21 de gener 2017

Understanding group decision making failure and success

Wiser: Getting Beyond Groupthink to Make Groups Smarter

Groupthink was a term coined by Irving James that explains how groups may tend toward uniformity and censorship. This is not an easy hypothesis to demonstrate. Conditions and environment may affect, randomised trials difficult to apply. But Hastie and Sunstein tried to answer two questions in a book:
  • Do groups usually correct individual mistakes? Our simple answer is that they do not. Far too often, groups actually amplify those mistake
  • But do groups actually succeed in surpassing the quality of the few best? Do they, in fact, combine information and enlarge the range of arguments? Do firms accomplish this feat? Do government officials? Unfortunately, the history of the human species suggests that all too often, groups fail to live up to their potential. On the contrary, many groups turn out to be foolish
The book has basically two chapters, how groups succeeds and how groups fail. Sounds interesting to know the details. I am unable to describe the whole details in a post.
there are sound messages for the role of leaders, and specailly a conclusion:
The failures of groups often have disastrous consequences—not just for group members, but for all those who are affected by those failures. The good news is that decades of empirical work, alongside recent innovations, offer a toolbox of practical safeguards, correctives, and enhancements. With a few identifiable steps, groups can get a lot wiser.
The toolbox refers to behavioral science (Kahneman and Tversky).Unfortunately, my impression is that too few people has read this book up to now.

20 de gener 2017

Stimulating ideas for drug development and pricing

New Health Technologies. Managing Access, Value and Sustainability

This new OECD report sheds light over several issues in an heterogeneous way, but the pharma chapter has a box that I want to highlight. It is really suggestive:

Future scenarios about drug development and drug pricing

These disruptive scenarios result from an expert consultation led by ShiftN and commissioned by the Belgian Health Care Knowledge Centre of Expertise and the Dutch Health Care Institute. The aim of the consultation was to imagine disruptive ways to finance R&D that could potentially better respond to public health needs.

Scenario 1: Needs-oriented Public-Private Partnerships
Public actors and drug developers are tackling public health priorities in vigorous and pragmatic partnerships. The public actor identifies indications representing high public health needs; specifies criteria for the performance levels of drugs to be developed for those indications; and indicates his willingness to pay. Through procurements with enforceable contractual commitments, the public actor enters into a partnership with drug developers to
find solutions for these needs. Developers are prepared to enter into the partnership and to give price concessions for a pre-negotiated fixed agreement on price and volume, and speedier access to market, which reduces their development risk. This drug development and pricing model is close to existing governmental procurement practices in researchintensive areas such as public transport, defence and space exploration.

Scenario 2: Parallel Drug Development Track
EU member states set up a parallel, not-for-profit drug development track that exists alongside, but independent of, the pharmaceutical and biotechnological industry. The aim of the parallel track is to develop cheaper drugs without compromising safety and effectiveness. After having made up an inventory of the public health gaps and priorities in health care, EU member state authorities ask leading public research institutes which
discoveries, assets, tools and capabilities they possess to develop solutions addressing (some of) the needs that were identified. Starting from the match between demand and available expertise, coalitions are built between these (not-for-profit) research institutes, payers, authorities and patients’ organisations. All these partners make the commitment to participate in an open and transparent way in clinical research projects. Intellectual
property (IP) rights are acquired early on in the development process by the partners of the consortium, and ownership is shared. Alternatively, the parallel research infrastructure can completely deprioritise ownership; i.e. inventions and developments in the parallel track are not protected and are in the public domain.

Scenario 3: Pay for Patents
A consortium of European countries join forces and establish a “Public Fund for Affordable Drugs”. Each of the participating countries deposits a fixed annual percentage of what it currently spends on drugs into the Fund. Private payers (including insurance companies) can also join the Fund. The Fund continuously screens the research market for “interesting” drugs that are being developed in Phase II or in Phase III for indications with clear health priorities. The Fund buys the patent from developers, conducts or commissions the last phases of research in public research institutes or subcontracts to private partners (with strict public oversight), and guides the submission process for market authorisation. Because the drug is then put on the market at a relatively low price, substantial savings are generated for the public payer. Once the system is functioning “at cruising speed”, these
savings can (partly) serve to replenish the Fund. The “Pay for Patents” model delinks R&D from manufacturing and sales. The prices decrease because the partners in the Fund consider medicines as public goods that should not be financed through monopoly prices.
Hence, once the patent is owned by the public sector, after a successful development and authorisation trajectory, the rights to produce, distribute and sell the drug can be licenced to manufacturers and distributors that provide the best deal in terms of quality, safety and accessibility for the lowest cost. As a rule, various private partners compete with each other, with the result that “new drugs enter the market at generic prices”.

Scenario 4: Public Good from A to Z
Drug development is essentially a public enterprise, and is radically re-oriented from serving private profits towards serving the public interest and patients’ needs. In a drug development system that is essentially a public enterprise, private drug companies still have a role, albeit with a completely different business model. They mainly manufacture drugs and deliver services to the public provider on a competitive basis. With drugs and other health technologies essentially public goods, patents and monopolistic prices have no role.
Patients and public health providers, not corporations, choose which unmet needs research should address. Public authorities regularly publish lists of research priorities, based on objectively established and patient-informed unmet medical needs. Governments organise and fund that research through a variety of mechanisms, including requests for proposals based on well-defined targets that any research team, public or private, can compete for, or milestone compensation, and active management of the innovation process. By paying directly for R&D and active management of the drug development pipeline, nations and health care systems pay much less than the patent-protected prices of the past. Ultimately, drug prices are set on the basis of the real costs of manufacturing, quality control and distribution, which are decoupled from R&D.
Source: Vandenbroeck, Ph. et al. (2016), “Future Scenarios About Drug Development and Drug Pricing”, Health Care Knowledge Centre (KCE) Report 271, D/2016/10.273/59, Health Services Research (HSR), Brussels.

13 de gener 2017

The size of waste in health expenditure and what to do about it

Tackling Wasteful Spending on Health

OECD is preparing the annual meeting for next Tuesday, and this week has released a report on what to do with waste in health expenditures. Recognising that we have a problem is the first step to define a solution. The report shows the reasons, the categories of waste and the policy and management approaches. The agenda for health policy makers is getting larger. Highly recommended reading for this weekend.

Four main reasons can explain why individual actors might contribute to wasting resources:
● First, they do not know better: cognitive biases, knowledge deficits, risk aversion and habits lead to suboptimal decisions and errors and deviations from best practice.
● Second, they cannot do better: the system is poorly organised and managed and co-ordination is weak. In these first two situations, for the most part, actors do not intend to generate waste and are doing their best but the outcome is suboptimal
● Third, actors could stand to lose by doing the right thing; this occurs when economic incentives are misaligned with system goals – for instance, when clinicians are paid for providing services irrespective of whether the services add value.
● Fourth, all categories of actors might generate waste intentionally, with the sole purpose to serve their self-interest. This last driver is in fact a variation on the third (poor incentives) but it more  explicitly points to fraud and corruption.

Three categories of waste:
● Wasteful clinical care covers instances when patients do not receive the right care. This includes preventable clinical adverse events, driven by errors, suboptimal decisions and organisational factors, notably poor co-ordination across providers. In addition, wasteful clinical care includes ineffective and inappropriate care – sometimes known as low-value care, mostly driven by suboptimal decisions and poor incentives. Last, wasteful clinical care includes the unnecessary duplication of services.
● Operational waste occurs when care could be produced using fewer resources within the system while maintaining the benefits. Examples include situations where lower prices could be obtained for the inputs purchased, where costly inputs are used instead of less expensive ones with no benefit to the patient, or where inputs are discarded without being used. This type of waste mostly involves managers and reflects poor organisation and co-ordination.
● Governance-related waste pertains to use of resources that do not directly contribute to patient care, either because they are meant to support the administration and management of the health care system and its various components, or because they are diverted from their intended purpose through fraud, abuse and corruption

Four categories of policy levers are relevant:
● Economic and financial incentives that seek to influence the behaviour of patients,
clinicians or managers; these are most relevant when poor incentives are the root cause
of the wasteful behaviour.
● Behaviour change policies and information support – including education, persuasion
and training – to address barriers to optimal decisions.
● Organisational changes, which include policies that modify the location, role, number,
co-ordination and tools available to accomplish specific tasks of various stakeholders.
● Regulations to mandate changes in behaviour, organisation or information.
In my opinion this report has extremely useful hints for policy makers, and should be in their toolkit. 

 Hergé-Tintin Exhibition au Grand Palais jusqu'a dimanche

12 de gener 2017

A review of 30 years of UK Health Policy

The Politics of Health Policy Reform in the UK: England’s Permanent Revolution

Three decades of health policy in UK explained in one book. This is what you'll find in the latest contribution of Calum Paton. It is a must read for any health policy maker, specially for those that considered UK NHS as a benchmark. There are hard statements to be considered. I have selected the following ones:

This book has been concerned with explaining politically why irrelevant solutions have been ‘the story’ in England, as regards health policy. So, at one level, the response could be, ‘So what? Yes, a lot of money has been wasted; now, let’s move on.’ This of course is the politician’s response.
Health policy in England over the last 25 years has been dominated by ideologically rooted policy salesmen, based either in think-tanks funded by private interests or operating as part of ‘sofa government’ in health policy (Paton 2012 ) and this has blurred the distinction between the public interest and private interests. There has been no countervailing advocacy of equal weight in defence of the public interest (defined here as an attempt to derive the interest of the whole community or nation rather than private beneficiaries).

The ‘rational’ interpretation of policy-making suggests to the present author, as described above, that policies are developed as means to an end, and that this ‘end’ consists in the solution to a problem which is generally accepted to be salient in the sense that a solution is necessary

Lens 1 Rationality
Lens 2 Pluralist Rationality
Lens 3 Power Elite; Structural Interests; Ruling Class
Lens 4 Garbage Can
Lens 5 Ideology; ‘radical’ power; ‘discourse’
Unifying lens: explaining 25 years

The political result of persistent English NHS upheaval is to weaken the legitimacy of the English NHS. The public, by a slow osmotic drip, comes to think that there must be something intrinsically wrong if the NHS is always being reformed, and if politicians, their advisers, and the media are persistently hand-wringing about it. As argued above, once an ill-thoughtout reform is set in motion and not ‘nipped in the bud’, it takes on a logic of its own. Reform begets reform—in part to repair mistaken initiatives from the previous round, and in part to make new initiatives, in the belief
common to both ‘managerialism’ and ‘market ideology’ that there is a better alternative out there.
This is not an argument against any reform at any time: it is an argument for more rationality in reform. Yet, it may plausibly be argued, I have presented a compelling case as to why such rationality has been absent from the trajectory of English health policy reform.

Taking politics out of the NHS would be to take politics out of politics. The answer is unspectacular and by no means a ‘silver bullet’ to solve the problem: the answer lies in a cultural change in terms of how politics, and in particular so-called public service reform, is viewed and practised.

The idea of taking politics out of the NHS has been shown to be a vain pursuit: every committee of the great and the good, and every report by an external ‘worthy’, proposing such comes to nought.
What is required to establish a health reform, or ‘anti-reform’, along the lines proposed above is something very different. It requires a consensus that health policy and the NHS do not benefit from market initiatives and ‘public service reform’ as a code for the market, whatever may be the case in the wider economy. In other words, one can be a believer in free markets and free trade, yet draw a line when it comes to health and some other public services, such as railways, which are either ‘natural monopolies’ or have other special characteristics.
I think that this kind of analysis is really welcome in a society that focuses on immediate issues and it is uncapable to understand the whole process that takes to long time to be built. For me, Calum Paton (for UK) and John McDonough (for USA) are my key references to understand health policy. Unfortunately, close health policy makers are far from using them.

PS. On the health reform industry:
The challenge for health policy analysis—which actually should mean the analysis of healthcare politics, an inconvenient truth which is itself often ignored—is often more to demolish fashionable, faddish, and foolish ‘new orthodoxy’ (if one can accept the oxymoron) than to propose some new policy ‘solution’. The problem is that ‘solutions’ are sexier, and also form the basis for an industry which sustains not only management consultants and private profiteers but also academics, think-tankers, and political advisers who combine punditry with policy proposals, to the delight of politicians
who are seeking their very own monument in the form of a ‘reform’.
The reform industry, including health policy academics, has in some cases spent more than 25 years proposing and advising on reforms which ‘dis-integrate’ the NHS only to come late to the table of integration.

08 de gener 2017

Revisiting efficiency measurement

Health system efficiency: How to make measurement matter for policy and management

A new book by WHO Euro has been published about efficiency measurement. It seems that this is a topic that would need a review and update. Unfortunately you'll not find any new message. Regarding output measurement, you'll find this statement: "QALYs are in principle a widely accepted outcome measure". I'll not comment again about it. QALYs are controversial, and you may find many posts in this blog on this topic. Therefore, this is a book you can skip reading it. You have to revisit efficiency measurement but with a different book.  In order to make measurement matter for policy and management, we do need a robust measurement toolkit. Right now there is too much noise to understand the message.