January 17, 2020

Episode based payment systems (2)

Value-based provider payment: towards a theoretically preferred design

The details of a payment system methodology are clearly described in this article. I was not surprised to confirm that the proposals we made two decades ago were in the same direction: two-part payment, fix and variable. Unfortunately nowadays we have a retrofuture system that nobody knows exactly how incentives really work. Of course, this is the first best for a discretionary behaviour by a resource allocator. This is a clear step in the wrong direction that started a decade ago. Without proper incentives, efficiency suffers, and to be clear this means less efficient healthcare for the patients. Unfortunately again, nobody cares about it.
The main contribution of this paper is twofold. Inspired by the societal debate on what
stakeholders in health care should ideally strive for, as well as by existing definitions of value, we first described and further specified the concept of value, facilitating the specification of requirements in the design of VBP. We conclude that, in this respect, value is ideally conceptualised as a multifaceted concept, comprising not only high quality of care at the lowest possible costs but also efficient cooperation, innovation and health promotion. Second, starting from these value dimensions, we derived various design features of a theoretically preferred VBP model. We conclude that in order to stimulate value in a broad sense, the payment should consist of two main components that must be carefully designed. The first component is a risk-adjusted global base payment with risk-sharing elements paid to a multidisciplinary provider group for the provision of (virtually) the full continuum of care to a certain population. The second
component is a relatively low-powered variable payment that explicitly rewards aspects of value that can be adequately measured.
The time to fix the current mess has arrived.

Jordi Sàbat

January 16, 2020

Episode based payment systems

Unraveling the Complexity in the Design and Implementation of Bundled Payments: A Scoping Review of Key Elements From a Payer’s Perspective

After per case based payment systems (DRGs) everybody was waiting for a comprehensive system to measure health services activities. And instead of focusing on episodes, what happened is that bundling was the new frame. Unfortunately, after all these years bundling has not provided the answer because the scope of measurement is related to several diseases and it is not holistic.
When everybody was asking for an alternative to fee-for service, the answer was in my opinion "patient focused episodes of care", but the US government decided otherwise and protected the interests of those that leverage fee-for-service.
Therefore, now it is the time to fix this mistake and take the right  road. In this article you'll find some issues to consider when you have to design a payment system. It still talks about bundling, forget it, substitute it by episodes and it will be fine.

Our framework provides a structured overview of the principal, literature‐based elements of the design and implementation of bundled payment contracts from a payer's perspective. We identified 53 elements that involve all procurement phases and relate to actors on all levels of the health care system. A better understanding of these elements can help payers and other actors devise a strategic approach and reduce the complexity of implementing these contracts. Compared with traditional FFS models, bundled payment contracts introduce an alternative set of financial incentives that affect the entire health care system, involve almost all aspects of governance within organizations, and demand a different type of collaboration among organizations. This is what makes the design and implementation of bundled payment contracts complex and is why they should not be strategically approached by payers as merely the adoption of a new contracting model but, rather, as part of a broader transformation to a more sustainable value‐based health care system, based less on short‐term transactional negotiations and more on long‐term collaborative relationships between payers and providers.

January 9, 2020

All you need to know about molecular diagnostics

Molecular Diagnostics Fundamentals, Methods, and Clinical Applications

Current advances in health sciences are available at the same time that diagnostic technology and knowledge provide new tools. This book is specially relevant because it summarises all the current state of the art on molecular diagnostics. Therefore a good suggestion for those who want to practice precision medicine.

Table of contents:
I. Fundamentals of Molecular Biology: An Overview
1. Nucleic Acids and Proteins
2. Gene Expression and Epigenetics
II. Common Techniques in Molecular Biology
3. Nucleic Acid Extraction Methods
4. Resolution and Detection of Nucleic Acids
5. Analysis and Characterization of Nucleic Acids and Proteins
6. Nucleic Acid Amplification
7. Chromosomal Structure and Chromosomal Mutations
8. Gene Mutations
9. DNA Sequencing
III. Techniques in the Clinical Laboratory
10. DNA Polymorphisms and Human Identification
11. Detection and Identification of Microorganisms
12. Molecular Detection of Inherited Diseases
13. Molecular Oncology
14. DNA-Based Tissue Typing
15. Quality Assurance and Quality Control in the Molecular Laboratory
A. Study Questions Answers
B. Answers to Case Studies

January 8, 2020

Tough days ahead for health policy

Sistema Nacional de Salud: retos y tareas pendientes tras la Gran Recesión

The issue of Revista ICE, a must read for the new health minister:


Innovación tecnológica y financiación de prestaciones

La colaboración público-privada en sanidad: hasta dónde y cómo delimitar sus fronteras

Reformas pendientes en la organización de la actividad sanitaria

La atención especilizada del Sistema Nacional de Salud durante la Gran Recesión. Gasto, utilización y variabilidad en el periodo 2004-2015

Atención a la dependencia y cuidados sanitarios: obligados a entenderse

Mirando más allá de los servicios de atención sanitaria: el papel de la salud pública

Diseño institucional y buen gobierno: avances y reformas pendientes

Crisis económica y salud: lecciones aprendidas y recomendaciones para el futuro

January 5, 2020

The public option for population health improvement

Addressing Social Determinants to Improve Population Health
Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health
The Public Option How to Expand Freedom, Increase Opportunity, and Promote Equality

This is what JAMA article says about population health
While health care organizations may not be equipped to address each of the root causes of their patients’ conditions, they need to broaden their perspective on how to address social determinants of health and use their expertise to influence initiatives on education, housing, employment, and other important health related social issues that take place beyond their immediate clinical purview.
"Need to broaden their perspective", this is the message for health care organizations according to the articoe. I'm not so sure about it. The message is not only for health care organizations, it is for public policies. This is much more difficult to address when there is not a public option for the whole population. A new book sheds light on this topic for the US policy.

PS. The Limits of Private Action: What the Past 40 Years Taught Us About the Perils of Unregulated Markets
PS. There Should Be a Public Option for Everything

January 4, 2020

How altruistic behaviors reduce pain

Altruistic behaviors relieve physical pain

That's it. You'll find the details in PNAS article:
For centuries, scientists have pondered why people would incur personal costs to help others and the implications for the performers themselves. While most previous studies have suggested that those who perform altruistic actions receive direct or indirect benefits that could compensate for their cost in the future, we offer another take on how this could be understood. We examine how altruistic behaviors may influence the performers’ instant sensation in unpleasant situations, such as physical pain. We find consistent behavioral and neural evidence that in physically threatening situations acting altruistically can relieve painful feelings in human performers. These findings shed light on the psychological and biological mechanisms underlying human prosocial behavior and provide practical insights into pain management.

Parov Stelar