Drivers of health cost variation

Variation in Health Care Spending:Target Decision Making, Not Geography

Variations in medical practice are well known and documented. Variations in costs, not so much, at least in our country. Now you can check what happens to geographic cost variations in US. Have a look at IOM report and you'll get the right approach to the issue:

Geographically-based payment policies may have adverse effects if higher costs are caused by other variables like beneficiary burden of illness, or area policies that affect health outcomes. Further, if there are substantial differences in provider practice patterns within regions, cutting payments to all providers within a region would unfairly punish low cost providers in high-spending regions and unfairly reward high cost providers in low spending regions.

A clear alert for any designer of payment systems. The Economist adds more details on this topic and finishes with an additional alert:

The transition from fee-for-service will inevitably be slow. In the meantime, it would help if the millions of Americans with private insurance had any idea what hospitals charge. In May CMS published hospitals’ price lists, showing huge gaps from one hospital to the next. But few patients pay these charges—it would be more useful to know the rate negotiated with their insurers. This transparency does not require restructuring the health system. It just requires hospitals to lift the veil on prices. If they don’t, a regulator may do it for them.

PS. For those that claim that our tax pressure is low. Have a look at taxes over labour costs (41,4%)  OECD average 35,6% (2012), why this figures are not broadcasted? The medium is the message? Who controls the medium? Does anybody consider that competitivenes is possible with such rates?

Where is the problem?

Rafael Nadal said in a recent article:

En el llibre Els mandarins explico que un dia, referint-se als ciclistes, Mariano Rajoy em va dir: "A veure, si tots es dopen, ¿on és el problema? Al final, el que guanya segueix essent el millor".

You'll find the right answer in an excellent article in The Economist: Doping in sport Athlete’s dilemma
The analogy between sports and doping fits quite well with politics and corruption. What next?

Evidence-based market failure

The market may fail to provide the right answer to some citizen's needs. We all know that. If we talk about long term care insurance, the failure is well documented. You may have a look at two NBER academic papers ( A and B ). If you want recent news on the US situation, WSJ provides you a detailed description of this big failure. Still waiting for the right public policy, here and there.

Difference in differences

We all know that the state as a unit of analysis for comparative health policy distorts the whole picture. It forgets that within the country there are huge differences in many key indicators. If you are not still convinced, have a look at the regional european statistics. For sure you'll avoid to achieve any conclusion about health care comparisons without taking into account such data.

A picture is worth a ...

Underestimation of health status

I am strongly convinced that health surveys used to estimate morbidity differ from objective measures. Such large differences are unknown and too often health policy and planning is exclusively based on self-assessed measures. A recent chapter in the book "Active ageing and solidarity between generations in Europe: First results from SHARE after the economic crisis" confirms my impression. Why is this so?. The authors say:

"Being female, older or highly-educated implies a lower probability to underestimate health, and this probability is higher if people are wealthier and have confidants in their social network. Besides, people are more likely to overestimate their health if they are older or wealthier; on the contrary, this probability is lower if they are homeowners or have someone in entourage to talk to."

Knowing how it works

Informe de la Central de Resultats. Àmbit hospitalari. Juliol 2013

Informe de la Central de Resultats. Àmbit sociosanitari. Juliol 2013

If there is a unique feature of catalan healthcare organization is the specific design for subacute, palliative and long-term care. This has been a strong effort to develop a network and capabilities that has taken many years. Now you can see details on the Central de Resultats related to "socio-sanitari"- care. The success is really high and patient satisfaction indicators reflect it.

Doing what works

Rediscovering the Core of Public Health

An update on the focus of public health is welcome. The article in the annual review is a good starting point:

Public health needs to transition from a twentieth-century model grounded in a biomedical model and categorical funding of disease-specific interventions to emphasize changes in the greatest determinants of health: our social and physical environments. Although improvements to date from public health need to be sustained, new perspectives and capabilities are essential to address contemporary and projected disease and injury burdens effectively.

The suggestion to analyse life trajectories sounds interesting. 

Are you satisfied?

If we take into account the results of the health barometer, the answer is YES, and now more than ever!. It sounds weird since the current debate about budget cuts would predict a decline in satisfaction with health services. Ctizens valued health care with 6.89 in 2012. We have right now slightly higher values than 2009, before the downturn. These figures require an explanation. It seems that there is a divorce between how people assess health services and how such situation is broadcast by the press? What's up?.

PS. Somebody has to fix this news.

 Remember, Katie Melua at Jardins de Cap Roig, this is the summer concert!

Genome sequencing mess

Since the world is more complex than it used to be, it is our duty to prevent any further complication. However sometimes some individuals forget it. The anouncement of sequencing genome for 100.000 citizens in UK last December raised controversy and BMJ right now publishes a head to head on this issue.
This blog has remarked many times that if effectiveness of any benefit is undemonstrated, then value is uncertain and potential harm of its application exists.
The summary of the position against sequencing is the following one:

If we sequence individuals’ DNA and tell them that they are genetically predisposed to be slightly more at risk of common diseases, we may be doing them a great disservice, demotivating them from behaving sensibly. And the private sector will see a marketing opportunity for all sorts of clinically unnecessary and potentially damaging screening, with further negative and unintended consequences. Possessing the technical ability to do something new is not an immediate justification for going ahead with it, especially in such an ethically complex area. Good medical practice requires tests to answer a specific question with a reasonable expectation of results being interpretable and useful. Currently, whole genome sequencing in healthy individuals has nothing to offer clinically because most of the data generated are meaningless; the maxim first do no harm still holds.

However, a subtile strategy has emerged recently. The Wellcome Trust will  finance with 3.2 m € a pilot study in London to analyse 97 cancer predisposition genes starting in 2014. It's not by chance, it coincides with Angelina Jolie double mastectomy recent news, and the patent expiration in 2014 of BRCA genetic tests. Is this a philantropic affair? or market access strategy?. The answer is yours.

PS. Beware of nonprofit foundations working for profit. This is a succesful strategy for market access when regulatory constraints have been set up and transparency rules apply. In such cases free lunches exist suspiciously,  but in the long-run they always disappear, and the social cost is enormous.

PS. A call to challenge "Selling Sickness"

PS. Save the date Sept 10-12 to prevent overdiagnosis.

Who pays and who benefits?

Lifetime Distributional Effects of Publicly Financed Health Care in Canada

A lifetime perspective on equity is needed. Short term analysis introduce confounding factors. Fortunately, today we have good news. The Canadian Institute of Health Information has released an interesting research using this approach, and these are the key results:

• Health care costs are higher for low-income groups, but differences are not as pronounced when estimated over the life course instead of in a single year (2011 in this analysis).
- Average lifetime health care costs are $237,500 per person in the lowest income group and $206,000 in the highest income group—a difference of 15%. The difference is much larger (60%) when considering the effect on a single year (2011).
• Tax payments to finance health care are higher among higher-income groups but, like health costs, the differences between income groups are less pronounced when taking a life course perspective.
- Over a lifetime, average annual tax payments to finance health care costs are approximately 8.5 times as high in the highest income group as in the lowest income group. A more pronounced difference of 10 times between groups is estimated when looking at 2011 only.
• Patterns of health care costs and tax payments for different income groups have an effect on the distribution of income.
- Average annual health care costs represent 24% of the income of the lowest income group ($4,220 of $17,500) but 3% of the highest income group’s average income ($3,350 of $114,900).
Although the corresponding tax payment amounts are much higher in high-income groups, in an average year over a lifetime, the lowest income group pays 6% of its income toward publicly funded health care services; the highest income group pays just less than 8%.
Lifetime average after-tax income in the highest income group is 5.1 times the income of the lowest group; after adding the dollar value of health care costs, the gap was reduced to 4.3 times.

Hopefully one day we'll have something similar for our country.

PS. Fyi - from BBC News.
The European Commission is launching legal action against Spain over the refusal of some hospitals to recognise the European Health Insurance Card.
The EHIC entitles EU citizens to free healthcare in public hospitals.
But some Spanish hospitals rejected the card and told tourists to reclaim the cost of treatment via their travel insurance, the Commission says.
A BBC correspondent says the Commission is not accusing cash-strapped Spanish hospitals of trying to make money. The Commission, which checks compliance with EU law, has requested information on the issue from the Spanish government - the first stage of an infringement procedure which could eventually result in a fine.

PS. The course on Health for all through primary care at Coursera-Johns Hopkins has started. Free for all.

Navigating through data

The Health Data Navigator

Undertanding health system performance starts with the availability of data. Many sources are available, but beyond data you need a framework for the analysis. Since this week a new and healthful source is the Health Data Navigator, the outcome of the Euroreach research. The toolkit summarizes in one document the approach. It is a helpful resource. The institutional basis for performance is often a key neglected element in the analysis. They follow the WHO Building Blocks perspective, although there are other options.
Beyond OECD data, we have right now a new database to check. Unfortunately our country has not joined this initiative by now.

PS. The six building blocks:
• Good health services are those which deliver effective, safe, quality personal and non-personal health interventions to those that need them, when and where needed, with minimum waste of resources.
• A well-performing health workforce is one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances (i.e. there are sufficient staff, fairly distributed; they are competent, responsive and productive).
• A well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health status.
• A well-functioning health system ensures equitable access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness, and their scientifically sound and cost-effective use.
• A good health financing system raises adequate funds for health, in ways that ensure people can use needed services, and are protected from financial catastrophe or
impoverishment associated with having to pay for them. It provides incentives for providers and users to be efficient.
• Leadership and governance involves ensuring strategic policy frameworks exist and are combined with effective oversight,coalition-building,regulation,attention to
system-design and accountability

Assesment and review

Disability weights in the Global Burden of Disease 2010: Unclear meaning and overstatement of international agreement

The Global Burden of Disease study is a huge effort to understand  worldwide population health. A former post explains some details and links. However, some calculations and estimates require and assessment and review. This is what Erik Nord explains in his article:

After a long history of changing concepts and methods in measuring ‘burden of disease’ the GBD 2010 has landed on ‘health’ as a unidimensional construct to be used forweighting multi-dimensional non-fatal health problems against each other and against death. At first glance this may look plausible. But the unidimensional health construct does not have a clear meaning. It likely also leads to biases in assessments of conditions that in everyday language are associated with ‘being ill’ as opposed to con-ditions which are not associated with ‘being ill’, namelystates of disability and the state dead. Furthermore, the transformation of ordinal data from paired comparisons into disability weights with purported ratio scale properties is not validated nor explained in a way that allows judgements of face validity.

And I would like to highlight this final consideration:

A value oriented burden of disease construct can either have a personal welfare content or a content that incorporates societal values in priority setting and resource allocation. Which of these would make the GBD enterprise most useful to decision makers is an important issue for further debate

I fully agree with this article. Aggregation without accurate metrics gives quick results, but uncertain for the implications we can derive, sometimes.

Death, taxes and fiscal deficit

Benjamin Franklin said: "The only things certain in life are death and taxes.". If he had lived here, he would have added "fiscal deficit" in its quote. And this is a constant since 1986, 8,1% of our GDP disappears and doesn't returns in services or infrastructures. And somebody is still interested in this money to use it for their preferences, and not for the tax-payers.
Yesterday we knew again that fiscal deficit was 16,543 million euros, a 8,5% of GDP of 2011. After 25 years, the accumulated amount of fiscal deficit is 306.267 million euros!!!. Can you imagine what represents this figure for a country of 7,5 million inhabitants?
Every year the fiscal deficit is equal to the sum of health, education and welfare expenditures. As far as a country can't survive with such bleeding, I'm convinced that we'll not discuss it again. Let's put it simply, time to say goodbye has arrived because it is socially unacceptable such discrimination and unfair relationship. Only one fourth of the fiscal deficit in one year would stop recent public budget cuts. The answer is only one: Goodbye.