Healthy and Wise

My AFR oped today argues that governments should make more information publicly available on how hospitals (and perhaps doctors) perform. Full text over the fold.

Shedding a Healing Light, Australian Financial Review, 11 March 2008

One of the astonishing statistical regularities of human life is the bell curve. Plot the test results of a class of students, the running times of a group of adults, or the blood pressure of men and women, and you will find that they trace out a bell-shaped pattern. At the very edges of the bell are a few people who do very well or very badly. As we move towards the centre there are others who are noticeably below average or above average. And the rest are clustered in the middle. So established is this pattern that statisticians call it “the normal distribution”.

In the case of the medical profession, the same pattern holds. Whenever data on the performance of hospitals or individual doctors is plotted on a curve, large gaps separate the best and the worst. There is nothing surprising in this; most of us can probably imagine the same distribution of performance in our own occupations. Yet it does suggest that choosing the right doctor can be good for your health.

Because information can help more patients choose the best service, and spur reform among the rest, it seems natural to think that data on hospital performance should be made publicly available. (Adjusted, of course, for the fact that some hospitals deal with older and sicker patients than others.)

To her credit, federal health minister Nicola Roxon has been pushing for just this outcome, supported by consumer group Choice. But attempts for more health data to be released into the public domain have been strongly resisted by the Australian Medical Association and some state governments. Their opposition to data release has been based around two arguments – both of which will be familiar to anyone who has followed the debate over the release of schools’ test score data.

First, they argue, the performance measures are imperfect. This is undoubtedly true, but it sets the bar too high. Last week, the Australian Financial Review published its list of Australia’s best lawyers, based on peer assessment. No-one would contend that these rankings are flawless, but they nonetheless provide a useful source of information to clients seeking to choose a lawyer, and may spur those who just missed out to lift their game.

Second, those who oppose data being released claim that it will lead to underperforming hospitals being stigmatised. But so long as the data are collected so as to minimise the potential for manipulation, and provide the broadest possible set of indicators, it will help identify the strongest and weakest hospitals. Rather than allowing poor performance to continue under a veil of secrecy, we should let a little sunlight in.

In his book Better: A Surgeon’s Notes on Performance, medical writer Atul Gawande discusses the impact that performance information had on the treatment of cystic fibrosis, a genetic disease that impedes lung capacity. While patients at the average treatment centre typically live to 33 years, those at the best centre typically live to 47. Over recent decades, the life expectancy of cystic fibrosis patients has increased substantially, as treatment innovations have percolated down from the leading centres. On its website, the Cystic Fibrosis Foundation now publishes data on the performance of all its centres in the United States. Yet even in an information-rich environment, the best centres have managed to outperform the rest. Information spurs innovation, but it cannot wipe out the bell curve.

Making hospital performance information publicly available should help all patients, but there are good reasons to think that the poor may benefit more than the rich. Under the current regime, information is restricted to doctors, nurses, and hospital administrators, who naturally share it with their friends. Publishing statistical data on hospital performance would democratise access to information – allowing everyone to see what the insiders already know.

In attempting to change the culture of information in Australian health, it is possible that those in favour of secrecy will prevail. Yet if they do, the effect may be to promote less reliable sources of information. For example, one rapidly growing website allows Australian patients to rate their doctors. But a quick browse shows it to be dominated by the ecstatic and the enraged. (Moreover, you also have to wonder about a site in which the infamous Queensland surgeon Jayant Patel is rated “average”.) The more comprehensive public data is, the less individuals will need to rely upon questionable sources of information.

Just as in the case of schools, making data on hospitals publicly available is a useful first step to spur reform. When insiders claim that the public can’t handle the truth, we should respond that taxpayers have a right to receive feedback on the services we fund. The more we can learn from the best, the better our public services can become.

Dr Andrew Leigh is an economist in the Research School of Social Sciences at the Australian National University.

An aside: Nicholas Gruen has also discussed this issue in a couple of opeds. He provides several examples in which better information has raised performance. The oped also benefited from NG’s comments before publication.

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8 Responses to Healthy and Wise

  1. Robin Hanson says:

    This is a standard battle in many countries. We’ve lost in the US, and I’m now visiting Switzerland and have been hearing about how they lost here. Is there any place where we’ve won and convinced them to make this info public?

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  3. Fred Argy says:

    Andrew, in principle, improving the flow of information (in health, education and other professions) is a great idea. It has been part of Nicholas Gruen’s grand reform vision for some time.

    But the information has to be comprehensive, accurate and reliable. If not, it can have perverse effects. I am told by my legal friends – even those who come out of it very well – that the AFR survey is a bit cock-eyed. And financial markets are currently feeling the impact of false assessments by totally discredited credit rating agencies.

    I would also want to be reassured that publishing health comparisons will not lead to an exodus of patients to the “best” performers, who would then raise their fees and crowd out the poor, producing a two tier quality health system – a bit like what has been happening with public/private schools.

    And who do you envisage providing the medical information and implicit ratings? A public agency? Or an “independent” private group? In the former case, the politics would be horrendous. Would the information be simply based on customer surveys or on independent assessments? If the former, how useful would that be given the complexities of medicine?

    I am not really against the idea – only sounding a few warnings.

  4. Andrew Leigh says:

    SJ, I regard that finding as quite specific to the way that you design the reporting system. If it’s done badly, it will create the wrong set of incentives.

  5. christine says:

    Re Robin Hanson: not Canada!

    But SJ and Fred do point out that the way you do would matter a lot.

    I know in the Canadian case there’s a lot of talk about providing information on waiting times – which you’d think would be sort of helpful to have, even if just to act as a signal to doctors about which areas were underserviced and therefore potentially lucrative places to set up shop. But measurement is not particularly simple, apparently.

  6. Molesworth says:

    Robin, they did something like this in Illinois too a few years back (Obama sponsored the relevant Bill in the State Senate, incidentally.) No idea how (or if) they tried to address the healthy-patient-selection-incentive issue or the apples-oranges issue though.

  7. Verdurous says:

    Comes down to choice really.

    If you don’t have any choice then league tables don’t matter much. The public health system for the most part does not offer choce of physician and so information regarding performance is a) of no help and b) potentially harmful to the therapeutic relationship.

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