Where perfection is the only acceptable goal.

by Nate Silver


This book on its face has little if anything to do with healthcare generally or Elder Care specifically.  BUT, there are a number of theories Mr. Silver posits, facts he espouses, conclusions he reaches and predictions and forecasts he makes that with just a little thought have MUCH to do with both.  Here are a few of my applicable takeaways for helping to improve the way we look at and use to improve healthcare for all Americans—young, old…rich, poor…liberal or conservative...native born or immigrant.  Here goes, with 4OurElders comments in bold:

1.)     “The signal is the truth (‘an indication of the underlying truth behind a statistical or predictive problem’.)”  “The noise is what distracts us from the truth (‘random patterns that might easily be mistaken for signals.’)”  This is a book about the signal and the noise and how to spot each in the Big Data era. The Big Data era we are in and which only continues to expand dramatically if not exponentially holds both promise and pitfalls.  “Before we demand more of our data, we need to demand more of ourselves….Big data will produce progress—eventually.  How quickly it does, and whether we regress in the meantime, will depend on US (emphasis added.)”   “[P]artisan beliefs can upset the equation in which more information will bring us closer to the truth…Meanwhile, if the quantity of information is increasing by 2.5 quintillion bytes per day, the amount of useful (emphasis in theoriginal) information almost certainly isn’t. Most of it is just noise, and the noise is increasing faster than the signal.”  Silver concludes that the problem is too much information hides the signals that are now that would really lead us to the truth that is there but hidden by all the noise.  The key for Silver is in wading through the massive amounts of “information” and finding the signals and putting them together to reach conclusions and find solutions to looming problems. There is no other area of critically important inquiry in which there is so much noise and so few detectable signals than in elder care specifically and health care generally.  There are literally tens of millions of pages on the internet about healthcare—most of it is outdated, irrelevant and often misleading and dangerous to consumers (patients and their families and loved ones.)   Author Malcolm Gladwell wrote a New Yorker magazine article (later included as a chapter in his book What the Dog Saw) entitled Open Secrets: Enron, Intelligence, and the Perils of Too Much Information. In that piece, Gladwell cites national security expert Gregory Treverton’s distinction between a puzzle and a mystery in the context of the hunt for Osama bin Laden (a puzzle) and the problem of Iraq once Saddam Hussein was toppled (a mystery.) For Treverton, a puzzle is when you do NOT have ENOUGH information so that to solve the puzzle you first may need MORE information; a mystery is when you have TOO MUCH information and what is needed is NOT MORE information but better analysis of the parts of the information in which the solution is buried—in Silver’s language, you need to separate the noise from the signal. Simply stated, we need far less information—but the information we do get needs to be far better; we need information that measures the right things in order to make healthcare providers more transparent and more accountable (see my Key Takeaways from Doctor Makary’s book Unaccountable, previously reviewed and still available on this website.)  The ONLY way we can make health care better and less expensive for us all is to make the need for less bad healthcare information (noise) and more good healthcare information (signals of truth) a reality asap—for all our sakes.

2.)     “[Humans] can never make perfectly objective predictions.  They will always be tainted by our subjective points of view….[A] belief in the objective truth—and a commitment to pursuing it—is the first prerequisite of making better predictions….The forecasters next commitment is to realize she perceives it imperfectly….[Therefore], we must think more carefully about the assumptions and beliefs that we bring to a problem.” 4OurElders is seeking the truth that will make healthcare better for us all. The truth, we believe, is drowned out by the reams of noise.  The data that contain the REAL information we all need, in too many instants is unbelievably and sadly NOT even collected by the providers.  In other instants, the data are collected but not tracked or measured by regulators or survey or rating agencies. In yet other instants it is collected, tracked and measured but remains unpublished and, therefore, the data remain unavailable to consumers. Each of these scenarios is a tragedy for healthcare consumers. We must reverse this status quo, which has led to worse, more expensive healthcare on average for most Americans.  We CAN do better and pushing the critical agenda 1) for reduction in if not elimination of the noise of useless information that is collected and published every day by perhaps well-meaning but misguided professionals, 2) sharpening the focus on collecting, tracking and measuring the data that contain the signals from which we will find the objective truth, which will allow us to better forecast healthcare outcomes for all of our sakes, is exactly what 4OurElders is all about. Healthcare remains BOTH a puzzle—where we need more (better) information and [elimination of the bad information]—and a mystery, where we need to eliminate bad data AND better analyze and synthesize the good information that already exists. Unless and until this is accomplished over time, healthcare in this country will continue to erode for most Americans despite all of the efforts of lawyers, providers, insurers, plaintiffs, regulators, politicians, surveyors and rating agencies.  This is the working hypothesis of 4OurElders, based on sorry results to-date over the last several decades, during which time healthcare overall has worsened in terms of results and costs.  We have set out to validate/invalidate/adjust our hypothesis and to build a consensus of how to avert the looming healthcare threat to our national integrity by eliminating the partisanship and noise and finding [and putting together in terms of a solution] the signals that are already present and that can become available by different data collection, measurement procedures and techniques, and publication requirements.

3.)     “I am convinced…that the best way to view [America’s  decade long financial crisis we are still in] is as a failure of judgment….We tend to focus on those signals that tell a story about the world as we would like it to be, not how it really is. We ignore the risks that are hardest to measure, even when they pose the greatest threats to our well-being.  In a paper, written by George Akerlof , cited by Mr. Silver and entitled The Market for Lemons, Mr. Akerlof  posited that “in a market plagued by asymmetries of information, the quality of goods [and services] will decrease and the market will come to be dominated by crooked sellers and gullible or desperate buyers.” Akerlof went on to tell Mr. Silver that “in a market [where] someone is trying to sell you something you don’t understand…you should think they are selling you a lemon.”  Wow!!!  While we would be the last group to call healthcare providers at any level “crooked,” we do believe that the information imbalance between healthcare providers and healthcare consumers does

 1) reduce the incentive for these providers to better their product/service and 2) result in people, who desperately need healthcare but lack the key information they need to make critical decisions/choices between competing providers, being accurately described as “gullible” or naïve and even uninformed. Given these circumstances, 4OurElders encourages ALL healthcare consumers, for their own health and safety, to follow Mr. Akerlof’s advice and initially assume the service being offered is a lemon and seek to rectify the information imbalance.  Part of our website is designed to help the elder care consumer to do just that—and, but for some of your time, IT’S FREE!

4.)    “A case where a prediction can bring about itself about is called a self-fulfilling prediction or a self-fulfilling prophecy.  This can happen with the release of a political poll….Voters in these cases may behave [in a way that fulfills the poll’s predictions], wanting to back a candidate who potentially wins the state rather than waste their vote, and the …poll is often the best indication of [a well qualified candidate]….Diseases and other medical conditions can also have this self-fulfilling property.  When medical conditions are widely discussed in the media, people are more likely to [seek medical help] and doctors are more likely to …diagnose them.”  4OurElders seriously hopes and expects that its prediction that healthcare will continue to erode absent a change in its culture among its various “community actors”—institutional providers (Hospitals, LTC facilities, Clinics, Rehab facilities, etc.), individual providers (docs, nurses, aids, mid-level providers like Nurse Practitioners and PAs, etc.), insurers, lawyers (both Plaintiff and Defense) and the courts, patients and their families, and regulators and legislators will cause a fuller recognition of “what is in it for us” and spur concerted action by all of the actors in the coming years to gain consensus on transparency and accountability  solutions that will reverse the deteriorating healthcare trend --for all our sakes!

5.)     Past performance is Not Indicative of Future Results.” All current measurements of the state of care and service in the healthcare sector, once made and released, are based on PAST performance, both good and bad.  Even if those doing the measuring  1) are measuring the right things,  2) are relatively unbiased,  AND  3) actually recognize and account/compensate for their inevitable biases that are always present as Silver observes--(and unfortunately we have found having even one of these 3 prerequisites is RARE if not unheard of) the data are always looking backwards—they are not measuring anything going on today.  Rather they are measuring yesterday and inferring there from tomorrow’s results—which, as Silver also observes above, is WRONG.  While 4OurElders believes its model is workable across the healthcare spectrum, we are sure it works in elder care because the concept has already been proved.  Real-time, current measurements and forecasts based on our proprietary tools and techniques for PEOPLE actually giving care at the time residency is to begin is exactly what we do, what we believe holds the key to improved elder care and what  separates us from what ANYONE else is doing or can do. And we strongly believe, based on our own experience, our procedures, tools, techniques, evaluation formulas and our people are able to provide our clients with the BEST predictors of the best possible experience and outcome a LTC resident and their family will have after choosing a home in the elder care setting based on our work.

6.)     “When a possibility is unfamiliar to us, we do not even think about it.” (Emphasis in original)Most consumers have no idea about what they need to know, or if they do know what they need to know they do not know how (or even whether) they can get it before signing up for care with a provider of healthcare at any level.  Having all the information you need to make the best informed choice is simply not the way “our father’s healthcare system” has functioned in the past.  It can and should be different going forward and 4OurElders’ goal, working with others out there with a similar goal, is to educate the consuming public about what they can and should know before choosing elder care housing. We then hope the model can expand to other parts of America’s healthcare system—for all our sakes.

7.)     Statistics are fine and can be very helpful—with judgment.  “The word objective is sometimes taken to be synonymous with qualitative, but it isn’t. Instead it means seeing beyond our personal biases and prejudices and toward the truth of a problem….Pure objectivity is desirable but unattainable in this world. [Some] forecasts…might rely on quantitative variables…while [others]… may consider qualitative factors as well. All of them, however, introduce decisions and assumptions that have to be made by the forecaster. Wherever there is human judgment there is the potential for bias. The way to become more objective is to recognize the influence of our assumptions play in our forecasts and to question ourselves about them….You will need to update your forecast[s] as facts and circumstances change. You will need to recognize that there is wisdom in seeing the world from a different viewpoint. The more you are willing to do these things, the more capable you will be of evaluating a wide variety of information without abusing it.” “Most…rely on their judgment to some degree when they make a forecast, rather than just take the output of a statistical model as it is.”  As part of its analysis of the level of care and service provided by the providers it evaluates, 4OurElders relies on some but not all statistics others compile as part of their work, but we go much further in our process because 1) there is too much noise and not enough signals of truth in so much of  available healthcare statistics and 2) our goal is very different than those creating and measuring the statistics. We have one real focus—the level of care and service in a given institution.  That is our only “bias” and we thing it is a good one.  We work hard to ferret out and eliminate any other bias about an organization, its history or the way it deals with us in our evaluation process.  And we provide the opportunity for feedback and we constantly re-evaluate our forecasts of care and service based on changes in the institution, from changes in ownership or management all the way to the 3rd shift CNA caregiver or her supervisor.  We understand that care and service is a moving target and we always try to see the world from the perspective of both the providers—institutional; and individual-- and the consumers of their services.

Fort Pierce, Florida



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