Data, Methods &
Measurement:
Commentary
Vincent Mor, Ph.D.
Public Health Program
Common Issues
 All authors call for more and more detailed data
 What health care workers DO; not just a count
 What is an error and how is it avoidable
 Understanding insurance affordability to understand
health insurance choices and preferences
 All call for more detailed data on physicians, hospitals
and health care consumers.
 But, labor market variation, differences in medical
culture and practice as well as local insurance market
variation mean universal data is needed
 Conflict between detailed data on a sample and limited
data on the population
Health Care Workforce
 Authors make a good point that “head counts”
are not enough and that counting specialists is
not enough; we need to know what providers do
 Volatility of workforce supply estimates seen
most clearly in nursing; after years, no longer a
shortage in this economic downturn. Now that
over 50% of physicians are women and
employed, will labor supply fluctuate?
Implications of workforce planning efforts?
Health Care Workforce (cont)
 While counting may be insufficient, using claims
does offer a picture of new developments
 Recent NEJM paper documented rise of hospitalists
and regional variation
 Recent JAMA paper examined “continuity” of inpatient
and outpatient physician care
 Advantage of aggregating all provider behavior
from UPINs via claims, given large labor market
variation; BUT, requires universal linked claims
 Need to explore ways to cross-walk universal claims
data with more detailed data collected on a sample
of providers.
The Science of Health Care
Delivery
 Important to identify “preventable” harm; one
reason its been so difficult to develop rigorous
measures to evaluate and compare providers’
safety profiles
 To differentiate type of harm, to adjust for
preventability or to link processes to outcomes
requires detailed data on treatment events, the
people treated and the outcomes experienced
 All complicated by heterogeneity of providers
and “patient sharing” that complicates
attribution
Health Care Delivery (cont)
 Regional variation in practices also alters the
denominator and context
 Re-hospitalization of post-acute SNF Medicare pts
varies from 10% in 30 days to over 30% by state;
correlates with overall Medicare spending ; errors
during hospitalizations will be more prevalent
 Hospital Adverse drug reactions rise with hours
post admission, even controlling for admit time
 Very meaning of “avoidable errors” can change as
a function of Managed Care interventions to
discharge patients post-surgery
 Finally, process to outcome relations not
simple
The Uninsured
 Identify 3 key issues we need to understand
better to develop better policy
 Why are folks not insured
 The implications of being uninsured
 Defining underinsurance
 All need better and more complete survey
data with panels able to address changing
insurance patterns with changing personal
employment and health situations
The Uninsured (cont)
 Propose a longitudinal panel frequent enough to
capture the many subtle changes in coverage,
income and competing household choices
enriched with data on available choices
 States’ policy differences, local market
conditions, provider competition and volatility of
the insurance market means planning such a
comprehensive effort on a sample will miss a lot
 Might consider a transparent insurance choice
market like Part D BUT this implies universal
insurance mandate to get information on all
people
Summary
 Papers on very different policy issues clearly identify
the data needs and challenges
 In each case, the tension between information depth
and universal information can be seen BUT labor,
insurance and provider markets are so different
 Not possible to have all data on all events of interest to
all researchers need models of integrating claims and
“research” data
 Use Claims as a sampling frame (MCBS, NHATS, etc.)
 Predict behavior of population based upon research data
 Research data may only be a hueristic
 Big Challenge to integrate these kinds of research