics that contribute to the failure to identify these things as organisational risk.”
While the capability review process only began in 2011, Keating says the methodology is solid and its results can be relied on.
“When you’re in a department, it’s hard to see the broader view,” he added. “And one of the striking things for me is that — I’ve done a lot of work and a lot of my research around the functioning of complex organisations, and the things which are described here, such as an organisational culture which doesn’t sufficiently value people, a lack of overall strategic view, problems in governance, problems around managing risk; these are the hallmarks of large, complex organisations.
“This is not an unfamiliar thing but it’s so common with large, complex organisations, [that] if you were running one you would expect to have to address these issues. And the interesting thing for me is they seem not to have put in place strategies to address these as risks within their organisational framework.”
More at The Mandarin: Agency report cards: Health, A-G’s, Veterans’ Affairs review
http://www.theguardian.com/technology/2014/dec/05/when-data-gets-creepy-secrets-were-giving-away
But these are straightforward failures of security. At the same time, something much more interesting has been happening. Information we have happily shared in public is increasingly being used in ways that make us queasy, because our intuitions about security and privacy have failed to keep up with technology. Nuggets of personal information that seem trivial, individually, can now be aggregated, indexed and processed. When this happens, simple pieces of computer code can produce insights and intrusions that creep us out, or even do us harm. But most of us haven’t noticed yet: for a lack of nerd skills, we are exposing ourselves.
At the simplest level, even the act of putting lots of data in one place – and making it searchable – can change its accessibility. As a doctor, I have been to the house ofa newspaper hoarder; as a researcher, I have been to the British Library newspaper archive. The difference between the two is not the amount of information, but rather the index. I recently found myself in the quiet coach on a train, near a stranger shouting into her phone. Between London and York she shared her (unusual) name, her plan to move jobs, her plan to steal a client list, and her wish that she’d snogged her boss. Her entire sense of privacy was predicated on an outdated model: none of what she said had any special interest to the people in coach H. One tweet with her name in would have changed that, and been searchable for ever.
An interesting side-effect of public data being indexed and searchable is that you only have to be sloppy once, for your privacy to be compromised. The computer program Creepy makes good fodder for panic. Put in someone’s username from Twitter, or Flickr, and Creepy will churn through every photo hosting service it knows, trying to find every picture they’ve ever posted. Cameras – especially phone cameras – often store the location where the picture was taken in the picture data. Creepy grabs all this geo-location data and puts pins on a map for you. Most of the time, you probably remember to get the privacy settings right. But if you get it wrong just once – maybe the first time you used a new app, maybe before your friend showed you how to change the settings – Creepy will find it, and your home is marked on a map. All because you tweeted a photo of something funny your cat did, in your kitchen.
Some of these services are specifically created to scare people about their leakiness, and nudge us back to common sense: PleaseRobMe.com, for example,checks to see if you’re sharing your location publicly on Twitter and FourSquare (with sadistic section headings such as “recent empty homes” and “new opportunities”).
Some are less benevolent. The Girls Around Me app took freely shared social data – intended to help friends get together – and repurposed it for ruthless, data-driven sleaziness. Using FourSquare and Facebook data, it drew neat maps with the faces of nearby women pasted on. With your Facebook profile linked, I could research your interests before approaching you. Are all the women visible on Girls Around Me willingly consenting to having their faces mapped across bars or workplaces or at home – with links to their social media profiles – just by accepting the default privacy settings? Are they foolish to not foresee that someone might process this data and present them like products in a store?
But beyond mere indexing comes an even bigger new horizon. Once aggregated, these individual fragments of information can be processed and combined, and the resulting data can give away more about our character than our intuitions are able to spot.
Last month the Samaritans launched a suicide app. The idea was simple: they monitor the tweets of people you follow, analyse them, and alert you if your friends seem to be making comments suggestive of very low mood, or worse. A brief psychodrama ensued. One camp were up in arms: this is intrusive, they said. You’re monitoring mood, you need to ask permission before you send alerts about me to strangers. Worse, they said, it will be misused. People with bad intentions will monitor vulnerable people, and attack when their enemies are at their lowest ebb. And anyway, it’s just creepy. On the other side, plenty of people couldn’t even conceive of any misuse. This is clearly a beneficent idea, they said. And anyway, your tweets are public property, so any analysis of your mood is fair game. The Samaritans sided with the second team and said, to those worried about the intrusion: tough. Two weeks later they listened, and pulled the app, but the squabble illustrates how much we can disagree on the rights and wrongs around this kind of processing.
The Samaritans app, to be fair, was crude, as many of these sites currently are:analyzewords.com, for example, claims to spot personality characteristics by analysing your tweets, but the results are unimpressive. This may not last. Many people are guarded about their sexuality: but a paper from 2013 [pdf donwload] looked at the Facebook likes of 58,000 volunteers and found that, after generating algorithms by looking at the patterns in this dataset, they were able to correctly discriminate between homosexual and heterosexual men 88% of the time. Liking “Colbert” and “Science” were, incidentally, among the best predictors of high IQ.
Sometimes, even when people have good intentions and clear permission, data analysis can throw up odd ethical quandaries. Recently, for example, the government has asked family GPs to produce a list of people they think are likely to die in the next year. In itself, this is a good idea: a flag appears on the system reminding the doctor to have a conversation, at the next consultation, about planning “end of life care”. In my day job, I spend a lot of time working on interesting uses of health data. My boss suggested that we could look at automatically analysing medical records in order to instantly identify people who are soon to die. This is also a good idea.
But add in one final ingredient and the conclusion isn’t so clear. We are entering an age – which we should welcome with open arms – when patients will finally have access to their own full medical records online. So suddenly we have a new problem. One day, you log in to your medical records, and there’s a new entry on your file: “Likely to die in the next year.” We spend a lot of time teaching medical students to be skilful around breaking bad news. A box ticked on your medical records is not empathic communication. Would we hide the box? Is that ethical? Or are “derived variables” such as these, on a medical record, something doctors should share like anything else? Here, again, different people have different intuitions.
Then there’s the information you didn’t know you were leaking. Every device with Wi-Fi has a unique “MAC address”, which is broadcast constantly as long as wireless networking is switched on. It’s a boring technical aspect of the way Wi-Fi works, and you wouldn’t really care if anyone saw your MAC address on the airwaves as you walk past their router. But again, the issue is not the leakiness of one piece of information, but rather the ability to connect together a thread. Many shops and shopping centres, for example, now use multiple Wi-Fi sensors, monitoring the strength of connections, to triangulate your position, and track how you walk around the shop. By matching the signal to the security video, they get to know what you look like. If you give an email address in order to use the free in-store Wi-Fi, they have that too.
In some respects, this is no different to an online retailer such as Amazon tracking your movement around their website. The difference, perhaps, is that it feels creepier to be tracked when you walk around in physical space. Maybe you don’t care. Or maybe you didn’t know. But crucially: I doubt that everyone you know agrees about what is right or wrong here, let alone what is obvious or surprising, creepy or friendly.
It’s also interesting to see how peoples’ limits shift. I felt OK about in-store tracking, for example, but my intuitions shifted when I realised that I’m traced over much wider spaces. Turnstyle, for example, stretches right across Toronto – a city I love – tracing individuals as they move from one part of town to another. For businesses, this is great intelligence: if your lunchtime coffeeshop customers also visit a Whole Foods store near home after work, you should offer more salads. For the individual, I’m suddenly starting to think: can you stop following me, please? Half of Turnstyle’s infrastructure is outside Canada. They know what country I’m in. This crosses my own, personal creepiness threshold. Maybe you think I’m being precious.
There is an extraordinary textbook written by Ross Anderson, professor of computer security at University of Cambridge. It’s called Security Engineering, and despite being more than 1,000 pages long, it’s one of the most readable pop-science slogs of the decade. Firstly, Anderson sets out the basic truisms of security. You could, after all, make your house incredibly secure by fitting reinforced metal shutters over every window, and 10 locks on a single reinforced front door; but it would take a very long time to get in and out, or see the sunshine in the morning.
Digital security is the same: we all make a trade-off between security and convenience, but there is a crucial difference between security in the old-fashioned physical domain, and security today. You can kick a door and feel the weight. You can wiggle a lock, and marvel at the detail on the key. But as you wade through the examples in Anderson’s book – learning about the mechanics of passwords, simple electronic garage door keys, and then banks, encryption, medical records and more – the reality gradually dawns on you that for almost everything we do today that requires security, that security is done digitally. And yet to most of us, this entire world is opaque, like a series of black boxes into which we entrust our money, our privacy and everything else we might hope to have under lock and key. We have no clear sight into this world, and we have few sound intuitions into what is safe and what is flimsy – let alone what is ethical and what is creepy. We are left operating on blind, ignorant, misplaced trust; meanwhile, all around us, without our even noticing, choices are being made.
• Ben Goldacre’s new book, I Think You’ll Find It’s a Bit More Complicated Than That, is published by Fourth Estate. Buy it for £11.99 at bookshop.theguardian.com
http://www.fiercehealthpayer.com/antifraud/story/data-analysis-adds-new-dimension-old-school-fraud-investigations/2015-01-13
In 2010, the FBI organized an undercover sting of a Brooklyn medical clinic that was suspected of Medicare fraud. Agents installed a hidden camera in an air conditioning vent and watched employees pay kickbacks to patients in exchange for Medicare identification numbers, which they used to bill Medicare $50 million in fraudulent claims.
Agents eventually arrested 16 people in connection with the scheme and used the video evidence, along with audio and video from wired elderly clients, in their prosecution. However, it was data analytics that led them to the Brooklyn clinic in the first place, according to The Times.
Data analytics has helped investigators build cases and uncover fraud faster and easier, particularly in areas such as Detroit and Miami that have been hotspots for fraud schemes. In some cases, data mining has helped stop fraud even before criminal charges come to light.
“The idea of using real-time data to generate fraud cases is unique,” Leslie Caldwell, chief of the Department of Justice (DOJ) criminal division, told the newspaper. “We have the ability to suspend–[when] there’s reasonable suspicion–[those] who are engaged in fraud even before they are prosecuted and indicted.”
The article points to the recruitment of Kirk Ogrosky, who spent time as a federal prosecutor in Miami. In 2006, the DOJ asked him to head the healthcare unit. Ogrosky accepted on the condition that the agency would “rethink the way they prosecute healthcare fraud, with an emphasis on real-time prosecutions.” Ogrosky began by searching for postal codes in which patient spending was three or four times the national average, and then employing old-school detective tactics to further the investigation.
“Most times, those zip codes would help generate a list of providers that had what I would call ‘medically impossible’ claims,” he told The Times. “[It was] like peeling an onion ring by ring–and yes, it always burnt my eyes at some point.”
Data analytics have since been used to uncover schemes related to chemotherapy drugs, home healthcare, and durable medical equipment. In Indiana, data-driven investigations have saved the state $85 million. FierceHealthPayer: AntiFraud previously reported on predictive models and algorithms such as the government’s Fraud Prevention System (FPS), which has led to more than $50 million in actual and projected savings in two years.
For more:
– read The Financial Times article