Wednesday, December 31, 2014

The price of life

A documentary about the rationing of high cost cancer drugs by the National Institute for Health and Clinical Excellence.

Tuesday, December 30, 2014

Do you really want to know about it?

Recreational genetics is entering into the consumer market. I have explained that governments should be active in restricting such practices because they are closely related with false advertising. Beyond that, governments should be aware also about the implications of creating anxiety in population. This documentary asks if patients should know about their genes, when there is no treatment.

PS. Have a look at this one, about ethical dilemmas on genetic testing:

Saturday, December 27, 2014

Le mécontentement des médecins liberaux

Les médecins libéraux français ont initié une grève jusqu'au 31 Décembre. Les raisons sont dans le projet de loi de santé qui disent l'"etatalisation" du système de santé. Ils demandent vraiment une augmentation de 8,6% des prix de visites de 23 à 25 . Aujourd'hui, je ai lu l'éditorial de Le Monde:  
Le revenu annuel moyen brut d'un generaliste est de 76.600 euros et celui d'un spécialiste de 121.00 euros. Ces revenus restent inférieurs de 25% à 30% à ceux de leurs homologues européens.

Pas mal. Les médecins urgence de l'hôpital ont déclaré une autre grève, le ministre a admis de baisser de 20% le nombre d'heures travaillées par an (!). Cela on peut dire que est un parfait opportunisme, selon le dictionnaire.
L'agitation pour la nouvelle loi est servi. De même en France se plaignent d'un projet de loi de nationalisation inexistante, près d'ici il ya des gens qui parlent de privatisation lorsque toutes les entités sont sous le contrôle publique. La perversion du langage a atteint les limites de l'empoisonnement de l'environnement

Juan Luis Guerra - En el Cielo No Hay Hospital

Wednesday, December 24, 2014

Mental Health in the policy agenda

Mental Health for Sustainable Development

The need for action in mental health is increasingly recognised. Although relevant improvements have been introduced in developed countries, there is a common view that more should be done. Some diseases like depression are at the top of the burden of disease and bring enormous pain and suffering to individuals and their families and communities. An interesting recent report has been released on the topic. This is the infographic:

PS. UK Health Secretary. Keynote address: the political imperatives to address mental health and depression

Tuesday, December 23, 2014

European health regulator on holiday

After Canada, the first european country that has allowed recreational genetic testing is UK. Some weeks ago the Ethics Research Committee approved the commercialisation of 23andme test that provides 100 genetic reports. Wired says:
The £125 spit test kit is not a diagnostic test, but instead identifies genes that are associated with inherited conditions including cystic fibrosis, Alzheimer's disease, Parkinson's disease and sickle cell anaemia. It's not just health information that can be discovered within the results of the test though -- there is also the opportunity for customers to learn more about their inherited traits and genetic ancestry.
Why has the UK approved it and the FDA has restricted the same test in the US?.  Some months ago I explained that european legislation was outdated. Now the genetic testing firm has profited from bad regulation to enter into european market with CE mark. Does anybody know where the regulator is spending their holiday?

PS. While being  so easy to regulate recreational genetic testing under current false advertising rules, why is only the US doing that?. You should know that closer than you think similar tests are available for you. Where is the catalan health regulator?

PS. Why is the tax regulator not on vacation?

Emile Claire Barlow - Jardin d'Hiver

Monday, December 22, 2014

Thinking and deciding

World Development Report 2015: Mind, Society, and Behavior

Our decision making patterns are based on multiple foundations. The new WB report summarises them in three sources: automatic, social and mental models.  In chapter 8 you'll find applications to health. Some of them may be naive, while others potentially useful. There is a trial and error process in all this stuff because of cultural implications. If there is a particular area to focus on, it is on health communication for behavioural change. There is a lot to learn from behavioral economics:
Understanding that people think automatically, interpret the world based on implicit mental models, and think socially allows policy makers to make major strides in improving health outcomes. Individuals sometimes value information highly (for example,
when seeking curative care), but at other times providing information is not sufficient to get people to change behaviors that undermine health. Framing effects that make social expectations and social approval more salient can sometimes encourage individuals to seek preventive care and adhere to treatment when they otherwise would not, even though the individual benefits exceed the individual cost.
PS. My former posts on nudging

PS. Post by BIT.

PS. TE on poor behavior.

PS. Excellent "30minuts" documentary about the Snowden's massive information leak ever. (Only until Dec 28th)

Friday, December 19, 2014

Global health surveillance

Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Is there any health convergence across countries?. You'll find the answer using the Global Burden of Disease study in a recent Lancet article (a must read).
Part of the answer depends on how the goals are framed—for example, what does convergence mean? In the development literature on economic convergence, convergence has been framed in terms of poverty rates or in terms of income inequality measured by the Gini coefficient or other measures of inequality. Work on convergence in life expectancy has tended to focus on measures of absolute difference rather than relative difference. We found unequivocal divergence in mortality rates for women aged 25–39 years and older than 80 years and for men aged 20–44 years and 65 years and older, similar to previous estimates of divergence of life expectancy at birth since the 1980s. In these age groups, both the Gini coefficient and the mean absolute diff erence in death rates are rising. In all other age groups, except girls aged 10–14 years, relative inequality is increasing but the absolute gap is  narrowing.
For most countries, the general pattern of reductions in age-sex specific mortality has been associated with a progressive shift towards a larger share of the remaining deaths caused by non-communicable disease and injuries. Assessing epidemiological convergence across countries depends on whether an absolute or relative measure of inequality is used. Nevertheless, age-standardised death rates for seven substantial causes are increasing, suggesting the potential for reversals in some countries.
If longevity is mostly improving everywhere, now the key issue should be to analyse global convergence on quality of additional years of life. 

PS. Check p.3499 of the supplementary information. And p. 150 for changes in total Life Expectancy 1990-2013,  (5,6 y men, 3,9 y women). If you read my previous post, you'll find interesting differences about what is going on with healthy life years for women.

Wednesday, December 17, 2014

Rethinking the practice of medicine

Team-Based Care: Saving Time and Improving Efficiency

When two years ago Eric Topol published a book on "The creative destruction of Medicine", many people thought it was a provocation. He was just borrowing the term keyed by Joseph Shumpeter for the economy as a whole. However, his message in my opinion still falls short. He was focusing strictly on changes that rely on technological innovations and he forgot organizational innovation.
Now, have a look at this recent article at FPM 
Drs. Hopkins, Sinsky and Peter Anderson all state that most outpatient visits can be divided into four distinct stages: 1) gathering data, 2) the physical exam, 3) medical decision-making, and 4) patient education/ plan of care implementation. Rather than the physician being responsible for all four stages, they recommend that a clinical assistant (a registered nurse, licensed practical nurse, or highly skilled medical assistant) perform the more clerical stages, one and four, while the physician focuses primarily on stages two and three. The clinical assistant stays in the room with the patient during the entire visit, gathering the history and doing all the documentation. The physician joins them for stages two and three before moving on to the next exam room where a second clinical assistant has set the stage by performing stage one. This allows the physician to see more patients, thus covering the costs of additional clinical assistants.
This proposal requires coordination and a reallocation of resources, roles and tasks. In certain diseases such a model has already been implemented. Is anybody able to extend it and amplify its impact on efficiency of the whole healthcare system?

PS. FT books of the year

PS. In UK some hospital mergers are prohibited. What a difference on the rule of law compared to ours!

Tuesday, December 16, 2014

Vertical equity in waiting lists

Three years ago I explained that it was good to know that prioritisation was going to start on the waiting lists. It was only the anouncement. Afterwards, it came the uncertainty after a phone call. On March 7th, 2013 the headline post of this blog was: Still waiting after all these months.
Many theoretical efforts have been devoted to improve vertical equity in waiting lists, now it's time to apply them. The moment of truth arrives when somebody has to apply objective criteria, and this raises concerns on the  status quo. This is precisely what it comes to my mind when reading this document. I can't find any reference to shared decision-making with patients, taking into account their interests and social preferences. It emphasizes the autonomy of the physicians for waiting lists management, but this is absolutely not enough.
Finally, the document says that budget cuts have to finish. Is this a political or a professional statement?. Everybody should know that budget cuts are related to our critical economic situation, with an unacceptable fiscal deficit. Why is there no reference to this constraint?. Is this a political or a professional option?

Monday, December 15, 2014

Overcoming political decay

Political Order and Political Decay: From the Industrial Revolution to the Globalization of Democracy

If I had to highlight two books of 2014 that will be considered classics in the near future, the first would be Piketty's on Capital in XXI century, and the second would be the Francis Fukuyama one: Political Order and Political Decay.
Both are worth reading. I've just finished the Fukuyama one, and covers one topic that appears in everyday headline news: corruption. In chapter 5 you'll find a wider explanation of patronage and clientelism and its impact on democracy.
Patronage is sometimes distinguished from clientelism by scale; patronage relationships are typically face-to-face ones and exist in all regimes wether authoritarian or democratic; whereas clientelism involves larger-scale exchanges of favors between patrons and clients, often requiring a hierarchy of intermediaries.
Clientelism is very different from a purer form of corruption where an official steals from the public treasury and sends the money to a Swiss bank account for the benefit of himself and his family alone. This type of corruption is sometimes labeled, following Weber,  prebendalism.
Fukuyama gave a speech to present his book last October at Harvard. Comments on his book appeared at FT, WSJ, The Guardian.or The Economist :
Political decay can take away the great advantages that political order has delivered: a stable, prosperous and harmonious society.
In my opinion, there are many signs of political decay. The question is wether we will be able to overcome such a situation in a disconnected state. Meanwhile, a better understanding in a historical perspective as the Fukuyama one, is highly recommended.

PS. Video of the Presentation at Harvard Institute of Politics

PS. Just released. OECD Foreign Bribery Report. An Analysis of the Crime of Bribery of Foreign Public Officials
Bribes are generally paid to win contracts from state-owned or controlled companies in advanced economies, rather than in the developing world, and most bribe payers and takers are from wealthy countries.
Bribes were promised, offered or given most frequently to employees of state-owned enterprises (27%), followed by customs officials (11%), health officials (7%) and defence officials (6%). Heads of state and ministers were bribed in 5% of cases but received 11% of total bribes.

PS. An example of how excess of transparency may inhibit some talented individuals to commit to public service as officials. We are creating strong barriers for a future high performing public service.

Friday, December 12, 2014

The successful recent trends in healthy life expectancy (3)

The Cost of an Additional Disability-Free Life Year for Older Americans: 1992–2005

We already know that the trend of healthy life expectancy is on the right track. If we all agree that under a universal coverage system, the aim should focus on being efficient and equitable at purchasing population health,  then a crucial question would be: how much does it cost an additional healthy life year?.
We do have such estimates for USA. A quite recent article says that the average discounted cost per additional disability-free life year is $71,000, assuming that half of the gains in healthy life expectancy were attributable to increases in spending.
Is this more or less than you would be willing to pay for it?. Recall how much we are spending per month of survival with cancer treatments. You can check it on p.254 of this article. As a society, currently we are paying from €562 (Erlotinib+Chemotherapy) up to €66,164 (Ipilimumab) for one month of additional survival and nobody cares about it. That's life!. Glups!

Thursday, December 11, 2014

Where is value created in hospital mergers?

Hospitals, Market Share, and Consolidation

In the current wake of private hospital mergers, somebody should ask the right question. Where is value created?. If the goal is to reduce competition and create an environment close to a monopoly, than we can understand that market rivalry will decrease, prices will be higher, consumers will lose. In my opinion, the current mergers process shows signs of value destruction or value redistribution rather than value creation. Antitrust authority has been condescendent with the recent events and its resolution has forgotten the basics. Once you approve the merger, there is no way out, no easy reversal of a "quasi-monopoly" as it is the case of Barcelona private hospitals from today, that 64% of beds will belong to one firm.
Cutler and Morton published a JAMA article stating that something should be done to prevent such situations.
Antitrust authorities are examining these consolidated systems as they form, but broad conclusions are difficult to draw because typically the creation of a system will generate both benefit and harm and each set of facts will be different. Moreover, the remedies traditionally used (eg, blocking the transaction or requiring that the parties divest assets) by antitrust authorities in cases of net harm are limited. For this reason, local governments may want to introduce new policies that help ensure consumers gain protection in the event of consolidation, such as insurance products that charge consumers more for high-priced clinicians and health care centers, bundling payments to clinicians and health care organizations to eliminate the incentives of big institutions to simply provide more care, and establishing area-specific price or spending target
And their point is: local governments. Antitrust authorities are unable to understand the unique conditions of local competition. Unfortunately, local governments have no authority over such matters here. Meanwhile, the harm (to competition) has already been made.

PS. As far as the poor quality regulation is the norm in our current state, the only way out is to escape from this disordered world. To disconnect asap, there is no other option.

PS. If you want to know the answer to my today's question, have a look at this article: The Impact of Hospital Mergers on Treatment Intensity and Health Outcomes. You'll find strong reasons to be concerned:
The primary specification results indicate that mergers increase the use of bypass surgery and angioplasty by 3.7 percent and inpatient mortality by 1.7 percent above averages in the year 2000 for the average zip code. Isolating the competition mechanism mutes the treatment intensity result slightly, but more than doubles the merger exposure effect on inpatient mortality to an increase of 3.9 percent.The competition mechanism is associated with a sizeable increase in number of procedures.
PS. If Antitrust economics helps to support these processes, then somebody should rethink the theory and its application from scratch.

Cartier-Bresson. Rome Exhibition. Must see.

Wednesday, December 10, 2014

The successful recent trends in healthy life expectancy (2)

Health at a Glance: Europe 2014

A new european health report by OECD has been released. It includes key data and information regarding how health systems are performing and citizen's health. Some days ago I was highlighting the successful achievement in healthy life expectancy in our country (as a temporal trend). Now we can compare these data with other countries and we can see that we are at the top 10 of EU-28.
Data can raise many comments. If you want to know the big change in health expenditure, look at p. 121. In 2000-2009 european expenditure growth rate was 4.7%, in 2009-2012 is -0.6%. In our specific case is still less. Now is the moment to remember those that some years ago said that health expenditure would never collapse because there were some factors (technology and ageing,...) beyond the control of decision makers.
In summary, we can confirm that healthy life expectancy has increased and resources have shrunk. That's all folks (up to now).

PS. On cross-fertilization between health economics and management.

Tuesday, December 9, 2014

How much does it cost (a drug)?

Once again you can check the cost of developing a new drug ($2.6 billion in years 1995-2007), a jump in real terms of 145% from its former 2003 estimate $802m. These figures were widely criticised. And now as you may imagine this is again a huge nonsense. The Economist and Forbes joke about this numbers and my view is even more sceptical.
I'm still waiting for an estimate of new drugs costs adjusted by value. Unless somebody is able to provide such a figure, I will avoid analysing in detail any cost accounting exercise.

Thursday, December 4, 2014

Risky lifestyle regulation, what's new?

Regulating Lifestyle Risks The EU, Alcohol, Tobacco and Unhealthy Diets

Since we all agree that lifestyles affect health, then more evidence is needed on what to do and how to do it. Fortunately, a new book summarises the state of the art on regulating lifestyles. Selected sentences from two selected chapters 14 and 15:
Nudging healthier lifestyles: Informing the non-communicable diseases agenda with behavioural insights
by Alberto Alemanno
In sum, most behavioural insights consist of ‘mechanisms rather than law-like generalizations’.66 For purposes of policy, it would therefore be valuable to have a better understanding of how the major findings of behavioural research apply within heterogeneous groups. Unfortunately, due to methodological and empirical complexity, current variety of behavioural studies.71 A number of different types of studies are possible, such as (a) experiments, (b) randomized controlled trials (RCTs) and (c) surveys. 
Using outcome regulation to contend with lifestyle risks in Europe Tobacco, unhealthy diets, and alcohol
by Stephen d. Sugarman
In conclusion, outcome regulation offers a new way to deal with lifestyle risks – risks that people now take but at a deep level want reduced. That is, mature peoplemostly do not want to smoke or get drunk or eat unhealthily. They have been enticed into doing so in substantial part because of marketing efforts by sellers of these products who have created social norms in support of their consumption. People also drink, smoke, and eat the wrong things because they provide short-termpleasure, even if they also bring with them long-term serious harms.

There are some debatable conclusions, however this book is a required reading for any health regulator.

PS, NYT article on mediterranean diet, original in BMJ..

Wednesday, December 3, 2014

The opportunity cost of delay in applying HTA

Some weeks ago I attended the meeting of the Spanish Health Techonology Assessment Association. The presentations and communications highlighted the current status on economic evaluation, and to be honest, an uncertain application and usefulness for public policy in our country. The reason?. There is a fear, a deep fear, that economic evaluation could guide some coverage decisions. Since this represents a reduction of discretionary powers, politicians prefer the status quo. Any change that represents an introduction of health technology assessment will reduce the degrees of freedom in their decisions. Is this fair for society? I would like somebody to calculate the opportunity cost for such a delay.

PS. I suggest you have a look at Sculpher, Peiró and Culyer presentations. My presentation was about stratified medicine, and J. Pons about the state of the art in HTA.

PS. Tomorrow, Conference at Fundació Grifols: Personal and collective determinants of health ailments, Whose responsibility is it?. Determinantes personales y colectivos de los problemas de salud, ¿de quién es la responsabilidad? I'll give a speech in the first session.

Tuesday, December 2, 2014

The successful recent trends in healthy life expectancy

Esperança de vida, lliure de discapacitat i en bona salut a Catalunya

If there is one measure to monitor continously in welfare policy, this is the case for healthy life expectancy. If somebody wants to track wether citizens, clinicians, health managers, politicians, firms, etc... are contributing to better life in the health arena, then this is the aggregate measure. If somebody were able to establish the right incentives for achieving the best benchmark, this would be great. Kindig suggested long time ago that "purchasing population health" should be valued according to healthy life expectancy.
Fortunately, new data about recent trends has been published and we can confirm that has increased over a period of 7 years, between 2005 and 2012 from 63 to 65.7 years for men and from 60.6 years  to 66.1 for women . In women the proportion of years lived in good health has gone up by 5 percentage points, from 72 to 77 % in men and has increased only one point from 81 to 82 %. In any case, in marginal and in absolute terms there is a substantial improvement . Nobody would have been able to foresee changes of this magnitude.
Some months ago I showed in this blog an alternative measure, the morbidity-adjusted life expectancy.  An alternative construct that allows easier geographic and temporal comparisons.
We are on the right track, contrary to those that thought with the crisis and cutbacks things would worsen. As you know and I have explained many times, there are lot of areas for improvement and we have not to reduce our effort to mantain this successful trend.

PS. My congratulations to the authors of the report. Excellent and helpful work.

Sunday, November 30, 2014

Manufacturing disease

Lethal But Legal: Corporations, Consumption, and Protecting Public Health

The quest for better regulation is an open-ended learning process. In democracy, governments maximize impact during their political term and better regulation deserves a longer term commitment. The costs and benefits of inaction for society are larger than for politicians. A recent new book explains that public health regulation and specifically on food policy, needs a complete overhaul. I've said this many times, in the book you'll find the details to take into account.
The author, Nicholas Freudenberg, DrPH, is Distinguished Professor of Public Health at the City University of New York School of Public Health and Hunter College and founder and director of Corporations and Health Watch, an international network of activists and researchers that monitors the business practices of the alcohol, automobile, firearms, food and beverage, pharmaceutical, and tobacco industries.I strongly suggest a quick look at their site, you'll find many interesting information, like the one related to Berkeley and soda-tax.

Friday, November 28, 2014

The fifth wave in population health

For debate: a new wave in public health improvement

Required reading.UK CMO et al. in The Lancet say:
A fifth wave of public health development is needed, and needed now, as a consequence of shifts in the burden of disease and persisting health inequalities, but also against the background of emergent features of modern society. In consideration of the previous waves, there has been a shift from the top-down approach involving structural changes (such as the public works of the 19th century), towards a positing of shared responsibility for health. This shift mirrors changing political ideology and increasing understanding of the contribution of individual behaviours and lifestyle choices to health outcomes.

PS. Health spending around the world in The Economist.
PS. Piketty under scrutiny, in WSJ.

Thursday, November 27, 2014

My keynote speech at Pla de Salut #plasalut14

This is my speech at the conference on Pla de Salut, the health planning process 2011-2015:

Em demanen que parli de les tendències de futur, i quan em van encomanar de venir avui, fet que agraeixo sincerament, els vaig dir que només puc explicar el present, que el futur el construïm cada dia tots plegats i per tant depèn de tots els que som aquí i dels que no.

Tots aquells que alguna vegada s’han dedicat a predir el futur, al final mai no volen mirar l’hemeroteca perquè majoritàriament els posaria en ridícul. Els economistes almenys no ens dediquem a endevinar el futur.

Ningú no hauria pogut preveure que des del 2008 ja portem 6 anys de disminució en el PIB, de menor riquesa. O que el PIB per habitant del 2013 fos inferior al de 7 anys abans, el 2006. En Thomas Piketty diu que la taxa de creixement de l’economia a llarg termini és de l’1,5%, tardarem molts anys en recuperar aquesta mitjana.

La duresa d’aquestes dades, mai vistes excepte en períodes de convulsió social i guerres, ens han recordat novament que els recursos són escassos, que sempre hi ha un dia que els deutes s’han de pagar, que fer dèficit públic indefinidament no és possible sense hipotecar el benestar de les generacions futures.

Que els recursos són escassos per les necessitats i demandes socials existents, és un fet, no és així perquè ho diguin els economistes. Els temps recents ens ha recordat que cal prioritzar, una tasca que sovint és molt feixuga i que força a compromisos entre tots.

Tots aquells que parlaven que la despesa sanitària creixeria indefinidament perquè hi havia factors incontrolables com l’envelliment i la tecnologia, han pogut contrastar que el món no s’ha aturat, malgrat tenir menys recursos, hem envellit més i millor i que tenim més tecnologia.

L’esperança de vida en bona salut ha augmentat en un període de 7 anys, entre 2005 i 2012 de 63 anys a 65,7 en homes, i en dones de 60,6 anys a 66,1. I a més a més sabem que en les dones la proporció d’anys viscuts en bona salut ha augmentat 5 punts percentuals, de 72 a 77%, i que en homes només ho ha fet en un punt, de 81 a 82%. En qualsevol cas en termes marginals i en termes absoluts hi ha una millora substancial. Ningú no hauria estat capaç de preveure canvis d’aquesta magnitud. I fins i tot molts haurien associat amb lleugeresa la disminució del PIB a un menor nivell de salut. Per tant, jo avui no em dedicaré a fer previsions.

El que si que podem fer avui és saber on som, i comprendre millor quin és l’equipatge necessari per al trajecte cap a una millor salut poblacional i individual, cap a un major benestar. La qüestió fonamental al darrera de tot debat de política sanitària és com assolir un millor nivell de salut per a la població i com reduir les desigualtats en salut existents. Podríem també dir-ne en termes estadístics, com augmentar la mitjana i reduir la variança.

I davant del risc d’emmalaltir podem preguntar-nos fins a on arriba la responsabilitat individual i col.lectiva amb la salut. És possible atribuir-ne una responsabilitat?

Resumint-ho molt, la salut depèn de les nostres decisions i comportaments, de factors econòmics i socials, factors físics i mediambientals, de l’assistència sanitària i de la genètica. Quina part correspon a cadascun és complexa d’esbrinar. Un professor de Wisconsin, David Kindig al que segueixo habitualment, sitúa el pes dels comportaments en un 30% del total (decisions individuals). I sabem que fins i tot, en la genètica podem influir en la mesura que els nostre hàbits condicionen també generacions futures, l’herència epigenètica és font d’expressió del genoma dels nostres descendents.

Si el nivell de salut és fruit de tots aquests factors que alhora depenen de cadascú de nosaltres i de la col.lectivitat, aleshores el paradigma clàssic de la producció, on hi ha un que ofereix els serveis –el productor, el sistema de salut- i un que els rep – el consumidor- es troba en lluny del que cal tenir en compte per tal de produir més salut.

I aquí comença el meu relat que pren com a referència 3 preguntes:

-què puc fer jo per la meva salut, la salut dels meus familiars i dels que m’envolten?

-què pot fer el meu país per la meva salut?

-quines eines ha de tenir el meu país per fer-ho possible?

Vull situar un apunt de prudència abans de començar, aquests tres punts obligarien com a mínim a una conferència cadascun. Per tant us prego que m’excuseu la brevetat.

Què puc fer jo per la meva salut?

El compromís amb la pròpia salut significa prendre decisions que contribueixen a mantenir-la i millorar-la. Hi ha riscos que podem evitar i és al nostre abast. La dificultat apareix en la mesura que “som persones humanes”.

La capacitat cognitiva humana ve impulsada per dos "sistemes": (Aquests "sistemes" no existeixen físicament, però el model funciona bé per explicar i predir fenòmens!)

- Sistema 1: funciona de forma automàtica i ràpidament, amb poc o cap esforç i sense sentit de control voluntari (Operacions automàtiques) .La majoria del temps, la nostra capacitat cognitiva ve impulsada pel sistema 1, i de forma prou eficient

- Sistema 2: dedica atenció activitats mentals que requereixen esforç (Operacions que requereixen control). Apareix quan les decisions o accions es tornen complexes i necessiten atenció, amb exigència de «concentració». És molt més lent. Daniel Kahneman.Thinking fast and slow, Penguin, 2012

Ambdós sistemes estan actius quan estem desperts.

• El Sistema 1 s'executa automàticament (sense esforç)

• El Sistema 2 es troba en mode de baix esforç, i només s’utilitza una petita part

• El Sistema 1 genera impressions, intuïcions, sentiments, intencions

• El Sistema 2 en general les accepta

• El Sistema 2 també controla contínuament el comportament.

Però quan el Sistema 1 es troba amb una dificultat, demana al Sistema 2 que l’ajudi:

- Quan es detecta un problema difícil

- Quan es detecta alguna cosa inesperada o improbable

- El Sistema 1 no es pot aturar. Funciona amb una heurística determinada i presenta biaixos.

Tot plegat pot representar un comportament allunyat de la racionalitat que el sistema 2 no necessàriament detecti. Una de les seves principals característiques és la mandra, el rebuig a invertir més esforç que l'estrictament necessari. Mentre no es detecta alguna cosa estranya, es limita a seguir les impressions del Sistema 1.

 Un dels descobriments importants dels psicòlegs cognitius en les últimes dècades és que canviar d'una tasca a una altra representa esforç, i especialment sota la pressió de la immediatesa

Si així es com funcionem, aleshores les estratègies que presuposen la presa de decisions racionals entren en contradicció. Sempre s’ha pensat des de les estratègies de salut pública que un individu ben informat, tractarà de prendre decisions que maximitzin el seu benefici de salut (i en això es fonamenten les actuacions en educació sanitària i difusió d’informació, necessàries però no suficients).

Però les persones humanes tenim molts biaixos cognitius en la presa de decisions, en destacaré només tres, que us sonaran familiars:

• Aversió de pèrdua: És la tendència de les persones a preferir, en major mesura, evitar les pèrdues, en comparació a la possibilitat d‘obtenir guanys.

• Prejudici o biaix de confirmació: És la tendència a buscar o interpretar informació d'una manera que confirmi les nostres pròpies preconcepcions.

• Ancoratge és la tendència humana comuna a confiar massa en la primera peça d'informació que s'ofereix ("àncora") en prendre decisions.

L’economia del comportament ha revisat el paradigma convencional del “consumidor racional” que satisfà els seus interessos, i busca explicar perquè som predictiblement irracionals. Sunstein i Thaler van formular en un llibre controvertit, en diuen “La petita empenta”, i resumint-ho molt em centraria en el que es coneix com arquitectura de l’elecció:

Cada situació d'elecció té una opció per defecte, explícita o no

• El valor per defecte és el que un seleccionador té quan decideix no fer res

• Quan demanem a les persones que trïin un element d'una llista, sovint és útil si l'arquitecte de l’opció especifica una opció per defecte que seria la millor per a la majoria de les persones, especialment aquelles que necessiten ajuda en l'elecció. Exemple: Els menus infantils i les opcions més saludables.

És èticament controvertida aquesta actuació? és paternalisme? Estic convençut que necessitem que ens ajudin, i ens cal saber més sobre com fer-ho. Sols, possiblement no ens en sortirem.

I aquí vull referir-me a la importància de l’estratègia poblacional en un moment que es fa un gran èmfasi en l'estratificació individual del risc. Ens convé apostar per l'estratègia poblacional de reducció de la taxa d'incidència de les malalties, i ens cal fer-ho mitjançant una millor regulació i uns millors comportaments, ambdues qüestions sobre esquemes renovats.

 Recordem Geofrey Rose un moment, a la paradoxa de la prevenció ens diu que “una mesura preventiva que ofereix molts beneficis a la població n’ofereix pocs a cada individu”, malgrat això Rose diu que no podem oblidar-nos d’actuar sobre els determinants de la incidència de les malalties. L’estratègia individual és insuficient. I una vegada sabem les nostres limitacions cognitives, ens cal reconstruir les estratègies de salut poblacional atenent a aquests nous plantejaments.

Per tant, som responsables de la nostra salut pel que fa a decisions i comportament, som responsables d'exposar-nos a riscos evitables, i alhora necessitem una petita empenta.

- que puc fer jo per la salut de la meva família i dels que m’envolten?

La implicació familiar i comunitària en la salut es troba també en el nucli de la millora de la salut. L’adquisició d’hàbits saludables comença a la família. El suport i afecte en cas de malaltia o dependència contribueix decisivament. A l’economia comportamental li preocupa el gregarisme, herd effect, perquè es troba en l’origen de moltes decisions per defecte que prenem. Som responsables doncs de contribuir a crear entorns saludables propers i d’evitar riscos extrems

- què pot fer el meu país per a la meva salut?

No sabem el dia que ens posarem malalts, ni quant costarà l’assistència, ni quant temps durarà la nostra malaltia. Ningú s’imagina al segle XXI que aquest risc pugui ser assumit individualment. A mitjans del segle passat, la majoria de països van començar el procés d’assumir aquest risc financer col.lectivament, és el que coneixem com assegurança social, la cobertura universal. Aquesta és una solució eficient a un problema que altrament no té resposta satisfactòria. En la mesura que el 1% de la població incorre en el 20% de la despesa sanitària anual, o el 5% incorre en el 50%, podem comprendre facilment que posar-se malalt en aquests casos suposaria ser pobre de solemnitat per tota la vida, del malalt i la seva família. Però fins i tot sense pensar en que un any podem ser dels que més gastem en el sistema de salut, considerem el cas d’avui mateix que han nascut nens i nenes La despesa mitjana total d’assistència sanitària – pública i privada- al llarg de tota la seva vida serà de 153 mil euros per les dones i 112 mil euros pels homes (sense tenir en compte els canvis en tecnologia i costos unitaris, dades actualitzades a 2014). Aquesta motxilla tant pesada només la podem assumir de forma col.lectiva.

Per tant, el primer de tot és preservar l’equitat en el finançament, i això s’assoleix mitjançant el mecanisme de l’assegurança social finançat fiscalment.

El segon aspecte a considerar del que pot fer el meu país per a la meva salut és tenir en compte com es distribueix la salut entre la població i que podem fer per millorar-ho. Cal tenir present l’equitat en la provisió. Tenint en compte que tenim dos aspectes, equitat horitzontal, tractar igual a iguals en determinada dimensió rellevant, en una zona geogràfica, mateixa necessitat-mateix accés i tractament, i equitat vertical, tractar desigual a desiguals, una distribució de recursos serà equitativa si en aquella zona geogràfica s’en destinen més a aquells que tenen més necessitat. Amb risc de simplificació diria un exemple, equitat horitzontal: garantia de temps màxim de llista d’espera igual, equitat vertical: priorització de la llista d’espera d’acord amb criteris objectius de necessitat i capacitat de benefici.

Estarem prou d’acord que en aquestes qüestions encara hi ha un llarg camí per recórrer. Un camí que és plagat de paranys que ens posem nosaltres mateixos en algunes ocasions. Admetre la priorització de recursos en base a necessitat i/o capacitat de benefici obliga a prendre decisions compromeses, que en algunes ocasions són més facils i assumibles que en altres. Equitat per tant no és exactament sinònim d’igualtat, ni solidaritat, malgrat que algú ho assimila amb massa facilitat.

El tercer aspecte és l’eficiència en la producció de salut, o com conseguir el màxim valor amb els recursos disponibles. Per tots aquells que tenen alguna reticència al concepte us diria, que des de l’economia ser eficient vol dir assignar recursos allà on podem assolir el màxim valor, i això en alguns casos vol dir reduir i en d’altres augmentar. L’eficiència no es refereix estrictament als costos, es refereix al valor, i per tant no hi ha eficiència possible sense tenir en compte un nivell de qualitat desitjable i assumible.

L’eficiència sorgeix dins de l’organització amb les múltiples decisions clíniques que es prenen, i també de les decisions de gestió, és clar. Eficiència també que sorgeix de la innovació en la tecnologia mèdica i de la informació.

Voldria distingir doncs algunes qüestions clau, del que podem fer per millorar l’organització. Les dues peces són: coordinació i incentius.

Coordinació que evita fragmentació i duplicitats, que obliga a posar-se d’acord i comprometre’s. Coordinació que obliga a proveïdors diversos a establir guies i trajectòries clíniques. Els darrers 12 anys he sigut testimoni d’excepció de l’esforç d’integració assistencial en el cas del Baix Empordà on he col.laborat en la recerca sobre la salut poblacional. Hem pogut publicar com la tasca realitzada en la direcció correcta aporta elevadíssim valor en salut malgrat les mancances en recursos.

La segona peça són els incentius, que ens obliguen a tenir en compte que quan prenem decisions també acceptem riscos, alhora que ens esforcem per assolir uns resultats. Cal compensar l’esforç diferencial, la uniformitat produeix “regressió a la mitjana”, i per tant no reconeix l’excel.lència i redueix oportunitats de millora. Jo sempre m’he preguntat quin és el motiu pel que cal ser majoritàriament funcionari per treballar al sistema de salut. De tota Europa, només Itàlia, Portugal, Espanya, Finlàndia i Suècia desenvolupen l’atenció primària en centres majoritàriament públics segons l’OCDE.

Amb tot això estic assenyalant que cal afrontar dues qüestions:

- un nou marc de desenvolupament de l’activitat assistencial i de l’organització on l’implicació professional estigui a l’arrel de la presa de decisions, on hi hagi assumpció de risc i responsabilitat, no només participació. El risc i la responsabilitat van aparellades al costat de qui assumeix la gestió de les entitats que proveeixen els serveis.

- i un nou sistema retributiu dels professionals de la salut que estimuli l’excel.lència i ajusti per aquells riscos fora del control dels professionals. No podem incorporar variables de les quals un no se’n pot fer responsable.

Però més enllà d’això, els incentius també sorgeixen de:

- mecanismes com la capacitat d’elecció. Si som capaços d’admetre que ens trobem davant pacients cada vegada més informats, també hem d’admetre en determinats casos que l’elecció es una mostra de preferència i per tant que en la mesura que sigui possible i acceptable acabarà en una major satisfacció de pacient i de professional. Ara bé, això també cal ajustar-ho i compensar-ho, altrament es produeixen desajustos inadmissibles.

- competència per comparació. Les publicacions de la central de resultats ens mostren variacions excessives dels indicadors que haurien de provocar una reducció dels intervals fet que fins ara no ha passat. La simple difusió d’informació és insuficient, cal ser valents i introduir mecanismes que evitin compensar per reingressos evitables o atenció inacurada. La competència per comparació és la que es dona en dimensions no-preu, per tant qualitat, i que porta implícita capacitat d’elecció cosa que no hi és per ara.

- professionalisme. Massa gent contraposa amb lleugeresa els incentius que provenen d’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 surt d’aquí. Malauradament, aquesta forma de pensar oblida el professionalisme3, al que Freidson atribueix “la tercera lògica”, més enllà de l’estat i el mercat. Qualsevol reforma sanitària que es plantegi al marge de la lògica del professionalisme restarà sense suport ampli. Un professionalisme entès més enllà de l’autonomia, considerant principis de comportament com els que Paul Starr i Paul Freidson han proposat:

- 1) altruisme: cal esperar dels professionals que en la resolució dels conflictes entre els seus interessos i els dels pacients es decantin a favor dels pacients

- 2) compromís de millora: cal esperar dels professionals l’aprenentatge i contribució als nous coneixements i la seva incorporació a la pràctica i

- 3) supervisió mútua; atesa l’especialització en el coneixement, els professionals cal que avaluïn el treball dels seus col·legues per protegir els pacients davant errors potencials.

- Aquesta perspectiva professionalista ens hauria d’obligar a reflexionar més enllà dels debats estèrils sovintejats. Fer les coses bé, i fer bé aquelles que cal fer, és la primera de les exigències i això obliga a un marc ètic professional que cal refermar. I cal refermar-lo perquè altrament el comercialisme fa via, i estic convençut que només més professionalisme evita més comercialisme.

L’eficiència que sorgeix de la innovació tecnológica en salut requeriria un capítol apart. Tant sols assenyalaré que malgrat els esforços en avaluació encara no som capaços de establir criteris clars sobre allò que aporta valor realment i quina quantia de recursos podem aplicar-hi. Més tecnologia no sempre és millor, i el sector salut acumula tecnologia i no la prioritza com caldria, és el que n’he dit recentment en un article el síndrome TMT, too much tecnology.

A les tecnologies de la informació hi hem dipositat moltes expectatives, però el sector salut és extraordinàriament lent en adoptar-les. El 2009 teníem 51,1 milions de visites d’atenció primària, el 2013: 45,1 milions, 6 milions menys, això és moltíssim. No podem atribuir total la reducció del 12% a la recepta electrònica però sens dubte hi ha contribuit. I les alternatives a la visita presencial haurien de ser objecte prioritari d’atenció. La forma com s’organitzen les tasques ha de tenir en compte tots aquest desenvolupaments, una altra forma de treballar. Per cert hem reduit 6 milions de visites sense cap copagament, no afegiré res més.

- quines eines ha de tenir el meu país per fer-ho possible?

Aquesta és una qüestió cabdal, de què ens servirà saber el que cal fer si no tenim les eines d’un estat per fer-ho?

Permeteu-me dir-vos que a mi no em fa por anar a l’hemeroteca, i vull mostrar-vos el que vaig dir ara fa una dècada, si l’any 2004 en un article a Annals de Medicina que es titulava, “D’on no n’hi ha no en pot rajar, repensant l’atenció i el finançament sanitaris”.

“La contradicció està servida. Si Catalunya té més renda que la mitjana espanyola, apareixerà una tensió social per gastar més recursos. Si els recursos es reben en funció de la població, és a dir la mitjana espanyola, aleshores no es pot tancar de cap manera el cercle. La despesa sanitària pública catalana no podrà augmentar si no es modifica el seu finançament autonòmic i, en la meva opinió, si no s’estableix un sistema equivalent al concert econòmic basc i navarrès. De no resoldre’s així, la sortida natural passarà per un progressiu deteriorament de les infrastructures, fallida econòmica i, per defecte, augment de la despesa sanitària privada. Provar qualsevol altra estratègia representa posar pedaços i propines, una estratègia que des de fa 23 anys s’arrossega i que s’ha mostrat insuficient. Cal un sargit profund d’aquesta situació, que només pot oferir el concert econòmic per a Catalunya.

Malauradament, la societat catalana no és encara prou conscient d’aquest fet. I els polítics reflecteixen aquest estat d’opinió. Molts pensen que la Generalitat hi ha de dedicar més recursos i que cal demanar més almoina (crèdits extraordinaris). El problema és molt més de fons i no observo la preocupació en aquesta direcció.

Els propers mesos seran decisius per a debatre la inclusió del concert econòmic en el marc del nou Estatut d’Autonomia. En la mesura que la despesa sanitària representa una tercera part del pressupost de la Generalitat, deixar d’incloure el concert econòmic com a mecanisme de finançament suposa equivocar-se com a mínim en un terç del problema.”

I així va ser, no hi va haver concert econòmic i som on som. Han passat deu anys, que haurien pogut ser molts menys i el benestar dels ciutadans hauria pogut millorar substancialment. Es el cost d’oportunitat que socialment hem de pagar per no haver encertat en un consens que alguns consideràvem imprescindible i que ara una majoria ja el situa en un altre entorn molt més fonamentat.

És per això que si ara hagués d’escriure novament l’article ho faria esperançat. “Encara que no n’hi ha, en pot rajar”, aquest seria el títol. Ho dic sincerament. El país s’ha adonat que la construcció del benestar col.lectiu i individual passa per un nou marc polític on ens permeti satisfer els nostres anhels i desitjos, que en salut passen al final per més esperança de vida en bona salut.

Les entitats clau del país representades al Consell del Servei Català de la Salut han fet un esforç per posar-se d’acord sobre el sistema sanitari que volem, el que vam anomenar Pacte Nacional de Salut, i que de bon grat vaig coordinar. El mes de març passat vam presentar-lo al Parlament. Si bé és cert que van desmarcar-se al darrer moment els grups polítics que no donaven suport al govern-se així com sindicats, també ho és que el document final incorpora elements seus perquè la majoria hi van contribuir decisivament.

Vull dir-vos la meva impressió: més enllà de l’escenificació política no vaig saber veure projectes ni propostes alternatives allunyades que no poguessin ser objecte de debat. És per això que crec que el consens és possible i és necessari. La ciutadania reclama que els serveis de salut estiguin a l’alçada del segle XXI, i per això seria un profund error que en un moment que ja tenim aprop on poguem decidir sobre el sistema de salut no arribéssim a un consens. Les reformes exitoses només són possibles amb consens, només quan la salut i benestar dels ciutadans es posa per davant de qualsevol lluita partidista.

Us convido que llegiu el document del Pacte Nacional de Salut aquells que no el conegueu, i com bé us podeu imaginar, alguns voldríeu més concreció i d’altres el trobareu insuficient. És tant sols un punt d’arrencada.

Hem viscut les passades tres dècades amb una ficció en la política sanitària, hem sentit a parlar sovint de que teníem competència plena en la sanitat. Tant sols un cop d’ull als detalls us pot convèncer que justament hem assolit molt millor salut sense tenir-ne la clau mestre que obre totes les portes. La clau mestre que no hem tingut té quatre vessants:

- la primera és la regulació del finançament. No hem pogut decidir sobre quants dediquem dels recursos fiscals al sector salut, la quantia ha vingut restringida per un sistema de finançament autonòmic premeditadament asfixiant, com diria Trias Fargas.

- la segona és la regulació de les professions. La pedra angular de tot sistema de salut resideix en professionals que en la seva quantia i la seva qualitat i talent són els que necessita un país. No hem pogut decidir sobre això en tots aquests anys, i hem anat a remolc d’un sistema desfasat, desplanificat i desajustat entre oferta i demanda. Avui ens trobem en un moment crític per resoldre-ho, el compte enrera s’ha iniciat i personalment vull dir-vos que de tot el que he dit és el que hem preocupa més. Només si som capaços de decidir sobre això podrem redefinir millor les tasques i papers dels professionals al sistema de salut.

- La tercera és la regulació de les prestacions. En tots aquests anys hem assumit amb el finançament existent la introducció de noves tecnologies, sense poder decidir sobre la seva oportunitat i valor. La incorporació de noves tecnologies s’ha produit en un entorn poc transparent. Si avui us pregunteu quin és el preu dels nous medicaments i com es fixa hi hauria motius per la preocupació.

- La quarta es la regulació de la salut pública, fonamentalment salut internacional i global, però també per exemple aspectes de política alimentària i mediambient. En un món globalitzat, el control del reglament sanitari internacional ha d’estar al nostre abast.

Podria detallar-ho més però, deixem-ho aquí. Hem construit la política sanitària i un nou sistema de salut sense la clau mestre, i això té molt de mèrit. Hem d’estar satisfets dels resultats en salut i alhora compromesos en la seva millora. Hem de conèixer els punts forts i febles que tenim, preservar allò que funciona, canviar tot allò que calgui en la mesura que augmentem l’eficiència i l’equitat del sistema de salut.

En el fons, ja ho he dit al principi, el futur el construim tots, cada dia que passa. Ens equivocaríem si pensessim que els reptes actuals de la política sanitària són cosa tant sols dels polítics, el compromís ciutadà i el compromís professional hi tenen molt a dir. És doncs el moment de compartir i aprendre de l’experiència de tots per tal d’afrontar un futur encoratjador.

Sunday, November 23, 2014

Depression and the burden of disease

The burden of disease in Catalonia, Spain, using disability-adjusted life years (2005-2010)

Depression ranks at the top of the burden of disease in Catalonia measured in DALYs (men 5.7% of total, while women 11.5%) .It is one of the most significant public health problems in the 21st Century.
The current situation requires a closer assessment and intervention. Patients impact and on families and relatives of patients is huge. Next Tuesday The Economist organises a conference on this topic with top speakers from around the world. A good opportunity to review the current situation.

Saturday, November 22, 2014

A new frame for measuring hospital efficiency and productivity

Observatori del Sistema de Salut de Catalunya. Central de Resultats. Àmbit hospitalari. Barcelona: Agència de Qualitat i Avaluació Sanitàries de Catalunya. Departament de Salut. Generalitat de Catalunya; 2013

The knowledge about the performance of our health care system is growing every day. It was difficult to foresee such a big change in transparency. Therefore, this is good news.
In the recent released report on hospitals, you'll find many detailed indicators and you can figure out how your hospital is performing according to several dimensions. There is on dimension that needs to be rebuilt, it's called "efficiency" in the report. As far as DRGs are a tool that was created three decades ago and only minor changes have been introduced, any comparison of length of stay by DRG is old fashioned. Measuring production by UME, (unitat de mesura estandarditzada) is another outdated measure. And resulting productivity measures include these biases. Thus, some additional effort should be made to measure efficiency in hospitals, in its services, as the aggregate makes a lot of noise.
Let me suggest a  book by Yasar Ozcan, although it is focused on DEA, maybe some ideas could arise. The basic reference is Measuring Efficiency in Health Care  Analytic Techniques and Health Policy.
An improvement of efficiency measurement is the next step to be taken.

PS. Today is one of the saddest days of the democracy. Spain has filed criminal charges over the president of our government and two ministers.This fact represents a lost opportunity to negotiate our exit. From now on, we enter in "terra ignota", things will be tougher.

PS. Two recommended books to understand what's going on: Constitutional violence, (especially chap. 4 legal violence) and Globalization and sovereignty

PS. Newsfeed, here.

Friday, November 21, 2014

A call for a political prescription to tackle obesity (2)

Overcoming obesity: An initial economic analysis

Some days ago, I was asking for a clear determination to our politicians to fight against the obesity epidemics. How? The just released McKinsey report provides 44 measures to implement and its potential impact. Have a look at it, and you'll be convinced that all we need is political will, social consensus and individual commitment to overcome this crucial issue.

Thursday, November 20, 2014

Fracking, No Thanks

The Real Cost of Fracking: How America's Shale Gas Boom Is Threatening Our Families, Pets, and Food

Can you imagine a country of 7.5 million citizens that their Parliament agrees to forbid fracking and only 12 judges may decide that this agreement is illegal?. This is just what has happened again.
Last June I explained the health related damages of fracking in this post, today I would like to draw attention to this book: The Real Cost of Fracking: How America's Shale Gas Boom Is Threatening Our Families, Pets, and Food where you'll find detailed explaination of what happens in practice if the government allows such a practice in your neighbourhood. More details in Slate:
In The Real Cost of Fracking, we learn about David, a 14-year-old boy who came down with a mysterious illness shortly after the start of nearby fracking operations. David had arsenic and phenol (a metabolite of the carcinogen benzene) in his blood. When he went to live with friends, the symptoms subsided. But when he returned home to play with his animals, the symptoms came back, even sending him to the hospital again.

We also meet Claire and Jason Wasserman. One day, Jason was outside near a well that was being flared, and he got a nosebleed that stopped after a little while. But the next morning, he went into the bathroom and yelled for Claire. Blood was gushing from his nose. Claire told him to tilt his head back and pinch his nose. But then blood started coming out of his eyes. “Close your eyes! Close your eyes!” she screamed. Then blood came out of his ears.
The moment to disconnect and avoid such damaging extracting strategies for individuals and the landscape has arrived, the Parliament has to enforce its own decision.

Wednesday, November 19, 2014

A call for a political prescription to tackle obesity

A political prescription is needed to treat obesity
Why Nudge?

Unless there is harm to others, the government cannot exercise power over people. This is the John Stuart Mill's "Harm principle", sometimes called the Liberty Principle. And governments have taken as given that individuals always take decisions in a rational way, fulfilling their preferences. As Cass Sunstein says in his last book "Why Nudge?", such a principle "raises serious doubts about many laws and regulations. Sometimes power is exercised over people in large part to promote their own good, finally people are note entirely sovereign over their body and minds". He argues in favour of paternalism in certain circumstances. We have already explained such details formerly in this blog.
Today I would like to suggest a reading to you, an excellent editorial in the Canadian Medical Association Journal. It is a call for action on obesity and specifically on food policy and taxation on sugar-sweetened beverages.

Our current approach to obesity relies on the assumption that people have choices, often fail to make the right ones, and should be educated and helped to make better choices. This view is simplistic and clearly absurd, given the continued rise in the prevalence of obesity in countries that have been tackling the problem for decades. Are millions of people really choosing to be overweight?

People are not as free to choose as we would like to believe. Neurobiological desires for sweet and high-fat foods gave humans a survival advantage in a world where food was scarce and every calorie counted. Where food is inexpensive and easily available, biological processes related to eating can mirror addiction and will lead to our destruction. We need to change our approach. We need incentives beyond educational messages. Strategies that include individual interventions,  school-based nutrition and activity interventions, incentives for active commuting and changes to the built environment should continue; however, we also need robust ways to restrict portion sizes and reduce the sale of sugar-sweetened beverages and other high-calorie, nutrient-poor food products. Our government needs to consider taxation as a tool to combat the consumption of these addictive foods and beverages, just as it regulates the sale of alcohol and tobacco products for the purposes of population health.
In USA, Berkeley is the first city that will intoduce the soda-tax after a recent ballot. Berkeley’s Measure D proposed imposing a 1-cent-per-ounce general tax on sugar-sweetened beverages and sweeteners used to flavor drinks. The measure will not dedicate funding to a specific cause and did not require only a majority of the vote.
I still remember how a similar measure was discarded some years ago in our country. The times to reconsider the introduction of a soda tax are coming.

Tuesday, November 18, 2014

Drug pricing 101 (2)

The New Drug Reimbursement Game. A Regulator’s Guide to Playing and Winning

In my former post I was backing a complete review of current drug pricing regulation. Any official that has to perform this task needs some fresh ideas and knowledge and this is precisely what a new book provides. In The New Drug Reimbursement Game by Brita A.K. Pekarsky you'll find the economic foundations for a new drug pricing regulation.
The basic argument:
Higher prices today mean increased economic rent for the pharmaceutical industry (Pharma) otherwise firms would not lobby for them. It is in Pharma’s interest to protect and seek these economic rents. Whether higher prices and more R&D today increase future health remains an empirical question. If higher prices also mean a higher net present value of the population’s health, then it is in the institution’s interest to increase prices. Given the institution’s objectives, the most effective strategy Pharma can use to protect these rents is “the Threat”: lowering prices is against the interest of health funders because it will reduce a population’s future health.
 The regulator’s challenge is to answer the following question:
• “How should rational institutions respond to the Threat?” (A rational response is one that is consistent with a given institution’s stated objective function, whatever this may be.)
This introduction places this research question in the context of current evidence and research, by addressing the following three questions.
• Is it plausible that the Threat exists and that it influences the price of new drugs?
• Is there rigorous empirical evidence that suggests that lower drug prices will result in reduced future health?
• Are economists in agreement as to the value of a decision threshold for new  drugs that accommodates characteristics of the health budget such as allocative and technical inefficiency?
And the conclusion:
When the Institution buys this new drug, it buys the health effects from this drug and the health benefits from future innovation. This is not the case with other health programmes. Therefore, unless the Institution pays a premium for the health effects from the new drug, the population will be worse off because innovation will be suboptimal and the future drug will not be produced.
Unfortunately, when you get to the end you'll miss any consideration about what innovation means. If you look at recent patterns of effectiveness of new drugs, you'll see that the value of innovation is under scrutiny, and most drugs would not pass the test. In my opinion, the regulator has to send signals about the value of health improvement in certain diseases and pharmaceutical companies should focus R+D on such fields and avoid others.
Therefore, a new companion to this book should be written. This is only a regulator's guide to play, but not to win. Take it only as a starting point.

PS. Just FYI, you'll not find the term "Budget impact analysis"  in the book, a close term Programme budgeting marginal analysis PBMA is what you'll find. It is suggested a price effectiveness analysis as a previous requirement for any PBMA, otherwise it makes no sense. This approach seems quite different to  yesterday's news.

Thomas Piketty speech at UPF Oct 2014, it starts at min 8:10. My post, last May.

Friday, November 14, 2014

Drug pricing 101

In his book "Reinventing the bazaar. A natural history of markets", John McMillan says:
Market design consists of the mechanisms that organize buying and selling; channels for the flow of information; state-set laws and regulations that define property rights and sustain contracting; and the market’s culture, its self-regulating norms, codes, and conventions governing behavior. While the design does not control what happens in the market—as already noted, free decision-making is key— it shapes and supports the process of transacting.
If we look at the pharmaceutical market, there are unique features. The government role is at the same time the "market designer" and mostly the monopsonist. The price setting mechanism relies on multiple regulations that evolve according to circumstances. For example, since 2012 there has been no information about patented drug prices accepted for public funding. It sounds quite weird in a moment that everybody is proud of boosting transparency. The debates over the new pricing decree are still more strange. The current mess was explained some months ago in this op-ed. The uncertainty now also embraces pharma-distribution, pharmacists complain about the system.
Such a pricing system is explained in  this presentation (details about pricing in p.6). As far as it is unsatisfactory for everybody, it needs to be rebuilt. My suggestion is that there is a need to start from scratch. John McMillan would say that we have to look for a clever market designer to reinvent drug pricing as soon as possible.

Tuesday, November 11, 2014

Is this the end, my friend?

The last 25 years of publicly funded health care have been marked by the unique ownership structure known as consortium. Consortia allowed a joint venture between ancient non-profit hospitals created by civil society and the public administration. The underlying rationale for such an ownership structure is strictly related to capital investment demand. Since non-profit foundations could not raise enough funds to fulfill new techonology and population health needs, the public sector funded new investments and participated in the boards of directors.
These sounds quite normal, it is a historic evolution and has a clear and common sense argument. However, public sector has not been able to include depreciation and replacement costs in the tariff and this has created greater need for resources.
Unfortunately, those consortia that had management autonomy and public administration in the boards are now being dispossessed from its original owners -the non-profit foundations- and being converted into public organizations.
This is a clear social plundering commited by the spanish Parliament in a recent law. You may have more details in this article (check p.46).
Is this the end? I think so, unless there is a clear mandate to change current regulation. Its impact maybe enormous: disappearing boards of directors, employees converted into "de facto" civil servants and its equivalent remuneration, and the most important: there is no reverse gear.
It is worrying how politicians can accept such a loss of dynamic efficiency before their very eyes. It is unacceptable that social created capital can be plungered this way. Politicians can stop the end of consortia, they should stop it.

PS. Two years ago I was blogging on the same topic. Unfortunately all the alerts were neglected.

PS. Must read, on ebola by I. Hernández.

Monday, November 10, 2014

I've already said that

It is really saddening to explain the same thing again and again. Seventeen years ago I explained the regulatory mess of parallel trade of drugs in Europe. I did it in an article in Información comercial española (unfortunately not available on internet). Two years ago, I insisted on the same disaster in this post.
Now you can see how mafia style practices of well known drug distribution companies were applied, have a look a this news. Surprisingly (!), there is no specific crime in the penal code for such practices.
I said that arbitragists were accumulating impressive amounts of money with international parallel trade and refusing to supply drugs to local pharmacies.It is quite astonishing that it took so long to understand it for justice. Is there anybody doing something to prevent such practices in the future? Where are politicians? On vacation again?.

PS. The government should cancel the license to these drug distribution firms immediately and ban any possibility of a new license in future. This can be done easily without waiting for any european directive.

PS. WSJ: What Catalonia's independence vote means