30 de setembre 2013

A transactional patient experience

When Seeing The Same Physician, Highly Activated Patients Have Better Care Experiences Than Less Activated Patients

Patient engagement with the treatment of the disease is increasingly relevant. It seems that we have rediscovered that successful outcomes not only depend on the health care system, the patient behaviour may change the course of the disease. The conceptualisation of this trend has come up with a new term: patient activation - a term referring to the knowledge, skills, and confidence a patient has for managing his or her health care-.
A recent article at HA highlights the issue:
Patients at higher levels of activation had more positive experiences than those at lower levels seeing the same clinician. The observed differential was maintained when we controlled for demographic characteristics and health status. We did not find evidence that patients at higher levels of activation selected providers who were more patient centric. The findings suggest that the care experience is transactional, shaped by both providers and patients. Strategies to improve the patient experience, therefore, should focus not only on providers but also on improving patients’ ability to elicit what they need from their providers.
Easier said than done. Anyway, this is not an excuse to put efforts in such direction.
 In addition, a recent study found that patients at higher levels of activation have lower health care costs than those at lower levels.
There is no reason for procrastination, given the current state of resource scarcity.

26 de setembre 2013

For another day

The Actress, the Court, and What Needs to Be Done to Guarantee the Future of Clinical Genomics

The introduction of new technologies and benefits in health care is always a perfect chaotic process. It starts with the creation of great expectations that have to be fulfilled (and publicly funded!). In some sense it could be understood as a remake of the Nintendo story of undersupply and artificial scarcity creation. Some genome based biomarkers fits partly with this paradigm.
The case of Angeline Jolie -double mastectomy after BRCA testing positive- was broadcasted worldwide in the weeks before the ruling against gene patenting. Creating uncertainty and scarcity artificially is a heavier combination. And in this situations is when common good has to be protected, and government has the key role.
Two selected messages from this week in PLOS Biology:
If clinical genomics is about to move forward at a more rapid pace due to broader public awareness and a more favorable legal climate then there is still work to be done on the ethical, regulatory, and legal fronts.

Celebrities are now drawing public attention to the utility of genetic testing. With the Supreme Court decision opening the door to more and perhaps cheaper entry into the testing market, the requisite infrastructure for managing risk and the rules for handling risk information must be strengthened. Making testing more widely available will only be morally acceptable if there are rules of the road in place.
 Meanwhile, our regulator is just waiting for another day, then it may be too late.

Music video by Nikki Yanofsky performing For Another Day. 
(C) 2010 Decca Label Group

25 de setembre 2013

Neither manipulated, nor influenced

Nudge and the Manipulation of Choice
A Framework for the Responsible Use of the Nudge Approach to Behaviour Change in Public Policy

When thinking on health behaviour change, the nudging approach is the trending topic. Let's remember the origins:
The contribution of Thaler and Sunstein’s Nudge, however, is not that of conveying novel scientific insights or results about previously unknown biases and heuristics (something that Thaler has championed in his academic publications. Instead, it is the notion of “nudge” itself, and the suggestion of this as a viable approach in public policy-making to influence citizens’ behaviour while avoiding the problems and pitfalls of traditional regulatory approaches.
A recent article explains details about two types of nudging:
Type 1 nudges and type 2 nudges. Both types of nudges aim at influencing automatic modes of thinking. But while type 2 nudges are aimed at influencing the attention and premises of – and hence the behaviour anchored in – reflective thinking (i.e. choices), via influencing the automatic system, type 1 nudges are aimed at influencing the behaviour maintained by automatic thinking, or consequences thereof without involving reflective thinking.
And both can be transparent or non-transparent.  An example of a transparent type 1 nudge is one used by the Danish National Railway agency. Speakers in city trains are used to announce “on time” when trains arrive on time. This nudge has been devised in order to get people to easily remember not just the negative, for example, when a train is delayed, but also the positive, when trains are on time. Non-transparent is closely related to manipulation of behavior and choice.

The authors conclude:

The characterization of nudging as the manipulation of choice is too simplistic. Both classical economic theory and behavioural economics describe behaviour as always resulting from choices, but the psychological dual process theory that underpins behavioural economics, used by Thaler and Sunstein, distinguishes between automatic behaviours, and reflective choices. Nudging always influences the former, but it only sometimes affects the latter. The conceptual implication of this is that nudging only sometimes targets choices.
That's a good point. More details inside the article.

PS Understanding the differences between:  Clinical Categorical vs. Regression Based patient classification systems.

PS. Waste vs. value by U. Reinhardt. Must read.

18 de setembre 2013

Investing heavily

Global Healthcare Private Equity Report 2013

Healthcare represents about 10% of global private equity in general. Since this is more or less the proportion of health expenditures on the GDP would sound normal. However, since more or less two thirds of this expenditure is public in western countries, we can say that currently private equity may be overweighted in health sector, compared to others. The reason is that private equity may expect better returns in healhcare than in other parts of the economy.
Anyway, if you are interested in the details of what's going on, I suggest you to have a look at: Global Healthcare Private Equity Report 2013.
A key message about who is investing and where:
One clear theme that emerged in 2012, however, was the growing level of private equity firms’ interest in healthcare in China, India and across the Asia-Pacifi c region (see Figure 3). With opportunities abounding and restrictions on foreign direct investment relaxing to some extent, Western funds are building up their presence in Asia-Pacifi c by opening new offi ces, especially in China and Southeast Asia. Over the next several years, deal activity is likely to continue heating up in new geographies as it stabilizes in traditional ones.
Despite the allure of new markets, Western investors face a healthy dose of competition from local investment firms that have already taken root in the regions and strategic players searching for new outlets for growth. At the same time, investors based in the Arabian Gulf region (including sovereign wealth funds) are also investing heavily in emerging markets, with the long-term goal of bringing much-needed healthcare solutions back to their home countries. Given their unconventional investment theme, such investors are often willing to accept lower returns, consequently bidding up valuations across the board.
I always say that if you want to know about the future, it is helpful to have a conversation with a private equity investor and a headhunter. Capital and talent drive the economy, and both are interested in the appropriate allocation of risk and reward.

16 de setembre 2013

Quo vaditis?

Resource allocation in health care is a nightmare for any regulator. Since competitive prices are unavailable, payment systems have to be designed in order to achieve a greater efficiency, better quality and access. Two decades ago a chapter in a book on that topic summarized the knowledge and potential applications. The title was: Hospital Groups and Case-Mix Measurement for Resource Allocation and Payment, and the authors: Pere Ibern, James C. Vertrees, Kenneth G. Manton,Max A. Woodbury. This was the result of my stay as a visiting researcher at Duke University, Center for Demographic Studies. I had the unique opportunity to share knowledge with extraordinarily talented people.
For many years, things moved smoothly. A summary of the state of the art in 2007 is provided in a chapter of this book (p.259).
After twenty years, things have changed, quo vaditis payment systems?. Right now we focus on incentives for integrated care, and accordingly payment systems have to follow a different path. Bundled care and episode of care, these are the crucial topics right now.
However, regulator's inertia and risk avoidance are the greatest constraints for change. It is difficult to leave the confort zone. Although we know that current payment systems require a new design, decisions are being delayed. The latest words of Seamus Heaney, recently passed away, fit perfectly as a key message: Noli timere, don't fear.

05 de setembre 2013

A central dilemma

Reconsidering the Politics of Public Health

These are difficult times for public health regulators. JAMA highlights the issue:
A central dilemma in public health is reconciling the role of the individual with the role of the government in promoting health. On the one hand, governmental policy approaches—taxes, bans, and other regulations—are seen as emblematic of “nanny state” overreach. In this view, public health regulation is part of a slippery slope toward escalating government intrusion on individual liberty. On the other hand, regulatory policy is described as a fundamental instrument for a “savvy state” to combat the conditions underlying an inexorable epidemic of chronic diseases. Proponents of public health regulation cite the association of aggressive tobacco control, physical activity, and nutritional interventions with demonstrable increases in life expectancy
The article presents 5 ways towards a solution. The fifth says:
Physicians may bear particular responsibility in addressing the problem that psychologists call “hyperbolic discounting”— the human tendency to discount the value of future conditions bya factor that increases with the length of delay. Physicians bear witness to regrets about prior unhealthy choices in poignant moments— for example, the ex-smoker who wheezes in trying to keep up with grandchildren—and work to prevent other patients from experiencing avoidable fates.Perhaps physicians and other health professionals, as a result, have a special duty to weigh in on how society mitigates the social and environmental conditions that lead toward unhealthy choices
Wishful thinking again?.
Why should physicians bear such huge responsibility? "Nanny physicians"? What about citizens?. As you know, my focus is on shared decision making. Unfortunately the article doesn't mention it.

PS. What's goign on in Catalonia? Have a look at WSJ today. This is not a dilemma, it's a fact.

PS. Are you willing to pay 12.380€ for an additional survival of 36 days -progression free in breast cancer- ?. NICE considers that cost per QALY of Eribulin is 91.778 €. Are you willing to pay this cost? Forget the question,  there is no dilemma, the social insurance will pay it for you as from today. We are rich enough to afford it.

PS. If somebody wants to know how neuromarketing is being applied, have a look at the following documentary: "Don't think, just buy". Public health regulators can learn a lot from this experience to counter commercial efforts on junk foods and beverages.