Thursday, April 28, 2011

Standardized testing isn't the answer, but...

The conundrum becomes, how do we ensure that teachers are doing something? Standardized testing scales well. It allows you to create quantitative measures for an enormous number of students and their teachers quickly and at relatively low cost. The time investment is reasonable. It's where the light is good*... that's why we keep looking at it.

But it's not where we're losing our keys, so we need to look there, even though it's harder. But, what do we do? Increase the administration load, when it's already crushing our schools in some cases, so that teachers can have better supervision? And then what do we do about the inherently subjective nature of such evaluations? What if the teacher and supervisor get along well, because they're the same gender and race, live in the same neighborhood, and have kids the same age? Can we trust that they will see the teacher's work objectively, without coloring it more rosily due to their affinity with that teacher?

Ultimately, I think we need to involve a LOT more voices in the process. Students and their families should be submitting teacher evaluations each semester, just as colleges collect professorial evaluations. Teachers should do peer evaluations, possibly trading with other schools. And it should be done in a cooperative, not adversarial, manner... teachers who are having problems should be offered training, support, etc. to identify the causes of those problems and address them, so that they don't have huge incentive to try to cover their tracks.

But all that is a lot of work, real work. People have to read comments, correlate information, control for various factors. We do need to look at whether a black teacher in a predominantly white district (or a white teacher in a predominantly black district, or an Asian teacher in a predominantly Latino district, or whatever) is consistently receiving lower scores, but without "backup," i.e. no one seems to be able to describe the problem... so maybe the only problem is implicit bias.

I don't think we can give up standardized testing completely. I think it's part of the equation. But people usually are teachers for long careers... and we have the technology to track outcomes for their students over a longer time horizon. If you've been a Kindergarten teacher for 12 years, and it turns out that 70% of your students are going on to college in a district where the typical rate is 40%, you can actually find out if there's a statistically significant correlation there and if maybe you're doing something right. You don't have to wait for college, though... you can look at how students are doing in terms of discipline, grade level of achievement, awards and recognition, and so on starting from the year after they leave you. I think that, with the right approach to data-mining, we could really illuminate some success stories -- and failures -- in our educational system.

Ultimately, though, when you observe that failure is more common than success across a school, you must look higher than the teachers. To have keep good employees, you need good management. Administration needs to be held accountable for their performance in a major way. Heck, if the front office staff is rude and lazy, it will impact performance negatively, because parents will feel disconnected, teachers will have trouble getting the resources they need, etc.

Every time the organization I work for submits a large grant proposal, we have to provide (several things, but among them) our 990 tax form and an evaluation plan. The 990 tells people what our overhead ratio is... how much are we spending on management and support staff like finance and human resources compared to how much we're spending providing direct services? And, how will we be able to tell if what we're doing works? Could we hold schools to that standard? What do you suppose the overhead ratio is for your school?

* For those who aren't familiar with the joke...
A police officer happens upon a drunk, searching for something on the sidewalk and in the gutter under a streetlight. He asks the guy if he needs help.
"Yeah, I lost my keys! Can't find them anywhere!"
The cop helps the guy search for a few minutes, but finds nothing. He asks, "Are you sure you dropped them here?"
"Aw, nah, I dropped them about 20 yards down that way."
"But... why are you looking here?" the cop asked.
"The light's better!"

Sunday, April 10, 2011

Health Care is a Market Failure, Part I: Shopping for a Doctor

I call this "Part I" because I'm sure I'll return to the topic. There are a LOT of ways in which health care is a market failure.

First of all, background:
  • A "market failure" is a good or service that cannot be efficiently distributed by a free market. These items usually have to be regulated heavily in order to be distributed in an efficient manner.
  • Adam Smith postulated a free market that could be completely regulated by the "Invisible Hand" as having three characteristics: Perfect Information, Perfect Competition, and Perfect Mobility. None of these is possible... but market regulation is generally about compensating for particular shortcomings in one of those categories.
So now the question: how do you shop for a doctor? Maybe we can start by looking at how you shop for other things...

If you want to know what brand of jeans to buy, you go to some stores, look for the size, cut, and color you're interested in, and try them on. Then you buy the ones that have the best combination of comfort and looking good (or at least not bad) on you.

If you want to figure out which TV to buy, you look at the features and specifications of each model, read reviews online, and go to a store to look at them. You don't know until you get it home how it's going to really look in your house, but you can usually choose something satisfactory by looking at the available information.

If you are trying to figure out which multivitamin works for you, you look at what quantities of each nutrient it has, what the fillers are, and so forth, then you buy a small bottle to try out. If you buy it at the right store, you can return it if it upsets your stomach or you have trouble swallowing it or something.

So what's the problem with doctor-shopping? First of all, there's practically NO information available about how a particular doctor practices. My health insurer lists for me where the doctor graduated, what year, and what hospitals they're affiliated with. These factors may influence my decision, but what I really care about is: will this doctor respect my observations and experience? Does s/he keep up with the latest research? Is his/her philosophy of care more focused on preventive, natural health, or on pharmaceutical or surgical interventions? If I come in with a complaint, how will the doctor proceed after ruling out the obvious and most dangerous stuff?

I'm very fortunate that, with my health care, I can basically make an appointment with any in-network doctor, pay the co-pay, and see them. I don't have to have a primary care physician or stay in a particular group. But this is still unsatisfactory: I go through a HUGE amount of paperwork and effort to go to an appointment that is intended as a doctor's visit, when all I want is to find out whether I like this doctor.

It's obvious why doctors don't schedule prospective patient interviews: there's no ICD9 code for them. They can't bill insurance for them, so they won't get paid. Few patients are willing to spend several hundred dollars out-of-pocket interviewing a handful of doctors. There's no trial size or satisfaction guarantee, much less the ability to try one on. And perhaps most important, we have absolutely no conception of how price compares between doctors. They're all going to charge "reasonable and customary" rates, because that's what they can get, no matter who the patient is.

What this means is, doctors do not have to compete with each other for patients. People pick a doctor based on whether they are in-network and convenient, and may switch from a doctor that has atrocious front-office staff or ridiculous wait times for appointments, but in general, we don't shop for a doctor we like. Instead, we put up with a doctor we're not deeply unsatisfied with.

Without competition, doctors have no incentive to differentiate their service, or even improve it. They will keep up their continuing education to the bare minimum to maintain licensure, they will schedule their patients as tightly together as they can without causing a riot, and they will give up on figuring out what's wrong after they've determined that you're not likely to die. They won't charge more for better service, or charge less for no-frills service, so everyone gets about the same mediocre attitude from the front office. They won't figure out how to reduce the paperwork burden on their patients. They won't invest in technology unless it improves their bottom line, because they're not in the habit of advertising that they have an EHR or that you can get lab results via email.

Now, yes, there are doctors who are different. They truly care about their patients and strive to create a healthy environment in their offices. They create brochures and websites to educate prospective patients about their services. They are rare, and they also often don't take insurance... because enough people know of them and love them that they don't have to, and because they simply can't take as many patients and keep up quality, so there has to be a throttle somewhere. (This also dramatically reduces their overhead, because they don't have to hire a bevy of medical billers to keep up with all the different insurance companies' claim forms and procedures... they just send you, the patient, an invoice.)

As much as I want single-payer health care, that model doesn't really address this particular problem. It may help a bit, by dramatically simplifying medical billing infrastructure (maybe we could finally get on ICD10!), but it won't change the competition. In fact, it may worsen the situation... one of the reasons why doctors don't bother promoting their services is because everyone needs a doctor, and there really aren't enough of them. As medical students continue to choose residencies in specialties over the primary care disciplines, this is becoming a bigger choke point, and single-payer health care would increase the market for primary care without increasing the pool of doctors.

I don't have a pat solution for this one. Require doctors to schedule five-minute interviews with prospective patients? Create a standard questionnaire for all doctors to fill out, so their answers can be posted somewhere? Clearly, part of the solution is that we need more primary care doctors, and the methods to make that happen are still fairly muddy (money is a big factor). Still, this is one compelling example of why the current health care system cannot efficiently distribute services, and needs overhaul.