What is the rule of law?

If we look around us these days we can detect that these conditions have mostly vanished in many public environments:

1. The government and its officials and agents as well as individuals and private entities are accountable under the law.
2. The laws are clear, publicized, stable and just, are applied evenly, and protect fundamental rights, including the security of persons and property.
3. The process by which the laws are enacted, administered and enforced is accessible, fair and efficient.
4. Justice is delivered timely by competent, ethical, and independent representatives and neutrals who are of sufficient number, have adequate resources, and reflect the makeup of the communities they serve.

 How can health policy be implemented in a setting that doesn't conform to such criteria?. Day by day, I'm more convinced that the problem is beyond any policy. Have a look at decree 16/2012, p. 31292, one criteria for public funding of drugs is:

- Social and therapeutic value of the drug and incremental clinical benefit, taking into account its cost-effectiveness relationship

New drugs are being accepted every month, and since June 2012 the Health Ministry hasn't updated the website. Nobody knows its cost-effectiveness. Some weeks ago a transparency law was approved. It's a joke. 
There is one and only option: disconnect asap and forget this nightmare.

PS. I said something similar one year and a half ago. 

PS. Is there any price-cap on publicly funded drugs? In France, the recommendation is to limit any new drug to 50.000€. You'll find it here p.15.  Let's see what really happens here. In UK, confidential discounts apply. Welcome to the transparent world!. Have a look at my previous post on the same topic and the table.

PS. Lewis Mumford dixit:
"For most Americans, progress means accepting what is new because it is new, and discarding what is old because it is old. This may be good for a rapid turnover in business, but it is bad for continuity and stability in life. Progress, in an organic sense, should be cumulative, and though a certain amount of rubbish-clearing is always necessary, we lose part of the gain offered by a new invention if we automatically discard all the still valuable inventions that preceded it.”

A disruptive global health policy agenda

The political origins of health inequity: prospects for change

In order to understand the roots of health inequality, political and institutional factors are crucial. However, they are difficult to assess and identify. This is precisely what Lancet does with the new initiative on Global Governance for Health. As you may know, I'm not a fan of certain approaches and research on inequality, however this document is a milestone to understand where we are and where global health policy should go. Just a caveat, somebody may consider that it is naïf to call for global governance for health if we are not able to define a global governance for peace (e.g. Siria). I'm among those.

PS. After reading this article at EP I'm convinced that we need to define governance mechanisms for better public management. The devil is in the details.

PS. A failed state is voting today against universal justice to avoid prosecution of Tibet genocide responsible. What a shame!, those that are voting the proposal should have been in a tibetan skin and they would change their minds.

PS. The Day We Fight Back against mass surveillance

Club des Belugas. Trip to Saint Topez from Chin Chin Sessions album.

Great Music

Time to refocus

Better health, better care, better value for all

Canada Health Council has analysed the impact of health reform one decade later. The report is worth reading, as long as it is full of details of what worked and what didn't. Despite the commitment to primary care, things didn't change as expected. They have to refocus. A key paragraph:

Although the resources to improve our health system and the health of Canadians were made available, the success of the health accords in stimulating health system reform was limited. Overall, the decade saw few notable improvements on measures of patient care and health outcomes, and Canada’s performance compared to other high-income countries is disappointing. Some pressing issues have been addressed including wait times, primary health care reform, drug coverage, and physicians’ use of electronic health records. But none of these changes have transformed Canada’s health system into a high-performing one, and health disparities and inequities continue to persist across the country.

 Governments think only in terms of office, citizens perspective focus on long-term welfare. Fortunately for Canadians, the council cares for a long-term performance assessment of health policies.

PS. Avoiding waste, Value-based medicine at GCVarela

Context and evidence based health policy

Health Care Systems in Low- and Middle-Income Countries

What works?. This is a difficult question. And this is exactly the issue that Anne Mills is addressing in her NEJM article. Her review of health systems in low and middle-income countries achieves and inconvenient but true conclusion:

On the basis of the evidence presented above, few clear-cut conclusions can be drawn with regard to the best strategies for strengthening countries' health care systems. An approach that works well in one country may work less well in another, and not all approaches are equally acceptable to all governments or their multiple constituencies. There is no one blueprint for an ideal health care system, nor are there any magic bullets that will automatically elicit improved performance. This is hardly surprising: health care systems are complex social systems,31 and the success of any one approach will depend on the system into which it is intended to fit as well as on its consistency with local values and ideologies.
A recent historical study of the contribution of the health care system to improved health in five countries identified a number of characteristics of successful health care systems Such systems were able to develop the capacity to select promising strategies and to learn from the efforts of other countries as well as from their own experimentation. The strengthening of a health care system requires a focus not only on specific strategies, such as those considered above, but also on the creation of an environment that supports innovation. Health care strengthening must thus be seen as a long-term process that involves complex systems and requires carefully orchestrated action on a number of fronts. The global community can help by supporting country-led processes of reform and by helping to create a stronger evidence base that contributes to cross-country learning.

I believe that such characteristics hold as well for high-income countries. Evidence for health policy is context based. No universal laws for implementation, only some criteria, some characteristics. Food for thought.

PS. " Our research suggests that the economics of vertical integration makes sense for payors in only a minority of markets.". McKinsey guys at HA blog. I agree.

False advertising

The concern over consumer protection is growing with new health technologies. This is not new, you may think. However the lawsuit by FTC against Genelink for misleading claims is the first case in a genetics testing company. Genelink said that they analyzed your DNA and afterwards send back nutritional supplements customized to your personal genome. The regimen, the company promised, was good for diabetes, heart disease, arthritis, insomnia and other ailments.On request by FTC, they were unable to confirm such promises.
Since you may find a similar test on the corner of the street, once again my question is: where is the regulator?

PS. Some months ago, was the FDA who asked 23and me to stop selling its genetics test kit.

PS. On DTC genetic tests, a good article.

An ongoing tug-of-war

Understanding Differences Between High- And Low-Price Hospitals: Implications For Efforts To Rein In Costs

Consolidation of private healthcare providers is an increasing trend nowadays. The exact implications for competition and choice are usually unknown. It is worth having a look at other markets. This article in HA explains the impact for the US context:

Prior research shows that private hospital prices vary considerably both within and across markets, even after differences in patient populations and services provided are accounted for. The wide variations in price and the high prices at some hospitals reflect an ongoing tug-of-war between increasingly consolidated buyers (health plans) and increasingly consolidated sellers (hospitals and hospital systems).

Given the intense and growing pressure to rein in the growth in private health insurance premiums, the continuation of current trends appears to be unsustainable. It remains to be seen whether or not health plans will somehow regain the upper hand. If they do not, more radical approaches—such as state-based rate setting or restrictions on contracting arrangements between hospitals and health plans—may gain traction.

PS. HA Blog, a comment.

PS. On limiting bisphenol in food.

PS. Health expenditures NEJM Graphic 

PS.Health Policy Basics: Health Insurance Marketplaces

PS. Are Human Genes Patentable? 

PS. Regulating 23andMe to Death Won’t Stop the New Age of Genetic Testing

Who is the owner?

While reading a recent op-ed on hospitals in a National Health System, suddenly I asked myself: but who is the owner?. The article was reflecting a new view on hierarchy and management of public organizations and was advocating for new cooperative models, horizontal schemes where professionals fit better than a pure civil servant. It may sound good, although it raises a certain fuzzy landscape. Who has the decision rights in a cooperative scheme? Who is the residual claimant?. Just check The Economist for a recent case and remember the potential implications if we translate such model in health care.
There are two sides of the coin: management and governance. Managers and owners have their specific roles. When somebody wants to play both, conflicts of interest arise. It's obvious. Unfortunately in public organizations, such considerations are too often forgotten. Public organizations require better governance designs, stronger and clearer, representing the preferences of the final owner: the citizen.

TMT syndrome

What It Will Take To Achieve The As-Yet-Unfulfilled Promises Of Health Information Technology?

Each day every newspaper wants to convince us over a new technology. In biosciences, journalists enjoy talking about "opening doors" to new cures, and rarely anybody checks afterwards if this anouncement is really in place and provides its expected outcomes. Most of what we see in the media regarding these anouncements are free adverts.
The promise of information technologies in health care is another example. Its application is crucial for success, it is available, but it takes a long, long time to be applied. The disapointing impact of IT on health care has been the last year's article most read in Health Affairs . It is not by chance. We live in a society with a "too much technology" -TMT- syndrome. Organizations can't digest it without internal change in management and governance. Why not create some organizational conditions for success?

Thrasymachus

Wikipedia dixit:

Thrasymachus was a citizen of Chalcedon, on the Bosphorus. His career appears to have been spent as a sophist at Athens, although the exact nature of his work and thought is unclear. He is credited with an increase in the rhythmic character of Greek oratory, especially the use of the paeonic rhythm in prose, and a greater appeal to the emotions through gesture.

Quote from Plato's Thrasymachus in Republic I

338c: Ἄκουε δή, ἦ δ᾽ ὅς. φημὶ γὰρ ἐγὼ εἶναι τὸ δίκαιον οὐκ ἄλλο τι ἢ τὸ τοῦ κρείττονος συμφέρον..[1] (“Listen—I say that justice is nothing other than the advantage of the stronger.”)

This forceful statement is dated from 426 BCE more or less. I'm just quoting it after 25 centuries.

Yesterday at Auditori. Jordi Savall and Le Concert des Nations. Impressive.

Pharma news

The growth in the number of pharmaceutical prescriptions per capita in 2013 has fallen by 6,9%, unit price 1,8% less, and total expenditure minus 8,6%, completing a 4 years cycle of negative deelopment. This means that 80% of the decrease is due to the number of prescriptions.
It seems that physicians are increasing the quality of prescription following a specific policy. This is good news. However, more assessment is needed.

PS. Recent statement at Davos Conference:
"Europe's light at the end of the tunnel looks more and more like an oncoming train"

Where is the regulator?

Understanding the Economic Value of Molecular Diagnostic Tests: Case Studies and Lessons Learned

Maybe we have just arrived at the expected moment, when the cost of one whole genome sequencing is below $1000. (mapping up to 25.000 genes). At the same time, one test for 21 genes may cost you $4.500. This is our crazy world. In the first case you will only know your genome, in the second there will be a probability of success from a certain therapy.
There's only one question: Does anybody know any information about the reliability of such probabilities beyond the firm that is selling the test?. Where is the regulator?
After reading a recent article on the value of molecular diagnostic tests, I'm convinced that we still remain in an uncertain world in need of transparency. Given such uncertainty, better keep calm until the regulator confirms the clinical utility and cost-effectiveness of molecular diagnostic tests.

Parov Stelar Band - Jimmy's Gang (Unplugged in Moscow)

PS. You may avoid watching "The wolf of Wall Street" if you read this article.

Poor quality regulation

Lyn Stout says in his book: Good laws makes good people. Today I would like to confirm again that bad regulation distorts markets. In 1999 it was decided that only group contracting for private health insurance would have some tax rebates, individual insurance lost such consideration. Fifteen years after, the government has decided that such rebates will be subject to social security contributions, this exactly means an increase in buyer's cost by 36%, 30% for the employer and 6% for the employee. In 2012 the average premium in the individual market was 731 €, while the group premium 562€. Such difference is huge since the product is nearly the same, and differential cost can't justify a discount of 23%. Former regulation may explain such distorsion, and precisely this was my argument in an article 3 years ago.
Nowadays group health insurance is not included under income tax, although it may be in the next step. Any government should assess how regulation distorts markets, and fit decisions to strictly improve markets functioning. I think that right now they are strictly thinking on more income and don't care about the impact that may be relevant next year.

On being accountable

FOCUSING ACCOUNTABILITY ON THE OUTCOMES THAT MATTER

A new report from a recent conference has been released. Accountable care is the term that summarises a US trend.
Beyond fashionable concepts, there is the reality. Let's take the definition for health care:

Delivering accountable care for a population involves five key components:
1. A specified population for which providers are jointly accountable.
2. Target outcomes for the population - outcomes that matter to individuals.
3. Metrics and learning, to monitor performance on outcomes and to learn from variation.
4. Payments and incentives aligned with the target outcomes.
5. Co-ordinated delivery, across a range of providers, of the care necessary for
achieving the desired outcomes.

My impression is that in our health system we already have good examples of such organisations. Unfortunately, some issues fail due to wrong regulation. For example, payment and incentives, an issue that should be reformed as soon as possible.

PS. Here you'll find an older post on the same topic of payment and incentives.

PS. Definition. Accountable. adjective \ə-ˈkau̇n-tə-bəl\ : required to explain actions or decisions to someone : required to be responsible for something

The one and only option

Imagine for a moment a country, their citizens are presumably under the same constitution and tax law. Some citizens in a geographic area have a per capita public budget for health care for 2014 equal to 1.541 €. Other citizens, 1.091 € or less. There is no possible argument to maintain such huge and increasing differences. Is there any clever politician in the room to treat such disease? For sure, there isn't.
Simplistically speaking, my understanding is that we could decrease taxes by 28% or otherwise increase public health expenditures by 41%. Since these options are not plausible, the third is to forget such country because it is unable to solve the real public policy challenges. And worst than that, it obliges to apply budget cuts to those that already are spending less. Since such problems have persisted for three decades, the one and only option is to leave, reform is not a credible option.

PS. Data