Inequality in the winner-take-all society

A recent op-ed by Joseph Stiglitz on "Innovation enigma" brought me to retrieve a book of 1995 by Robert H. Frank, "The Winner-Take-All Society: Why the Few at the Top Get So Much More Than the Rest of Us". Nowadays, the issue of raising inequality is on headlines, and often it is considered as a consequence of economic crisis. 
Frank argued two decades years ago that more and more the current economy and other institutions are moving toward a state where very few winners take very much, while the rest are left with little. He attributes this, in part, to the modern structure of markets and technology. It was written before the impact of internet on business and it was a clear alert about what has happened.
Now Thomas Piketty in his book "Capital in the 21st century" argues additionally that when the rate of capital accumulation grows faster than the economy, then inequality increases. And inequality is not an accident but rather a feature of capitalism that can be reversed only through state intervention. The book thus argues that unless capitalism is reformed, the very democratic order will be threatened.
If you combine both perspectives, you must be convinced that it is not only an issue of state intervention, I can't imagine certain parts of global markets ("winner-take-all" ) being abolished or reformed without a global government. That's why I'm not sure about the size of the current threat and when it will explode.
Stiglitz adds an uncertain landscape for innovation, and therefore for future dynamic efficiency of markets (Shumpeter style).
Taking all these pieces together, there is no clear recommendation. Today I just want to state again that correlation is not causation. Inequality and crisis are a contemporary fact, though the trend goes back a long way and it is very much deeper. Avoiding reductionist perspectives is my first suggestion.

PS. Since the implications of wealth inequality and health are huge as I explained in this post, my today comment maybe adds more shades instead of light.

PS. "Health inequalities result from social inequalities. Action on health inequalities requires action across all the social determinants of health." The Marmot Review: Fair Society Healthy Lives

PS. If you want to know why Messi's salary has increased this week, have a look at Frank's book, the answer is there.

Predictive modeling in health care

Predicting Patients with High Risk of Becoming High-Cost Healthcare Users in Ontario (Canada)
 
Predicción del riesgo individual de alto coste sanitario para la identificación de pacientes crónicos complejos

Two articles appear on the same topic, published at the same time, in Canada and Catalonia (I am coauthor of the latter). The results of both studies are similar. Their goal is to identify those patients that will belong to the highest spenders next year.
Canada results:

If the top 5% patients at risk of becoming HCUs are followed, the achieved sensitivity and specificity is 42.2% and 97%, respectively. These values suggest very reasonable predictive power, indicating that the model picks up 42.2% of all high-cost healthcare users and correctly identifies 97% of those who are not high users.

Catalonia results:

En el modelo, todas las variables fueron estadísticamente significativas excepto el sexo. Se obtuvo una sensibilidad del 48,4% (intervalo de confianza [IC]: 46,9%-49,8%), una especificidad del 97,2% (IC: 97,0%-97,3%), un VPP del 46,5% (IC: 45,0%-47,9%) y un AUC de 0,897 (IC: 0,892-0,902).

The models are slightly different, while the results are close.

I suggest you have a look at them, predictive modeling is one of the main current topics of health services research. Some people consider that it is under the umbrella of Big Data, although it was born before such a term was created.

PS. A must read. Bob Evans, and The Undisciplined Economist: Waste, Economists and American Healthcare

PS. In memoriam: Gary S. Becker, 1930-2014. The Becker-Posner blog is terminated.

The forthcoming systemic drug industry?

While reading WSJ this week I found that big changes are happening in the pharmaceutical industry. We all know that the former message was: if the industry business model is broken, the best is to manage its decline (John Kay FT dixit). I also explained such trend in this post. Consultants predicted 5 alternative strategies, now the 6th is in place.
The trend is focused towards a new industry structure after the failure of the two parts model: innovative and generic. WSJ says:

A wave of mergers and acquisitions is reshaping the global pharmaceutical industry. Many drug companies are narrowing their focus, dropping out of noncore businesses and bulking up where they have the size and expertise to generate significant sales growth.

The deals would leave fewer competitors with larger revenue streams in each segment of the drug business, from prescription medicines and vaccines to drugs for livestock and pets.

 After the failure of the standard innovative model throught patents, the alternative is to concentrate on rare diseases, and on highly profitable market segments -low volume and high profit-. Concentration is taking place also in commoditizated markets (generics).
Such a level of market concentration should lead to competition policy concerns, since the rivalry is not at industry level, it is at therapeutic group level. Unfortunately regulators are on vacation again. Maybe one day we will complain about a systemic industry that some of its parts may collapse and creates larger risks than returns, but it will be too late.

PS .Def: Systemic risk can be defined as the likelihood and degree of negative consequences to the larger body. With respect to federal financial regulation, the systemic risk of a financial institution is the likelihood and the degree that the institution's activities will negatively affect the larger economy such that unusual and extreme federal intervention would be required to ameliorate the effects

PS. Pharma megamergers, do they work?
PS. Reinhardt, as clear as ever in his blog: Congress and the Belief That Human Life Is Priceless

Facts and data

Balanç de l’atenció mèdica i sanitària públiques del 2013

- The impact of the decree that changes the health system towards a Social Security-based (April 2012) is: 3,4% citizens are not covered (216.900). However, the government has decided to introduce an exception and all continues as it was in the former National Health System. (That's rule of law! an example of articulated institutions)
- Primary care visits have decreased again in 2013: 5,17% (!) (7 million visits less than in 2008)
- Emergency visits, a decrease of 1%
- Specialty visits, an increase of 2,9%
- Inpatient care, no change -0,2%
- Ambulatory surgery, an increase of 3%
- Electronic drug prescriptions, 91% of coverage
- Satisfaction level: 8,06, better than 2008 (7,43)
- Health expenditure over GDP 8,3% (2011). A  0,3 pp increase on public and private expenditure  over GDP since 2008. Public expenditure 5,6%, Private expenditure 2,7% over GDP (2011).

More details in the report.

The drivers of HTA decisions

Decision making by NICE: examining the inuences of evidence, process and context

Two reductionists views can be avoided. There is one that puts all the eggs in one basket of QALYs, the opposite that considers that QALYs are flawed and the solution is far away. Beyond such extremes, there is the need to assess new techonogies, and this is precisely what NICE does. An interesting article revisits the current drivers used by NICE to take decisions. These are the conclusions:

The results suggest that the variability in decisions observed can be explained by a combination of clinical, economic, process and socio-economic factors. The analysis showed that the proportion of restrictions and non-recommendations issued by NICE are increasing over time relative to recommendations. The analysis also confirmed that the demonstration of clinical and economic value is central to NICE decisions.

New factors not previously reported to have an effect on NICE decision making were identified, including the effect of clinical superiority on NICE decision making, the effect of the ICER on the likelihood of both restriction and recommendation and that NICE decision making was sensitive to process variables as well as socioeconomic factors.

Interesting guide to convince those that already have a reductionist mind. The evidence, the process and the context has to be taken into account.

TMT syndrome (2)

Some months ago I wrote a post on TMT syndrome. It raised the interest of some followers and I was asked to prepare a larger op-ed for a bulletin (in spanish):

El síndrome TMT ante la destrucción creativa

Hoy en día podemos conocer con precisión las preferencias de lectura en una revista electrónica; podemos identificar cuántos acceden a ella y así nos podemos aproximar a las preocupaciones de los lectores. Health Affairs es una revista de referencia en política y gestión sanitaria y, en el ranking de artículos leídos en 2013, la primera posición la ocupa una revisión sobre una asignatura pendiente: la adopción de las tecnologías de la información en el sector salud [1]. El artículo se pregunta si las tecnologías de la información en Estados Unidos están interconectadas, ampliamente implantadas, utilizadas adecuadamente y si se ha producido el cambio organizativo esperado. La respuesta a cada cuestión es simplemente negativa. Y como todo artículo que desea resumir algo complejo en cinco páginas y recurre a generalizaciones, la conclusión a la que llega es parcial. Porque hay una gran mayoría de tareas pendientes por hacer y también hay otras que ya se han hecho y fueron publicadas en el propio Health Affairs cuatro años antes, como es el caso, por ejemplo, de Kaiser Permanente [2]. La barrera fundamental a la adopción de la tecnología tiene que ver con la organización y los incentivos. Entornos de atención fragmentada y con pago por acto médico tienen todos los ingredientes necesarios para que la adopción de tecnologías de la información se deje para otro día.

La tecnología está disponible, la organización está llamada a prepararse para adoptarla, pero en muchos casos, los incentivos escasean. De lo mucho que hay escrito al respecto, me sigue interesando el libro que coordinó Louise Liang desde Kaiser Permanente [3]. En él, los protagonistas de la experiencia de implantación de la historia clínica electrónica describen su visión y las perspectivas de futuro. Los últimos capítulos interesan en especial. Cuando el uso de aplicaciones móviles parece que sea el próximo milagro para la salud [4], David Eddy y Louise Liang se olvidan de ello y se concentran en explicar la importancia de las trayectorias en enfermos crónicos y los modelos probabilísticos que hay detrás del “Archimedes Model”. Todo dirigido a un solo objetivo: mejorar la toma de decisiones compartidas entre médico y paciente. De este modo, llegan al núcleo esencial del valor potencial de las tecnologías de la información: mejorar las decisiones y mejorar el proceso de atención.

Estoy convencido que estamos en el sector salud ante el síndrome TMT (too much technology, demasiada tecnología). Las organizaciones son incapaces de digerir la transformación potencial que tiene implicaciones cruciales en el coste y en la calidad. Los requisitos para que esta transformación sea efectiva se han descrito en múltiples ocasiones y ahora, en un contexto económico de límites a la inversión, puede que haya una barrera adicional a la organizativa.

En nuestro entorno próximo, hay casos ejemplares de adopción de historia clínica electrónica. Hay organizaciones que desde hace más de una década disponen de información digitalizada completa de la población que atienden [5], del mismo modo que hay entornos donde escasean ejemplos similares, como sucede en la sanidad privada.

La cuestión emergente es dilucidar hasta qué punto la digitalización generalizada en el sector salud será capaz de modificar ampliamente la “función de producción” de la salud tal como la conocemos hasta ahora. Con ello quiero referirme fundamentalmente a la asistencia sanitaria y a los comportamientos saludables.

Eric Topol ha sido capaz de resumir en un libro lo que está sucediendo y lo que puede suceder [6]. Más allá de confirmar las tendencias conocidas y sus implicaciones, al final, cuando llega al capítulo sobre la necesaria “plasticidad de los médicos”, nos muestra el panorama al que las organizaciones, los profesionales y el regulador han de enfrentarse próximamente.

En el capítulo relativo al “homo digitus”, nos aporta su conclusión: “La especie humana está digitalizando la propia especie, este es el agente último de cambio de la vida. Y esto va más allá de un simple cambio, es la esencia de la destrucción creativa que conceptualizó Schumpeter”. ¿Seguiremos en medio del síndrome TMT o finalmente entraremos en un proceso de destrucción creativa? Si alguien os plantea este dilema, desconfiad del reduccionismo; estoy convencido que estamos en medio del proceso, aunque no podemos dilucidarlo.

Referencias

[1] Kellermann AL, Jones SS (2013). What it will take to achieve the as-yet-unfulfilled promises of health information technology. Health Affairs, 32(1):63-8.

[2] Chen C, Garrido T, Chock D, Okawa G, Liang L (2009). The Kaiser Permanente Electronic Health Record: transforming and streamlining modalities of care. Health Affairs, 28(2):323-33.

[3] Liang LL, ed. (2010). Connected for Health: Using Electronic Health Records to Transform Care Delivery. San Francisco CA: Jossey-Bass.

[4] The Economist (2014). Health and happiness. 1st February.

[5] Saigí F (2007). La informatització de la informació sanitària: projectes i experiències d’història clínica compartida. Vol. 1, Cap 4. En: Universitat Oberta de Catalunya, Generalitat de Catalunya. Projecte Internet Catalunya. Modernització tecnològica, canvi organitzatiu i serveis als usuaris en el sistema de salut de Catalunya. Barcelona: UOC.

[6] Topol E (2012). The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. New York: Basic Books.

Is it possible to internalize externalities of risky behavior?

Risking Your Health. Causes, Consequences, and Interventions to Prevent Risky Behaviors

Behaviour Change

Today I bring a World Bank Report and a UK Parliament report, both on behaviour. The first is closely related to developing countries, though the same messages are for developed ones. I don't know who exactly is paying the bill for such risky behaviours. Measures to internalize externalities are not so easy to implement, though the document explains some of them.
The second report is an introduction to behavioral economics for politicians. I'm convinced that we do need to know more about this, although there is no unifying theory and prescriptions are fuzzy by now.

PS. Today we can confirm that Google scans your gmail messages.
PS. Today we can also confirm again that internet is an unsafe network
PS. Bloomberg on behavioral finance.

The home and the neighborhood

Transforming Specialty Practice — The Patient-Centered Medical Neighborhood

The coordination of health services requires intense relationships between primary and specialized care. Though this is obvious, sometimes there is a need to insist on it. And this is precisely what an article at NEJM does. It explains the components to assess the Patient centered medical home and the patient centered specialty practice.
This is a US style organizational design, although some european private organizations should keep an eye on such developments. The current organization of private practice is too far from the requirements of a modern practice of medicine and to fulfill patient expectations. The pressures for organizational change unfortunately will not arise from inside, the confort zone always plays its role.

PS. Video on low value care and how to avoid it, at NEJM.

The Health of Catalans

La salut de la població de Catalunya en el context europeu

Comparing population health between countries allows to understand the scope of the differences. Some of them are unwarranted and others require an explanation. Anyway, it is good to confirm in a new report that the health of catalans has achieved a top level in Europe. The key indicator is healthy live years. As a summary it works, but when you go into details, then some  problems arise: obesity, tobacco, colon cancer, diabetes,...
Comparing public expenditures , Catalonia spends less than other countries with similar GDP. And the opposite is true for private expenditures (p.16). Unfortunately, data is  from 2010 and things have changed a lot, on GDP and health expenditure. My guess is that right now we are spending publicly a larger percentage than 6%. An update is needed in order to know better our current position.

A pivotal moment in the history of medicine

What the Tamiflu saga tells us about drug trials and big pharma

Today the long article by Ben Goldacre published in  The Guardian is a required reading. Those that have some doubts regarding the effectiveness of oseltamivir will see them vanishing. The Cochrane review explains the size of side effects and controversies that have surrounded such drug since flu pandemic in 2009.
The most important message goes beyond tamiflu, it is related to transparency in drug trials:

This is a pivotal moment in the history of medicine. Trials transparency is finally on the agenda, and this may be our only opportunity to fix it in a decade. We cannot make informed decisions about which treatment is best while information about clinical trials is routinely and legally withheld from doctors, researchers, and patients. Anyone who stands in the way of transparency is exposing patients to avoidable harm. We need regulators, legislators, and professional bodies to demand full transparency. We need clear audit on what information is missing, and who is withholding it.
Finally, more than anything – because culture shift will be as powerful as legislation – we need to do something even more difficult. We need to praise, encourage, and support the companies and individuals who are beginning to do the right thing.

Understanding UK health reform

A primer on health economics and policy

Social values in health and social care

In just 38 pages Tony Culyer explains  the basics of health policy. It is not a review, these are a collection of key insights that basically come from his book. This is the outline:

• Introduction
• Liberalism versus libertarianism
• The market versus the state
• Public versus private insurance
• Equity versus equality
• Inequalities of health versus inequalities of health care
• Equity versus efficiency
• Needs versus wants
• Prices versus rationing
• Financial protection versus quality of life
• Public versus private
• Agents versus principals
• Universality versus selectivity
• Comprehensiveness versus limited benefit bundles
• Centralisation versus decentralisation
• Competition versus collaboration
• Experts versus citizens
• Mixing values and other things
• Key messages 

Take this sentence, as an exemple:

Cost is also a value and no mere matter of accountancy. If we introduce a new
health care procedure, the cost will have to come out of expenditure elsewhere
in the NHS –unless there is a concurrent increase in the NHS budget. But less
expenditure elsewhere will normally imply reduction of service elsewhere and
a consequential health loss. The true cost of getting more care (and hence
health) in one area of activity is therefore the minimum necessary loss of care
(and loss of health) elsewhere. This is the important notion of opportunity cost.

Many politicians don't want to hear such messages. I stronlgy suggest you to read this booklet from Kings' Fund.
.

Cost-effectiveness as a proxy of value

GUIA I RECOMANACIONS PER A LA REALITZACIÓ I PRESENTACIÓ D'AVALUACIONS  ECONÒMIQUES I ANÀLISIS D'IMPACTE PRESSUPOSTARI DE MEDICAMENTS EN L’ÀMBIT  DEL CATSALUT

As resources are scarce we do have to prioritise. That's it, we can't escape. We do need a proxy to assess relative incremental value of the technologies and procedures for a disease, otherwise decisions would be arbitrary. In such situation a methodologic guide is welcome to provide credible information. This is precisely what the guide by CatSalut is contributing to. It explains criteria and ways to present economic evaluation and budget impact analysis. A well designed guide that unfortunately right now will have a limited application. The reason is that government can't completely decide about it. It's an issue of months.

Unsafe medical devices regulation

Improving Medical Device Regulation: The United States and Europe in Perspective

The regulatory differences between Europe and US are quite well known since the breast implants scandal. A US citizen was not able to receive such implant because FDA had not approved. The rationale is not related to such a case, it is the current system of notified bodies that really doesn't protect population health. However, US needs also to improve. Milbank Quarterly article says:

Overall, US and European evidence requirements for devices introduce not only risks to patients but also the wrong incentives to generate the needed evidence to better understand and evaluate the benefits and risks of new devices. Considering that manufacturers often take advantage of existing evidence from already marketed devices to gain approval for a new device, they are reluctant to undertake new clinical studies. In addition, because later devices may be able to claim equivalence, the first manufacturer to market does not have a very strong incentive to undertake extensive clinical studies.

The steps to improve regulation are detailed in the article. Surprisingly, notified bodies is again the chosen option in the current review of the legislation. Citizens should know it before voting.

PS. Milbank says it is an original investigation, you may check the same title and authors some months before in Value in Health