Why Actuaries Need “Street View”

I remember playing with Google Maps for the first time. It was startling to get a zoomed-out view of your neighbourhood, your city, your country. In business-school speak this is the view from 30 000 feet. And this is the view that being an actuary affords you. We have the ability to look at the patterns formed by data, to join the dots in unexpected ways, to rise above the detail. Working in healthcare this means thinking about questions like how to allocate resources across provinces, or figuring out ways of measuring healthcare quality, or using statistical methods to benchmark healthcare providers.

I recently had the privilege of attending a workshop on maternal health at Stellenbosch University. The workshop was a gathering of academics, policymakers and NGOs. The day was an emotional roller coaster that left me deeply affected. There were many statistics that shocked me: the high proportion of maternal deaths that are preventable[1], the low proportion of mothers who have access to an ultrasound during pregnancy, the low proportion of pregnant mothers who indicate that their pregnancy was planned. But more affecting than the statistics were the personal stories. And the very real impact that people on the ground are able to have[2].

Dr Yogan Pillay, DDG in the National Department of Health responsible for HIV/AIDS, TB and Maternal, Child and Women’s Health was one of the speakers. He talked about was the difference between the view from 30 000 and the view from 3 feet. The phrase resonated with me. The view from 3 feet is more akin to Google street view than it is to Google maps. Our view of the healthcare system is closer to a view from 30 000 feet than it is to a view from 3 feet. We work with data that is disconnected from the patient. And we very seldom stop to think about the human implications of the work that we do.

It is tempting to think that perhaps we could make more of a difference working at 3 feet than we could at 30 000 feet. But, as with many things, this is a false dichotomy. What our work requires is that ability to work at 30 000 feet but with a deep consciousness of what happens at 3 feet.

It is essential that we regularly hear, and then integrate into our work “3 feet stories” – stories from those on the ground, the front line. These stories are powerful because they show up opportunities to use our skills in innovative ways to make far-reaching changes. Let’s take, as an example, the issue of 90% of women giving birth in the public sector not having access to ultrasound technology. We were told that it would be too expensive to roll out ultrasound technology. I don’t know about you but my mind refuses to accept that. We have the skills to be able to think about ways of doing it cheaper and more efficiently (using compact technology, creating mobile services, training non-clinical people to read ultrasounds and so on) and then building an investment case to demonstrate that the benefits outweigh the costs.[3] And most importantly, figuring out ways to finance it.

We need to be more involved in the public sector, in a way that allows us to see how the system works and what the issues are. This is turn allows us to pick projects where we could use our understanding, experience, alternative thinking, research and actuarial skills to make a difference. A huge potential area involves helping public hospital facilities obtain and understand their data better. Most data is collected at facility level only for the purposes of being sent to the provincial and national departments of health.  Facilities simply cannot afford to spend the time or money in understanding or using the data. Most facility and hospital managers have the power to make decisions based on this data but they just don’t know it or don’t have the right kind of data or resources.  In the same way that we do managed care programme reviews for clients, there are services in the public health sector that are run as programs that could be reviewed.  Antenatal maternal care, immunization, primary care radiology, primary care dentistry, for example, lend themselves to having reviews to help them identify gaps and impact.

There are applications of the “3 feet” idea in the private sector too. As examples: we need to pay closer attention to the patient journey; when we advise on managed care interventions we need to consider the administrative impact on the provider; when we increase the co-payments on a particular benefit we need to think about whether patients can afford the out-of-pocket payment.

Google Maps is amazing because you can switch between the view from 30 000 feet and street view. Can you imagine if all healthcare actuaries came with that added functionality: “now with street view”?


[1] http://www.kznhealth.gov.za/mcwh/Maternal/Saving-Mothers-2011-2013-short-report.pdf

[2] http://www.philani.org.za/what-we-do/the-mentor-mother-programme/

[3] http://pubs.sciepub.com/jpm/1/3/3/

http://www.ncbi.nlm.nih.gov/pubmed/19643790

 

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