At a legislative conference in Cambridge, Ohio, Bruce Katz stressed the importance of cities and metro areas to the state's overall prosperity. Acknowledging the decline of Ohio's older industrial cities, Katz noted the area's many assets and argued for a focus on innovation, human capital, infrastructure, and quality communities as means to revitalize the region. 

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At a legislative conference in Cambridge, Ohio, Bruce Katz stressed the importance of cities and metro areas to the state's overall prosperity. Acknowledging the decline of Ohio's older industrial cities, Katz noted the area's many assets and argued for a focus on innovation, human capital, infrastructure, and quality communities as means to revitalize the region. 

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Editors’ Note: Terrorist groups don’t emerge out of nowhere, and wars are perhaps the richest soil for seeding and growing violent groups of all stripes, writes Dan Byman. This post originally appeared in the Washington Post.

Study after study has found no common profile of a terrorist. It is hard to explain why, say, almost four times as many recruits leave Sweden to fight with the Islamic State as from neighboring Norway, though Sweden’s population is only twice Norway’s. Pundits and politicians alike speculate on why individuals might embrace terrorism, but such a question risks missing one obvious point: Having a terrorist group around in the first place is one of the most important factors in influencing an individual’s choice to join.

Terrorist groups don’t emerge out of nowhere, and wars are perhaps the richest soil for seeding and growing violent groups of all stripes. Without the wars in the Middle East there would be no Islamic State, and it is not the only one: al-Qaida, Hezbollah, and other extremist groups all emerged out of regional civil wars. The formation of such groups is a political phenomenon, and so, too, is the radicalization of foreign fighters from the West.

Terrorist groups are rarely the cause of civil wars. Iraq’s civil war began in 2003 after the U.S. invasion and occupation; Syria’s civil war began with peaceful protests against a brutal dictator in 2011; and Libya’s strife came after a terrorist-supporting dictator was toppled in the same year.

Rather, such wars beget and foster terrorism in several ways. Terror itself is often a tool in war, used to sow an atmosphere of fear and undermine governments. Assassinations of rival political leaders, bombs for police and military recruits and random violence against civilians—these are all methods learned from Insurgency 101.

Groups such as al-Qaida and now the Islamic State exploit new wars wherever they can. Terrorist groups linked to civil wars seek supporters in the United States, Europe, and other areas outside the theater for reasons both obvious and obscure—and these factors generate more terrorists. This pull is especially strong when identities cross borders—as does a religious identity like Islam—and when local ties are weak or the community as a whole is poorly integrated, as the Muslim community is in many European countries.

Foreigners might join these groups for altruistic reasons, to help the genuinely oppressed (the Syrian people facing Bashar al-Assad, or the Afghans facing the Soviets). Yet often the oppression is a myth, or at least greatly exaggerated: One powerful narrative of the Islamic State is that Sunni Muslims are facing a global Shiite conspiracy led by Iran and Hezbollah.

Still others join because they are true believers and want to live the dream. In different ways, the war takes them out of their humdrum or depressing present, giving them a new life: “I’m the most content I have ever been in my life,” tweeted one young American woman who had gone to live in the Islamic State, ending the tweet with a heart emoji. Many are merely thugs who spent time in jail or otherwise led delinquent lives: Joining the Islamic State or a similar group gives them a license to kill and torture.

Because there is no single profile, terrorist groups such as the Islamic State seek to appeal to many different ones. Propaganda stresses the good life in the caliphate, the glory of fighting for God, the oppression the community is facing, and glorified ultra-violence. Religion matters, but only as a badge of meaning and belonging rather than for its specific ideological content. By professing religious beliefs, a young Muslim male can go from marginalized and alienated in his home country to part of God’s army, defending his people with his own sex slaves to boot. Yet one study of the European foreign fighters found that most were theologically illiterate. Omar Mateen, the Orlando shooter, may not have understood the difference between the theologies espoused by the Islamic State, al-Qaida and Hezbollah.

As long as these wars rage, the problems they generate will not stay confined to the Middle East. Only a fraction of a fraction end up fighting, and even fewer engage in terrorism, but only a small number need to respond for the problem to be serious.

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.

Editors’ Note: In a recent interview with Foreign Policy Interrupted, Tamara Wittes was asked about how the situation in the Middle East has changed since she published her 2008 book Freedom’s Unsteady March. Five years after the Arab uprisings and the start of the Syrian civil war, and a year and a half after the Islamic State captured Mosul (along with the world’s attention), Tamara says that many of the same fundamental dynamics in the Middle East are still at work.

The situation in the region has changed so dramatically since then, but I think that the fundamental insights that informed that book remain true. The underlying drivers of change in the Middle East are still there in terms of the demographic drivers, the economic drivers, the technological drivers that I described in the book; they are all still present.

Although there’s a lot of disorder and a lot of violence, and that leads people on the ground to prioritize security and to search for security in different ways, that doesn’t mean that they’re going to be satisfied. It doesn’t mean that the, “well, at least it’s not ISIS” line is going to suffice for governments in the Middle East for very long.

The underlying drivers of change are still present, the pressure for change is still present, and a lot of those pressures are about the simple fact of individual empowerment. Expectations shifted, and people, individuals, have the ability to act in ways that they didn’t before. States and governments have to accommodate that. It’s affecting politics all over the world, and the Middle East is not immune.

So the question becomes: how are governments going to learn to accommodate that and turn it into a strength? I think that the United States does have a really important role to play there. There were mistakes that the Bush administration made—setting aside his vision of Iraq, which has of course been very thoroughly discussed and assessed. But even in terms of non-military intervention to try to advance reform, the critique I made in the book is that the Bush administration was overly focused on political process and elections in particular. I think that one of the other lessons that has come of recent years is that the United States and other Western countries get very focused on political institutions and think, well, if we set up a judicial system, and we set up a parliament, and a constitution, then the gears in the machine sort of start to turn, the states start to function. Look at the rebuilding efforts in Afghanistan, for example.

But what we see in the Middle East today is that formal institutions aren’t enough. People have to have trust in the institutions, and people and communities have to have sufficient agreement on the basic rules of the game to make those institutions legitimate and authoritative. And that’s what’s missing in a lot of places around the region right now, that there isn’t enough dialogue and debate and ultimately negotiated agreement on the basic rules of the game. So I think that the challenge for the United States and others who care about stability in the Middle East going forward is how to help cultivate platforms for that kind of dialogue, and how to help cultivate the skills and the mechanisms for resolving very fundamental questions about how government should be organized and what should be the role of religion and politics, and what’s the balance between individual rights and collective identity.

These are big, big, questions, and right now, in too many places, they are being fought over violently. But the questions still have to be answered, and so the challenge is helping develop ways to do that, to do it peacefully.