The challenge of setting fair priorities

Public views on principles for health care priority setting: Findings of a European cross-country study using Q methodology

The clash between equity and efficiency is featured nowadays with hepatitis C drugs. High prices mean that access requires some kind of prioritisation. An interesting article may help to understand it:

 Resources available to the health care sector are finite and typically insufficient to fulfil all the demands for health care in the population. Decisions must be made about which treatments to provide. Relatively little is known about the views of the general public regarding the principles that should guide such decisions

The tension between equity and efficiency in the health care sector is apparent in a range of routine decisions and practices. For instance, in the prioritisation of patients on a waiting list, the aim to maximise overall health benefits from treatment may be at conflict with that of obtaining an equitable distribution of health and health care.

 Now ask yourself about the following principles to allocate health resources:

(I) “Egalitarianism, entitlement and equality of access”;

II) “Severity and the magnitude of health gains”;

(III) “Fair innings, young people and maximising health benefits”; 

(IV) “The intrinsic value of life and healthy living”; 

(V) “Quality of life is more important than simply staying alive”.

 Are you able to set a ranking? Does a general ranking of priorities always apply to all cases?. Not so easy. This is exactly what they do in the article and the results are:

Given the plurality of views on the principles for health care priority setting, no single equity principle can be used to underpin health care priority setting. Hence, the process of decision making becomes more important, in which, arguably, these multiple perspectives in society should be somehow reflected.

Let's think about the somehow...

PS. Sofosbuvir vs. NICE . And the winner is?

The satisfaction paradox and the need for a dose of realism

A paradox is a "situation that is made up of two opposite things and that seems impossible but is actually true or possible". This is exactly what is happening to satisfaction with health services in times of economic recession. Everybody would think that less budget damages satisfaction perception. What's going on is exactly the opposite. Satisfaction with health services is increasing (from 79% of people satisfied with the public system in 2006 to 88% in 2013). And this is also happening in the UK, John Appleby et al. from King's Fund say:

Overall public satisfaction with the NHS increased to 65 per cent in 2014 – the second highest level since the British Social Attitudes survey began in 1983. Dissatisfaction with the service fell to an all-time low of 15 per cent.

One interpretation of the increase in overall satisfaction for the NHS is that it is likely to reflect a vote of support for the NHS as an institution in difficult times. A lack of objective improvement in NHS services and the fact that improvements in satisfaction appear to have been driven by an 11 percentage point increase in satisfaction among Labour supporters and those without recent contact with the service, may lend weight to this analysis. This may especially be the case given that some see the NHS as currently under threat, for example from privatisation, and some feel ministers and others have been too critical of the NHS and its staff.

Official measures of performance tell a different story: NHS funding has been under increasing pressure since 2010 and there have been well-publicised performance problems with high-profile targets such as the 4-hour A&E waiting time standard and the 18-week maximum wait from referral to treatment. At the same time, the media has featured negative stories about the financial position of NHS hospitals and the need for additional investment in the service.

This context suggests a possible alternative explanation for the increase in satisfaction in 2014. We know that what drives changes in satisfaction is not straightforward – and almost certainly is never simply satisfaction with the NHS per se, for all respondents to the survey. Political beliefs, attitudes towards the government of the day, media stories and expectations of the NHS will shape people’s satisfaction.

So, while satisfaction improved in 2014, this is not necessarily synonymous with an improvement in the actual performance of the NHS, nor does it simply reflect an actual improvement in satisfaction. Nevertheless, it is clear that public satisfaction with the NHS and support for it as an institution remains high.

I suggest you have a look at the report. Satisfaction is a different dimension from performance, good point. If overall performance is based on healthy life expectancy, then the conclusion for us would be the same. We have increased healthy life expectancy all these years.

Those that complain about austerity want to forget such results. Also journalists. They don't figure out that the issue is a balanced budget and cutbacks have not been applied on an ideological foundation as some pretend. Anybody can blame over budget cuts, but immediately they would have to understand what they would do at home if their income is 7 years less than  before (2013 GDP per capita is less than those in 2006!!!). For sure they would return to an expenditure level simliar to previously,  in one way or another. Can anyone defend that these are ideological budget cuts at home?.
You can't live permanently in increasing debt, I'm satiated of cheap populism. A dose of realism is required.

PS. As you may notice, realism begins after reading the data, but you have to read them.

Stratified medicine in Europe

Stratified medicine in European Medicines Agency licensing: a systematic review of predictive biomarkers

The potential of predictive biomarkers for the development of stratified medicine has been highlighted for more than a decade. The current situation is very concrete. In Europe, EMA has accepted 49 biomarker-indication-drug combinations over 16 years, mostly used in cancer and as a predictive of drug efficacy, and in a minor scale of drug toxicity (4 cases).
These data confirm that currently the new wave of "personalised" or stratified medicine is really minor, although the investments and return expectations are huge.

Given the large body of literature documenting research into potential predictive biomarkers and extensive investment into stratified medicine, we identified relatively few predictive biomarkers included in licensing. These were also limited to a small number of clinical areas.

 Just released

Healthy behavior strategies

Healthy Behavior Change in Practical Settings

This is the article to read today. If you don't have enough time, have a look at this figure and ask yourself if you can apply it.

PS. Afterwards you may fill the questionnaire (Article 4) to check your understanding.

Psychological wellbeing and health

Subjective wellbeing, health, and ageing

What is the relationship between wellbeing and age?. This is precisely what this article tries to disentangle considering three types of subjective wellbeing:

• Evaluative wellbeing: evaluations of how satisfied people are with their lives
• Hedonic wellbeing: feelings or moods such as happiness,sadness and anger
• Eudemonic wellbeing: judgments about the meaning and purpose of life

Is it possible that positive subjective wellbeing is a protective factor for health?
Their conclusion:

Research into subjective wellbeing and health at older ages is at an early stage. Nevertheless, the wellbeing of elderly people is important, and evidence suggests that positive hedonic states, life evaluation, and eudemonic wellbeing are relevant to health and quality of life as people age. Health-care systems should be concerned not only with illness and disability, but also with supporting methods to improve positive psychological states.

Do you have any clue of how to do it?

Deciding by default

Choosing Not to Choose. Understanding the Value of Choice

The core of the application of behavioural economics to decision making on health lies in my opinion in choice architecture. I explained that 2 years ago in this post. Now Cass Sunstein is providing us with a new book that shows the details and rules for "choosing no to choose", a must read.

The choice among impersonal default rules, active choosing, and personalized default rules cannot be made in the abstract.To know which is best, both choosers and choice architects need to investigate two factors: the costs of decisions and the costs of errors (understood as the number and magnitude of mistakes). An understanding of those kinds of costs does not tell us everything that we need to know, but it does help to orient the proper analysis of a wide range of problems.
It should be obvious that a default rule can much reduce the costs of decisions. When such a rule is in place, people do not need to focus on what to do; they can simply follow the default. But a default rule can also increase the costs of errors, at least if it does not fit people’s situations; it can lead them in directions that make their lives go worse.

In approaching the underlying issues, he shows five propositions. I'm right now in the middle of the book. I can't have a final opinion, however I'm sure that this will be a key reference for the future.

Knowing what works

A systematic review of barriers to and facilitators of the use of evidence by policymakers

Evidence-based health policy should be grounded on knowledge on what works. Too often we see that policy-maker decisions' are far from that. Understanding why, is the first step to fixing it. In this article you'll find a systematic review on this topic:

The most frequently reported barriers were the lack of availability to research, lack of relevant research, having no time or opportunity to use research evidence, policymakers' and other users not being skilled in research methods, and costs . The most frequently reported facilitators also included access to and improved dissemination of research, and existence of and access to relevant research. Collaboration and relationships between policymakers and research staff were all reported as important factors.

Incentives, a modern frame (2)

Ética de los incentivos a profesionales sanitarios

Revisitng this report released 5 years ago, and comparing some statements with a former post, I can find relevant differences. Though this one is applied and the former is more general, the perspective is focused on having clear answers to specific problems. The definition, appropriateness and foundations of the argument requires deeper elaboration, in my opinion. That's why I suggest you should read the book.

Incentives, a modern frame

Strings Attached: Untangling the Ethics of Incentives

I've found extremely appealing the chapter 2 of the book "Strings Attached", it helps to understand the etimology of incentives as a word in the english language and its meaning:

For more than 250 years, starting in about 1600, the word “incentive” meant “inciting or arousing to feeling or action, provocative, exciting.” Uses cited by the authoritative Oxford English Dictionary include: “The Lord Shaftesbury . . . made an incentive speech in the House of Lords (1734),” or “This Paper is principally designed as an incentive to the Love of our Country (1713).” The last example cited of the term in this sense is dated 1866 and, like the others, it comes from an English source. Then there is a striking change. “Mr. Charles E. Wilson . . . is urging war industries to adopt ‘incentive pay’—that is, to pay workers more if they produce more.” This is the first example from the same dictionary of the use of the term in its contemporary sense, and it is an American example dated three quarters of a century later in 1943.

There is a huge gap in time, place, and meaning between the two sorts of citations, a gap that introduces several puzzles. What was happening in America when the new meaning of incentives was introduced? Why is this conception missing from the vocabulary in the seventeenth and eighteenth centuries, the very years in which the idea of a market economy was being discovered and articulated? We are accustomed to believe that our thinking about political economy rests on the work of the likes of John Locke, Bernard Mandeville, Adam Smith, David Hume, Jeremy Bentham, James Mill, John Stuart Mill, and the authors of The Federalist Papers. But with very few exceptions, “incentive” does not appear in any of their writings.

Beyond chapter 2, the whole book deserves to be read.

Data, data, data

That's the buzzword: big data. You'll find it in the top articles of 2014 in Health Affairs or in the Forbes Health Care Summit. This summit is where to go if you want to know what's going on in health care in the US, otherwise you cuold have a look at the video. Wether this is really going to create more value widely still remains to be seen.

The politics of calories

Why Calories Count

Marion Nestle says in her book:

In some ways, the calorie environment could not have been more brilliantly constructed to overcome physiological controls of overeating.

The new labeling initiatives have been really minor up to now. Wether they will have beneficial effects in the long run is still unknown. Calorie labeling should be extended when eating outside home and to alcohol.
The government has not paid enough attention to food regulation and specially to information about calories. In the book there is a guide for improvement. This is the previous step in any nudging effort. To be clear, information disclosure is the very beginning of any consumer protection and health promotion policy in this field.

The pivotal role of MSF in global health

Life in Crisis: The Ethical Journey of Doctors Without Borders
MSF: how a humanitarian charity found itself leading the world’s response to Ebola

I've just finished reading a book on MSF, a compelling story of more than 4 decades of support in health and humanitarian crisis.

Life in Crisis tells the story of Doctors Without Borders/Médecins Sans Frontières (MSF) and its effort to save lives on a global scale. Begun in 1971 as a French alternative to the Red Cross, MSF has grown into an international institution with a reputation for outspoken protest as well as technical efficiency. It has also expanded beyond emergency response, providing for a wider range of endeavors, including AIDS care. Yet its seemingly simple ethical goal proves deeply complex in practice. MSF continually faces the problem of defining its own limits. Its minimalist form of care recalls the promise of state welfare, but without political resolution or a sense of well-being beyond health and survival. Lacking utopian certainty, the group struggles when the moral clarity of crisis fades. Nevertheless, it continues to take action and innovate. Its organizational history illustrates both the logic and the tensions of casting humanitarian medicine into a leading role in international affairs.

Their achievements are really impressive and nobody can imagine what could have happened this year with the Ebola outbreak without them. To understand their contribution I would like to recommend the article in BMJ:

 The charity had a team in Guinea when the outbreak began in March and has followed the virus as it has spread—building treatment centres in locations as disparate as the jungle and capital cities, deploying mobile units, providing technical support to governments, and training staff. Today MSF has more than 3400 staff on the ground (with one international staff member for every 10 local staff members) and says that it has cared for almost 4000 patients confirmed to have Ebola and many more suspected cases.

 We all have to appreciate their enormous work in such a difficult conditions and their example offers a good guide to understand that beyond governments, well organised nonprofit institutions play a critical role in supporting public health.

PS. I am quite concerned about the nurse's behaviour in the spanish ebola case. Yesterday she admitted that she hadn't told the physician about her exposure to an ebola case. This situation has strong ethical implications, does anybody care about it?

The growing evidence on compression of morbidity

Health, functioning, and disability in older adults—present status and future implications

There is currently a wide debate about chronic care and multimorbidity. Some messages appear that this is strictly connected with ageing, and forget the details. Though disease process have to be tackled, we have to ask ourselves about wellbeing in later life. A key issue is to understand its impact on functioning and disability. This is precisely what a recent article in The Lancet offers. The research question:

Will the years gained be productive and healthy, or will elderly people live longer lives in conditions of ill health? Three main hypotheses have been proposed to address this question.² The compression of morbidity hypothesis posits a situation for which the age of onset of morbidity is delayed to a greater extent than life expectancy rises, thereby compressing morbidity into a short period at a late age.³ The expansion of morbidity hypothesis maintains the opposite, that increases in life expectancy are matched or exceeded by added periods of morbidity.⁴ Both compression and expansion of morbidity could happen in absolute or relative terms—ie, changes in the absolute number of years lived with disability—or in terms of healthy life expectancy as a proportion of total life expectancy.

And a conclusion:

 Our systematic examination of the scientific literature shows that support for morbidity pattern hypotheses varies mainly according to the type of health indicator. Disability-related or impairment-related measures of morbidity tend to support the theory of compression of morbidity, whereas chronic disease morbidity tends to support the expansion of morbidity hypothesis.

This is an article to read and file for the future. The basic approach is defined, the difficulty is about the data. My impression is that we need to use morbidity adjusted life expectancy measures, as those I presented in this blog some months ago. The advantages are clear compared to healthy life expectancy that needs a lot of hypothesis and are based on surveys and self perceptions. Morbidity adjusted measures use  disease codes directly. Why not apply them widely?

PS. The whole series on ageing in The Lancet.

Fasten seat belts (3)

My former posts (1) and (2) alerted about the end of drug pricing as we have known and the begining of an opaque world where nobody knows how much money is involved in getting the value of a specific drug, except the manufacturer. The rationale for that are the confidential agreements between governments and drug firms. Up to now have been seven risk-sharing agreements, and beyond these, central government has set up additional five agreements. This latter agreements are really open-ended budgetary ceelings because it is difficult to estimate when the maximum amount is reached. This is precisely what it is explained by the official in charge of this issue in the journal.
Therefore we have changed the pricing system for an opaque open-ended budgetary ceeling system. It sounds incredible, but that's how it is. I can't believe that nobody worries about it.

PS. Genes and behaviour, on TE. I posted the initial research three years ago in this blog.

Health care under civil conflict

Current situation in Syria deserves a better understanding and international support. Beyond the refugee crisis there is a huge health tragedy:

More than 12 million people are impacted by the violence, with 7.6 million people displaced inside the country and more than 3 million displaced in neighboring nations. Some refugees live in formal camps, but the majority are living in Jordan, Lebanon and Turkey. Refugees have also fled to Egypt and Iraq, and many remain inside Syria but have had to leave their homes. Many have also been affected by the terrorist Islamic State group.

A difficult moment, and things may get worse. I would like to suggest a look at this documentary from PBS Frontline:  The Rise of ISIS in english and in catalan here until Jan 18th.

Involved in our own health

People in control of their own health and care

 From King's Fund report:

Different perspectives (p.11)

• A consumerist approach: health and health care is seen as a marketplace in which patients (consumers) are involved by making choices about services, and the health care market responds to their preferences. Patient involvement is then a means to improve quality.
• A democratic approach: people have political, social and economic rights as citizens, and those who use or are affected by a public service should be involved in how it is run, and have certain rights regarding what they receive from that service.
• An ethical and outcomes-based approach: involvement is seen as the ethical thing to do, and the best approach to improve outcomes. This means recognising that good care comprises the application to individual circumstances of evidence-based medicine along with knowledge and experience. Patient involvement is essential to the judgement of relative risk and benefit associated with decision-making.
• A value-based approach: to achieve truly the best value for money from our health and care system, we must know and respond to what people need and want. In this way, we can deliver care that meets their preferences and patients receive ‘the care they need (and no less), and the care they want (and no more)’ (Mulley et al 2012).
• An approach based on sustainability: it is increasingly difficult for health systems to provide the best possible care to everyone as the prevalence of long-term conditions increases and the population ages. By involving people in managing their own health and care, and keeping well and independent, we can minimise our use of services.
• A person-centred care approach: our health and care system should be  focused on its users, promoting independence and co-ordinated around people’s full needs rather than being fragmented and siloed. Patient involvement is an essential component of delivering a more person-centred service that is tailored and responsive to individual needs and values.

The forgotten perspective in the list, though quoted in the text (p.16):  A behavioural economics approach: we try to do our best for our health but the autopilot decides without our full control. Some help (nudging) is needed.

The message:  "Embarking on an honest conversation about rights and responsibilities requires consideration of people’s motivation and the capability to engage."

PS. Nudging and the European Union, by Alberto Alemano.

PS. BIT Publication: EAST.Four simple ways to apply behavioural insights

PS. Regarding Hepatitis C treatment costs, It is good to remember this post by U. Reinhardt:

With this offer curve, a health system confronts the rest of the nation with two morally challenging questions:

1. Is there a maximum price above which society no longer wishes to purchase added QALYs from its health system, even with the most cost-effective treatments (e.g., Point C)?

2. Should that maximum price be the same for everyone, or could there be differentials – for example, a lower maximum price for patients covered by taxpayer-financed health programs (e.g., Medicaid, Tricare, the Veterans Administration health system and perhaps Medicare), a wide range of higher prices for premium-financed commercial insurance, depending on the generosity of the benefit package that the premium covers, and yet higher prices for wealthy people able to pay out of their own resources very high prices to purchases added QALYs for the family?

Collapse and equilibrium in public-private health care provision

The Public–Private Pendulum — Patient Choice and Equity in Sweden 

Circle and the NHS: operation game

The introduction of competition and private provision in publicly funded systems is under unstable equilibrium. The case of Sweden is explained in detail at NEJM. The focus of the article is on primary care and pharmacy.
The collapse of the first privately operated hospital of NHS is described in the FT.
Four years ago I quoted in this post a McKinsey report about how to introduce choice in health care.  The UK failure reflects at least that the government and Circle forgot to read the McKinsey article, while Sweeden has done its homework.



FT Video: Circle and the NHS: operation game
Jan 9, 2015 : Circle, the first private company to take over the running of an NHS hospital, said it was negotiating to end its contract on Friday, two years after it began. Lex's Oliver Ralph and Joseph Cotterill discuss what went wrong.

This is the end, and now what do we do?

Last November I wrote a post asking myself if we had arrived at the end of the public health care system  as we have known it. Today I confirm that we have arrived at this point. I am not alone in this feeling, check this blog, and you'll find similar views. It is really sad to see how a society can lose its opportunities for the future, because neighbours are enacting laws that block any potential solution.Therefore, if we can't change the law there is no need to agree on resolutions in our "Parliament" against it. We can't agree against rule of law, therefore what we have to do is to disconnect as soon as possible and create our own regulations.

Forget current troubles, enjoy this video clip by Juan Luís Guerra - Tus besos

Individual decisions and behaviours: the key for a better health

Informe de salut 2013

After looking at this report on the health of catalans, I would select three issues of general concern: premature death, overweight and alcohol intake (p.29). On premature death, there are five leading causes (p.28): lung cancer, ischemic heart disease, suicide, traffic accidents and other heart diseases. Lung cancer is related to tobaco consumption and we all know that this is the leading preventable cause of disease, disability and death. Though taxation may impact, it relates to an individual decision and behaviour.
The second issue, overweight, needs to be addressed through public policy and depends partially on individual decision and behaviour, again. And the same applies to alcohol intake.
We already knew all that, therefore, what is the next step?

The risk society

One of the most important achievements of our society is how we have been able to manage certain risks in the last century. The mandatory pooling of health risks is in my opinion the most crucial one. Risk regulation on different hazards has protected population from many damages. Medicines regulation agencies would be a good example of that if they worked properly, and we all know it is not always the case. However, it is much better to have them than not, as happens with medical devices in Europe.
Last week, Ulrich Beck died. He is one of the most prominent sociologists of our times. His book, The Risk Society, is still a key reference after four decades. Anthony Giddens has written an excellent obituary that reflects his contributions. We all have to learn from Beck's clever perspectives and observations. In my opinion, up to now we have been able to improve the social management of risks, however there are many shadows that raise doubts about the future. Some people call them the end of the welfare state, while I would like to focus is on new ways of risk protection that are affordable, given the current (and critical) state of public finances.

Health and income 2013

Understanding the autopilot and nudging it

Nudging: A Very Short Guide


Today I would suggest you to spend one hour watching an excellent documentary about "The magic of unconscious", in catalan here until Jan 9th, and in english here.

Cass  Sunstein recently has published the short guide to nudging and those interested in any concrete application should look at these ten tools:

1. Defaults
2. Simplification
3. Social norms
4. Increases in convenience
5. Disclosure
6. Warnings
7. Precommitments
8. Reminders
9. Eliciting intentions
10. Informing people of the nature and consequences of their own past choices.

Wether they may work or not depends on the details and environment. The hardest task.