As of last week, it has been a full year since the U.S. Export-Import (Ex-Im) Bank—the government export credit agency which lends money to foreign buyers of American exports—has been unable to approve loans over $10 million. This is because Senator Richard Shelby, Republican of Alabama, is single-handedly holding up the nomination of a third member to the Ex-Im Bank’s five person board; all transactions over $10 million require board approval, and short of its required quorum of three members, no major loans can get through. Looking beyond the immediate fight over Ex-Im, however, underlying trends in both American and international politics suggest commercial diplomacy is on the rise.

The Ex-Im Bank is but one of many instruments of American commercial diplomacy; there is a wide range of policies the government uses to actively help individual American companies compete abroad. Through the Overseas Private Investment Corporation (OPIC), the U.S. government sells political risk insurance to American firms investing in “risky” developing countries. Moreover, U.S. ambassadors frequently lobby foreign governments to award procurement contracts to American firms. Similarly, officials from the Department of State, Department of Commerce, and Office of the U.S. Trade Representative often advocate for U.S. companies involved in investment disputes with foreign governments. What distinguishes active commercial diplomacy from general foreign economic policy—such as signing trade agreements—is that in involves deploying the resources and reputation of the government to help specific firms in particular transactions, rather than broadly setting the rules of the road for all firms to follow. It represents a significantly greater co-mingling of interests and activities between public and private actors.

While both Secretary of State John Kerry and Secretary of Commerce Penny Pritzker have placed considerable emphasis on advancing commercial diplomacy, the long running struggle to keep Ex-Im operating underlines the political fault lines that cut through the issue. On the one hand, as highlighted in the Ex-Im fight, commercial diplomacy can be criticized as crony capitalism or corporate welfare. Government resources are being used to support private gains. Thus those who prefer free and unfettered markets may see commercial diplomacy as simply another form of unnecessary government intervention, akin to industrial policy. At the same time, as globalization has come under attack from both the left and the right in this election cycle, it is easy to see how encouraging further globalization through commercial diplomacy could face populist pushback. Those supporting commercial diplomacy tend to favor greater integration in the global economy—a view which has found little support in the 2016 campaigns to date.

And yet, the current trends in American political debates over globalization may ultimately presage more, not less, reliance on commercial diplomacy. If politicians increasingly view the global economy through a zero-sum, mercantilist lens, they may be more eager to use the power and purse of the U.S. government to help American firms “win” abroad. Indeed, Congress, which has historically been more protectionist than the executive branch, has also consistently pushed the State Department to do more to actively defend the interests of U.S. companies operating overseas (see, for example, here and here). Aggressively fighting to help U.S. companies win contracts and compete abroad could be one plank of an “America First” policy. Thus even if America, and the world, becomes more protectionist, foreign economic policy may become even more preoccupied with assertive commercial diplomacy, even as interest in seeking mutual benefits through economic liberalization subsides.

If the U.S. government does start to prioritize more actively helping American firms in their foreign operations, it will still have a ways to go to catch up to many other countries. China, of course, is well known for using state resources to advance the commercial goals of Chinese firms venturing abroad—which should not be surprising, given that many of these firms are state-owned enterprises. But a number of other advanced democracies—including Japan, Korea, Germany, and France—also have closer and more coordinated relationships between big business and government than the U.S. does. And most of these countries show no signs of slowing down. As a recent report (PDF) from the Ex-Im bank notes, “In the wake of slowing global growth, foreign export credit agencies are becoming more aggressive.” In fact, some of these agencies are capitalizing on Ex-Im’s current plight, offering American companies export financing in return for the promise of job creation. General Electric Co., for instance, recently announced it would expand production in France because Coface, the French equivalent of Ex-Im, will finance GE projects in a number of emerging markets—the type of financing that GE used to get from Ex-Im.

Looking forward, unilateral disarmament in the competitive world of commercial diplomacy—as the U.S. is currently doing with the Ex-Im Bank—is likely to become increasingly rare. The ultimate effects of this accelerating international competition, in both economic and political terms, remain to be seen.

       

       

       

Legislative proposals to accelerate and improve the development of innovative drugs and medical devices generally focus on reforming the clinical development and regulatory review processes that occur before a product gets to market. Many of these proposals – such as boosting federal funding for basic science, streamlining the clinical trials process, improving incentives for development in areas of unmet medical need, or creating expedited FDA review pathways for promising treatments – are worthy pursuits and justifiably part of ongoing efforts to strengthen biomedical innovation in the United States, such as the 21^st Century Cures initiative in the House and a parallel effort taking shape in the Senate.

What has largely been missing from these recent policy discussions, however, is an equal and concerted focus on the role that postmarket evidence can play in creating a more robust and efficient innovation process. Data on medical product safety, efficacy, and associated patient outcomes accrued through routine medical practice and through practical research involving a broad range of medical practices could not only bolster our understanding of how well novel treatments are achieving their intended effects, but reinforce many of the premarket reforms currently under consideration. Below and in a new paper, we highlight the importance of postmarket evidence development and present a number of immediately achievable proposals that could help lay the foundation for future cures.

Why is postmarket evidence development important?

There are a number of reasons why evidence developed after a medical product’s approval should be considered an integral part of legislative efforts to improve biomedical innovation. First and foremost, learning from clinical experiences with medical products in large patient populations can allow providers to better target and treat individuals, matching the right drug or device to the right patient based on real-world evidence. Such knowledge can in turn support changes in care that lead to better outcomes and thus higher value realized by any given medical product.

Similarly, data developed on outcomes, disease progression, and associated genetic and other characteristics that suggest differences in disease course or response to treatment can form the foundation of future breakthrough medical products. As we continue to move toward an era of increasingly-targeted treatments, this important of this type of real-world data cannot be discounted.

Finally, organized efforts to improve postmarket evidence development can further establish infrastructure and robust data sources for ensuring the safety and effectiveness of FDA-approved products, protecting patient lives. This is especially important as Congress, the Administration, and others continue to seek novel policies for further expediting the pre-market regulatory review process for high-priority treatments. Without a reliable postmarket evidence development infrastructure in place, attempts to further shorten the time it takes to move a product from clinical development to FDA approval may run up against the barrier of limited capabilities to gather the postmarket data needed to refine a product’s safety and effectiveness profile. While this is particularly important for medical devices – the “life cycle” of a medical device often involves many important revisions in the device itself and in how and by whom it is used after approval – it is also important for breakthrough drugs, which may increasingly be approved based on biomarkers that predict clinical response and in particular subpopulations of patients.

What can be done now?

The last decade has seen progress in the availability of postmarket data and the production of postmarket evidence. Biomedical researchers, product developers, health care plans, and providers are doing more to collect and analyze clinical and outcomes data. Multiple independent efforts – including the U.S. Food and Drug Administration’s Sentinel Initiative for active postmarket drug safety surveillance, the Patient-Centered Outcomes Research Institute’s PCORnet for clinical effectiveness studies, the Medical Device Epidemiology Network (MDEpiNet) for developing better methods and medical device registries for medical device surveillance and a number of dedicated, product-specific outcomes registries – have demonstrated the powerful effects that rigorous, systematic postmarket data collection can have on our understanding of how medical products perform in the real-world and of the course of underlying diseases that they are designed to treat.

These and other postmarket data systems now hold the potential to contribute to data analysis and improved population-based evidence development on a wider scale. Federal support for strengthening the processes and tools through which data on important health outcomes can be leveraged to improve evidence on the safety, effectiveness, and value of care; for creating transparent and timely access to such data; and for building on current evidence development activities will help to make the use of postmarket data more robust, routine, and reliable.

Toward that end, we put forward a number of targeted proposals that current legislative efforts should consider as the 2015 policy agenda continues to take shape:

Evaluate the potential use of postmarket evidence in regulatory decision-making. The initial Cures discussion draft mandated FDA to establish a process by which pharmaceutical manufacturers could submit real-world evidence to support Agency regulatory decisions. While this is an important part of further establishing methods and mechanisms for harnessing data developed in the postmarket space, the proposed timelines (roughly 12 months to first Guidance for Industry) and wide scope of the program do not allow for a thoughtfully-, collaboratively-considered approach to utilizing real-world evidence. Future proposals should allow FDA to take a longer, multi-stakeholder approach to identify the current sources of real-world data, gaps in such collection activities, standards and methodologies for collection, and priority areas where more work is needed to understand how real-world data could be used.

Expand the Sentinel System’s data collection activities to include data on effectiveness. Established by Congress in 2007, Sentinel is a robust surveillance system geared toward monitoring the safety of drugs and biologics. In parallel to the program for evaluating the use of RWE outlined above, FDA could work with stakeholders to identify and pursue targeted extensions of the Sentinel system that begin to pilot collection of such data. Demonstration projects could enable faster and more effective RWE development to characterize treatment utilization patterns, further refine a product’s efficacy profile, or address pressing public health concerns – all by testing strategic linkages to data elements outside of Sentinel’s safety focus.

Establish an active postmarket safety surveillance system for medical devices. Congress has already acted once to establish device surveillance, mandating in 2012 that Sentinel be expanded to include safety data on medical devices. To date, however, there has been no additional support for such surveillance or even the capability of individually tracking medical devices in-use. With the recently finalized Unique Device Identifier rule going effect and the ability to perform such tracking on the horizon, the time is now to adopt recent proposals from FDA’s National Medical Device Postmarket Surveillance System Planning Board. With Congressional authorization for FDA to establish an implementation plan and adequate appropriations, the true foundation for such a system could finally be put into place.

These next steps are practical, immediately achievable, and key to fully realizing the intended effect of other policy efforts aimed at both improving the biomedical innovation process and strengthening the move to value-based health care.

      

Overview

Increasing educational attainment is likely to reduce conflict risk, especially in countries like Pakistan that have very low levels of primary and secondary school enrollment. Education quality, relevance and content also have a role to play in mitigating violence. Education reform must therefore be a higher priority for all stakeholders interested in a more peaceful and stable Pakistan. Debate within the country about education reform should not be left only to education policymakers and experts, but ought to figure front and center in national dialogues about how to foster security. The price of ignoring Pakistan’s education challenges is simply too great in a country where half the population is under the age of 17.

There has been much debate concerning the roots of militancy in Pakistan, and multiple factors clearly come into play. One risk factor that has attracted much attention both inside Pakistan and abroad is the dismal state of the national education sector. Despite recent progress, current school attainment and literacy levels remain strikingly low, as does education spending. The Pakistani education sector, like much of the country’s public infrastructure, has been in decline over recent decades. The question of how limited access to quality education may contribute to militancy in Pakistan is more salient now than ever, given the rising national and international security implications of continued violence.

The second half of 2009 witnessed not only the Pakistani government stepping up action against insurgents but also the release of a new Pakistan National Education Policy that aspires to far-reaching and important reforms, including a commitment to increase investment in education—from 2 to 7 percent of gross domestic product. Hundreds of millions of dollars in international education aid have been newly pledged by donor countries. This renewed emphasis on education represents a substantial opportunity to seek to improve security in Pakistan and potentially also globally over the medium to long term. Policymakers both inside and outside Pakistan should give careful consideration to whether and how education investments can promote peace and stability, taking into account what we now know about the state of the education sector and the roots of militancy.

This report takes a fresh look at the connection between schools, including but not limited to Pakistan’s religious seminaries, known as “madrasas,” and the rising militancy across the country. Poor school performance across Pakistan would seem an obvious area of inquiry as a risk factor for conflict. Yet to date, the focus has been almost exclusively on madrasas and their role in the mounting violence. Outside Pakistan, relatively little attention has been given to whether and how the education sector as a whole may be fueling violence, over and above the role of the minority of militant madrasas.

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EXECUTIVE SUMMARY

In the face of unprecedented global challenges, effective global cooperation increasingly requires a partnership between state and non-state actors. Many international institutions now involve non-state actors in arenas that were once the exclusive province of states. The paper analyzes the evolution of civil society participation in the governance of international institutions and highlights the shift from a model based on consultation toward a model of multistakeholder governance. The paper argues that consultation is a less effective approach to involving civil society in achieving the mission of these institutions and suggests that more robust forms of multi-stakeholder participation by civil society can foster greater accountability and better deliberation. It analyzes competing claims about the desirability of including civil society in the governance of international institutions and suggests that an emerging constituency model can promote more effective multi-stakeholder governance. Constituency structures are already central features of several global health institutions and are now being contemplated by institutions in other sectors, including by the Education for All—Fast Track Initiative.

Multi-stakeholder approaches to governance are likely to become more widespread in the years to come in order to harness the contributions of a plethora of private actors engaged in responding to a wide range of global challenges. Even with enhanced cooperation between states, it is increasingly clear that non-state actors are essential to responding to key challenges across a wide range of sectors. Although it is possible to imagine expanded cooperation between state and non-state actors without opening up the governance structures of international institutions, it is less likely that these institutions will be successful in the longrun without a shift toward greater multi-stakeholder involvement in the institutions themselves.

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Editor’s note: In the "Becoming Brilliant" blog series, experts explore the six competencies that reflect how children learn and grow as laid out by Kathy Hirsh-Pasek and Roberta Golinkoff in their new book "Becoming Brilliant."

The world is morphing into a place that no one can foresee. How can we prepare students to live and work in that place?

Not long ago, people could learn job skills and use them indefinitely, but now jobs and skill sets are becoming obsolete at an alarming rate. This means that students, and later adults, need to expect and thrive on challenges and know how to turn failures into stepping stones to a brighter future.

When I was a beginning researcher I wanted to see how children coped with setbacks, so I gave 5th graders simple problems followed by hard problems—ones they couldn’t solve. Some hated the hard ones, some tolerated them, but, to my surprise, some relished them. One unforgettable child rubbed his hands together, smacked his lips, and declared, “I love a challenge!” Another said, “I was hoping this would be informative.” They didn’t think they were failing, they thought they were learning. Although this was years ago, they were already 21st century kids.

I knew then that I had to figure out their secret and, if possible, bottle it. With help from my graduate students, figure it out we did. And we are learning how to bottle it too. 

So, what was their secret?

Our research has shown that these children tend to have a “growth mindset.” They believe that their basic abilities, even their intelligence, can be developed through learning. That’s why they love challenges and remain confident through setbacks. Their more vulnerable counterparts, however, have more of a “fixed mindset.” They believe their basic abilities are just fixed—set in stone­. So their key goal is to look and feel smart (and never dumb). To accomplish this they often seek easy over hard tasks. And when they do encounter setbacks, they tend to feel inept and lose confidence. Research shows that even exerting effort can make them feel unintelligent. If you’re really good at something, they believe, you shouldn’t have to work at it.

These mindsets make a difference. In one study we tracked hundreds of students across the difficult transition to seventh grade, akin to entering a new world with harder work, higher standards, and a whole new structure. Those who entered with more of a growth mindset (the belief that they could develop their intelligence) fared better. Their math grades quickly jumped ahead of those of students with a fixed mindset and the gap became wider and wider over the next two years. This was true even though the two groups entered with equivalent past achievement test scores.

Recently, we were able to study all the 10th-graders in the country of Chile. We found that at every socioeconomic level students with a growth mindset were outperforming their peers with a fixed mindset. What was most striking was that when the poorest students held growth mindsets they were performing at the level of far richer students with fixed mindsets.

What’s exciting is that we have been able to teach a growth mindset to students through carefully designed workshops. In these workshops, students learn that their brain can grow new, stronger connections when they take on hard learning tasks and stick to them. They learn to avoid categorical smart-dumb thinking and instead focus on their own improvement over time. They hear from other students who have benefitted from learning a growth mindset. And they learn how to apply growth mindset thinking to their schoolwork. In these workshops students also do exercises, such as mentoring a struggling peer using what they learned about the growth mindset. Such workshops have been delivered both in person and online and have typically led to an increase in students’ motivation and achievement, particularly among students who are encountering challenges—such as difficult courses, school transitions, or negative stereotypes.

We have also studied how teachers and parents can foster a growth mindset in children. Sadly, many do not—even many of those who hold a growth mindset themselves! This is because adults, in their eagerness to motivate children and build their confidence, can tend to do things that foster a fixed mindset.

Here is what we’ve found:

• Praising children’s intelligence conveys that intelligence is fixed and promotes a fixed mindset and its vulnerabilities. Praising the children’s learning process—their strategies, hard work, and focus—and linking it to their progress conveys a growth mindset.

• Reacting to children’s failures with anxiety, false reassurances, or comfort for their lesser ability (“Don’t worry, not everyone can be good at math”) can foster a fixed mindset. Reacting with compassionate questions and plans for future learning conveys a growth mindset.

• Research shows that how math teachers react to their students when the students are stuck is critical. Teachers can help students develop growth mindsets by sitting with them, trying to understand their thinking, and then collaborating with them on how to move forward and what to try next.

But how can teachers themselves develop more of a growth mindset?

In some quarters, a growth mindset became a “requirement.” This led many educators to claim a growth mindset without really understanding what it is or how to develop it. We have suggested that educators understand, first, that a growth mindset is the belief that everyone can develop their abilities. It is not simply about being open-minded or flexible. Second, they must understand that all people have both mindsets and that many situations, such as struggles or setbacks, can trigger a fixed mindset. Finally, they must learn how their own fixed mindset is triggered so that they can work to stay in a growth mindset more often.

As we prepare students to thrive in the new world, we can influence whether they see that world as overwhelming and threatening or whether they greet it with the confident words “I love a challenge.” The latter are the ones who can make the world, whatever it’s like, a better place.  

      

Five years have passed since several Arab countries revolted against their repressive regimes, and peace and stability are nowhere in sight. The unraveling of their political systems pushed these countries into challenging transition processes where violence is always a serious possibility. Yemen and Libya’s civil wars present blunt examples of failed transitions, raising concerns about protracted political instability, not only in those two countries, but potentially in neighboring ones as well. Tunisia theoretically managed to complete its transition successfully. It ratified a new constitution, addressing the need for a new social contract, and held two rounds of elections. Tunisia also passed a transitional justice law to provide a framework for adjudicating both victims’ grievances and perpetrators’ crimes of the past political era. Nonetheless, Tunisia finds its stability challenged by increasing levels of polarization between its various societal segments.

The fact of the matter is that political transitions take a long time—years if not decades—and transitioning countries face the risk of violence. Arab Spring societies are unlikely to transition to sustainable peace and stability as long as they are wracked by deep divisions. Therefore, national reconciliation is paramount to reducing the societal polarization that currently cripples Libya and Yemen and threatens Tunisia’s progress. To attain enduring peace and stability, post-revolution states must engage in inclusive national reconciliation processes, including a national dialogue, a truth-seeking effort, the reparation of victims’ past injuries, dealing with the former regime, and institutional reform. Women, civil society, and tribes, among other social forces, can support the transition process. Yemen, Libya, and Tunisia have each taken specific approaches to trying to reconcile their post-revolution societies, raising or diminishing the chances of civil war or a healthy transition.

An inclusive national dialogue is the starting point of a comprehensive national reconciliation process. It gives transitioning societies an opportunity to develop a vision and theoretical framework for their futures, gives legitimacy to transition processes, and encourages negotiation and compromise. Tunisia held a homegrown national dialogue driven mainly by civil society organizations and Yemen completed an eight-month, U.N.-assisted national dialogue conference. Libya’s engagement in U.N.-led negotiations raised questions over whether all parties had representation.

As each society suffered decades of repression and has a number of unanswered questions, investigating—and dealing with—the truth about the past is also essential. Relatedly, determining how to handle former regime elements has profound implications for post-revolution transitions. While Libya opted to purge all those who served in Muammar Qaddafi’s regime through adopting its “Political Isolation Law,” Yemen chose to grant President Ali Abdullah Saleh immunity from prosecution in return for his abdication—sacrificing justice to preserve peace. However, Saleh later returned to politics, allying with the Houthis to take over the state, meaning Yemen ultimately achieved neither justice nor peace. Tunisia, on the other hand, has adopted a transitional justice law that mandates, among other measures, the investigation and prosecution of the state’s crimes since 1955. While the resulting Truth and Dignity Commission has received thousands of complaints from victims of past abuses, progress has otherwise been slow, as the body has struggled to establish an effective organizational structure or execute a clearly defined work plan. Controversy over the selection of commissioners and an overall lack of publicity has also hindered the truth-seeking process.

Reparations are another important part of the pursuit of justice and healing. Done correctly, they can bring previously marginalized and abused segments of society back into the mainstream, where they can make positive contributions to the development of the country. Yemen and Tunisia experienced extensive human rights violations during the decades-long reigns of Saleh and Zine El Abidine Ben Ali, while lacking the resources to engage in meaningful and comprehensive rehabilitation of victims of past abuses. This left the two countries’ transition processes struggling with a major component—the victims—feeling further marginalization added to their past traumas. Libya, however, who has the resources to fund a process of thorough rehabilitation of victims of its dictatorship, slid into civil war that prevented the proper addressing of past wounds.

Even if these societies overcome their polarization at the personal level, however, they will not accomplish successful transitions unless their healing is accompanied by institutional reforms. “Regime renovation” rather than “regime change” in Yemen presented a serious obstacle to deep reforms of state institutions, eventually leading to some segments of security units taking part in Saleh-Houthi coup against the transitional government. After the collapse of the Qaddafi regime, revolutionaries and militias demanded a purge as a method of institutional reform—similar to de-Baathification in Iraq. The purge contributed to the outbreak of a civil war. Tunisia, on the other hand, approached institutional reform from a different angle and succeeded in putting together a sound formula, but it is facing serious challenges to implementation.

Ultimately, a variety of actors have played key roles in Libya, Yemen, and Tunisia’s national reconciliation processes. In all three countries, women have been integral to bringing about change, and must continue to be involved in reshaping their countries. As agents of change, women helped to initiate the uprisings in Yemen and Libya, and have already proven to be effective agents of reconciliation. In Yemen and Libya, tribes are key stakeholders that must be incorporated after decades of manipulation and marginalization. Depending on the way they become involved, tribes could play key role in either stabilizing or destabilizing transitions. Domestic civil society groups have been essential to Tunisia’s progress so far, and are fast developing in Yemen and Libya. Their continued involvement—and assistance from international groups—will go a long way toward consolidating new states that honor human and civil rights.

The processes of national dialogue, truth seeking, reparation, accountability, and institutional reform, especially if supported by key agents of reconciliation, including women, civil society, and tribes, can combine to create the momentum needed to bridge divides and help post-Arab Spring societies move toward sustainable peace, stability, and development.

This piece was originally published on the Yale Press Blog.

For more of Ibrahim Fraihat’s analysis on Yemen, Libya, and Tunisia after the Arab Spring, read his new book “Unfinished Revolutions” (Yale University Press).  

       

       

       

       

Five years ago, my mother needed an orthopedic surgeon for a knee replacement. Unable to find any data, we went with an academic doctor that was recommended to us (she suffered surgical complications). Last month, we were again looking for an orthopedic surgeon- this time hoping that a steroid injection in her spine might allay the need for invasive back surgery. This time, thanks to a recent data dump from CMS, I was able to analyze some information about Medicare providers in her area and determine the most experienced doctor for the job.  Of 453 orthopedic surgeons in Maryland, only a handful had been paid by Medicare for the procedure more than 10 times.  The leading surgeon had done 263- as many as the next 10 combined. We figured he might be the best person to go to, and we were right- the procedure went like clockwork.

Had it been a month prior to the CMS data release, I wouldn’t have had the data at my fingertips. And I certainly wouldn’t have found the most experienced hand in less than 10 minutes.

It’s been a couple of month since the release of Medicare data by the Centers for Medicare and Medicaid (CMS) on the volume and cost of services billed by healthcare providers, and despite the whiff of scandal surrounding the highest paid providers (including the now-famous Florida ophthalmologist that received $21 million) the analyses so far have been somewhat unsurprising. This week, coinciding with the fifth Health DataPalooza, is a good time to take stock of the utility of this data, its limitations, and what the future may hold.

The millions of lines of data was exactly as advertised: charges and paid services under traditional Medicare “fee-for-service,” including the billing provider’s ID and the costs to Medicare. The initial headlines touting “Medicare Millionaires” relied on some basic arithmetic and some sorting.  And the cautions piled up: the data could reflect multiple providers billing under a single ID; payments are not the same as a provider’s actual take home income; it’s not complete information as it doesn’t contain information about other insurers, or even Medicare Advantage, and so on.

But perhaps most damning was how little insight the data seemed to provide on the quality or value of care provided, as opposed to volume of services.  As Lisa Rosenbaum wrote in the New Yorker, “So much of that good isn’t captured by these numbers. You don’t bill for talking to a patient about how he wants to die. There’s no code for providing reassurance rather than ordering a test.”

Where is the value in the data?

Data bear witness to the fundamental flaw of the payment system that generates them. The absence of information on quality, safety, appropriateness, or outcomes appears to have been a genuine revelation to many, but it is in fact exactly the type of output that we should expect from this volume-based system that we have built. This is not a critique of the data release. It is an indictment of our payment system.

Data is revealing important trends in how we pay doctors differently. Not all physician payments are created equal, and the data certainly shows the disparities across specialties, primary care, and others. For example, the average total annual Medicare payment to geriatricians was less than $100,000, while dermatologists and radiation oncologists (who presumably also see non-elderly patients) received on average $200,000 and $360,000 respectively. The important question will be why and should it continue?

Figure 1: Distribution of Total Medicare Pay by Provider Type, 2012 

Source: Author's calculations based on Medicare data released in April 2014

Data is revealing important indicators of cost and pricing – a major contributor to rising health care costs. Why is it that a brief visit with a geriatrician is worth $13; a 45-minute visit with a geriatrician sorting through medications, educating family members, and developing a quality of life plan with a terminal cancer patient is worth $79; and a dermatologist treating suspected skin cancer can earn upwards of $600 for a procedure that takes them minutes?

Data sheds light on practice patterns. The data is also revealing important variances in utilization of drugs and treatments. For example, a block apart on Park Avenue, two ophalmologists differ significantly in their use of treatments for macular degeneration. One uses expensive injectable drugs and gets paid over $10,000 per injection, while the other receives less than $500 for the lower-cost equivalent.

A CBS News report looked at spinal fusion surgeries—a procedure where there is almost no evidence demonstrating a net benefit to patients compared to other conservative therapies. They observed that “while the average spine surgeon performed them on 7 percent of patients they saw, some did so on 35 percent.”

At the extremes, outlier “practice pattern” begins to raise questions of potential improper billing or outright fraud and abuse. For example, simply looking at the frequency and volume of services provided to individual beneficiaries can identify concerning outliers. This laboratory company billed for 28,954 blood glucose reagent strips in 2012- for 88 patients. And yes, that’s highly unusual.

Figure 2: "Outlier" Medicare Billing for Blood Glucose Reagent Strips, 2012

Source: Author's calculations based on Medicare data released in April 2014

One clinical social worker billed for 1,697 separate days of service on 28 patients (the size of the bubble is proportional to the total amount of reimbursement by Medicare in 2012).

Figure 3: "Outlier" Medicare Billing for Days of Service, 2012

Source: Author's calculations based on Medicare data released in April 2014

The most extreme outlier, Dr. Gary Ordog, was named by NPR and ProPublica in their examination of providers who are outliers on their pattern of coding for the highest intensity office. Ordog had previously lost the right to bill California’s state Medicaid program, and yet continued to charge Medicare for over $500,000 in billing in 2012. It’s important to caution however, that even in these extreme outliers, statistics alone cannot provide definitive evidence of abuse. There is a need for formal investigation.

Medicare and law enforcement officials will need to create new processes for dealing with a potential flood of outlier reports from amateur sleuths like me.

What's Next for Medicare Data?

Data can be trended. Updates of data releases can begin to show us not just snapshots, but moving pictures of our healthcare system as it undergoes rapid changes. The New York Times reported on the increase in charges for certain frequent causes of hospitalization between 2011 and 2012. It will be interesting to see whether the data release itself, and the Steven Brill landmark Time article on hospital charges, have an impact on reversing these trends.  

Data can be “mashed up”.  The value of open data is hugely greater than the sum of its parts. As more and more data becomes available, the files can be cross-linked and “mashed up” to be able to answer questions no one database could have.  ProPublica linked together cobbled together data on state actions and sanctions on physicians with the Medicare data release to ask why these physicians are still being paid by Medicare.

What does the future hold? Correlations with drug prescribing data, meaningful use, and referral patterns are possible today, Sunshine Act disclosures and quality reporting, and much more is soon to come.

As we get comfortable with the data, analysts can move past the basics of arithmetic and sorting, we have an opportunity to make more ‘meaningful use’ of this data. We can begin to identify practice patterns, overuse, variations in geography or demographics, and potentially even fraud and abuse. As more and more data becomes available, the files can be cross-linked and “mashed up” to be able to answer questions no one database could have addressed. What will determine the value of the Medicare data release will be the creativity of those data scientists, epidemiologists, and health services researchers (amateur as well as professional) who can ask the challenging questions that must be answered.