Who should get treatment?

Who should receive treatment? An empirical enquiry into the relationship between societal views and preferences concerning healthcare priority setting

The concern for an equitable and fair allocation of healthcare resources requires a prioritisation approach. Otherwise we are going to live in an arbitrary and opaque world.
An article from the Netherlands explains what people think about three perspectives:

The view “Equal right to healthcare” comprises an egalitarian view on health and healthcare. People with this view consider access to healthcare a basic human right. Everyone is equal, hence has an equal right to healthcare. According to people with this view, prioritisation should solely be based on the need for care and prioritisation based on patient, disease, and intervention characteristics, such as the effect of treatment, is opposed. What is considered to be “the right care” is a matter of personal concern for patients and, according to people with this view, patients should be supported in their treatment choices regardless of the costs.

The view “Limits to healthcare” comprises a view with a strong concern for providing “the right care” for patients. People with this view consider health-related quality of life to be an important outcome of treatment. According to people with this view, providing the right care may imply refraining from (life prolonging) treatment. People with this view do not consider cost-effectiveness to be an important criterion for priority setting, although they do consider it important to make good use of money. Hence, providing treatments that generate minimal benefits should be avoided. Priority setting based on patient characteristics is rejected, with an exception made for lifestyle. According to people with this view, patients who are culpable of their own disease should receive lower priority and prevention should receive higher priority in allocation decisions.

The view “Effective and efficient healthcare” comprises a utilitarian view on health and healthcare. People with this view consider it important to generate as much health for society as possible given the budget constraint, and consider a patient’s capacity to benefit from treatment important when setting priorities. Although people with this view focus on the cost-effectiveness of treatments, they do believe it is not possible to “put a [fixed] price on life”. The value of health benefits depends on circumstances and patient characteristics, such as age and culpability, and hence these should be taken into account in priority setting.

 And the result is:

 The majority of respondents was matched to the view “Equal right to healthcare” (64.5%), followed by “Limits to healthcare” (22.5%), and “Effective and efficient healthcare” (7.1%). A minority of respondents (5.9%) could not be matched

My impression is that we change such criteria according to the exact setting we are in a precise moment. That's why beyond societal criteria we do need professional criteria. Sounds too easy to solve the prioritisation exercise according to three principles.

PS. Still waiting for the book:Rationing and Resource Allocation in Healthcare: Essential Readings

 Juan Genovés exhibition at Marlborough gallery

On experts and priorities

Priorización de intervenciones sanitarias. Revisión de criterios, enfoques y rol de las agencias de evaluación

Often I hear that prioritisation of benefits could be solved by evaluation agencies and the appropriate application of cost-effectiveness analysis. As times goes by, I'm convinced that this is a way to avoid if we consider how priorities should be set. In other words, leaving this issue to a technical perspective is not enough. There is a need for a deliberative way to tackle the complexities of prioritisation.
Anyway, if you want to know a review that takes as given the experts view, check this article. If you want to understand the whole issue from a broader perspective, then read the book I quoted in this post some months ago.

 Carlos Diaz at Sala Parés

Waiting guarantee(d)

International comparisons of waiting times in health care – Limitations and prospects

Waiting times are the natural barrier for access to health care in non-market health systems, where willingness to pay it is not the criteria to allocate resources. Regulators know it and they set up some guarantees, a maximum time for access, otherwise there is a need to find an alternative. While this system may appear an improvement, it may produce some distorsions in incentives.
In my opinion, waiting times should be reviewed on a prioritisation criteria, and may be after some guaranteed should be applied. General guarantees distort the aim of such process.
Anyway, we are still waiting for a regulation on prioritisation of waiting lists. Long time ago was anounced, and long time ago was blocked. There is no reason to delay it indefinitely.
If you want to have a look at international data, read this article and its methodological considerations:

The study shows the need for a more coherent approach to waiting times measurement, if  international comparisons are to be made. Currently, there are wide differences in what  countries measure and how they measure it, were they start the measurements and what measures are presented. Few international comparisons of waiting times have been published and none has solely relied on official national statistics.

 

With The Changing Lights, Stacey Kent attains an even higher level of accuracy 

of tone and delicacy of expression.

 Don't miss this concert!

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?

Learning to say no

Cost effective but unaffordable: an emerging challenge for health systems

There are big questions unanswered in health policy, and the social willingness to pay for a costly and effective technology is one of them. In a recent article, a description and controversies of NHS budget impact policies are explained:

The budget impact test means that technologies costing the NHS more than an additional £20m a year will be “slow tracked,” regardless of their cost effectiveness or other social or ethical values. This risks undermining the existing opportunity costs framework.

Therefore if there is a costly and effective therapy that has an impact budget greater than 20m, than next steps are uncertain in UK. This is the setting.
Really this affects all health politicians, and the issue is related to prioritisation and price regulation. The "solution" to the first issue is to delay prioritisation to the next minister, and what it is possible is to renegotiate prices of drugs. As I have said many times, prices are a fiction, because what it is under negotiation is a contract with the government, therfore the whole amount (p·q).

Budget impact is essentially the price per patient multiplied by the number of patients treated. Yet the prevalence of someone’s condition should not determine their access to treatment. The principle of equity means that like cases should be treated as like; the NHS Constitution requires the NHS to respond to the clinical needs of patients as individuals.

Righ now in Catalonia cost-effectiveness is a also a fiction, since prices are confidential, and it is not possible to estimate the ratio. Budget impact is the option.

Prix Pictet. Photo Exhibition in Barcelona

You can't miss it

Fasten seat belts (4)

The times for drug prescription following prioritisation have arrived. Hepatitis C drugs have paved the way for such a move.There were some informal attempts for certain medicines and it was decided by clinical committees (i.e. for rare diseases), but now it has changed. The government has decided who has to get what and when, this is absolutely new. Have a look at this draft of strategic therapy for Hepatitis C treatment.
Any physician asking for hepatitis C drugs will have to explain the compliance with the criteria and ask for approval.
I said some weeks ago that a new paradigm in drug pricing was starting, right now I have to say that drug prescription priorisation by rules is the new trending topic, at least in our neighbourghood. Wether this prioritisation is based by cost-effectiveness criteria remains to be seen.

La priorització de les llistes d'espera

 Managing surgical waiting lists through dynamic priority scoring

De ben poc serveix que els ciutadans tinguin cobertura obligatòria d'assegurança del risc d'emmalaltir si a la pràctica no hi ha possibilitat d'accedir als serveis en el temps i forma acurats. Les llistes d'espera són la mostra evident i contrastada de que hi ha un problema gros, molt gros. I sabem que el primer motiu pel qual la gent paga voluntàriament una assegurança privada és perquè hi ha dificultats d'accés a l'assegurança obligatòria pública. I ja hem arribat al 31% de la població.

Ja fa tretze anys que es va publicar un document sobre priorització de les llistes i onze d'aquest. També fa onze anys que el Parlament va demanar que hi hagués un temps garantit d'accés, i el 2015 es va publicar un decret que diu:

Els criteris que han de regular l’establiment de la priorització d’accés dels pacients per a les prestacions sanitàries que tenen establert un termini de referència són els següents:

a) L’impacte de la malaltia sobre la qualitat de vida, incloent-hi aspectes com l’afectació de la vida diària, la qualitat de vida, el dolor, la dependència i la càrrega per a la família.

b) Els riscs associats a la demora en la realització de la prestació, entre els quals s’inclouen la gravetat potencial de la malaltia, el risc de desenvolupar comorbiditat o complicacions greus, la reducció de l’efectivitat de la intervenció o de la prognosi desprès de la intervenció, a mesura que augmenta el temps d’espera.

c) L’efectivitat clínica de l’actuació, tenint en compte el grau de millora que la intervenció aconsegueix en temps real.

d) L’ús i consum de recursos sanitaris durant l’espera a causa de l’estat dels pacients.

e) Els criteris que estableixi el Departament de Salut derivats del consens de les societats científiques.

D'acord, necessitem criteris. Després es mostren al decret els processos amb garantia: oncològics, cirurgia cardíaca i cataractes, i altres intervencions amb termini de referència. Però no hi ha cap requeriment de transparència sobre l'aplicació d'aquests criteris.

Vull saber quant pacients estan esperant i miro el juliol 2023 i aquesta és la situació de la llista d'espera d'intervencions:

- Intervencions amb termini de referència: 153.431 pacients esperant

- Intervencions oncológiques: 2.201 pacients esperant

- Cataractes i pròtesis genoll i maluc: 30.795 pacients esperant

-Cirurgia cardíaca: 238 pacients esperant

Només per intervencions quirúrgiques hi ha 186.665 pacients esperant per ser atesos. Massa gent (2,5% de la població). El nombre de persones en llista espera a desembre del 2003 era de 66.567 (1% de la població).

L'any passat al mateix mes de juliol hi havia 177.856 pacients. En un sol any hem assolit una fita notable, augmentar la llista d'espera en un 5% més de pacients esperant per una intervenció quirúrgica. No hem trencat la tendència i això hauria de preocupar a tothom, però malauradament la letargia de la política sanitària fa que no passi absolutament res. 

A més a més caldria afegir-hi també, les llistes d'espera de proves diagnòstiques i consultes externes. I ens enduríem una altra nefasta sorpresa.

Cal fer-nos algunes preguntes. I a la pràctica com es prioritza? els criteris s'apliquen amb objectivitat? Però sobre això no en sabem res. L'altre dia llegia un article que em va semblar encertat perquè introdueix la priorització dinàmica i la formalitza en un model. Posa ordre a les idees i permet una aplicació ordenada del problema d'accés. A les conclusions diuen:

Under the DPS system, all stakeholders can place more confidence in the appropriateness of patients’ assigned priority. The system increases equity across all patient categories and provides consistent processes for clinicians to assess clinical need, while also including an effective and efficient means of implementation. As such, it is intended that implementation of the DPS system will increase public trust and confidence in the systems used to prioritise elective surgeries. Features of the DPS system could also be extracted to suit the needs of individual healthcare systems. For example, clinical factor selection forms may be used independently of the DPS system and could be an effective tool to aid current prioritisation practices, providing an objective metric for waiting list staff to gauge the severity of patients and better inform prioritisation decisions.

Doncs això, transparència i confiança en els criteris de priorització, això és el que cal, més enllà d'una solució estructural a un problema estructural d'accés. És a dir planificar millor l'oferta i millorar la gestió dels serveis.

 

Joan Miró

Setting priorities explicitly (or not)

PRIORITISING HEALTH SERVICES OR MUDDLING THROUGH

A chapter of this book explains who does what in prioritisation (resource allocation and rationing).
I've found of interest this classification of rationing:

• Rationing by denial. Exclusion of specific services or treatments from the National Health System portfolio (often explicitly) or from one healthcare provider (near always implicitly) that believes that such treatment or service is inappropriate.
• Rationing by selection. Exclusion of some patients of some treatments because they do not meet certain eligibility criteria fixed by the regulator (often explicitly) or the provider (near always implicitly). 
• Rationing by delay. The demand that cannot be met by a rigid offer remains on hold (waiting list) and the wait acts as a barrier to access and, in many cases, as a de facto denial of care. 
• Rationing by deterrence. Barriers placed, either consciously or unconsciously, by the healthcare providers that make it difficult for patients to find out about, and book appointments with, some healthcare services. 
• Rationing by deflection. Patients being shunted off to another institution, agency or programme. 
• Rationing by dilution. Services continue being offered to patients, but with fewer resources, and the quality of care gets worse

 And the summary:

In conclusion, adequate priority setting is not about choosing either to muddle through implicit rationing or to be corseted by an exhaustive, rigid and explicit interventionist structure at the macro, meso and micro decision-making levels. This dichotomy fails to capture the complexity of priority setting in practice. We need more and better explicit priority setting, not to substitute but to improve implicit priority setting.

 

 Weegee by Weegee

Physicians' standards of conduct

Professing the Values of MedicineThe Modernized AMA Code of Medical Ethics

JAMA has decided to start JAMA Professionalism, a new department.

The goal of the articles in this section is to help physicians fulfill required competencies on this topic. According to the American Board of Medical Specialties definition, professionalism is “…a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations.” Taking responsibility for executing professional responsibility seems intuitive enough. But what does it mean to adhere to ethical principles? How are the ethical principles defined? 

Good questions. And the answers for US physicians are in the new AMA Code of Medical Ethics.
A multi-year effort to modernise that has provided an interesting outcome. You can check for example, regarding prioritisation of resources, what should be done? in chapter 11 you'll find the answers. A good suggestion for our physicians' associations and their outdated codes.
 

Pandemètica

 The shared ethical framework to allocate scarce medical resources: a lesson from COVID-19

Durant la pandèmia i des d'aquest blog he parlat repetidament dels principis ètics en l'assignació de recursos. Ara l'Ezequiel Emanuel i en Govind Persad des del Lancet fan un article de resum imprescindible. I diuen:

The ethical allocation of scarce medical resources entails a three-step process: (1) elucidating the fundamental ethical values for allocation, (2) using the values to delineate priority tiers for scarce resources, and (3) actually implementing the prioritisation to faithfully realise the fundamental values. The COVID-19 pandemic engendered many assessments and reports on the ethical allocation of vaccines, therapeutics, and other medical interventions that have elucidated the definitive ethical framework for distributing scarce resources. The pandemic also provided major tests for implementing ethical allocation frameworks, revealing important lessons on the challenges of moving from theory to practice, and  refinements that would enhance realisation of the ethical framework

I després d'explicar els tres passos, mostren quins són els valors fonamentals per assignar recursos mèdics escassos en aquesta taua: 

Table 2Fundamental values for allocating scarce medical resources

	Definition
Maximising benefits and preventing harm	Preferential allocation of medical resources towards individuals who can gain most benefit and protection against harm; harms can be broad to include both health (eg, death) and non-health (eg, poverty); harms can occur directly from the disease and indirectly when health-care system functioning is compromised
Mitigating disadvantage	Preferential allocation of medical resources towards people who are disadvantaged by income, race, ethnicity, religion, or other characteristics
Equal moral concern	Treating similar people similarly, and not discriminating on the basis of morally irrelevant characteristics such as race, ethnicity, or religion; typically requires not treating people the same, but treating people in different circumstances (eg, in communities with a higher or lower burden of COVID-19) differently
Reciprocity	Preferential allocation of medical resources towards people, communities, or countries who in the past took on burdens to address the current health problem
Instrumental value	Preferential allocation of medical resources towards people who will be able to mitigate harms and disadvantage of others; not an independent value but facilitates realising the other values particularly benefitting people

I després entren en detalls de documents que han tractat la qüestió, i alhora els reptes en la seva aplicació pràctica, i conclouen:

The lessons learned clarify that the ethical framework to guide allocation entails five substantive values—minimising harms, mitigating disadvantage (ensuring equity), equal moral concern (not identical treatment), reciprocity, and instrumental value. The pandemic also helped to clarify the establishment of priority tiers that primarily emphasise instrumental value, minimising harm, and mitigating  disadvantage.

Article de referència, per guardar. 

A Foto Colectania ara

Where is the trade-off?

The fallacy of the equity-efficiency trade off: rethinking the efficient health system

What goes first? An equitable health system or an efficient one?. You'll see in some textbooks this biased trade-off formulation.

 A more appropriate question would be, “what is more important for a population, a health system that delivers equitable (fairly distributed) health outcomes or a health  system that maximises health gains?” The difference between the meaningless first question (which does not contrast outcomes) and the potentially meaningful second question (which does contrast outcomes) is critical.

 On a continuum of health gains and equity, possible goals of a health system include:
✯ Achieving the greatest health gains for a given input without regard to whether this means concentrating the gains in one (social) group: a traditional health outcomes focus,

✯ Achieving the fairest distribution of health for a given input without regard to the actual level of health achieved: a non-traditional outcome focus on (one form of) health equity, and

✯ Achieving an appropriate balance between the greatest health gains for a given input subject to the constraint of fairly distributing the health gains across social groups: an outcome balancing health equity and health gains

If finally there is a prioritisation on waiting lists, we would focus on the third option. Unfortunately I wrote a post 5 years ago on the same topic...and still waiting for its application.

PS. The trade off started with A. Okun 40 years ago, from a macroeconomics perspective. Have a look at the anniversary at Brookings.

PS. "Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases. Thus, public health is concerned with the total system and not only the eradication of a particular disease." WHO dixit. Can you imagine asking citizens about a Public Health Survey?. The term doesn't make any sense. All over the world the common term is Health Survey if you want to ask people about their health perception, except in Catalonia. So weird, somebody should check it, maybe it's a mistake.

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?

Who is worse off?

Health, priority to the worse off, and time

The prioritisation of resource allocation towards the worse off is a well known rule. What does this mean exactly?

 There are many dimensions in which someone can be worse off (e.g., in terms of wellbeing, health, opportunities, resources), and there are many ways to give priority to someone (e.g., by giving extra weight to their claims, lexical priority to their claims, or by earmarking a fixed amount of resources for their claims). Furthermore, there are many different reasons why one might want to give priority to benefits to the worse off: is it because it is good to promote equality for its own sake, good to promote equality for other reasons, because benefits to the worse off matter more, because the worse off typically fall under some sufficiency threshold, or for many of these (and maybe other) reasons

The precise argument is described in a recent article that combines the complete lives approach with the forward looking approach, and says:

 I believe that the focus on complete lives has been beneficial in that it is a step away from a complete focus on current distributions of health. However, I think that the arguments presented in this paper give us reason to adopt a more nuanced approach to how to rank individuals in terms of who is worse off with the purpose of giving priority to certain benefits in light of unequal distributions of health over time. Such an approach accepts that both the complete lives view and the forward looking view that only takes into account current and future health states, matter. This leads to the complicated question of how to combine these views. Some work that addresses how to combine  concerns for simultaneous segment inequality and complete lives inequality has appeared recently, but the question needs further attention.

Therefore, it is still a work in progress.

Guinovart at Galeria Joan Prats

The healthcare funding conundrum (once again)

Fiscal Sustainability of Health Systems. Bridging Health and Finance Perspectives

Forget economic forecasts, most of them have failed many times. You don't need to be precise about the size of the GDP devoted to health in 2030, it will definitely be more expenses than now. The OECD tries in a new report to review these forecasts and to spread fear in the near future. I think that our societies before the great recession, were able to manage to some extent fiscal deficits. Now it is different, the size of the deficit for future generations is unacceptable.
The report reviews former approaches to supply side and demand side measures for cost-containment. A well known story on the macro-prescription for governments.  My view is not reflected in the document. I have highlighted many times the importance of organizational change, the micro-perspective, i.e. the changes in the structure of incentives and coordination mechanisms in the health system.
This is the most challenging effort for any government, because organizational change and prioritisation represents an attempt to modify the current status quo. Governments are affraid of it, but in my opinion somebody has to handle this conundrum and tell  the population exactly that unless we change current health care organizations, taxes will not be sufficient to pay the bill. Then two options will be open to us: out of pocket or no access. This is the message that this report is unable to explain clearly and now it's time for somebody to disseminate it.

PS. Read the Fiscal Sustainability of Health Systems: Policy Brief 

Is there any justification for interventions that aren't cost-effective?

Ethics, priorities and cancer

This is one of the most challenging questions nowadays. Anthony Culyer sheds light n this difficult issue in a recent article applied for cancer care. These are his nine  arguments:

Argument 1: the whole health maximisation assumption underlying the approach is misconceived. health care is about more than just promoting health. Other objectives commonly include financial protection (e.g. from the out-of-pocket expenseof costly interventions), innovation, and all those listed earlier
Argument 2: innovation is stifled by the strict application acost-effectiveness threshold that is too low
Argument 3: the use of standard outcome measures, like theEQ-5D QALY or averted DALYs, underestimates the health benefits of cancer treatments
Argument 4: the assessment of benefit excludes the beneficial effects that treatment and its consequences have on those who care for cancer patients
Argument 5: the opportunity cost argument is weak. There are always efficiency savings that can be found in any systemwhich mean that the alleged sacrifice of health represented by the threshold is spurious. the actual sacrifice is much smaller
Argument 6: cancer is a scary disease and people who suffer from it deserve to have access to treatments that would fail aconventional cost-effectiveness test
Argument 7: for some cancer patients a costly and not very effective treatment may offer a “last chance” to someone in despair. such a situation might exist if no intervention of any kind existed for these patients or if the patient suffered from a rare form of cancer
Argument 8: cancer is a “severe” disease and should accordingly be given a higher priority than less severe diseases
Argument 9: many cancer patients have a short life expectancy even with treatment. a quasi-utilitarian argument might cite the law of diminishing marginal value: even small gains for such people are to be valued more highly than the same gains of equivalent quality of life for people with an already long expectation of life. alternatively, there is the more direct emotional appeal “Our moral response to the imminence of death demands that we rescue the doomed proof"

These arguments fall into two broad groups. Some are questionsof social value: how should we value health gains of particular kindsand should we value them differently according as they accrueto different people? Others are questions of fact: would informa-tion about the quantitative size of the effects in question lead us to conclude that cancer is indeed a special case? The burden of proof in both cases lies with those making the assertion that cancer is, indeed, special. That burden of proof is not impossible to bear.

Is cancer a special case? The question may apply to many diseases and will provide more difficulties than answers. In the end any analysis relies on distributive justice principles and according to different views you'l apply different prioritisation criteria.

PS. The article was published in a cancer journal. I was surprised by the new perspective by Tony Culyer.

PS. What do you think about a new cancer inmunotherapy service that may cost $750.000???

Le Corbusier Guitariste (1960)

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Why are we waiting?

Waiting Time Policies in the Health Sector What Works?

One could say quickly, waiting lists exist in NHS because prices are mostly absent and insurance plays a role. In consumer markets, waiting lists appear when there are creators of scarcity as Brandenburger-Nalebuff explained in his book as a specific strategy, or when there is a temporary mismatch between supply and demand. Since the solution in health care is not to introduce prices and forget insurance, we have to ask about the best practices on tackling such issue. The report by OECD says:

Supply-side waiting time policies, by themselves, are usually not successful. In the earlier OECD study on waiting time policies, the most common policy was to provide increased funding to health providers to decrease waiting times, and this type of policy continues to be a common approach. It has almost invariably been unsuccessful in bringing down waiting times over the long term. Generally, there is a short-term burst of funding that initially reduces waiting times, but then waiting times increase, and occasionally return to even higher levels when the temporary funding runs out. The other main supply-side policy is increasing hospital productivity, by introducing new payment methods such as activitybased financing (ABF) using diagnosis-related groups. This increases hospital productivity, but does not necessarily decrease waiting times.

The most promising tool is prioritisation within a waiting list. The cases of Norway and Australia are interesting examples to check. Nearer here we started with research, and finally a decree was prepared to be released. Unfortunately last April we received a phone call saying it was not possible to rule on waiting lists, that somebody would do it for us. At that moment I said that the intervention of health policy started. The answer today to the initial question - why are we waiting- is at least this one: we have made unnecessary political concessions and we should apply our legislation, we don't need the intervention from outside. That's it.

PS. Data on waiting lists at December 2012.

The farce of confidential drug prices

We are approaching the end of cost-effectiveness as we have known. If you can't use the price of the drug because it is confidential, then there is no possibility of cost-effectiveness analysis. As far as Pfizer has sued a public agency because its officials have leaked the prices, then everybody that uses such information is at risk of being sued. I had already said that some time ago, when in our country we moved to confidential prices. This trend is ridiculous, getting better discounts comes at the price of opacity. And opacity is an extraordinary arm to prevent competition and constrain prioritisation. Qui prodes? It's up to you to get the answer, for me it's clear. If money comes from taxes, the citizens have to know the final price paid. The time to finish such farce has come.

PS. On why external reference pricing is meaningless (p.36):

The practice of lowering list prices through discounts, rebates and similar financial arrangements15 between public payers and the MAH is wide-spread. 22 countries reported that discounts, rebates or similar financial arrangements (e.g. managed-entry agreements such as risk sharing schemes) – either statutory (i.e. based on a law) or confidential (based on agreements) – are in place. As will be discussed later in more detail (cf. Chapter 4.1.2), the widespread use of the discounts and similar provides financial benefits to the country using it, but the other countries referencing to that country do not benefit from the lower prices since they refer to undiscounted higher prices.

Rembrandt. Self portrait

Current exhibition in Caixaforum - Barcelona