26 d’octubre 2016

Being loyal to your health system

Entitats d’assegurança sanitària lliure de Catalunya 2014

Your country may have decided that publicly funded health coverage is mandatory for all citizens. Therefore, there is no opt-out posible. Your taxes or contributions will fund the system. What happens if you are not satisfied with the access or quality of services? You may complain, but unfortunately its impact will be negligible most of the times. This is the voice option in Hirschman terms. Voice is really a political and confrontational perspective, while  Exit is the alternative option.
While both exit and voice can be used to measure a decline in an organization, voice is by nature more informative in that it also provides reasons for the decline. Exit, taken alone, only provides the warning sign of decline. Exit and voice also interact in unique and sometimes unexpected ways; by providing greater opportunity for feedback and criticism, exit can be reduced; conversely, stifling of dissent leads to increased pressure for members of the organization to use the only other means available to express discontent, departure. The general principle, therefore, is that the greater the availability of exit, the less likely voice will be used.

Hirschman provides light to what is going on in our health system. Right now one fourth (24,9%, p.29) of the population has decided to "exit" the publicly funded health system. Well, really they can't exit, they pay twice, and this is the reason why it is said they have duplicate health insurance, the same services covered twice.
Hirschman  says that loyalty could reduce exit, however current health policy trends are exactly producing the opposite, reducing loyalty to the public system. And this could be the reason why every year there is an increase of departures. Well, really there are communication vessels and people switch between the systems according the services needed.
This is exactly what's going on, and somebody should ask: is this efficient in social terms?. My answer is absolutely not, you'll never pay twice if you want to buy a loaf of bread, why should be this the case for health insurance for 66% of Sarria district citizens, one third (37,5%) of Barcelona citizens or one fourth of catalan citizens?.
Beware of the warning sign of decline while health policy is encouraging hospital nationalization.

PS. Just to be clear, I'm not arguing for a formal opt-out system. It is unacceptable and outdated. I'm just asking for an efficient system that members engage in long-term loyalty relationships.

24 d’octubre 2016

When voters do not control the course of public policy

DEMOCRACY FOR REALISTS Why Elections Do Not Produce Responsive Government

These are tough days for voters. Specially for those that believe in the folk theory of democracy -people vote according to their preferences, and governments act according to their ideological foundations. It's a good moment to retrieve the rationale for voting and I pick three statements from a book:
In the conventional view, democracy begins with the voters. Ordinary people have preferences about what their government should do. They choose leaders who will do those things, or they enact their preferences directly in referendums. In either case, what the majority wants becomes government policy— a highly attractive prospect in light of most human experience with governments. Democracy makes the people the rulers, and legitimacy derives from their consent.
Unfortunately, while the folk theory of democracy has flourished as an ideal, its credibility has been severely undercut by a growing body of scientific evidence presenting a different and considerably darker view of democratic politics. That evidence demonstrates that the great majority of citizens pay little attention to politics. At election time, they are swayed by how they feel about “the nature of the times,” especially the current state of the economy, and by political loyalties typically acquired in childhood.
We will argue that voters, even the most informed voters, typically make choices not on the basis of policy preferences or ideology, but on the basis of who they are— their social identities. In turn, those social identities shape how they think, what they think, and where they belong in the party system. But if voting behavior primarily reflects and reinforces voters’ social loyalties, it is a mistake to suppose that elections result in popular control of public policy. Thus, our approach makes a sharp break with conventional thinking. The result may not be very comfortable or comforting. Nonetheless, we believe that a democratic theory worthy of serious social influence must engage with the findings of modern social science. 
I agree absolutely with this view. A highly-recommendable book.

23 d’octubre 2016

The times are changing back: hospital nationalization returns

Let's imagine you are the owner of a hospital. Basically you provide private care (85%) and you have a specific contract with the public sector that represents the remaining 15% of the income. One day, you wake up in the morning, turn on the radio and you hear the health minister that wants to buy the whole hospital for a price that is half the annual income. At a first glance you may think it is a joke, but what happens if it is not? Let's wait for what's going on the next days.
This signaling strategy is the most inappropriate to send if you really want a goal. The first message is: nationalization is a possible idea that a politician may set in the agenda again. The second is: a low price could induce the hospital owners to say no -the natural answer- and the minister would be happy because the responsibility of failure -ironically- wouldn't be his. The distraction manoeuvre would have ended. In such situations, strategically the best reply by the owner is just to say the hospital is not on sale.
In summary, a complete strategic mess in its goals and its means. An outdated nationalization trend could be back at least in the discourse. I hope will not succeed. Meanwhile nobody has explained the efficiency according to ownership -another signal that ideology is what counts, not efficiency. This is a greatest deception to citizens and at the same time undermines the system and its institutions. Unfortunately, the times are changing back. Something radically different should be done to improve citizen's health.

Chris Cornell "The Times They Are A-Changin' BACK"

Come gather 'round people from far & wide
Keep for yourselves while the river's run dry
And you find that your tears are getting harder to cry
There's a thirst in your soul that's invading
Start digging your wells, & fall dead in your tracks
'Cause the times, they are a changin' back

Here come bards and the bloggers, who are losing your heads
Only write by repeating what others have said
Now the ones and the zeros, they don't know how to lie
If it's written then it must be a fact
Now winners & losers are equally lost,
And the times they are a changin' back

Come presidents blue, and congressmen red
We do what's been undone and undo it again
As we carry the load for the 1%, who bought you your seat at the table
Well the wine pours red and the hearts turn black, And the times they are a changin' back

Come all you media, women and men
24 hours a day scare the shit out of them
If fear is your business then business is grand
There's always someone somewhere dying
And I know if it gets slow you'll take up the slack
Cause the times they are a changin' back

Come pass the baton in the relay of time
Where death is the only true finish line
And we look to the past or the future is blind
Are we sure that we're equal to the task
Cause I can't help but see the writing on the wall
It reads: the times they are a changin' back

PS. Bob Dylan's message to Nobel Committee after being found by Quim Monzó and Pere Gimferrer in this video:

21 d’octubre 2016

What explains economic growth? (2)

Deirdre McCloskey presenting "How the World Grew Rich: The Liberal Idea, Not Accumulation or Exploitation" at Nobel Conference, Sept 29, 2016

PS. Quote of the day:_
What is crucial is our ability to engage in continuous conversation, testing one another, discovering our hidden presuppositions, changing our minds because we have listened to the voices of our fellows. Lunatics also change their minds, but their minds change with the tides of the moon and not because they have listened, really listened, to their friends' questions and objections.
 A.O. Rorty, "Experiments in Philosophical Genre: Descartes' Meditations," pp. 545-565 in Critical Inquiry 9: 562

20 d’octubre 2016

What explains economic growth?

Bourgeois Equality. How Ideas, Not Capital or Institutions, Enriched the World

This is the great question that Deirdre Nansen McCloskey tries to answer in her last book of the trilogy. If we want to continue to improve our living standards we should confirm that we are on the right track. And she says:
"an anti-bourgeois rhetoric, specially if combined with the logic of vested interests, has in many ocasions damaged societies"
She focuses specially on how specific places changed their views on those that create value. Part IV explains how a pro-bourgeois rhetoric was formed in England around 1700:
In other words, the attitude of medieval Europe and its church toward the bourgeoisie was nothing like entirely hostile, especially in northern Italy and in some of the ports of Iberia and the Baltic, even if it did not result in the business-dominated civilization of the southern Low Countries after 1400, and more widely Holland after 1568, and England after 1688. Barcelona, for example, was from medieval times an exception to the antibourgeois character of the rest of Spain—as in some ways it still is, and as Basque Bilbao came to be in the nineteenth century
 Realizing the potential depended on a bourgeois ideology adopted by whole societies, not merely by the bourgeoisie itself. The ideology had been foreshadowed in the Hanse towns such as Lübeck and Bergen and Danzig, and in some trading towns of southern Germany, and in the prosperous little cities of Flanders and Brabant, in Barcelona, in the Huguenot strongholds of France, and especially in the northern Italian cities such as Venice, Florence, Genoa, and the rest.
In summary, a change in ideas modified deeply wealth creation. I can't summarise 768 pages. My recommendation is to read it if you are interested in economic history. The key questions are answered there and in two previous books. You may agree or not, but persuasive style of Mccloskey is guaranteed. Some parts are repetitive and controversial, but the amount of quotes and knowledge is amazing. You'll enjoy the impressive erudition of Deirdre McCloskey.

PS. Today in the news has started a new anti-bourgeois campaign, the goal is to increase the taxes of the super-rich. It just sounds really as the opposite of what Deirdre says that has allowed us the betterment process of the last three centuries. Our economics minister is professor of economic history. It would be good that somebody gifts him the book and convinces him to read it.

PS. While I was studying my PhD, in rhetorics course, Deirdre came. I will always remember how she argued about the need to change economic methodology. Unfortunately after two decades, the academic profession has taken the opposite direction, a mathematical perspective.

PS. Eduard Bonet, from ESADE, is quoted several times in the book. I would like to acknowledge his guidance on this topic.

19 d’octubre 2016

The coming wave of new health technologies

AHRQ Healthcare Horizon Scanning System
Report of a Pilot Project: Rapid Cost Analyses of Selected Potential High-Impact Intervention Reports

Unfortunately the US government has discontinued the Healthcare Horizon Scanning System. It was a framework to detect innovations before entering into the market. One of the last reports was on cost impact of these technologies:
We completed 53 rapid cost analyses on 55 topics over a period of 4 months from July through November 2014. The topics consisted of selected Potential High Impact  ntervention reports published in 2013 and 2014. These 55 topics had a designation of  oderate or high potential for high impact in those reports. To estimate potential costs of these new and emerging interventions, we sought to identify data on the following:  revalence of the disease or condition targeted by each intervention; actual or projected  doption of the new intervention; costs of the intervention; costs of a similar intervention; and costs of an alternative intervention used for the disease or condition
It seems that something similar is being proposed in Europe.  Let's wait and see. Meanwhile check the canadians.


17 d’octubre 2016

How bad health regulation leads to unsafety medical devices in Europe

Comparison of rates of safety issues and reporting of trial outcomes for medical devices approved in the European Unión and United States: cohort study

The topic sould be at the top of health policy agenda (at least as it is in this blog). New evidence confirms the additional safety risks of european bad regulation.
In the European Union, medical devices are approved by private notified bodies if they meet performance criteria and are likely to be safe, but notified bodies generally do not require evidence of effectiveness for most devices. Many high risk devices are approved faster in the EU than in the United States, where the Food and Drug Administration usually requires prospective clinical trials of such devices.
And the results are in BMJ:
The unadjusted rate of safety alerts and recalls for devices approved first in the EU was 27% (62/232) compared with 14% (11/77) for devices approved first in the US. The adjusted hazard ratio for safety alerts and recalls was 2.9 (95% confidence interval 1.4 to 6.2) for devices approved first in the EU.
This means exactly 2.9-fold greater rate of safety alerts and recalls and a 4.6-fold greater rate of recalls than devices approved first in the US  (and if you look at the confidence intervals you'll get more worried).  How can we trust the european regulator?. For decades, European Union has leaved its citizens with less safety protection than is required for medical devices. A perfectly designed absurdity to disseminate risk for european citizens that the new proposed regulation is unable to correct.

PS. If you wnat to understand the differences between EU and US regulation, read this NEJM article or Milbank one..

14 d’octubre 2016

Beyond the hype: the controversy over wearables

Effect of Wearable Technology Combined With a Lifestyle Intervention on Long-term Weight Loss

If you want to know if some device is effective, there is a standard way to demonstrate it: a clinical trial. This is precisely what has been done on the impact of wearables on weight loss. And the result is:
Among young adults with a BMI between 25 and less than 40, the addition of a wearable technology device to a standard behavioral intervention resulted in less weight loss over 24 months. Devices that monitor and provide feedback on physical activity may not offer an advantage over standard behavioral weight loss approaches.
That's amazing! Why is there so many articles pushing wearables for weigth loss when there are very few clinical trials, and their results are clearly against their use?. This is a marketing bubble and somebody should tell clearly that they could use wearables but for other reasons.

PS. Let's imagine that somebody wants to relate wearables for weight loss reduction with insurance premiums! Nothing to add.

The Bahama Soul Club, Cuban Tapes

13 d’octubre 2016

European Union Health: in the middle of nowhere

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability

If there is an example of how one part of an organization can't speak with the other is the European Union and Health Policy. If we are talking about medical devices, health issues are at the back, industry is writing the regulations. If we are talking about options for improvement, economics unit  explains what health unit has to do. A perfectly designed mess.
Take the example of this week. A Joint report, that is an economics report with elementary mistakes for any health economist. Take this statement:
"Competition between hospital providers can lead to higher quality under strict price regulation." (p.70)
Does anybody know what does really mean strict regulation? Who is writing such things and being paid with our taxes?.
If you check another report on the topic by experts of the European Union you'll find an opposite recomendation.
"The conditions for competition to be a useful instrument vary across countries, health care subsectors and time. There is no golden rule or unique set of conditions that can be met to ensure that competition will always improve the attainment of health system goals." (p.4)

Definitely, the EU is in the middle of no judicious health policy.
In summary, an avoidable report that you can skip reading and devote your time to hearing Bob Dylan music for example, the new Nobel Prize.


Come gather 'round people where ever you roam
And admit that the waters around you have grown
And accept it that soon you'll be drenched to the bone
If your time to you is worth savin'
Then you better start swimmin' or you'll sink like a stone,
For the times they are a' changin'!
Come writers and critics who prophesy with your pen
And keep your eyes wide the chance won't come again
And don't speak too soon for the wheel's still in spin
And there's no tellin' who that it's namin'
For the loser now will be later to win
For the times they are a' changin'!
Come senators, congressmen please heed the call
Don't stand in the doorway don't block up the hall
For he that gets hurt will be he who has stalled
There's a battle outside and it's ragin'
It'll soon shake your windows and rattle your walls
For the times they are a' changin'!
Come mothers and fathers throughout the land
And don't criticize what you can't understand
Your sons and your daughters are beyond your command
Your old road is rapidly agin'
Please get out of the new one if you can't lend your hand
For the times they are a' changin'!
The line it is drawn the curse it is cast
The slow one now will later be fast
As the present now will later be past
The order is rapidly fadin'
And the first one now will later be last
For the times they are a' changin'!

Written by Bob Dylan • Copyright © Bob Dylan Music Co.

06 d’octubre 2016

A new missed opportunity

After all these years, a new proposal for regulating in vitro diagnostics and medical devices in EU is available. Current regulation was enacted in 1998, and this one could be applicable in 2022, 24 years after, pas mal for the busy politicians!.
And this is a proposal, there were previous unapproved proposals, and this one has to pass the Council and the Parliament. I will not enter into the details.
It was supposed to increase safety and efficacy, but the main problem remains with who has to enforce them. Notified bodies, a subcontracting regulatory firms network, with vested interests with industry can't claim independence. And specifically, the methods for evaluate the analytical validity, clinical validity and utility is uncertain. No regulator will confirm us that the cut-off values of diagnostic tests are set according to the best evidence and greatest benefit. In US, FDA is the responsible.
In summary, a new missed opportunity for european citizens. A greater risk and uncertain effectiveness in diagnostic tests and medical devices.

PS. The latest known example of the impact of wrong regulation is this one. Those affected can't read this blog, they are blind.

Josep Moscardó