Investing heavily

Global Healthcare Private Equity Report 2013

Healthcare represents about 10% of global private equity in general. Since this is more or less the proportion of health expenditures on the GDP would sound normal. However, since more or less two thirds of this expenditure is public in western countries, we can say that currently private equity may be overweighted in health sector, compared to others. The reason is that private equity may expect better returns in healhcare than in other parts of the economy.
Anyway, if you are interested in the details of what's going on, I suggest you to have a look at: Global Healthcare Private Equity Report 2013.
A key message about who is investing and where:

One clear theme that emerged in 2012, however, was the growing level of private equity firms’ interest in healthcare in China, India and across the Asia-Pacifi c region (see Figure 3). With opportunities abounding and restrictions on foreign direct investment relaxing to some extent, Western funds are building up their presence in Asia-Pacifi c by opening new offi ces, especially in China and Southeast Asia. Over the next several years, deal activity is likely to continue heating up in new geographies as it stabilizes in traditional ones.
Despite the allure of new markets, Western investors face a healthy dose of competition from local investment firms that have already taken root in the regions and strategic players searching for new outlets for growth. At the same time, investors based in the Arabian Gulf region (including sovereign wealth funds) are also investing heavily in emerging markets, with the long-term goal of bringing much-needed healthcare solutions back to their home countries. Given their unconventional investment theme, such investors are often willing to accept lower returns, consequently bidding up valuations across the board.

I always say that if you want to know about the future, it is helpful to have a conversation with a private equity investor and a headhunter. Capital and talent drive the economy, and both are interested in the appropriate allocation of risk and reward.

Quo vaditis?

Resource allocation in health care is a nightmare for any regulator. Since competitive prices are unavailable, payment systems have to be designed in order to achieve a greater efficiency, better quality and access. Two decades ago a chapter in a book on that topic summarized the knowledge and potential applications. The title was: Hospital Groups and Case-Mix Measurement for Resource Allocation and Payment, and the authors: Pere Ibern, James C. Vertrees, Kenneth G. Manton,Max A. Woodbury. This was the result of my stay as a visiting researcher at Duke University, Center for Demographic Studies. I had the unique opportunity to share knowledge with extraordinarily talented people.
For many years, things moved smoothly. A summary of the state of the art in 2007 is provided in a chapter of this book (p.259).
After twenty years, things have changed, quo vaditis payment systems?. Right now we focus on incentives for integrated care, and accordingly payment systems have to follow a different path. Bundled care and episode of care, these are the crucial topics right now.
However, regulator's inertia and risk avoidance are the greatest constraints for change. It is difficult to leave the confort zone. Although we know that current payment systems require a new design, decisions are being delayed. The latest words of Seamus Heaney, recently passed away, fit perfectly as a key message: Noli timere, don't fear.

A central dilemma

Reconsidering the Politics of Public Health

These are difficult times for public health regulators. JAMA highlights the issue:

A central dilemma in public health is reconciling the role of the individual with the role of the government in promoting health. On the one hand, governmental policy approaches—taxes, bans, and other regulations—are seen as emblematic of “nanny state” overreach. In this view, public health regulation is part of a slippery slope toward escalating government intrusion on individual liberty. On the other hand, regulatory policy is described as a fundamental instrument for a “savvy state” to combat the conditions underlying an inexorable epidemic of chronic diseases. Proponents of public health regulation cite the association of aggressive tobacco control, physical activity, and nutritional interventions with demonstrable increases in life expectancy

The article presents 5 ways towards a solution. The fifth says:

Physicians may bear particular responsibility in addressing the problem that psychologists call “hyperbolic discounting”— the human tendency to discount the value of future conditions bya factor that increases with the length of delay. Physicians bear witness to regrets about prior unhealthy choices in poignant moments— for example, the ex-smoker who wheezes in trying to keep up with grandchildren—and work to prevent other patients from experiencing avoidable fates.Perhaps physicians and other health professionals, as a result, have a special duty to weigh in on how society mitigates the social and environmental conditions that lead toward unhealthy choices

Wishful thinking again?.
Why should physicians bear such huge responsibility? "Nanny physicians"? What about citizens?. As you know, my focus is on shared decision making. Unfortunately the article doesn't mention it.

PS. What's goign on in Catalonia? Have a look at WSJ today. This is not a dilemma, it's a fact.

PS. Are you willing to pay 12.380€ for an additional survival of 36 days -progression free in breast cancer- ?. NICE considers that cost per QALY of Eribulin is 91.778 €. Are you willing to pay this cost? Forget the question,  there is no dilemma, the social insurance will pay it for you as from today. We are rich enough to afford it.

PS. If somebody wants to know how neuromarketing is being applied, have a look at the following documentary: "Don't think, just buy". Public health regulators can learn a lot from this experience to counter commercial efforts on junk foods and beverages.

Humanity cannot be owned

Gene Patenting — The Supreme Court Finally Speaks

In light of recent resolution of US Supreme Court on gene patenting, beyond technicalities, the most important is the final decision. All nine Justices of the Court agreed that the segments of DNA that make up human genes are not patentable subject matter. The Myriad case has raised expectations, now the business model is more clear than yesterday, at least in US. However, nobody talks about those patents already acknowledged and what it happens.
The best summary is in the NEJM article:

The Myriad decision will be an important symbol for those who seek to foster scientific discovery by protecting and expanding the public domain. It also has symbolic resonance with the ideal that our common humanity cannot be owned. The Universal Declaration on the Human Genome and Human Rights declares the human genome to be “the heritage of humanity” and that “the human genome in its natural state shall not give rise to financial gains.”

In Europe the patentability of genetic materially is legally protected by the EU's Biotech Directive, which holds that "biological material which is isolated from its natural environment or produced by means of a technical process" may be patentable "even if it previously occurred in nature." FP says: European firms may now have a lot more leeway than their American counterparts.
Does this make any sense? We should start a review process of genetic patents legislation immediately.

A picture is worth a ...

The World Bank HNP Data

Health expenditure as a share of GDP around the world

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!