Tagged: health Toggle Comment Threads | Keyboard Shortcuts

  • feedwordpress 17:53:30 on 2018/07/22 Permalink
    Tags: , , , , health, , , ,   

    The Tragedy of the Data Commons 

    Before, and after?

    A theme of my writing over the past ten or so years has been the role of data in society. I tend to frame that role anthropologically: How have we adapted to this new element in our society? What tools and social structures have we created in response to its emergence as a currency in our world? How have power structures shifted as a result?

    Increasingly, I’ve been worrying a hypothesis: Like a city built over generations without central planning or consideration for much more than fundamental capitalistic values, we’ve architected an ecosystem around data that is not only dysfunctional, it’s possibly antithetical to the core values of democratic society. Houston, it seems, we really do have a problem.

    I know, it’s been a while since I’ve written here, and most of my recent stuff has focused on Facebook. I’ve been on the road the entire summer, and preparing to move from the Bay area to NYC ( that’s another post). But before you roll your eyes in anticipation of yet another Facebook rant, no, this post is not about Facebook, despite that company’s continued inability to govern itself.

    No, this post is about the business of health insurance.

    Last week ProPublica published a story titled Health Insurers Are Vacuuming Up Details About You — And It Could Raise Your Rates.  It’s the second in an ongoing series the investigative unit is doing on the role of data in healthcare. I’ve been watching this story develop for years, and ProPublica’s piece does a nice job of framing the issue. It envisions  “a future in which everything you do — the things you buy, the food you eat, the time you spend watching TV — may help determine how much you pay for health insurance.”  Unsurprisingly, the health industry has  developed an insatiable appetite for personal data about the individuals it covers. Over the past decade or so, all of our quotidian activities (and far more) have been turned into data, and that data can and is being sold to the insurance industry:

    “The companies are tracking your race, education level, TV habits, marital status, net worth. They’re collecting what you post on social media, whether you’re behind on your bills, what you order online. Then they feed this information into complicated computer algorithms that spit out predictions about how much your health care could cost them.”

    HIPPA, the regulatory framework governing health information in the United States, only covers and protects medical data – not search histories, streaming usage, or grocery loyalty data. But if you think your search, video, and food choices aren’t related to health, well, let’s just say your insurance company begs to differ.

    Lest we dive into a rabbit hole about the corrosive combination of healthcare profit margins with personal data (ProPublica’s story does a fine job of that anyway), I want to pull back and think about what’s really going on here.

    The Tragedy of the Commons

    One of the most fundamental tensions in an open society is the potential misuse of resources held “in common” – resources to which all individuals have access. Garrett Hardin’s 1968 essay on the subject, “The Tragedy of the Commons,” explores this tension, concluding that the problem of human overpopulation has no technical solution. (A technical solution is one that does not require a shift in human values or morality (IE, a political solution), but rather can be fixed by application of science and/or engineering.) Hardin’s essay has become one of the most cited works in social science – the tragedy of the commons is a facile concept that applies to countless problems across society.

    In the essay, Hardin employs a simple example of a common grazing pasture, open to all who own livestock. The pasture, of course, can only support a finite number of cattle. But as Hardin argues, cattle owners are financially motivated to graze as many cattle as they possibly can, driving the number of grass munchers beyond the land’s capacity, ultimately destroying the commons. “Freedom in a commons brings ruin to all,” he concludes, delivering an intellectual middle finger to Smith’s “invisible hand” in the process.

    So what does this have to do with healthcare, data, and the insurance industry? Well, consider how the insurance industry prices its policies. Insurance has always been a data-driven business – it’s driven by actuarial risk assessment, a statistical method that predicts the probability of a certain event happening. Creating and refining these risk assessments lies at the heart of the insurance industry, and until recently, the amount of data informing actuarial models has been staggeringly slight. Age, location, and tobacco use are pretty much how policies are priced under Obamacare, for example. Given this paucity, one might argue that it’s utterly a *good* thing that the insurance industry is beefing up its databases. Right?

    Perhaps not. When a population is aggregated on high-level data points like age and location, we’re essentially being judged on a simple shared commons – all 18 year olds who live in Los Angeles are being treated essentially the same, regardless if one person has a lurking gene for cancer and another will live without health complications for decades. In essence, we’re sharing the load of public health in common – evening out the societal costs in the process.

    But once the system can discriminate on a multitude of data points, the commons collapses,  devolving into a system rewarding whoever has the most profitable profile. That 18-year old with flawless genes, the right zip code, an enviable inheritance, and all the right social media habits will pay next to nothing for health insurance. But the 18 year old with a mutated BRCA1 gene, a poor zip code, and a proclivity to sit around eating Pringles while playing Fortnite? That teenager is not going to be able to afford health insurance.

    Put another way, adding personalized data to the insurance commons destroys the fabric of that commons. Healthcare has been resistant to this force until recently, but we’re already seeing the same forces at work in other aspects of our previously shared public goods.

    A public good, to review, is defined as “a commodity or service that is provided without profit to all members of a society, either by the government or a private individual or organization.” A good example is public transportation. The rise of data-driven services like Uber and Lyft have been a boon for anyone who can afford these services, but the unforeseen externalities are disastrous for the public good. Ridership, and therefore revenue, falls for public transportation systems, which fall into a spiral of neglect and decay. Our public streets become clogged with circling rideshare drivers, roadway maintenance costs skyrocket, and – perhaps most perniciously – we become a society of individuals who forget how to interact with each other in public spaces like buses, subways, and trolley cars.

    Once you start to think about public goods in this way, you start to see the data-driven erosion of the public good everywhere. Our public square, where we debate political and social issues, has become 2.2 billion data-driven Truman Shows, to paraphrase social media critic Roger McNamee. Retail outlets, where we once interacted with our fellow citizens, are now inhabited by armies of Taskrabbits and Instacarters. Public education is hollowed out by data-driven personalized learning startups like Alt School, Khan Academy, or, let’s face it, YouTube how to videos.

    We’re facing a crisis of the commons – of the public spaces we once held as fundamental to the functioning of our democratic society. And we have data-driven capitalism to blame for it.

    Now, before you conclude that Battelle has become a neo-luddite, know that I remain a massive fan of data-driven business. However, if we fail to re-architect the core framework of how data flows through society – if we continue to favor the rights of corporations to determine how value flows to individuals absent the balancing weight of the public commons – we’re heading down a path of social ruin. ProPublica’s warning on health insurance is proof that the problem is not limited to Facebook alone. It is a problem across our entire society. It’s time we woke up to it.

    So what do we do about it? That’ll be the focus of a lot of my writing going forward.  As Hardin writes presciently in his original article, “It is when the hidden decisions are made explicit that the arguments begin. The problem for the years ahead is to work out an acceptable theory of weighting.” In the case of data-driven decisioning, we can no longer outsource that work to private corporations with lofty sounding mission statements, whether they be in healthcare, insurance, social media, ride sharing, or e-commerce.

     

     

     
  • feedwordpress 14:40:09 on 2017/04/03 Permalink
    Tags: , health, , ,   

    Bad Policy Makes Us Sick. Business Must Lead Us Back. 

    The post Bad Policy Makes Us Sick. Business Must Lead Us Back. appeared first on John Battelle's Search Blog.

    WALL-E-382

    (Cross posted from NewCo Shift)

    Walking around Disneyland with my daughter the other night, I found myself face to face with one of our country’s most intractable taboos.

    (Disneyland is still awesome for me, as a kid from 1970s LA. Truly magical.)

    If you’re an observer of crowds, one of the more prominent features of the Disneyland crowd is how generally overweight our country has become (I live in the Bay area, and readily admit my interaction with folks on most days is not representative of a broad cross section of our population). I’d estimate at least a third of the folks at Disney are seeing Mike and Molly-level images in the mirror — and about 2–3% or so have more weight than they can carry around, and have therefore graduated to “mobility scooters.”

    These industrial strength scooters have become commonplace at the Happiest Place on Earth. I’m guessing from the name that they were initially created for disabled and elderly folks, but clearly they’ve been reinforced for more rigorous duty. For every one of them we saw piloted by a fellow with a knee brace or an elderly grandmother, there were ten requisitioned for moving Big People around.

    For a spell, I sat on a bench with my daughter and watched them wheel by.

    I fell into reverie, thinking about how our policy choices have led to a predictable and avoidable epidemic, and how that epidemic mirrors many others in what is increasingly feeling like a gravely ill society. Our maddening melange of libertarian individualism, technological (and medical) savior-ism, American exceptionalism, and steroidal capitalism has delivered us a health care horror show — one with an endless appetite for cheap food, expensive medicine, and hollow self-delusion.

    It strikes me nowhere can we identify how badly we need a new compact between business and society than right here on Disney’s Main Street USA. Libertarians and fanatical anti-regulation types love to claim that individual responsibility is paramount, and I suppose that means the growing percentage of obese people in our society are all at fault, and deserve the shame our culture heaps upon them. I tend to believe otherwise, that outcomes are driven by inputs, and right now, the inputs in our society are making us very, very sick.

    Can we face up to this fact without dehumanizing or victimizing the people who now comprise more than a third of the US population? Is talking out loud about this issue even allowed? (I think I’m about to find out…)

    It certainly feels taboo, because these are real human beings we’re talking about, and our society relentlessly shames overweight people as lacking will power and failing to conform to ideal body images projected in popular culture.

    But come on, America’s obesity epidemic has been building for decades, and it’s only getting worse. When will we call it what it really is: A public health crisis, driven by outdated and dangerous policies around food subsidies and health care?

    First and foremost amongst those failed policies is our society’s approach to food — how we grow it, how we market it, and certainly how we eat it. In short, we subsidize cheap calories — in particular sugar and corn syrup — and we’ve forsworn nutrition for convenience. Food companies, driven as all businesses are by profit and policy inputs, are literally rewarded for selling as much of their product to us as they can, regardless of the consequences. It feels an awful lot like our approach to energy — just as we’re hooked on cheap and environmentally damaging carbon-based fuels, we’ve built an entire economy on cheap and physically destructive food, and there are extraordinarily powerful forces at work insuring things stay that way.

    (I should note that I actually do not lay blame at the feet of these forces — I believe they exist because we’ve created a system that requires them to act the way they do. The only way to change that is to change the rules of the system, not to reactively punish large corporations for doing what our society incentivizes them to do.)

    Adding to the policy failure is our society’s approach to health care. Everyone seems to agree it’s a mess, but we have to think systemically if we’re going to fix it. Believe what you will about Obamacare, but they got one thing absolutely right: The new program instituted a historic shift from a reactive to a proactive stance. How? Through the economic lever of how payments were processed. The old government healthcare (and let’s not fool ourselves, the government is the single largest force in healthcare, period) paid set fees for service. This created a moral hazard in the market, as actors organized themselves around creating as many payment opportunities as possible. Need a knee replacement because you’re overweight? Check, there’s a fee for service. Knee replacement didn’t work, because you’re overweight and/or didn’t have proper follow up by your doctor? Check, we’ll do another one. Broke your hip because the second knee buckled? Check, there’s a third service to get paid for.

    Obamacare is in the process of shifting government payments away from fee-for-service and toward outcomes — doctors and hospitals are paid a certain amount for a positive health outcome, and that’s that. No more triple knee surgeries — you get paid when the patient’s surgery is proven to have worked. There’s a set amount for that outcome, and that’s it. This kind of economic incentive drives markets to optimize for proactive health care — the kind that creates early detection of potential obesity, supplying nutrition education so the knee replacement is never needed in the first place.

    It’s exactly this kind of thoughtful, informed policy we need right now if we’re going to solve our country’s obesity epidemic. And given the current administration, it’s highly unlikely we’ll see much of it coming out of Washington over the next four years. That means one thing: our country’s largest food and health care companies must get in front of this crisis, andlead. Whether or not they do, it’s abundantly clear is that our current crop of politicians will not. Meanwhile, our society is getting sicker, poorer, and more alienated. That’s not a recipe that’s good for anyone.

    The post Bad Policy Makes Us Sick. Business Must Lead Us Back. appeared first on John Battelle's Search Blog.

     
c
compose new post
j
next post/next comment
k
previous post/previous comment
r
reply
e
edit
o
show/hide comments
t
go to top
l
go to login
h
show/hide help
esc
cancel