An excellent video that crystallizes concerns about how we are feeding our children… they even claim to be able to do something about it..!!
Strong4Life.com – Children’s Healthcare of Atlanta
Singapore appoints first Chief Data Scientist
this is a brilliant move….
http://www.futuregov.asia/articles/2014/aug/14/singapore-governments-first-chief-data-scientist-p/
ANALYSIS, CONNECTED GOVERNMENT, GOVERNMENT ANALYTICS
SINGAPORE GOVERNMENT’S FIRST CHIEF DATA SCIENTIST PRABIR SEN ON HIS NEW ROLE AND GOALS
From traffic updates to tax returns, cities and countries have more data than ever before – but how can they manage it?
FutureGov has exclusively interviewed Prabir Sen, Singapore government’s first Chief Data Scientist. He was appointed by the Infocomm Development Authority of Singapore (IDA) in January, and spoke on why his role was created, what he wants to achieve and the challenges he faces.
Vision to be a global analytics hub
Singapore aspires to be the world’s centre of data science and analytics. This vision required a dedicated team to guide the development of skills on data sciences and advanced analytic across the government and industry. The role of the Chief Data Scientist and his supporting team, called the Data Sciences Group, were created to drive the private and public sectors’ adoption of data analytics, said Sen.
Sen is excited about the potential for expanding Singapore’s work in this area: “I wonder if it is possible to invite the international sports and games industry, such as the Olympics Association, to collaborate with Singapore-based tech companies and talents on sports analytics right here in Singapore? Is it possible to attract aerospace and logistics companies here to do machine-to-machine data analytics? Is it possible to drive the multinational consumer good corporations to work with local small tech companies on advanced consumer insights?”
Using analytics to improve quality of decisions & lives
The government believes that data analytics has huge opportunities to impact government services and improve citizens’ lives in a wide range of areas, such as healthcare, transportation, education, retail and waste management.
A large volume of data is being generated from sensors and mobile devices today. This includes communication between person-to-person, person-to-machine and machine-to-machine, added Sen. He and his team are tasked to evaluate and apply advanced analytics techniques and models that can help organisations get a “360-degree view on people, technology and policies to improve the quality of decisions and improve citizens’ lives and journey of experience at various touch points.”
Cross agency data analytics
The greatest opportunity for using analytics within government is what Sen calls “cross data analysis”, where one agency can use data of another agency to solve their problem. “For example, the Ministry of Manpower can analyse healthcare data from Ministry of Health to determine skill gaps and future talent development requirements, or, transportation use environment to determine impact of weather in commuters’ behaviour” he said. “Such cross data analyses also require greater attention to and better governance of data protection, privacy and anonymity,” he added.
Some agencies are currently using this strategy and are achieving great results, he said, and the Singapore government is now encouraging them to explore more cross-agency data use.
Innovation therefore requires agencies to be even more ready to experiment: “Data analytics is fanning the flames of entrepreneurship in the Singapore government, to adopt a philosophy called ‘start up’. Government is obviously not a start up but initiatives to effect change are best thought of as start-ups where we should be more ready to trial and be comfortable with small failures.”
“Compare a project that takes months and costs a lot of money; with one that takes two persons and a couple of weeks of effort. If the former fail, it will be catastrophic, while a failure of a small trial is still acceptable. We can adopt a risk management methodology where the cost of failing becomes exceedingly tiny,” he said.
Developing analytics talent
One of Sen’s key performance indicators is to strengthen data talent locally. According to a recent IDA release, “McKinsey forecasts that there will be a shortage of 140,000 to 190,000 data sciences and analytics professionals by 2018 in just the US alone”.
Sen shared that the need to increase the local data talent pool is a real challenge. Most organisations are struggling to recruit enough candidates with the right skills. “We are shorthanded in several areas: data scientists who have both computational experience and business acumen, data visualisers who are skilled in both analytics and graphic design, analytics consultants who hold domain knowledge besides their analytics experience, and data engineers who can source and integrate data from disparate systems.”
Retaining this data talent is even more difficult, he continued. “Most of these data professionals are creative people. They require space and freedom and a stimulating environment to explore new approaches and insights that challenge them. So we need to facilitate and grow this local community, to drive engagement with them, pulling together users, data analytics companies, cloud providers to form an ecosystem to exchange ideas.”
To this end, IDA has launched a Massive Open Online Course (MOOC) on data science and analytics this month, offering locals the chance to develop the vital skills to respond to the growing demand for data professionals. The class has attracted more than 350 registrations from both the private and public sector.
Chief Data Officer vs Chief Data Scientist
Sen also clarified how his role is different from a Chief Data Officer. “A Chief Data Officer typically has responsibility to govern and protect data, and find ways to use data across the agencies. My role, on the other hand, is to find ways to build transformative products using data sciences, analytics and insights; drive rapid development and adoption of analytical techniques, and develop the local data and tech talent.”
The skills and experience that make a good Chief Data Scientist, Sen added, is not limited to quantitative and computation proficiency. The candidate must be good at understanding human behaviour, how people go about solving their problems and making decisions, and able to think laterally to engage in cross-cutting strategic dialogues. Most importantly, he must be able to learn, unlearn and relearn.
Learning will be vital as Singapore seeks to become a global hub for analytics. Agencies are being challenged to work together on trialling new approaches, while the government is seeking to build greater scientific communities and talent in the city state. Ultimately, though, these efforts could lead to greater personalisation of citizen services – a new way in which the government engage and does business with its customers.
What Uber for healthcare might look like
Interesting take on imagining the future of healthcare.
http://www.kevinmd.com/blog/2014/08/uber-health-care-will-look-like.html
What the Uber of health care will look like
For a very long time, one of the most valuable business assets in New York City was a yellow cab taxi medallion. With recent value in the $1 million dollar range, ownership of the medallion was a virtual cash annuity, combined with equity growth (in 2004 medallion prices were in the mid $200,000 range and have increased in value 15% year over year in the 9 years since). As one owner once put it, “it even makes money for me while I sleep,” since the cars can be rented when the owner is off shift.
Medallion owners tend to fall into two categories: private practitioners and fleet owners. Private practitioners own their own car, have responsibility for maintenance, gas and insurance, and tend to use the cash flow to live while allowing the medallion to appreciate over the course of their career. They then cash out as part of their retirement plan.
Fleet owners have dozens of medallions; they lease or buy fleets of automobiles and often have their own mechanics, car washes and gas pumps. They either hire drivers as employees or, more often, rent their cars to licensed taxi drivers who get to keep the balance of their earnings after their car and gas payments.
In London, taxi drivers have to invest 2 to 4 years of apprenticeship before they can take and pass a test called “The Knowledge.” However, like NYC, finally getting that a licence to operate a Black Cab in London is a hard-working but stable way to earn a living.
Now imagine that someone comes along that can offer all the services of the NYC yellow cab or the London Black Cab directly to the general public, but does not have to own the medallion, own the car or employ the driver. With as much as 70% lower overhead, they provide the same service to the consumer; in fact they are so consumer friendly that they become the virtual gatekeeper for all the taxi and car service business in the community.
How, you ask? Outsourcing the overhead and just-in-time inventory management; they convince thousands of people to drive around in their own cars with the promise of a potential payment for services driving someone from point A to point B. All these drivers have to do is meet certain standards of quality and safety. This new company does all the marketing and uses technology to make the connection between the currently active drivers and those in need of a ride; they provide simple and transparent access to a host of cars circulating in your neighborhood, let you know the price and send a picture and customer rating of the driver, all before he or she arrives, and they process the payment so no money ever changes hands.
This is the premise behind Uber, a very disruptive take on the taxi business. As a recent article in Bloomberg noted, the slower rate of growth in medallion value is already attribute to the very young company; a recent protest by Black Cab drivers in London resulting in an eight-fold increase in Uber registrations.
Now imagine that a new health care services company comes to your community offering population health management services on a bundled payment or risk basis. They guarantee otherwise inaccessible metrics of quality and safety to both large employers and individual consumers. They employ only a handful of doctors, but do not own any hospitals, imaging centers or ambulatory care facilities.
However, they are masters at consumer engagement, creating levels of affinity and loyalty usually found with consumer products and soft drinks. They use a don’t make me think approach to their technology, seamlessly integrating analytics and communications platforms into their customers lives, and offer consumers without a digital footprint a host of options for communications, including access to information and services via their land lines or their cable TV box. They leverage high-level marketing analytics to determine who will be responsive to non-personal tools for engagement, like digital coaching, and who requires a human touch.
Care planning is done based on clinical stratification and evidence; population specific data is used to determine the actual resources required to achieve clinical, quality and financial goals. (A Midwest ACO has more problems with underweight than obesity, do they need to maintain their bariatric surgery center?) Physicians serve as “clinical intelligence officers,” creating standing orders across the entire population, implemented by non-clinical personnel; they also create criteria for escalation and de-escalation of services and resource allocation based on individual patients progress towards goals. They employ former actors and actresses as health coaches and navigators, invest heavily in home care and nurse care managers and use dieticians in local supermarkets to support lifestyle changes (while accessing and analyzing the patients point-of-purchase data to see what they are really buying).
The primary relationship between patients and their health systems is with a low cost, personal health concierge: Primary care physicians are only accessed based on predetermined eligibility criteria and only with those physician who agree to standards of quality and accountability are in the network. Multi-tiered scenario planning for emergencies is built into the system. For professional resources only required on an as-needed basis, such as hospital beds, surgeons and medical specialists, access is negotiated in advance based on a formula of quality standards and best pricing but only used on a just-in-time basis.
They are not a payer, although a professional relationship with them is on a business-to-business basis. They are a completely new type of health system, guaranteeing health and well being, transparent in their operations and choosing their vendors based on their willingness and ability to achieve those goals. In doing so, they significantly reduce the resources necessary to achieve goals for quality of care and quality of health across the entire population; they treat quality achievement as an operational challenge and manage their supply chain accordingly.
Am I suggesting this a new model of care? No, I am personally an advocate for physician-driven systems of care. But this kind of system is very possible, and there are companies working on models of national ACOs using many of these principles.
The Uber of health care will have much less to do with the mobile app; and far more to do with creating value by minimizing overhead, designing flexible operations, supporting goal-directed innovation and bringing supply-chain discipline to the idea of resource-managed care delivery. It will involve embracing models of care delivery that leverage emerging evidence on non-clinical approaches to health status and quality improvement, and focusing on designing goal-directed interactions between people, platforms, programs and partners.
I can hear more than a few of you creating very good reasons why it wont work (“You can’t put an ICU bed out to bid!”), but these scenarios are very doable. If we want to revitalize the experience of care for patients and professionals, we must be willing to acknowledge and embrace dramatically different, often counter-intuitive, new operating models for care that will require new competencies, forms of collaboration and reengineering the roles and responsibilities of those who comprise a patients’ health resource community.
Steven Merahn is director, Center for Population Health Management, Clinovations. He blogs at MedCanto.
Georgia O’Keeffe on being terrified
I’ve been absolutely terrified every minute of my life — and i’ve never let it keep me from doing a single thing I wanted to do
Georgia O’Keeffe, 99
Barnes: Cap specialist fees to maintain access to medicare
Good call…
http://www.medicalobserver.com.au/news/call-to-cap-specialists-fees-gathers-support
Call to cap specialists’ fees gathers support
7th Aug 2014
Flynn Murphy all articles by this author
THE former Howard government adviser who reignited the co-payment debate is back. In his sights: exorbitant out-of-pocket expenses being charged by overpaid specialists.
Terry Barnes has called for the fees that surgeons and other specialists can charge to be capped at their AMA-recommended rates. And if they charge too much they should be refused access to Medicare, he told Medical Observer.
“If the AMA schedule is considered fair and reasonable, then any out-of-pocket in excess of that is, by definition, unreasonable,” Mr Barnes said.
“What I propose is that if the government gives ground on cutting the GP rebate [for the co-payment], the quid pro quo is that the government works together with the AMA to reduce patient out-of-pockets.”
Mr Barnes showed MO a recent anaesthetist’s bill that saw him pay four times the rebate he was entitled to under the MBS.
“She should have delivered an anaesthetic with her [bill],” he said.
The proposal is backed by the Grattan Institute’s Dr Stephen Duckett, a prominent health economist who gave evidence to the recent Senate inquiry into out-of-pocket costs.
In his submission to the inquiry, Dr Duckett reported that for people in the lowest disposable income decile, average fees for specialists were nearly four times the average GP fee.
“I think it’s a good idea,” he said of Mr Barnes’s call.
“I think the profession has to have some responsibility for moderating out-of-pocket costs. There is an issue here about professional responsibility.”
The comments follow a statement from the Royal Australasian College of Surgeons (RACS) expressing concern about reports of “excessive… even extortionate” and “unethical” surgical fees being charged to patients by its own members.
RACS president Professor Michael Grigg said the reported fees were “damaging to the health system and to the standing of surgeons and the surgical profession”.
“RACS believes that extortionate fees, where they are manifestly excessive and bear little if any relationship to utilisation of skills, time or resources, are exploitative and unethical. As such, they are in breach of the college’s code of conduct and will be dealt with by the college,” the statement said.
But an RACS spokesman said the college does not support a cap on fees.
An AMA spokesman said: “The AMA is currently in talks with the government on the disastrous and hugely unpopular budget co-payments proposal, and doubts that the government would be rushing to adopt any other ‘thought bubbles’ from the author of that policy.”
The Strange, Difficult Questions CEOs Ask in Job Interviews
I like these… good for provoking a reaction…
https://www.linkedin.com/today/post/article/20140807094555-20017018-13-ceos-share-their-favorite-job-interview-questions
The Strange, Difficult Questions CEOs Ask in Job Interviews
Interview questions: Everyone has them.
And everyone wishes they had better ones.
So I asked smart people from a variety of fields for their favorite interview question and what it tells them about the candidate.
1. Why have you had X number of jobs in Y years?
This question helps me get a full picture of the candidate’s work history. What keeps them motivated? Why, if they have, did they jump from job to job? And what is the key factor when they leave?
The answer shows me their loyalty and their reasoning process. Do they believe someone always keeps them down (managers, bosses, etc.)? Do they get bored easily?
There is nothing inherently wrong with moving from job to job — the reasons why are what matters.
— Shama Kabani, The Marketing Zen Group founder and CEO
2. If we’re sitting here a year from now celebrating what a great twelve months it’s been for you in this role, what did we achieve together?
For me, the most important thing about interviews is that the interviewee interviews us. I need to know they’ve done their homework, truly understand our company and the role… and reallywant it.
The candidate should have enough strategic vision to not only talk about how good the year has been but to answer with an eye towards that bigger-picture understanding of the company — and why they want to be here.
— Randy Garutti, Shake Shack CEO
3. When have you been most satisfied in your life?
Except with entry-level candidates, I presume reasonable job skill and intellect. Plus I believe smart people with relevant experience adapt quickly and excel in new environments where the culture fits and inspires them. So, I concentrate on character and how well theirs matches that of my organization.
This question opens the door for a different kind of conversation where I push to see the match between life in my company and what this person needs to be their best and better in my company than he or she could be anywhere else.
— Dick Cross, Cross Partnership founder and CEO
4. If you got hired, loved everything about this job, and are paid the salary you asked for, what kind of offer from another company would you consider?
I like to find out how much the candidate is driven by money versus working at a place they love.
Can they be bought?
You’d be surprised by some of the answers.
— Ilya Pozin, Ciplex founder
5. Who is your role model, and why?
The question can reveal how introspective the candidate is about their own personal and professional development, which is a quality I have found to be highly correlated with success and ambition.
Plus it can show what attributes and behaviors the candidate aspires to.
— Clara Shih, Hearsay Social co-founder and CEO
6. What things do you not like to do?
We tend to assume people who have held a role enjoy all aspects of that role, but I’ve found that is seldom the case.
Getting an honest answer to the question requires persistence, though. I usually have to ask it a few times in different ways, but the answers are always worth the effort. For instance, I interviewed a sales candidate who said she didn’t enjoy meeting new people.
My favorite was the finance candidate who told me he hated dealing with mundane details and checking his work. Next!
— Art Papas, Bullhorn founder and CEO
7. Tell me about a project or accomplishment that you consider to be the most significant in your career.
I find that this question opens the door to further questions and enables someone to highlight themselves in a specific, non-generic way.
Plus additional questions can easily follow: What position did you hold when you achieved this accomplishment? How did it impact your growth at the company? Who else was involved and how did the accomplishment impact your team?
Discussing a single accomplishment is an easy way to open doors to additional information and insight about the person, their work habits, and how they work with others.
— Deborah Sweeney, MyCorporation CEO
8. What’s your superpower… or spirit animal?
During her interview I asked my current executive assistant what was her favorite animal. She told me it was a duck, because ducks are calm on the surface and hustling like crazy getting things done under the surface.
I think this was an amazing response and a perfect description for the role of an EA. For the record, she’s been working with us for over a year now and is amazing at her job.
— Ryan Holmes, HootSuite CEO
9. We’re constantly making things better, faster, smarter or less expensive. We leverage technology or improve processes. In other words, we strive to do more–with less. Tell me about a recent project or problem that you made better, faster, smarter, more efficient, or less expensive.
Good candidates will have lots of answers to this question. Great candidates will get excited as they share their answers.
In 13 years we’ve only passed along one price increase to our customers. That’s not because our costs have decreased–quite the contrary. We’ve been able to maintain our prices because we’ve gotten better at what we do. Our team, at every level, has their ears to the ground looking for problems to solve.
Every new employee needs to do that, too.
— Edward Wimmer, RoadID co-founder
10. Discuss a specific accomplishment you’ve achieved in a previous position that indicates you will thrive in this position.
Past performance is usually the best indicator of future success.
If the candidate can’t point to a prior accomplishment, they are unlikely to be able to accomplish much at our organization–or yours.
–– Dave Lavinsky, founder of Guiding Metrics
11. So, what’s your story?
This inane question immediately puts an interviewee on the defensive because there is no right answer or wrong answer. But there is an answer.
It’s a question that asks for a creative response. It’s an invitation to the candidate to play the game and see where it goes without worrying about the right answer. By playing along, it tells me a lot about the character, imagination, and inventiveness of the person.
The question, as obtuse as it might sound to the interviewee, is the beginning of a story and in today’s world of selling oneself, or one’s company, it’s the ability to tell a story and create a feeling that sells the brand–whether it’s a product or a person.
The way they look at me when the question is asked also tells me something about their likeability. If they act defensive, look uncomfortable, and pause longer than a few seconds, it tells me they probably take things too literally and are not broad thinkers. In our business we need broad thinkers.
— Richard Funess, Finn Partners managing partner
12. What questions do you have for me?
I love asking this question really early in the interview–it shows me whether the candidate can think quickly on their feet, and also reveals their level of preparation and strategic thinking.
I often find you can learn more about a person based on the questions they ask versus the answers they give.
— Scott Dorsey, ExactTarget co-founder and CEO
13. Tell us about a time when things didn’t go the way you wanted — like a promotion you wanted and didn’t get, or a project that didn’t turn out how you had hoped.
It’s a simple question that says so much. Candidates may say they understand the importance of working as a team but that doesn’t mean they actually know how to work as a team. We need self-starters that will view their position as a partnership.
Answers tend to fall into three basic categories: 1) blame 2) self-deprecation, or 3) opportunity for growth.
Our company requires focused employees willing to wear many hats and sometimes go above and beyond the job description, so I want team players with the right attitude and approach. If the candidate points fingers, blames, goes negative on former employers, communicates with a sense of entitlement, or speaks in terms of their role as an individual as opposed to their position as a partnership, he or she won’t do well here.
But if they take responsibility and are eager to put what they have learned to work, they will thrive in our meritocracy.
— Tony Knopp, Spotlight Ticket Management co-founder and CEO
Economist on doctor review sites
http://www.economist.com/news/international/21608767-patients-around-world-are-starting-give-doctors-piece-their-mind-result?fsrc=scn/tw_ec/docadvisor
Patients’ reviews
DocAdvisor
Patients around the world are starting to give doctors a piece of their mind. The result should be better care
WHEN a patient in Illinois did not like the result of her breast-augmentation surgery, she reacted like many dissatisfied customers: by writing negative comments about her doctor on websites that feature such reviews. Her breasts, she said, looked like something out of a horror movie. Other unhappy patients joined her online, calling the doctor “dangerous”, “horrible” and a “jackass”. He sued them for defamation. (The cases were later dropped.)
Other doctors have filed similar lawsuits, mostly in America. Though few have won, their reaction illustrates a discomfort with patient reviews felt by many of their colleagues. Some question the accuracy and relevance of the feedback; others complain that privacy rules prevent them from responding. Sites often have just a handful of ratings per doctor, meaning results can be skewed by a single bad write-up.
But increasingly, doctors cannot afford to ignore them. They often lead the results of searches for doctors’ names. In America, the world’s biggest health-care market, firms that offer health insurance are making employees pay a bigger share, pushing them to search for guidance online. The most sophisticated sites are attracting more users by including reviews and other features. ZocDoc also lets patients make appointments. Offerings from Vitals include a quality indicator it has built using data from 170,000-odd sources. Castlight Health includes prices gathered from insurance bills and other data. The differences can be startling—the cost of a brain scan in Philadelphia ranges from $264 to $3,271.
With around 60 review sites, America leads the way. But they are also popping up in other countries where patients pay for at least part of their care. Practo, an Indian firm that schedules appointments with doctors, plans to start publishing patients’ reviews later this year. More and more Chinese patients, who generally do not have a regular family doctor, are using a site run by Hao Dai Fu (“good doctor”) to navigate their country’s unstructured health system, says Haijing Hao of the University of Massachusetts. It has profiles of around 300,000 doctors and over 1m reviews.
Increasingly, doctors, hospitals and health systems are seeking to turn the trend to their advantage. Some now offer incentives, such as prize draws, for patients to go online and rate them. A survey by ZocDoc found that 85% of doctors on its site looked at their ratings last year. And a handful of health-care providers have even started to publish reviews themselves. The University of Utah, which runs four hospitals and ten clinics, was one of the first, in 2012. Its doctors’ complaints about independent sites encouraged it to publish patient feedback that was already being collected for internal use. Some of its doctors now have hundreds of reviews.
Preparing staff for the publication of all the comments, good and bad, took a year, says Brian Gresh, who helped create the university’s system. But their worries appear to have been groundless: most reviews are positive, and patient-satisfaction scores improved after the move. Happy patients communicate and co-operate better with their doctors, says Tom Lee, the chief medical officer of Press Ganey, a firm that surveys patients on behalf of health-care providers, including for the University of Utah. Its boss, Pat Ryan, predicts that plenty of other hospitals will follow suit.
Some doctors are still sceptical, fearing, for example, that patients may judge a hospital on its decor rather than its care. But patients are rarely swayed much by such trivia, insists Mr Ryan: “If you have flat-screen televisions and your communication is poor, you will get very bad scores.” Moreover, the feedback reminds doctors that every meeting with a patient matters, so they try harder.
America’s government has started to link health-care payments with patient feedback: Medicare, a federal scheme for over-65s, recently started to give bonuses to hospitals that score well. The Cleveland Clinic, a big hospital, uses these data to improve its care. Britain’s National Health Service has surveyed patients for over a decade (though not on the performance of individual doctors) and published the results online—though some think it could use its findings better.
But many other governments do not even ask patients for their opinions. German doctors and hospitals, for example, have fought efforts to link funding with quality of care, says Maria Nadj-Kittler of the Picker Institute Europe, a research organisation, and are therefore hostile to patient reviews. This is a missed opportunity. Patients who hold their doctors accountable make them better and more efficient. That is good news no matter who pays.
Outsource physician behaviour change to the experts: Big Pharma
So pay for performance doesn’t work. This is hardly surprising when you see the compromise and mediocrity forced upon policy makers to get ideas through. There have been instances of success in health care. Indeed, one could argue that the exemplary success of big pharma in changing physician behaviour has provided a rod for its own back. Why not harness this expertise in getting under the skin of doctors, and pay big pharma sales outfits to guide physician practice in constructive directions, rather than being distracted by flogging pills that don’t really work that well anyway, and potentially harm? Might have a chat with Christian.
http://www.nytimes.com/2014/07/29/upshot/the-problem-with-pay-for-performance-in-medicine.html
“Pay for performance” is one of those slogans that seem to upset no one. To most people it’s a no-brainer that we should pay for quality and not quantity. We all know that paying doctors based on the amount of care they provide, as we do with a traditional fee-for-service setup, creates incentives for them to give more care. It leads to increased health care spending. Changing the payment structure to pay them for achieving goals instead should reduce wasteful spending.
So it’s no surprise that pay for performance has been an important part of recent reform efforts. But in reality we’re seeing disappointingly mixed results. Sometimes it’s because providers don’t change the way they practice medicine; sometimes it’s because even when they do, outcomes don’t really improve.
The idea behind pay for performance is simple. We will give providers more money for achieving a goal. The goal can be defined in various ways, but at its heart, we want to see the system hit some target. This could be a certain number of patients receiving preventive care, a certain percentage of people whose chronic disease is being properly managed or even a certain number of people avoiding a bad outcome. Providers who reach these targets earn more money.
The problem, one I’ve noted before, is that changing physician behavior is hard. Sure, it’s possible to find a study in the medical literature that shows that pay for performance worked in some small way here or there. For instance, a study published last fall found that paying doctors $200 more per patient for hitting certain performance criteria resulted in improvements in care. It found that the rate of recommendations for aspirin or for prescriptions for medications to prevent clotting for people who needed it increased 6 percent in clinics without pay for performance but 12 percent in clinics with it.
Good blood pressure control increased 4.3 percent in clinics without pay for performance but 9.7 percent in clinics with it. But even in the pay-for-performance clinics, 35 percent of patients still didn’t have the appropriate anti-clotting advice or prescriptions, and 38 percent of patients didn’t have proper hypertensive care. And that’s success!
It’s also worth noting that the study was only for one year, and many improvements in actual outcomes would need to be sustained for much longer to matter. It’s not clear whether that will happen. A study published in Health Affairs examined the effects of a government partnership with Premier Inc., a national hospital system, and found that while the improvements seen in 260 hospitals in a pay-for-performance project outpaced those of 780 not in the project, five years later all those differences were gone.
The studies showing failure are also compelling. A study in The New England Journal of Medicine looked at 30-day mortality in the hospitals in the Premier pay-for-performance program compared with 3,363 hospitals that weren’t part of a pay-per-performance intervention. We’re talking about a study of millions of patients taking place over a six-year period in 12 states. Researchers found that 30-day mortality, or the rate at which people died within a month after receiving certain procedures or care, was similar at the start of the study between the two groups, and that the decline in mortality over the next six years was also similar.
Moreover, they found that even among the conditions that were explicitly linked to incentives, like heart attacks and coronary artery bypass grafts, pay for performance resulted in no improvements compared with conditions without financial incentives.
In Britain, a program was begun over a decade ago that would pay general practitioners up to 25 percent of their income in bonuses if they met certain benchmarks in the management of chronic diseases. The program made no difference at all in physician practice or patient outcomes, and this was with a much larger financial incentive than most programs in the United States offer.
Even refusing to pay for bad outcomes doesn’t appear to work as well as you might think. A 2012 study published in The New England Journal of Medicine looked at how the 2008 Medicare policy to refuse to pay for certain hospital-acquired conditions affected the rates of such infections. Those who devised the policy imagined that it would lead hospitals to improve their care of patients to prevent these infections. That didn’t happen. The policy had almost no measurable effect.
There have even been two systematic reviews in this area. The first of them suggested that there is some evidence that pay for performance could change physicians’ behavior. It acknowledged, though, that the studies were limited in how they could be generalized and might not be able to be replicated. It also noted there was no evidence that pay for performance improved patient outcomes, which is what we really care about. The secondreview found that with respect to primary care physicians, there was no evidence that pay for performance could even change physician behavior, let alone patient outcomes.
One of the reasons that paying for quality is hard is that we don’t even really know how to define “quality.” What is it, really? Far too often we approach quality like a drunkard’s search, looking where it’s easy rather than where it’s necessary. But it’s very hard to measure the things we really care about, like quality of life and improvements in functioning.
In fact, the way we keep setting up pay for performance demands easy-to-obtain metrics. Otherwise, the cost of data gathering could overwhelm any incentives. Unfortunately, as a recent New York Times article described, this has drawbacks.
The National Quality Forum, described in the article as an influential nonprofit, nonpartisan organization that endorses health care standards, reported that the metrics chosen by Medicare for their programs included measurements that were outside the control of a provider. In other words, factors like income, housing and education can affect the metrics more than what doctors and hospitals do.
This means that hospitals in resource-starved settings, caring for the poor, might be penalized because what we measure is out of their hands. A panel commissioned by the Obama administration recommended that the Department of Health and Human Services change the program to acknowledge the flaw. To date, it hasn’t agreed to do so.
Some fear that pay for performance could even backfire. Studies in other fields show that offering extrinsic rewards (like financial incentives) can undermine intrinsic motivations (like a desire to help people). Many physicians choose to do what they do because of the latter. It would be a tragedy if pay for performance wound up doing more harm than good.
The Universal Hot Crazy Matrix
https://www.youtube.com/watch?v=qHQWlFtSptU
Whitman: I swear to you, there are divine things more beautiful than words can tell
I swear to you, there are divine things more beautiful than words can tell – Walt Whitman