Undermining agency theory

The Rhetoric of the Economy and the Polity

Two statements from an excellent article by D. McCloskey:
 
A criticism on agency theory:

The Great Recession gave us all some perspective on how agency theory works. The deepest problem in agency theory in any of its forms (public choice, law-and-economics, finance, whatever) is the same as the problem in prudence-only political theory, subject to the Nussbaum Lemma. The theory declares that one has an “obligation” tomake profit (and further that the economic analyst has an obligation to articulate such a theory, always, and has an obligation not to talk about the ethics of  managerial or scientific obligation, since these are matters of value about which one has an obligation not to dispute). But where does the obligation come from? It comes in fact from the ethical responsibilities of a manager to her professionalism, her stewardship, her stakeholders’ interests, or her promotion of the common good. The agent is not a pure prudence-only, Max U creature after all, just as the Hobbesian selfish individual is not. In the very theory that
denies ethics to the agent, she is imagined to be driven by an ethic, albeit a tacit and abbreviated one. Kant fell into a similar self-contradiction when he claimed to base ethics on reason alone, yet gave no account of the reasons an agent would want to act on reason.

About the crisis:

If we have a crisis, it is one of ethics. Bad People (mainly Bad Men) did it. But the baddest men are the political theorists and business-school professors who recommend an approach to the politics of life that omits the virtues. Is that you, looking at yourself in the mirror?

My understanding is that we have emphasized agency teory beyond its initial purpose. The combination of agency and utilitarism forgets professionalism. I share the view of McCloskey.

PS. 30 years after Fama-Jensen famous article on separation ownership and control.

PS. Another article against agency theory.

PS. Nussbaum Lemma:  I think it implausible to suppose that one can extract justice from a starting point that does not include it in some form, and I believe that the purely prudential starting point is likely to lead in a direction that is simply different from the direction we would take if we focused on ethical norms from the start.
McCloskey interpretation: You have to put the rabbits into the hat if you are going to pull them out.

Courts as market makers

Recent decision invalidating Myriad patents has had immediate results. The market of genetic tests on breast and ovarian cancer has new entrants. The price of the test has decreased 40% (!) in just four months after the resolution. More entrants are expected in the next future for more tests.
The question is still the same, is there any clear cost-effectiveness analysis available for such tests? Why homebrew tests (LDT) are beyond any regulation? Does any regulator care about all this issues?. The answer is: up to now, we can't see any efforts. Patents create artificial monopolies, courts may create markets when invalidate patents,  but patients are concerned about health improvement and value. In an asymetric information environment, the regulator can't take permanent holidays. Overdiagnosed population doesn't necessarily mean healthier population.

 Forbes Healthcare Summit 2013

Insurance Companies Enter A New World

A cause and consequence of progress (2)

The Great Escape: Health, Wealth, and the Origins of Inequality

Although Angus Deaton qualifies himself as cautiously optimistic in the book, some paragraphs may help to understand his caveats:

Our children and grandchildren cannot possibly expect a unique exemption from the forces that brought down previous civilizations. In Europe and North America we have grown to believe that things will always get better. The past 250 years have seen unprecedented progress, but 250 years is no great span of time compared with the long-lived civilizations of the past who doubtless thought that they were destined to last forever.

On growth:

Economic growth is the engine of the escape from poverty and material deprivation. Yet growth is faltering in the rich world. Growth in each recent decade has been lower than in the previous one. Almost everywhere, the faltering of growth has come with expansions of inequality. In the case of the United States, current extremes of income and wealth have not been seen for more than a hundred years. Great concentrations of wealth can undermine democracy and growth, stifling the creative destruction that makes growth possible. Such inequality encourages the previous escapees to block the escape routes behind them.
Mancur Olson predicted that rich countries would decline like this, undermined by the rent seeking of an ever-growing number of focused interest groups pursuing their own self-interest at the expense of an uncoordinated majority. Slower growth makes distributional conflict inevitable, because the only way forward for me is at your expense. It is easy to imagine a world with little growth but endless distributional conflict between rich and poor, between old and young, between Wall Street and Main Street, between medical providers and their patients, and between the political parties that represent them.

The inevitability of distributional conflict is the issue to take into account. This is in my opinion the greatest concern for the future, unless we are able to build firewalls to protect the foundations of social welfare.

 “The Kennedys” at Galería Loewe by Mark Shaw until Nov 15th

A cause and consequence of progress

The Great Escape: Health, Wealth, and the Origins of Inequality

I have spent this long weekend reading the last book by Angus Deaton. It appeared in the list of FT business books of the year, although was not shortlisted. You may find a short reference at The Economist and an article by the author at Foreign Policy. As you know, I'm a follower of his works. You'll find references in previous posts 1, 2.
The book is worth reading. The topic and the author deserves spending time on it. And specially right now, with dubious prospects about economic growth and how it will affect to inequality.
Let me highlight some paragraphs from the book.
On inequality paradox:

Inequality is often a consequence of progress. Not everyone gets rich at the same time, and not everyone gets immediate access to the latest life-saving measures, whether access to clean water, to vaccines, or to new drugs for preventing heart disease. Inequalities in turn affect progress. This can be good; Indian children see what education can do and go to school too. It can be bad if the winners try to stop others from following them, pulling up the ladders behind them. The newly rich may use their wealth to influence politicians to restrict public education or health care that they themselves do not need.

On efficiency and the economists:

Economists—my own tribe—think that people are better off if they have more money—which is fine as far as it goes. So if a few people get a lot more money and most people get little or nothing, but do not lose out, economists will usually argue that the world is a better place. And indeed there is enormous appeal to the idea that, as
long as no one gets hurt, better off is better; it is called the Pareto criterion. Yet this idea is completely undermined if wellbeing is defined too narrowly; people have to be better off, or no worse off, in wellbeing, not just in material living standards. If those who get rich get favorable political treatment, or undermine the public health or public education systems, so that those who do less well lose out in politics, health, or education, then those who do less well may have gained money but they are not better off. One cannot assess society, or justice, using living standards alone. Yet economists routinely and
incorrectly apply the Pareto argument to income, ignoring other aspects of wellbeing.

On inequality and what to do about it:

Inequality can spur progress or it can inhibit progress. But does it matter in and of itself? There is no general agreement on this: the philosopher and economist Amartya Sen argues that even among the many who believe in some form of equality, there are very different views about what it is that ought to be made equal. Some economists and philosophers argue that inequalities of income are unjust, unless they are necessary for some greater end. For example, if a government were to guarantee the same income for all of its citizens, people might decide to work a lot less so that even the very poorest might be worse off than in a world in which some inequality is allowed. Others emphasize equality of opportunity rather than equality of outcomes, though there are many versions of what equality of opportunity means. Yet others see fairness in terms of proportionality: what each person receives should be proportional to what he or she contributes. On this view of fairness, it is easy to conclude that income equality is unfair if it involves redistributing income from rich to poor.

On Aid and Politics, (chapter 7).

The arguments about foreign aid and poverty reduction are quite different from the arguments about domestic aid to the poor. Those who oppose welfare benefits often argue that aid to the poor creates incentives for poor behavior that help to perpetuate poverty. These are not the arguments here. The concern with foreign aid is not about
what it does to poor people around the world—indeed it touches them too rarely—but about what it does to governments in poor countries. The argument that foreign aid can make poverty worse is an argument that foreign aid makes governments less responsive to the needs of the poor, and thus does them harm.

Aid is a controversial issue, and Deaton was criticised for it at NYT .  You may find here a recent example that supports anecdotically the argument of Angus Deaton. It's up to you, the final view on this difficult topic.

PS. On inequality in our days, at NEG.

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!

Mounting evidence about sugar-obesity link

Sugar: Consumption at a crossroads

Should the government and health officials do more to reduce consumption of sugar, and will they in your opinion? The answer is yes, 90% of the European population consider that governments need to act,  but only 52% believe the governments will do it, according to the Credit Suisse Equity Research Nutrition Survey, 2013. You'll find the details in this report.
Why so many people consider that right now something should be done about sugar intake?. Basically because everybody is increasingly convinced about the relationship between excessive sugar consumption and obesity.
The report is a good guide for all the implications and potential governmental regulation and industry self-regulation.
Definitely, something should be done, asap.

The value of clinical pathways

Beneficis de l’organització de l’atenció sanitària a les persones amb ictus: mortalitat evitada i impacte econòmic

The size of efficiency improvement that stems from wide application of clinical pathways is huge.The stroke case has shown a reduction in 7,1% of deaths between 2005 and 2012. The study adds some estimates about benefits for society of saved years: 540 m euros. I'm not so sure about this figure, since it doesn't adjust for quality. The issue deserves a larger research, we need to understand the outcomes and quality of such protocol, known as "ICTUS Code".
Anyway, these are promising results and a good reason to strengthen clinical pathways on a general basis.

The rights and wrongs of headlines

Imagine that you see this headline in the newspaper: "Private health insurance has new 100.000 members". You may think, that's quite a lot. And you forget to read that this news reflects two years, not only one. And you go inside the report and you see that in 2011 there was an artificial jump because 4 companies had not reported previously.
And finally you are looking desperately for the right number. How many people have really bought a voluntary insurance policy in 2012? The answer is 47.370 new members, that's the right figure.
The duplicate coverage ratio is up 0,20 percentage points, to 24,6% of the population (1.842.121) p.22.
And that's all. Forget the newspaper, go straight to the report. This is the advantage of internet access and the reason why some journalists should rethink their work, they should avoid press releases and verify data.

PS.You'll not be able find the original press release on the internet, it has been removed.

ED Crowding

Informe de l’activitat notificada al Registre del conjunt mínim bàsic de dades d’urgències

How many visits to the emergency department are really urgent?. Up to now we hadn't a clear answer. A recent report says clearly that according to triage data, 13,3% of visits at hospitals ED are non-urgent. Is this figure accurate?. Well, if we look at the US, 12% of visits are non-urgent. We know that triage data is the only possible source for this evaluation right now. Other approaches are possible, but require larger effort.
From the data, we can conclude that reducing non-urgent care at ED is always important, but may have low impact on ED crowding.
In p.13 of the report I find that 3,9% of visits have uncertain funding. I can't understand why. Only 4.681 visits were performed under international social security agreements, it seems that there are very few cases.
Anyway, it is the first release of the report, and this is good news. We need such information to understand what's going on.

Behavioural economic-informed regulation

From Nudging to Budging: Using Behavioural Economics to Inform Public Sector Policy

Is it possible to design a regulatory mechanism to budge the private sector away from socially harmful acts?. Adam Oliver, from LSE offers his view at the Journal of Social Policy:

The role of government is not, for the most part, to interfere with personal lifestyle choices unless those choices present harms – or negative externalities – to others, although the government may be warranted in enforcing some behaviours designed to protect people principally from themselves if the intervention is considered openly and explicitly and supported widely, such as seatbelt legislation. The most effective way of preventing people or organisations harming others is to regulate their activities. Nudge is anti-regulation, but behavioural economics is not.

An awareness of the main behavioural economic findings – for example, present bias, reference points, loss aversion and nonlinear probability weighting – can help to inform decisions on where and how to regulate (for instance, traffic light food labelling), and may also ensure that public officials gain a better understanding of their own decision making limitations.

As I have said before, the idea sounds appealing, its implementation remains uncertain.

The size of the loss

Estadística dels centres hospitalaris de Catalunya, 2011

We live in difficult times. Economic downturn continues, although some politicians say the opposite. If we take 2011 hospital data, the size of the loss of private acute hospitals was 4,9% of income (33,7 m euro), for public utilization hospitals: 1,3% (71,7 m euro). Two different patterns emerge, in private hospitals income and expenditure increases, while in public hospitals income and expenditure drops (p.32). Public beds per 1000 inhabitants falls in 14 basic points, while in private is quite the same (+1 basic point).
Let's wait for 2012 report.

Charting a new territory: health systems vulnerability

Learning from Economic Downturns How to Better Assess, Track, and Mitigate the Impact on the Health Sector

Regarding the measurement of country-specific health system vulnerability to economic crises in comparison to peers and over time, the WB new report says:

Compared to other fields, such as food security (Food Price Watch 2012; Messier et al. 2012) and environmental vulnerability (SOPAC 2010), the health system lags behind in providing standardized definitions, metrics, and applied tools that would help assess crisis-related vulnerabilities. There are no descriptive tools that would allow for retrospective comparison, let alone predictive tools that would enable early warning signals.

The vulnerability assessment that they propose sounds of interest at a first glance. Spain, Cyprus, Italy and Greece are at the top of european ranking of vulnerability (p.60). Data come from 2010, rigth now the position would be a different one, even worse than before. The problem is that variation within each country is huge, comparing countries is an easy way to forget such differences.

Fundamental misconceptions about health economists and economics

Economics: the biggest fraud ever perpetrated on the world?

Twitter is a risky tool. Your short messages are seen worldwide, be careful. Richard Horton, editor of The Lancet, sent 10 tweets about economics and economists. Ten misconceptions, one behind the other. Certain people consider that such sentences doesn't deserve an answer, they only reflect the personality and knowledge of the author. Others, like David Parkin, John Appleby and Alan Maynard think the opposite and they decided to write a comment this week in The Lancet. This is an article for the files. And it fits perfectly as a recommended reading for those that share these controversial views of Richard Horton:

Panel: Tweets from @richardhorton: “Economics, second only to ‘management’, may just be the biggest fraud ever perpetrated on the world.”
The case against economics:
1 The promise economics offers is seductive: how to allocate scarce resources in society.
It’s a false promise.
2 Economists write as if the economy=society, and societal problems=economic problems. The confl ation is false too.
3 Once there was political economy = economics, ethics, politics. Economists have stripped morality from economics, leaving an arid science.
4 The high points of economic thinking are theories, not data. Reliable experimentally derived data are anathema for most economists.
5 Economists see health as an economic good. It is an opportunity cost, with zero intrinsic value.
6 Rationality, for the economist, means subjecting every thought/decision to a cost-benefit analysis. A wholly narrow view of humanity.
7 The big idea in economics is the market. The assumption is that human beings make cost-benefit decisions based only on self-interest.
8 The essence of economics is price. For those in health who argue for access free at point of delivery, we kill the soul of the economist.
9 Economists deny the existence of citizens. They see only consumers.
10 Finally, it’s acceptable to worsen the lives of some provided the gains of others compensate. Economists institutionalise inequality.A sum of nonsense sentences, one behind the other. 

After reading the comment to each of these tweets, it will be difficult to maintain the same position.
And the authors' conclusion:

What motivated Horton’s critical outburst about economics and economists is not clear. More than 40 years ago, an essay by Alan Williams to defend economic evaluation admitted its imperfections, but concluded with Maurice Chevalier’s view on old age: “Well, there is quite a lot I don’t like about it, but it’s not so bad when you consider the alternative!”Economics, like medicine, is imperfect. The challenge for practitioners of each is to ensure that the perfect does not drive out the good. Our practices may at times be imperfect, but that should not inhibit our drive to improve clinical practice and economic activity for the benefit of all our patients and citizens. We all must strive to avoid confused analysis in displays of modest understanding of each other’s work.

Becoming a physician in your country

Once again I have to explain that we live in a weird country. Imagine for a while that you are at the moment of taking the difficult decision about your future professional career. Imagine that you would like to become a physician. You live in a country that still needs new physicians and in the near future a lot of them will retire. If you succeed on that challenge, then you belong to one third (37%) of those that this year have entered into the profession.
The question is why are we not able to fill the remaining 73% with candidates coming from our towns and cities?. There is a perfect messy regulation that blocks any posibility that the students interested in medicine, with excellent curricula and grades, can enter university.
This is a way to constrain career and life development for new generations and restrict access to close professionals for the population. A complete human made disaster. There is only one possibility to survive in such situation, a quick disconnection.