El mantra del moment és la necessitat d'avaluació econòmica de les prestacions sanitàries. Ho sabem, res de nou. I jo avui em pregunto si recitar aquest mantra ens durà a l'objectiu esperat que és assolir més valor i millor distribuït amb els recursos disponibles. I aquí és on entren dues variables en joc, l'eficiència i l'equitat. Ara com ara, observo al meu voltant un reduccionisme metodològic excessiu, alhora que un enfoc exclusiu en l'eficiència. Com si això de l'avaluació econòmica es pogués resoldre amb la comptabilitat dels QALYS- anys de vida ajustats per qualitat.
Afortunadament, en Tony Culyer ens recorda les dues Ps:
My concerns about HTA relate to the fact that, when applied, it inevitably has a political context. It is political both with a large ‘‘P’’ and a small one. The large ‘‘P’’ relates to the political ideology of health services and springs from the notion of a public interest element of health services. This is an interest that can be cast in many languages, for example, in political language, ‘‘solidarity’’, or in Marxian language, ‘‘from each according to their ability, to each according to their need’’, or in neoclassical economic language,‘‘public goods’’ and ‘‘caring externalities’’. It finds particular expression in the idea, which I think can be first attributed to Archie Cochrane,4 that the only health care warranting public financing or public delivery is health care that is demonstrably effective. The small ‘‘p’’ political context, is the context in which the political creator of the National Institute of Health and Clinical Excellence (NICE), Frank Dobson, when asked as Secretary of State for Health whether he thought it would work, said ‘‘Probably not, but it’s worth a bloody good try.’’ Applied HTA is political both in the sense that it inherently embodies value judgments, including ones about equity or fairness, and in the sense that the identification and acceptance of value judgments of any kind require a process within the body politic; one, moreover, that needs to have particular characteristics if it is to lead to acceptable decisionsL'article cal llegir-lo sencer, i ens explica la història de dos dracs que si desperten poden ser molt entremaliats, necessiten atacar i matar. El primer drac és l'equitat, i com s'incorpora a l'avaluació de tecnologies sanitàries i el segon és la nostra ignorància del procés sobre com integrar precisament l'equitat en aquesta avaluació de tenologies. La dificultat de combinar evidència per articular conceptes poc evidents com és el cas de l'equitat. Si no som capaços de defensar-nos del segon drac o el desterrem, difícilment ens haurem salvat de l'atac del drac número 1. Sobre aquest complex procés comença amb una cita que comparteixo:
‘‘Arguably the biggest threat to our public health care system is not our ability to pay for the increasing cost of care, but rather a loss of public confidence.’’L'article dona pistes per superar els dos dracs, però tampoc penseu que siguin definitives. I subscric plenament els paràgrafs de conclusió:
"HTA would be wise to broaden its horizons, turning away from what is largely just an algorithm to find ways to take seriously the myriad value and ethical issues, which currently still have the unfortunate appearance of afterthoughts tacked onto, but essentially excluded from, the core decision logic, and to develop an empirical program to rival, mutatis mutandis, that of CEA and CER. After all, nonmonetary values, although less easily measured perhaps than monetary ones, are still subject to empirical estimation, and the values that individuals actually cherish ought, at the least, to inform decision makers’ values. This is not merely a matter of expanding the algorithm but also, as I have tried to show, a matter of developing suitable processes that generate information through the participation of stakeholders while also facilitating the thoughtful assessment of what is known"PS. Al mateix número del MDM hi ha molt material, que el deixo per un altre dia. I en especial a online first també de Culyer. Si algú té dificultat d'accedir, només ha de dir-ho.
PS. Bon article d'en Josep Colomer sobre Europa.
PS. Al blog d'en Jason, sobre el frau a la recerca en càncer. Ell creu que és la punta de l'iceberg. Caldrà seguir-ho. A CBS trobareu un 60 minutes.
'Calgary 88', d'Antònia Font. on Vimeo.
