Transparency is so hard.


I look at the transparency issue not as a moral right, but as a business tactic, tool and threat.

1. If you run around acting like the things you do will never be seen in public, you’re going to get busted. Sooner or later, the marketplace is going to see the effects of your actions, and living as if this is certain makes it far more likely that you’ll find a happy ending.

2. Your job as a marketer is to tell a story, which is a lot like putting on a show. If you can use the tools of transparency to tell that story better, do it! But if your audience will enjoy the story more (and your business will be more likely to succeed) if you apply some misdirection and magic, then why not?

1. Why hospitals (+ health care, etc.) (are starting to) make an attempt at transparency.

2. For the time being, transparency at most hospitals does not make the story more compelling, at least not in the “let’s attract more patients” sense.  Also why hospitals (+ health care, etc.) are not more prudently pursuing Number 1.

Getting past transparency as punishment

From The Plain Dealer:

“I’m very upset about it,” said state Rep. Linda Bolon, a Democrat from Columbiana County, who said her father died from a hospital-acquired infection three years ago.

As she should be.  The Ohio legislature created the Hospital Measures Advisory Council in 2006 to work on transparency:

A state panel in August recommended a long list of measures that would add Ohio to a growing number of states requiring public disclosure of hospital infections. The proposal also gives consumers important information about whether hospitals monitor hand-washing among staff, whether workers are vaccinated against flu, and how well facilities staff infection-control programs.

However, the Ohio Hospital Association has recently backed legislation that threatens the “milestone effort to inform consumers about certain hospital infections and whether facilities follow practices to reduce infection rates” and “gut the proposal and hamstring the panel from making future recommendations.”

Troubling.  We need to get past the perception that transparency is going to hurt hospitals.  It will hurt bad hospitals.  Transparency will only aid quality improvement efforts.

The (dis)incentives of transparency

Paul Levy (CEO of Beth Israel Deaconess Medical Center in Boston and health care transparency champion and CEO blogger): “Shouldn’t there be some correlation between what you get paid for doing something and the quality of what you do?”

That quote from an intriguing exposé of sorts in The Boston Globe (a fair presentation of the situation in my opinion).  The bottom line: Partners Healthcare in Boston (generally) makes quite a bit more (around 30 percent) than other hospitals in the state (Massachusetts has lots of good hospitals, especially in Boston).  So the question is: why?  Here’s the secret: it’s less about quality and more about market control.  What’s more is that it is happening in nearly every corner of this country.

Okay, so the free market is the United States of America.  Economists have a list of conditions in order for markets to be “perfectly competitive;” they include: large numbers of anonymous buyers and sellers, easy mobility of resources, homogeneous goods, and perfect access to information.  Health care, more or less, fails on every condition.

It is very difficult to efficiently, effectively, and equitably distribute resources when a market fails.  What that translates to is that health care costs more than it needs to (for a multitude of reasons).  But the argument here is that more information would prevent such wide disparities in payment (especially when a requisite increase in quality is not the reason for a higher price).  If insurers knew what hospitals collected from other insurers; if hospitals knew what insurers paid other hospitals; if patients and payers could effectively compare quality; if hospitals could benchmark quality against other hospitals; a more efficient, effective, and equitable distribution of health care dollars would occur.

All of that above summed up in one word: transparency.  We need: complete financial and quality of care transparency.  Watch health care costs fall and quality improve as hospitals start competing on outcomes and cost effectiveness instead of on market share and perceived notoriety.

Ross Dawson at Trends in the Living Networks writes:

Secrecy has its place in business, but it is highly over-rated. In most cases there is no valid reason not to share information, just a disinclination to give away things. We are going to see transparent models increasingly favored moving forward.

A disinclication indeed.  Transparency is the future.  It’s how we’re going to improve our health care system.

The “New Health Care:” Informed Patients

Tom Peters’ recent discussion with friends is nothing new.  This conversation is happening at dinner tables, around kitchen counters, and surrounding fireplaces the nation over.

But the question comes here: why do so few patients still not question the quality of health care?

We (health care) know mistakes are happening.  Our perception has been that patients know mistakes are happening as well.  But the “quality” of health care is in the eye of the beholder.  Perception is reality.  Patients have a tendency to perceive quality as everything but what health care experts have deemed clinical quality.

It becomes very obvious that we (health care) have failed patients in educating them about what clinical quality health care means.  Every reason being old health care.  The health care of blind trust and walls built so high in order to “protect” “us” from information slipping into “their” hands.

The new health care redefines “protect” “us” and “their.”  The new health care demands full participation.  It demands honesty, communication, and understanding.

We’ve got some work to do.  Transparency efforts are a start.

Mr. Peters brings to light why many health care organizations are fearful of complete transparency:

Make no mistake, this is a story of lousy management and sloppy leadership—not, primarily, the result of lousy health policy.

Make no mistake, this is a story of unconscionably lousy management and almost criminally sloppy leadership—not, primarily, the product of bad health policy.

If patients aren’t motivation enough to tirelessly improve quality, then a flat out indictment of “unconscionably lousy management and almost criminally sloppy leadership” is.  What are you doing to assure the highest (read: the H-I-G-H-E-S-T) quality of care is being provided at your organization?

Pricing Transparency Debate

There’s some debate on the usefulness of pricing transparency (as it stands) in health care here here and here at the Health Care for All Healthy Blog.

Here’s the gist of the discussion at HCFA:

Of course, we’re not so neutral in this discussion. Paul’s [Levy, health care CEO who blogs] worried about accuracy and validity. Charlie’s [Baker, health care CEO who blogs] view is let’s get this started, and make improvements along the way. Our concern, which we wrote about two days earlier (with two interesting comments added), is whether this is really worth it. Our point, that price transparency may not be too useful, and could lead to price increases, was picked up by this week’s lead Modern Healthcare article.

I understand all sides.

Creating measures that are accurate and valid is vitally important to develop a reliable comparison tool that we can all agree upon and create together.

On the other hand, health care moves incredibly slowly—and if we wait until the data used is agreeable to all parties involved, comparisons may be impossible until mid-century.

The misplaced incentives of health care financing make for creative pricing strategies.  The risk that prices could rise from transparent data is real.

But in the end, if consumerism is to truly take over health care decision making, complete transparency must become the norm: knowing the cost of care is an important component of the revolution.

Transparency is transparency is transparency. But only if its truly transparent.

Importing Quality Measures?

In an effort to one-up CMS (kidding), the NHS will publish surgical mortality rates on their NHS Choices website.

From the Guardian:

The government is preparing to publish for the first time the death rates of patients undergoing major surgery at NHS hospitals in England, the Guardian has learned.

The move will expose alarming variations in the mortality rates of NHS trusts carrying out commonplace procedures, including hip and knee replacements and surgery of the oesophagus and abdominal aorta, the main blood vessel.

It will be the first time anywhere in the world that a government has systematically exposed the work of rival hospital teams, giving patients an opportunity to choose to be treated where their lives are least at risk.

The thinking:

Ministers think publication of the figures will drive up standards by forcing trusts to improve performance or withdraw from medical specialties at which they do not excel.

The future:

At this stage the published data will give results for hospital units, not individual surgeons. But Ben Bradshaw, the health minister, has instructed that the NHS Choices website should eventually let patients compare the performance of individual surgeons and GPs, heralding a big switch in the balance of medical power in favour of the patient.

Disclosure of the mortality data of hospitals will be followed by the publication of a wider range of indicators showing the outcome of treatments across many branches of medicine.

The take away:

[NHS Medical Director Sir Bruce] Keogh added: “Some will squeal that the data is not good enough, but the only way we can improve it is by using it.

“The writing has been on the wall since the inquiry into the deaths of children at Bristol Royal Infirmary 10 years ago, [which showed how poor practice was allowed to persist because the mortality rates were not disclosed]. There has been a lot of talk about more openness, but we as a profession have not made much progress. So I am now inviting the institutions of medicine to step up to the plate and help us accelerate the process. We want their help.”

(Complete) Transparency is coming…

Forcing the Transparency Conversation

If not by carrot, then definitely with a stick.

CMS placed advertisements in 58 newspapers on Wednesday publicizing area hospital satisfaction rates found on the Hospital Compare website.  The ads reported the results of two questions: “The percentage of patients who always got help when they needed it. And the percentage of patients who got antibiotics one hour before surgery.”

Interesting approach.  Especially as web use increases and newspaper readership declines.  Maybe they are looking to reach a different audience.  But as an example of generational difference: I’m willing to bet more hospitals were concerned when they heard their results would be published in a newspaper than just on the website.

PS, the first patient satisfaction survey were not required.  So not hospitals reported.

More coverage: Comarow on Quality, Health Blog, USA Today

Personal Transparency

Kevin Kelly has an interesting take on an article at the The Guardian:

The price of total personalization is total transparency.

The original phrasing from Seth Finkelstein:

We cannot expect that having large warehouses of data on individuals will be free from unintended consequences, especially when there are incentives to try to build highly detailed models of everyone’s lives. The price of total personalisation is total surveillance.

Hospitals are under fire to become completely transparent.  That’s a good thing.  Here’s the challenge: while hospitals become more transparent, so is the personal information of the people inside the hospital (employees included).  But it may not even be the fault of the hospital.  With more and more information divulged in web searches, social networks, online activities, emails, etc. the patient may need to consider their personal transition from privacy to transparency.

Transparency is K-I-N-G: (Another) Redux

60 Minutes had an interview with Dennis and Kimberly Quaid Sunday evening, see video here.

The Quaid’s, if you will remember, went through a scary ordeal several months ago as their newborn twins were administered Heparin 1000 times that of which was prescribed. The gist of the story is that it was a preventable medical error—and was eerily similar to the 2006 events that transpired to sextuplets in Indiana, killing three.

Cedars Sinai is prominently displayed in the 60 Minutes piece and has received an abundance of negative press over the error. The thing about it, and the public is beginning to find this out, is that preventable medical errors happen quite often. In fact, the Institute of Medicine says 1.5 million people a year are injured as a result of medical errors. The Quaid’s have filed a lawsuit against Baxter, the maker of Heparin; to this point they have decided against filing a lawsuit against Cedars Sinai. The family is also starting a foundation to reduce medical errors.

I see a series of outcomes from this scenario: the call for higher quality in hospitals is only going to intensify. As Americans become more aware of the issues inside hospitals, the pressure for hospitals to rectify those issues will only increase. But here’s the problem: many hospitals will turn and run from transparency (yes, efforts to improve quality are happening everywhere, just not reported all the time), becoming even more secretive about avoidable mistakes to prevent the negative media onslaught that could occur.

That’s completely the wrong thing to do. The right thing to do is to start reporting everything publicly. More transparency is what is required here, not less. As I’ve written before, “increasing transparency not only helps consumers, it will make us better. And that should be the goal of being transparent: making ourselves accountable to ourselves.”

Transparency is K-I-N-G: Redux

Lots of “transparency” items on the interweb recently. Promoting this discussion is always a good thing.

“As more of the responsibility for health care is pushed down to individuals through insurance products like high-deductible health plans and health savings accounts, more and better information — and access to it — becomes critical. Patients and families can become smarter consumers, capable of exerting market pressures that improve quality and lower cost, if given the chance,” writes Christopher Parks in a Tennessean editorial. He continues, “What is needed is greater transparency” (emphasis mine).

Parks is the co-founder of change:healthcare, an organization dedicated to transparency. “The company is charged with developing and providing people with the tools and information they need to make the best decisions possible as a healthcare consumer.”

Another take on transparency, although decidedly more pro-transparency for the organization’s sake of which I have blogged here before.

InsureBlog has a recent transparency update as well.

But it seems this news item really got the transparency debate going. What, you say does Facebook have to do with transparency in health care? Plenty…

APM’s Marketplace brings us this great commentary: “It’s a transparent society, so get naked” by teen CEO (futile attempt at word creation) Ben Casnocha.

Will universal transparency happen in health care in the next few years? Let’s hope so, but probably not. But I can tell you it will happen when the Facebook and MySpace crowd is in charge. It’s the world we’ve grown up in. It’s what we know.

As Mr. Casnocha says:

And transparency isn’t all-or-nothing. Today’s networks have detailed privacy settings you control. As blogger Jeff Jarvis has put it, “Publicness is good so long as we decide how public we want to be.” Like it or not, the transparent society is here.

Most of my friends are out on the Web, where we tell the world who we are and what we think. Those who are still fully clothed shouldn’t be surprised if folks start asking, “What are you trying to hide?”

Only the question will be: what’s your hospital trying to hide?