Saturday, November 24, 2007

Transparency - In a Clash All By Myself

Health Care Transparency and Returns on Social and Personal Investments

The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function.

Francis Scott Fitzgerald, 1896-1940, The Crack-up, 1936

Let me be perfectly clear.

I am for transparency, clarity, openness, honesty, integrity, accountability, data measurement and management, sunshine laws, collaboration, joint ventures, the common good, adequate returns of social investments, public disclosure of outcomes and ties to pharmaceutical companies, and physician teamwork to improve care.

I am against rigid, arcane laws requiring armies of attorneys to interpret and which stifle physician-physician and physician-hospital collaboration and joint ownership.

I am for physician individualism, competition, economic freedom, adequate compensation, innovation, personal creativity, self-interest, wealth creation, inherent human nature tendencies, doing well by doing good and reasonable returns on personal investments.

I am against unbridled and unfettered greed, monopolies, and oligopathies.

I am, in short, in a clash all by myself. To be clear, and that’s what this discursive essay is all about, I believe more health care transparency is a good thing, and, at the same time, I believe total transparency has inherent limitations.


Revenue-producing ancillary services in doctors’ offices. In theory, physicians ought to make all their money for time spent with patients, not on side investments. . But as every doctor knows, given falling reimbursements for time spent, those who preach transparency delude themselves. Besides health consumers like one-stop shopping, even if a doctor’s business interests are involved. It’s about convenience, not conflict of interests.

Referral to services in which you have part-time ownership – such as joint ownership of MRI or CT scanners. Pete Stark not withstanding, to whom should you refer – to local hospitals, to competitors, to academic institutions, to others who profit from your referrals? Should you reward yourself – or others? To many, self-reward is more commonsensical.

Use of medical devices in which you have a financial interest, you believe in, have developed, have a patent on, or receive royalties from. Suppose you think your device is best thing on the market, which is why you conceived it. . Personally I believe doctors should tell your patients of financial interests, royalties, and self-interests. The proposal before Congress, the Physician Payment Sunshine Act of 2007, requiring companies to publicly disclose payments of $25 or more to physicians may be a good thing.

Wide deployment and diffusion of data of factual information, i.e., data, from multiple sources funneling into a common data tank so government, payers, and consumers can objectively judge for themselves the best value, the best providers, the best outcomes, and the best deal. In some circles, this is known as Health 2.0 – or management by data –reformulating algorithms in an open and transparent market. I applaud data diffusion, but doubt its practicality.

Universal communication through electronic medical records systems between hospitals and doctors so everybody can coordinate care and everybody can know what everybody else is doing with standards and controls to continuo sally improve quality, outcomes, and safety. Good idea, hard to do, given costs, privacy and security returns, and dubious returns on hospital and physician investments.

I trust I have been clear I’m for common social ends lofty goals can bring and against the realistic barriers human nature brings.

For doctors, transparency poses nettlesome problems – interference with improving the bottom line, keeping up a leg up on your competition, attracting patients, and concealing secrets of your success.

Then, on the part of doctors, there are other problems as well – expense of data input, loss of productivity during the transition to computers, use of your own data against you, lack of capital resources to install systems, the huge amount of work to get a system up and running, start-up costs of $25,000 to $50,000 per doctor to get EMRs off the ground, and maintenance costs of $5000 to $10,000 to maintain.

Good will, trust, and desire for the common good and better health care may overcome barriers to transparency – such as privacy, common terminologies, security, and cost. Maybe we’ll find a way to pay. But convincing doctors there’s a business and clinical case to be made for transparency will be formidable – with attractive but uncertain long term social gains but intractable and certain short term problems.

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