Els horitzons del professionalisme en medicina

Almenys hi ha dos autors clau, al meu entendre, per a iniciar-se en la comprensió del fenòmen del professionalisme mèdic: Paul Starr i Eliot Freidson. El primer ho tracta a: The Social Transformation of American Medicine, i el segon a Professionalism: The Third Logic. 

Més enllà d'altres consideracions, m'ha interessat la qüestió des de fa temps en la mesura que massa gent contraposa amb lleugeresa Estat i Mercat (privatització) com dues forces excloents davant una reforma sanitària. Segons el senderi ideològic de cadascú, s'enroca en una o altra opció i no en surt d'aquí. Malauradament aquesta forma de pensar oblida el professionalisme, al que Freidson li atribueix "la tercera lògica", més enllà de l'Estat i el Mercat. 

En David Blumenthal escrivia precisament sobre això el 1994 a HA, en ple debat de la reforma sanitària d'en Clinton, destaco:

In most national health care debates the topic has been raised principally by opponents of reform–often organized medicine–and has been used for the explicit purpose of obstructing progress and protecting the self-interested prerogatives of the medical profession. Whatever the reform proposal, it is decried as a threat to medical professionalism and implicitly, therefore, a threat to the quality of care and the satisfaction of patients. This use of the professionalism issue is a great misfortune whose dimensions become apparent if one examines the true role and significance of professionalism in health care reform. The simple fact is that health care reform cannot succeed-politically or substantively–unless it preserves and bolsters the professionalism of physicians and other health care providers.

It should be clear that I am defining professionalism somewhat differently than it is defined in much political discourse. Many doctors equate professionalism with autonomy-to be left alone to do what they want, not only medically but financially. Autonomy, however, is not a divine right of medical or other professionals. Rather, as Paul Starr and Paul Friedson have pointed out, it is a legal, institutional, and moral privilege that is granted by society and that must be earned by health care providers through observing certain standards of behavior, including at least the following.1 (1) Altruism: Professionals are expected to resolve conflicts between their interests and their patients’ interests in favor of the patients. (2) A commitment to self Improvement: Professionals are expected to master new knowledge about their trade and to incorporate it continually into their practice. They also are expected to contribute individually to the knowledge base that informs their discipline. (3) Peer review: Because of their specialized knowledge, professionals are uniquely positioned to supervise the work of their peers, to protect consumers against failures of professionalism.

Aquesta referència hauria d'obligar a pensar a més d'un. Fer les coses bé, és la primera de les exigències, i això obliga a un marc ètic que cal refermar. Però també hi ha més coses a tenir en compte en el professionalisme.
En un article crític, Arnold Relman explicava a JAMA la seva visió sobre la decadença del professionalisme als USA:

This undermining of professional values was an inevitable result of the change in the scientific, economic, legal, and social environment in which medicine is now being practiced. A major reason for the decline of medical professional values is the growing commercialization of the US health care system.

Endangered are the ethical foundations of medicine, including the commitment of physicians to put the needs of patients ahead of personal gain, to deal with patients honestly, competently, and  compassionately, and to avoid conflicts of interest that could undermine public trust in the altruism of medicine.

Si us interessa aprofundir més en el tema, acaba de publicar-se per part del consell britànic de les professions sanitàries un informe que mostra les perspectives de la qüestió mitjançant focus grups amb estudiants. Hi ha detalls suggerents, però l'abast de l'estudi és limitat. Trobo interessant que obrissin el ventall de professions analitzades.
Mentrestant, ara com ara i aquí, el professionalisme és una matèria optativa a la carrera de medicina.
Quant sonen vents de reforma, alguns ho consideren una amenaça al professionalisme mèdic, una amenaça a la qualitat, com deia Blumenthal. Res més lluny quan es fan bé les coses, convé resituar el professionalisme en el seu lloc amb una perspectiva oberta.

PS. Per cert, en Paul Starr acaba de publicar: Remedy and Reaction The Peculiar American Struggle over Health Care Reform. Must-read.

PS. Per a conèixer el sistema sanitari suís aneu a OECD. I sobre Canadà, Indicadors de Salut.

Professionalism, current challenges (2)

 Medical Professionalism In An  Organizational Age: Challenges And Opportunities

This article aims to start a dialogue on how these changes may affect the key responsibilities of medical professionalism: putting patient interests first, maintaining and enhancing physicians’ medical  competence, and sustaining trust in the doctor-patient relationship. We identify several potentially effective strategies. They include policies to promote an institutional culture committed to professionalism and to enlarge physicians’ role in institutional leadership. We also address how the principles of professionalism might guide physician compensation formulas, policies governing transparency, and best practices for strengthening the relationships between physicians and newly empowered patients.

 

Professionalism, current challenges

 Medical Professionalism In An Organizational Age: Challenges And Opportunities

What strategies might organizations implement to make it more likely that clinicians can live up to the core responsibilities of professionalism?

This is the question. The answer in this article, at least in part.

 One useful beginning point is with institutional culture, “that which is shared between people within organizations… the shared way of thinking…the values, beliefs and assumptions.If the organizational culture does not support the responsibilities of professionalism, then people are able to fulfill them only through acts of personal heroism.

 Transparency is another controversial area where physician leadership might buttress professional responsibilities. Organizational policies vary considerably on how clinical data should be collected, identified, and shared.

Although it is simpler to identify the challenges and opportunities now confronting medical  professionalism than to propose effective responses to them, the approaches set forth here—with their focus on organizational culture, leadership, compensation, transparency, and doctor patient relationships—are intended to stimulate further discussion.

Matisse exhibition at Pompidou

 

El professionalisme en la seva màxima expressió

Choosing Wisely. Helping Physicians and Patients Make Smart Decisions About Their Care
Fa poc em demanaven que m'expliqués millor sobre el professionalisme. Els que llegiu aquest blog ja sabeu que em refereixo a tres grans opcions per a millorar l'eficiència: Estat, mercat i professionalisme. Es tracta d'opcions no excloents, sino que són complementàries, només cal triar tant sols la dosi acurada. I precisament en la dosi és on ens podem passar de frenada o quedar-nos curts.
I en referència al professionalisme, ara fa 10 anys que l'American Board of  Medicine va publicar Medical Professionalism in the New Millennium: A Physician Charter. Cal recordar el que diu al principi:

Professionalism is the basis of medicine's contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession.

At present, the medical profession is confronted by an explosion of technology, changing market forces, problems in health care delivery, bioterrorism, and globalization. As a result, physicians find it increasingly difficult to meet their responsibilities to patients and society. In these circumstances, reaffirming the fundamental and universal principles and values of medical professionalism, which remain ideals to be pursued by all physicians, becomes all the more important.

The medical profession everywhere is embedded in diverse cultures and national traditions, but its members share the role of healer, which has roots extending back to Hippocrates. Indeed, the medical profession must contend with complicated political, legal, and market forces. Moreover, there are wide variations in medical delivery and practice through which any general principles may be expressed in both complex and subtle ways. Despite these differences, common themes emerge and form the basis of this charter in the form of three fundamental principles and as a set of definitive professional responsibilities.

I els tres principis:

Principle of primacy of patient welfare. This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician–patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.

Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients' decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.

Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

Doncs bé, ara més que mai crec que el professionalisme ha de suplir l'ineficàcia de l'Estat i els desequilibris del mercat per tal de resoldre les dificultats del sistema de salut. Ho ha de fer ajustant-se a aquests principis i cal aplicar-los en totes les seves implicacions. Quan el dilluns a Els Matins de TV3 preguntaven sobre els pacients que demanen als metges que els precriguin medicaments, la resposta ha de ser només una, aplicar els tres principis, i si no afegeix salut, no cal prescriure perquè ja s'ha saltat el primer. Una actitud condescendent o que hi ha poc temps per visita, esdevenen excuses allunyades d'aquests principis.
Des del JAMA, m'han donat la pista per aquesta reflexió, i aquest primer paràgraf el podeu aplicar també per al nostre país, encaixa la mar de bé:

The polarizing political environment makes it difficult to conduct rational public discussions about this issue, but clinicians and consumers can change the nature of this debate to the potential benefit of patients, the medical profession, and the nation. The initial focus should be on overuse of medical resources, which not only is a leading factor in the high level of spending on health care but also places patients at risk of harm.

PS. En economia de la salut aquest tema del professionalisme es tracta malauradament d'esquitllada. L'econometria cau lluny i per parlar d'eficiència és més còmode pensar en metodologies (DEA et al.) que en decisions clíniques professionals que resulten difícils de modelitzar. Ens caldrà fer un esforç a tots plegats per canviar la situació.

PS. Per tal de conèixer millor què són les Health Insurance Exchanges, mireu aquest blog, el dels estudiants de la BGSE.

PS. Aquells que no vau poder seguir la meva intervenció a Els Matins de TV3, la trobareu aquí.

Commercialism in health and medicine

Buying Health: The Costs of Commercialism and an Alternative Philosophy

There are only three topics of health policy in the newspapers (unfortunately): waiting lists, copayments and privatization. As soon as one topic drops from the agenda, the informational cascade starts with the following one. The last one, privatization is still a concept in need of definition and measurement. I already covered this issue last year and I don't want to repeat it.
Today I would like to insist that beyond a new framing of the concept, maybe we have to change the scope and the term. The right term could be commercialism. We have to understand better how and when commercialism is undermining professionalism.
Jerome Kassirer wrote an excellent piece (US oriented) in Cambridge Quarterly of Healthcare Ethics some years ago that it is still a reference for today. His words:

Professionalism is fundamentally a pact with society. In recognition of certain behaviors and attributes, society confers professional status on us. These privileges are not bestowed, but are earned, and they must be renewed repeatedly for the status to be preserved. Professional behaviors include technical competence that is valued and that adds value, a commitment to self-improvement, a commitment to selfmonitoring and self regulation, and a commitment to use the unique knowledge and competence for the best interests of our patients. This last requirement should include a commitment to resolve conflicts of interest in our patients’ favor.

Is money trumping professionalism? Certainly the pharmaceutical money tsunami is having major adverse effects. It tends to distract faculty into emphasizing profitable research and to neglect their teaching duties. It replaces openness with secrecy, it privatizes knowledge, and it replaces part of the social commons by commercializing discovery. In many instances, it downplays knowledge as a social good. It has also created a culture within which the design of studies is sometimes jiggered to create positive results, in which unfavorable results are sometimes buried, where communication of results is sometimes hindered for commercial reasons, and where bias in publications and educational materials has gone completely unchecked

Maybe there are excessive generalizations, but take it as a general statement to be confirmed by facts and data.
Churchill and Churchill go beyond the usual scope. Their recent article abstract says:

This paper argues that commercial forces have steadily encroached into our understanding of medicine and health in modern industrial societies. The impact on the delivery of personal medical services and on common ideas about food and nutrition is profound and largely deleterious to public health. A key component of commercialization is reductionism of medical services, health products and nutritional components into small, marketable units. This reductive force makes both medical services and nutritional components more costly and is corrosive to more holistic concepts of health. We compare commercial and holistic approaches to nutrition in detail and offer an alternative philosophy. Adopting this alternative will require sound public policies that rely less on marketing as a distribution system and that enfranchise individuals to be reflective on their use of medical services, their food and nutrition choices, and their larger health needs

I deeply agree with such perspective.

Quan la tecnologia afegeix disciplina

Disciplined doctors: The electronic medical record and physicians' changing relationship to medical knowledge.

Si encara hi ha algú que té un dubte sobre perquè costa introduir la història clínica informatitzada, ha de llegir aquest article de Social Science and Medicine. L'argument és clar:

The EMR is powerful, this paper argues, not only because of its technical efficiency but also because of its ideological effects, as it changes doctors’ relationship to medical knowledge in such a way that doctors’ understandings of their professional roles become consistent with their subordination to bureaucratic authority.

Es tracta d'un treball qualitatiu suggerent i alhora pot generar controvèrsia. L'autor s'en va anar a una Accountable Care Organization, CalcuCare, va entrevistar metges i va veure què passava amb la història clínica. Per exemple, a l'article explica l'impacte en els protocols-GPC:

While protocols have been an integral part of medical practice for decades (see Berg, 1997), the EMR enhanced their effects in at least three ways. First, protocols were structured into physicians’ interaction with the EMR systemdfor example, once a doctor diagnosed a patient with a certain condition, a particular set of orders was generated automatically (under most circumstances the physician could change the orders, but only after consciously rejecting the protocol). Second, the EMR system allowed physician administrators to easily see which doctors were deviating from the protocols most often. Finally, since the EMR allowed for systemwide comparisons of physician practice and patient outcomes, it was able to combine medical treatment with real-time research in ways that facilitated the ongoing development of new protocols and evaluation of existing ones.

I cap al final diu:

Doctors may continue to feel in control of their profession as professionalism itself becomes more technocratic. Light (2010) discusses this as a transition toward a “new professionalism” based on accountability and value.

Reflexió interessant a tenir en compte.

Wordle del proper article

Physicians' standards of conduct

Professing the Values of MedicineThe Modernized AMA Code of Medical Ethics

JAMA has decided to start JAMA Professionalism, a new department.

The goal of the articles in this section is to help physicians fulfill required competencies on this topic. According to the American Board of Medical Specialties definition, professionalism is “…a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations.” Taking responsibility for executing professional responsibility seems intuitive enough. But what does it mean to adhere to ethical principles? How are the ethical principles defined? 

Good questions. And the answers for US physicians are in the new AMA Code of Medical Ethics.
A multi-year effort to modernise that has provided an interesting outcome. You can check for example, regarding prioritisation of resources, what should be done? in chapter 11 you'll find the answers. A good suggestion for our physicians' associations and their outdated codes.
 

The culture of group responsibility

Physician Professionalism in Employed Practice

Last JAMA issue is devoted to professionalism in medicine. A must read. I would like to highlight one article that sheds some light on the current situation:

Much can be learned from the decades of successful physician group self-regulation in such organizations as the Permanente Medical Groups and the Mayo Clinic. In these and other similar organizations, individual professional responsibility has been enhanced by a strong culture of group responsibility that has produced high-quality patient services and generally satisfied physicians. However, in  suchorganizations, the physicians are self-governed, a setting that not only supports self-regulation but also may fundamentally differ from other newer models of physician employment.

This is exactly what I was saying in my speech last Thursday. We do need a complete overhaul of the physician employment relationship in public and private health care. Current models are outdated and to take no action is not an option.

The deep side of medicine and the gift of time

Deep Medicine

Nowadays the impact of Artificial Intelligence in Medicine is unknown. Every other day you may hear about robots and how they will replace humans. Nobody knows about it, distrust charlatans. The only thing that is real is what is already happening. Eric Topol has tried to do this in his new book Deep Medicine. But at the same time he considers that AI will let physicians humanise medicine, "the gift of time", and says:

"As machines get smarter, humans will need to evolve along a different path from machines and become more humane"

This may be Eric Topol's desire, nothing to add. My view is quite different. I'm not sure about the contribution of AI to a humanised medicine . This has to do with professionalism, not with AI. And the incentives for professionalism are plunging, while commercialism is on the rise. This is the key issue.
The remaining elements of the book are of interest to explain the current state of advances in apps and tools for clinical decision making. You'll find helpful information and a great summary of AI in medicine. However, my suggestion is that you can forget the subtitle of the book: "How artificial intelligence can make healthcare human again". It's naïve.

Undermining agency theory

The Rhetoric of the Economy and the Polity

Two statements from an excellent article by D. McCloskey:
 
A criticism on agency theory:

The Great Recession gave us all some perspective on how agency theory works. The deepest problem in agency theory in any of its forms (public choice, law-and-economics, finance, whatever) is the same as the problem in prudence-only political theory, subject to the Nussbaum Lemma. The theory declares that one has an “obligation” tomake profit (and further that the economic analyst has an obligation to articulate such a theory, always, and has an obligation not to talk about the ethics of  managerial or scientific obligation, since these are matters of value about which one has an obligation not to dispute). But where does the obligation come from? It comes in fact from the ethical responsibilities of a manager to her professionalism, her stewardship, her stakeholders’ interests, or her promotion of the common good. The agent is not a pure prudence-only, Max U creature after all, just as the Hobbesian selfish individual is not. In the very theory that
denies ethics to the agent, she is imagined to be driven by an ethic, albeit a tacit and abbreviated one. Kant fell into a similar self-contradiction when he claimed to base ethics on reason alone, yet gave no account of the reasons an agent would want to act on reason.

About the crisis:

If we have a crisis, it is one of ethics. Bad People (mainly Bad Men) did it. But the baddest men are the political theorists and business-school professors who recommend an approach to the politics of life that omits the virtues. Is that you, looking at yourself in the mirror?

My understanding is that we have emphasized agency teory beyond its initial purpose. The combination of agency and utilitarism forgets professionalism. I share the view of McCloskey.

PS. 30 years after Fama-Jensen famous article on separation ownership and control.

PS. Another article against agency theory.

PS. Nussbaum Lemma:  I think it implausible to suppose that one can extract justice from a starting point that does not include it in some form, and I believe that the purely prudential starting point is likely to lead in a direction that is simply different from the direction we would take if we focused on ethical norms from the start.
McCloskey interpretation: You have to put the rabbits into the hat if you are going to pull them out.

Fiduciary duty in medicine

Professionalism, Fiduciary Duty, and Health-Related Business Leadership

Professionalism is a key concept to understand the practice of medicine. I have emphasized many times this issue in this blog. Today I would like to take one step further and to define the fiduciary duty of all healthcare professionals, specially those at management positions. In JAMA you'll find an article that elaborates the idea:

Fiduciary duty captures the simple idea of an obligation to act in the best interest of another person or party. The fiduciary is entrusted with the care of another person and must ensure that the person’s interests take precedence over the fiduciary’s own interests. Fiduciary duty is familiar to physicians in their relationship to patients, but in business, executives have a fiduciary duty to “the shareholders and the corporation.” A fiduciary relationship contrasts with a contractual one (in which mutual obligations are largely spelled out), and it imposes more extensive expectations of leaders. Fiduciaries are held to a higher standard precisely because of their power to affect the well-being of others who rely on their judgment and cannot adequately monitor and assess the fiduciary’s actions.

PS. Fiduciary duty concept is better developed under common law rather than civil law. Therefore, we need to rethink its implications.

Toni Catany, Photo-Exhibition in Barcelona

The fight between commercialism and professionalism in medicine (3)

The Price We Pay
What Broke American Health Care--and How to Fix It

Health care is perhaps today’s most divisive, territorial political issue. But many of the needed solutions are not partisan; they’re American. We are at a pivotal juncture. Spending on health care threatens every aspect of American society. The time for commonsense reform has arrived. All of us can play a part in driving badly needed reforms, both in the marketplace and in the policy world.

As a society, we should embrace a basic set of patient rights, including a right to obtain a timely quote for a shoppable medical service. Lawmakers should look at the price transparency trails blazed by Florida, New Hampshire, and Maine. The prerequisite of any free market is viewable pricing information—not just inflated charges, but the actual amounts of settled bills. New policies should ensure a level playing field to make the free market functional again, to cut the waste and restore competition to the marketplace.

I disagree with the author. Competition it is not the tool for a fairer health care. Wishfull thinking will not drive us to an improvement.

The priceless conundrum in healthcare

Pricing the Priceless: A Health Care Conundrum

Allocating resources in health care is a pivotal taks and three tools are used to solve it: market, government and professionalism. Briefly, in the market, prices paid would try to reflect information needed to take a decision for the supply side and demand side (hypotetically). Government allocates resources according to information of a benevolent ruler (biased and incomplete information). Professionals decide over the need of care according to "rules and guidelines" and specific patient situation (hypotetically).
As you may imagine, all these three approaches are used everyday in every health system in the world, and unfortunately they are imperfect, basically due to asymetric and incomplete information on one side, and incentives on the other.
Joseph Newhouse wrote a book fifteen years ago, that summarized many of these conundrums. The first is that we don't find prices, we find "administered prices" in health care, those set by insurers (private and public), and:

Setting administered prices is inevitably fraught with error, and because of lags in adapting to technological change, the extent of the error increases as pricing systems age.

This is reason why today we use the term payment systems instead of pricing. Payment systems try to combine different dimensions beyond price, sometimes volume, sometimes quality. Basically they want to correct the error of administered prices.
Unfortunately, the book finishes with a worrying  statement:

This is the conundrum of medical pricing; all arrangements that can be implemented have important drawbacks. Although variation in ideology plays a role in the payment methods that different countries use, the wide variation in institutional arrangements around the world as well as the ongoing efforts at attempting to reform and improve those arrangements in almost every country are consistent with that conundrum.

My impression differs a little bit, it is not and ideological issue. Payment methods differ because risk transfer may be possible or not. In a public system, finally the State assumes all the risk. In a private system, providers  market power may reduce the opportunities to transfer such risk.  Professionals in a public and private system don't assume financial risk, they decide but it is finally transferred to insurers and providers. Nowdays, the issue is still open for debate.

Incentives and behavior

THE MORAL ECONOMY
WHY GOOD INCENTIVES ARE NO SUBSTITUTE FOR GOOD CITIZENS

For those interested in pay for performance, the book by Samuel Bowles will open their minds to new perspectives. The rationale behind the Homo economicus needs to be adjusted to ethical and altruistic motives, professionalism in other words. This explanation of the prisoner's dilemma is helpful.

In the Prisoner’s Dilemma game, defecting rather than cooperating with one’s partner maximizes a player’s payoff, irrespective of what the other player does. Defecting in this game is what game theorists call a dominant strategy, and the game is extremely simple; it does not take a game theorist to figure this out. So, assuming that people care only about their own payoffs, we would predict that defection would be universal.

But when the game is played with real people, something like half of players typically cooperate rather than defect. Most subjects say that they prefer the mutual cooperation outcome over the higher material payoff they would get by defecting on a cooperator, and they are willing to take a chance that the other player feels the same way (and is willing to take the same chance.

When players defect, it is often not because they are tempted by the higher payoff that they would get, but because they know that the other player might defect, and they hate the idea that their own cooperation would be exploited by the other. We know this from what happens when the Prisoner’s Dilemma is not played simultaneously, as is standard, meaning that each person decides what to do not knowing what the other will do, but instead is played sequentially (one person chosen randomly moves first). In the sequential game, the second mover usually reciprocates the first player’s move, cooperating if the first has done so, and defecting otherwise. Keep in mind the fact that avoiding being a chump appears to be the motive here, not the prospect of a higher payoff. 

Stanton at Galeria Barnadas

The corporatization of medicine

Private Equity Acquisition of Physician Practices

From Annals of Internal Medicine:

The current environment is accelerating the disappearance of independent practices and fueling the corporatization of medicine. Many of the largest practices have already been acquired by a hospital, insurer, or private equity firm. No peer-reviewed evidence examines the effect of private equity acquisitions on the quality and cost of patient care; physician professionalism; or the experience of patients, physicians, or staff; little evidence examines the effect of hospital or insurer acquisitions.

Improving population health (2)

References of my speech

Carreras, Marc, et al. "Morbilidad y estado de salud autopercibido, dos aproximaciones diferentes al estado de salud." Gaceta Sanitaria (2019).

Postman, Neil. Amusing ourselves to death: Public discourse in the age of show business. Penguin, 2006.

Lakoff, George. The political mind: why you can't understand 21st-century politics with an 18th-century brain. Penguin, 2008.

Barer, Morris L., et al., eds. An Undisciplined Economist: Robert G. Evans on Health Economics, Health Care Policy, and Population Health. McGill-Queen's Press-MQUP, 2016.

 Pere Ibern, Jordi Calsina. Més enllà de la separació de funcions: organitzacions sanitàries integrades. Fulls econòmics del sistema sanitari, Nº 35, 2001, págs. 17-20

Harris, Jeffrey E. "The internal organization of hospitals: some economic implications." The Bell Journal of Economics (1977): 467-482.

Freidson, Eliot. Professionalism, the third logic: On the practice of knowledge. University of Chicago press, 2001.

Topol, Eric. The patient will see you now: the future of medicine is in your hands. Basic Books, 2015.

Kindig, David, and Greg Stoddart. "What is population health?." American journal of public health 93.3 (2003): 380-383.

Mateu i Serra, Antoni. "Salud en Todas las Políticas e intersectorialidad en la promoción de la salud: el Plan Interdepartamental de Salud Pública (PINSAP) de Cataluña." Medicina Clínica 145.Extr. 1 (2015): 34-37.

Verschuuren, Marieke, and Hans Van Oers, eds. Population Health Monitoring: Climbing the Information Pyramid. Springer, 2018.

Hansen, Pelle Guldborg. "BASIC: Behavioural Insights Toolkit and Ethical Guidelines for Policy Makers." (2018).

Kahneman, Daniel. Thinking, fast and slow. Macmillan, 2011.

Courtwright, David T. The Age of Addiction: How Bad Habits Became Big Business. Harvard University Press, 2019.

Kindig, David A. Purchasing population health: paying for results. University of Michigan Press, 1997.

Baciu, Alina, and Joe Alper, eds. Financing Population Health Improvement: Workshop Summary. National Academies Press, 2015.

Paying for (Artificial) Intelligence

 The US Government Will Pay Doctors to Use These AI Algorithms

The US Centers for Medicare & Medicaid Services (CMS) recently said it would pay for use of two AI systems: one that can diagnose a complication of diabetes that causes blindness, and another that alerts a specialist when a brain scan suggests a patient has suffered a stroke. The decisions are notable for more than just Medicare and Medicaid patients—they could help drive much wider use of AI in health care.

The incentives for technology adoption are related to professionalism, organizational, and economic. In this case are the latter one.Though, FDA must have cleared both algorithms, and this is the case. 

We could also think on using AI for reducing radiation exposure in CT scans for example..

EU is lagging behind developed countries in this (and many other issues)...

The fight between commercialism and professionalism in medicine (2)

Ensuring America's Health

The Public Creation of the Corporate Health Care System

A second book on the same topic on US healthcare. And the regulatory messages are:

Despite the political uproar surrounding the ACA, many citizens, including the legislation's opponents, acknowledged the need for some type of reform. Indeed, ACA antagonists were most effective raising the specter of how federal programming would worsen health care rather than boasting about prevailing arrangements. Poor service distribution, fragmented care, and uneven service quality had long characterized U.S. medicine. But policymakers and voters were primarily concerned about the uninsured and the exorbitant costs that ranked American health care as the world's most expensive. These flaws helped push the ACA over the finish line. And the program has thus far proven resilient, withstanding presidential and congressional contests as well as significant court challenges.
The ACA built new rooms atop a defective, jerry-built edifice. The public option would have put the nation firmly on the path toward a nationalized, universal system by creating a government-managed plan and using regulations and mandates to enfeeble and eventually drive out private coverage. Readers can decide for themselves the wisdom of creating a centralized system. Nonetheless, because the ACA failed to secure fundamental, structural reform, it will be unable to rein in costs while also maintaining or improving the quality of care. Indeed, this narrative has illustrated how a fusion of public and private power constructed an institutionally tangled health care system that, even under the banner of comprehensive reform, policymakers were ultimately unable to rescue from the insurance company model.

Right now it seems that ACA is not enough. Let's wait and see.

Dynamic risk adjustment in provider's payment

Prevention and Dynamic Risk Adjustment

Adjusting Medicaid Managed Care Payments for Changes in Health Status

"Risk-adjustment methods have an inherent structural flaw that rewards preventable deterioration in enrollee health status and improved coding of disease burden", this is the key statement in Fuller et al. article. The answer they provide is the introduction of an additional payment adjustment according to changes in health status for similar mix of enrollees. The payment adjustment being proposed is based on changes in aggregate relative payment weights for all enrollees avoiding any individual adjustment.
This is a concrete application of the initial dynamic risk adjustment proposal that Eggleston et al. made in 2007. They suggested a two step payment system: a conventional risk adjustment (for variations in population health outside the provider’s control) and an additional one related to prevention efforts.
There is still a lot to learn about it. Let's keep an eye on this crucial topic.

PS. Have a look at Commonwealth Fund anouncement: "Our initiative recognizes that a wide range of factors influence providers’ choices, beyond financial rewards or penalties, including intrinsic motivation and medical professionalism, organizational influences, and policy" (see Box)

Doctor crisis. What crisis?

The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care

Last May I saw this press release about a book by a physician from Kaiser Permanente. Initially I thought that it would be a book for those interested uniquely in US healthcare. I started reading "The Doctor Crisis" last week and still can't stop. It has captured my attention. His observations about the practice of medicine and the pressures that physicians are under, are similar in any developed country, maybe the intensity is not the same. Anyway, in the book there is a reference of a work by Sinsky et al.:  In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices, a must read:

The current practice model in primary care is unsustainable. We question why young people would devote 11 years preparing for a career during which they will spend a substantial portion of their work days, as well as much of their personal time at nights, on form-filling, box-ticking, and other clerical tasks that do not utilize their training. Likewise, we question whether patients benefit when their physicians spend most of their work effort on such tasks.³⁰ Primary care physician burnout threatens the quality of patient care, access, and cost-containment within the US health care system.

We set out in search of joy in practice. What we found were pockets of professional satisfaction.

I missed this article when it appeared last year.What they explain is in my opinion what exactly should be done. As Tom Bodenheimer says, “the Triple Aim should be a quadruple aim, with clinician and staff satisfaction a necessity to achieve the other three aims.”  Considering it as an input and not only as a goal itself is the right approach. More on Berwick's triple aim, at IHI.
I am only at the begining of the book, but I wanted today to reflect this critical issue of our health systems. Something should be done beyond the triple aim. Organizational innovation is required. Right now I am not able to perceive such effort around here.

PS. About the title, focusing only on physicians is a too narrow perspective for those who have to lead a better health care , why not "transdisciplinary professionalism"?

PS. A suggestion: their blog.