How newcomers become bureaucrats?

Becoming Bureaucrats Socialization at the Front Lines of Government Service

It is quite surprising how public service management usually is considered from a reductionist perspective. Some people think that if we understand the rules and incentives that underlie in public service, then we can understand its performance. The constraints to change the factors that drive performance are well known and it seems that nothing can be done to surpass inertia.
A new book provides fresh air on this issue. It argues that:

Bureacratic behavior follows a logic of appropriateness (LOA). This decision-making theory, developed by James March and Johan Olsen, suggests that organizational behavior is associated with norms that individuals develop about what constitutes appropriate, exemplary behavior

A key message:

The traditional understanding that bureacracies change people may be true but beside the point. More important , in this account, is how bureacracies find people and how people find them.

I still don't understand why most physicians-nurses-... in NHS must be civil servants. I have said that many times and nobody has been able to find an argument. In my opinion this is one of the pieces that reflects an outdated system without the possibility to break its inertia.

Outsourcing boards of directors?

BOARDS-R-US:RECONCEPTUALIZING CORPORATE BOARDS

A comment in The Economist suggests a new approach: outsourcing boards of directors. Such a strategy would be justified to solve the current widespread and deep-rooted problems. They provide some examples and we all know some disfunctions. However, such proposal is open to dispute and the conflicts of interest that may arise may not compensate the professional approach of such "firms". On the other hand something should be done and may be this is an interesting approach for publicly owned firms as far as they are not exposed to market competition. Health care could be an example of a sector to experiment and to improve providers' governance.
The original article is in Stanford Law Review.

Is nudging ethical?

The challenges and opportunities of ‘nudging’

A forthcoming Editorial in the Journal of Epidemiology and Community Health provides some amunition for those interested on nudging.

The answer to the question if nudging is an ethically acceptable way of governing people’s behaviour depends on the ethical principles one adheres to. Our core point is that there is no magic trick, any form of policy intervention will impose a criterion against someone’s will, and democracy requires: (1) transparency from the political system in terms of the values selected in deciding and designing an intervention; (2) and at least an evidence-based justification of choice.

If the preferences of an individual change, then we cannot state that his first choice is better/equal/worse than his second one without introducing a ranking among his preference systems. As a result, value-free interventions cannot be defined.

If no magic bullet is available on the policy side, the same applies to research. In the domain of health, behavioural approaches must cope with the challenge of not neglecting the socioeconomic and contextual determinant of health inequalities

We argue that neglecting socioeconomic variables would be clearly a mistake also in the design of nudge. However, our point is precisely that behavioural science (and nudge as its policy implication) can incorporate an analysis of social and cultural factors, and avoid cognitive universalism.

Easier said than done. For an op-ed, it fits with the audience, for a strict and concrete policy recommendation requires further elaboration. I can't see  a practical and concrete applicable approach nowadays. Let's continue waiting.

PS. Must read, on medical devices in BMJ.A systematic review of new implants in hip and knee replacement

PS. A flawed PNAS article unveiled. Again and again, where is peer-review?

Jordi Pintó at Galeria Banadas

Retrofuturistic payment systems (2)

Long time ago I alerted about a potential payment system that tried to convince everybody and didn't satisfied its goals for equity and efficiency. I was concerned about reproducing the mistakes of the past and creating flaws for the future. What I said more than two years ago, has been recently confirmed more or less by a recent decree. Its detailed analysis goes beyond any post in a blog. The retro part is related to an administrative discretionary classification of hospitals that was initially defined two decades ago (Decree  June 30th, 1992) and failed afterwards. The future part is related to a dual payment system: population and service based that will be defined according to idiosyncratic situations. Both are the pillars of uncertainty in the model.
Right now the most important task to accomplish will be to think about its next reform.

Recruiting and wage bargaining in health care

Wage-setting in the Hospital Sector
Huge differences in physician wages are well-known even after adjusting for PPP. Regulatory design on how recruiting and remuneration is set differs across countries and within them. Now OECD explains such differences for some of them.
If we all agree that health care management requires some autonomy level, the recruiting function should be delegated to managers. This is what happens in most OECD countries, except in Italy, Ireland, Greece, Spain, (and Israel) p. 19. Right now I remember that these are the same countries that needed some bailout... This is not by chance...it's by design...
Somebody should change such status, recruiting and remuneration needs flexibility and adaptation to local conditions.

PS. Paper from ECB  INSTITUTIONAL FEATURES OF WAGE BARGAINING IN 23 EUROPEAN COUNTRIES,THE US AND JAPAN

PS. NYT. For those with melanoma, Will the NHS be able to pay 150,000$ for living one additional year of life with a 69% probability?

Dynamic risk adjustment in provider's payment

Prevention and Dynamic Risk Adjustment

Adjusting Medicaid Managed Care Payments for Changes in Health Status

"Risk-adjustment methods have an inherent structural flaw that rewards preventable deterioration in enrollee health status and improved coding of disease burden", this is the key statement in Fuller et al. article. The answer they provide is the introduction of an additional payment adjustment according to changes in health status for similar mix of enrollees. The payment adjustment being proposed is based on changes in aggregate relative payment weights for all enrollees avoiding any individual adjustment.
This is a concrete application of the initial dynamic risk adjustment proposal that Eggleston et al. made in 2007. They suggested a two step payment system: a conventional risk adjustment (for variations in population health outside the provider’s control) and an additional one related to prevention efforts.
There is still a lot to learn about it. Let's keep an eye on this crucial topic.

PS. Have a look at Commonwealth Fund anouncement: "Our initiative recognizes that a wide range of factors influence providers’ choices, beyond financial rewards or penalties, including intrinsic motivation and medical professionalism, organizational influences, and policy" (see Box)

Our health and its determinants (2)

The Relative Contribution of Multiple Determinants to Health Outcomes

There are five major categories of health determinants: genetics, behavior, social circumstances, environmental and physical influences, and medical care. If this is so, do we know the relative importance of each factor?
Last February I posted in this blog a figure by Kindig that explains their contribution. Now a Health Affairs brief summarises different views. Check Exhibit 1, and you'll see there that behaviour represents 35-50% of health status according to different estimates.
The message is clear in our current evironment of mostly non-communicable diseases, we have to find better ways to change behaviour towards healthier people. Decisions and actions, short and long term, risk and responsibility, costs and benefits, trade-offs of every day life.

PS. Must read:  The Ethics of Ebola.

The first three doses of ZMapp were administered to the American medical missionaries Kent Brantly and Nancy Whitebol, who have recovered, and the Spanish priest Miguel Pajares, who has since died. Some offered a practical justification for the widely criticized selection of Brantly and Whitebol: It makes sense to treat health workers first, so that they can continue to help others. But this argument largely fell apart with the selection of the 75-year-old Pajares.

PS.  "Only four companies today make vaccines, compared to 26 companies 50 years ago.". My concerns about a future systemic drug industry are closer than expected (at least in vaccines).

Patient switching-behaviour

Enquesta de salut de Catalunya 2013

Consumer loyalty is a top goal for any maketeer, and the Nielsen Global Survey of Loyalty Sentiment says that to achieve it, offering the best price is the most persuasive tool to motivate consumers to swap devotion to a brand, service provider or retailer. If you enter into healthcare arena, service prices don't play the same role, mandatory insurance coverage is the standard (in developed countries), and voluntary insurance is the option (prices are relevant in this latter case).
What happens when one fourth of the population (~24%) buys voluntary insurance?. They have two options for healthcare access. The last health survey gives the answer (Table 3. p. 44): 57,9% of members go to private services, 29,5% use public services, 12,4% don't use any service. This is the switching behaviour pattern according to access and perceived quality of services, not price.

PS. I suggest a close look to the survey, many interesting things appear inside. Deeper analysis is needed using microdata.

PS. A former post on a related topic.

The impact of information and communication technologies

The number of primary care visits per capita in 2007 was 7,1, nowadays this figure has dropped to 5,9, a reduction of 17% in six years. That's a lot. In absolute terms you get the astonishing figure of 4,5 million visits less! In 2013 the total number of visits in primary care was 44,7 million.
I have taken 2007 as the year for comparison for one reason: there was no electronic drug prescription. I don't know all the reasons behind such huge decrease, however information technology has helped for sure. Righ now, 92% of all prescriptions are electronic. A wide assessment of such period is needed.
Such figures are only a partial evidence of the transformation through technology in one specific area - drug prescription-, now the next step is to go further in other fields: organization of work and communication between physician and the patient. These areas may take advantage of technology and help to change the "production function". However, somebody should also think about the impact on a redefiniton of professional roles and tasks, an issue that is frequently left for another day.

PS. Unfortunately, this good news you'll not find in any newspaper. Nowadays, most of them are interested only in the dark side.

PS. Don't forget that such a decrease in utilization of services has been achieved without any copayment strategy.

The deprivation of human rights and the health crisis

The  situation in northern Irak is critical. More than 1.4 million displaced people, severe human rights abuses and violation of international humanitarian laws. Those people are in need of water and basic sanitation services. Health services are overwhelmed by this situation.
Maybe this is the largest tragedy of our days, innocent people taken out from home and left without anything.
The answer by developed countries is becoming too late and too little. Have a look at EU press release (20 m € in 2014 while Saudi Arabia 500m $, Lancet says). This is an additional reason why I feel very far from european policies and citizenship.

PS. Must read (please beware of potential conflicts of interest): Updating Cost-Effectiveness — The Curious Resilience of the $50,000-per-QALY Threshold

PS. FT :  " the right to vote stands above the decisions of a political tribunal.”

Sisley. From Tita Cervera  St. Feliu exhibition

The people's support for public health care

If you want to know what may drive you to participate in a demonstration, just ask the people. This is precisely what CEO report has done with this question:
"Tell me, please, if the following could have driven or push you to participate in a protest or claim" and the options were: tax increase, improving democracy ,corruption, defense of public education, defense of public health care, evictions, budget cuts, the right to vote.
And the winner is? The defense of public health care with 91,1%.
Good to know, if you didn't before. A clear message for any politician that cares about well-being of the population.

PS. If you want to know how many citizens consider that fundamental changes in health care are necessary, CIS has published the figure: 33%, the highest in the period 1995-2013 (p.10), those who think that  some changes are necessary: 45% (p.9). Something should be done.
Support for public provision of primary care: 60%, on hospital care: 50%. Closer data on 2013 by CEO-CatSalut have not been published, my last comment is here.

Homer. From Tita Cervera  St. Feliu exhibition

Copayments as deterrents

If you want to know if copayments deter drug consumption just ask the people.This is precisely what CEO has done. In their report p.33 they reflect that 85% of citizens have not decreased their consumption, while 13% say yes, and 2 % dont know (?). The posted question maybe is not the best since the word copayments doesn't appear and there is no adjustment over the former copayment regime (retired vs active population). Anyway, we don't know if this 13% of people that say they have reduced it, is for inappropriate medications or appropriate ones. Still looking for the right assessment, this is only the first glance.

PS. How can we measure media power?

 Andrews. From Tita Cervera  St. Feliu exhibition

The uncertainty over genomics sequencing value in clinical decision making

Assessing Genomic Sequencing Information for Health Care Decision Making: Workshop Summary

"The value of genetic sequence information will depend on how it is used in the clinic", key statement that needs some elaboration. This is precisely what the IOM report does, you'll find in their pages the current situation about how genomics may impact in decision making. In chapter 5 you'll understand how an insurer decides about coverage of such tests according to 5 criteria:

1. The test or treatment must have final approval from appropriate governmental regulatory bodies, where required;
2. scientific evidence must permit conclusions about its effect on medical outcomes;
3. technology must improve net health outcomes;
4. the technology must provide as much health benefit as established alternatives; and
5. the improvement in health must be attainable outside investigational settings.

Unfortunately, if you start from the first one, you'll find a complete lack of references by governmental bodies on the approval of such tests. Therefore, I can't understand from the chapter how successful they are on such process.
While reading the book you'll increase your uncertainty about outcomes and value of genomic tests instead of reducing it. This was my impression. Let's wait for future good news, again.

PS. Summary of the report:
"Clinical use of DNA sequencing relies on identifying linkages between diseases and genetic variants or groups of variants. More than 140,000 germline mutations have been submitted to the Human Gene Mutation Database and almost 12,000 single nucleotide polymorphisms have currently been associated with various diseases, including Alzheimer’s and type 2 diabetes, but the majority of associations have not been rigorously confirmed and may play only a minor role in disease. Because of the lack of evidence available for assessing variants, evaluation bodies have made few recommendations for the use of genetic tests in health care."

Consensus in health policy

Some months ago I posted on the same topic. Now you can read my short article in the annual report of the Col.legi de Metges.(text in catalan)

El consens en la política sanitària: el Pacte Nacional de Salut

La política sanitària i els valors socials. La immediatesa i dinamisme del món en que vivim ens porta massa sovint a considerar la política sanitària com el fruit de la decisió puntual, anecdòtica i controvertida del moment. Ens cal una mirada més panoràmica per comprendre que darrera tota política sanitària hi trobarem uns valors socials que li donen fonament. És a dir judicis de valor sobre allò que és bo per a la societat. En ocasions es referiran als objectius o resultats finals i en d’altres als mitjans per assolir-los. Si bé la seva rellevància és determinant per als objectius, en relació als mitjans cal tenir present a més a més la seva efectivitat, i per tant un judici expert sobre allò que de veritat funciona.

L’objectiu final de tota política sanitària descansa sobre la millora de la salut poblacional però va més enllà. L’any 2006 la Unió Europea va considerar que els sistemes de salut són un pilar de la protecció social, de la cohesió i de la justícia social, i assenyala que la universalitat, l’ accés a l’assistència de qualitat, l’ equitat i solidaritat són els valors europeus compartits[i]. En aquest marc i en el seu desenvolupament és on es fonamenta la política sanitària.

El consens en política sanitària. L’adopció de decisions públiques en relació a aquests valors essencials requereix d’un consens polític. Pertoca al parlament i al govern assenyalar què signifiquen exactament aquests valors compartits (objectiu) i quines decisions cal adoptar per assolir-los (mitjans). L’existència d’un consens social sobre aquestes qüestions esdevé una peça clau de l’engranatge. Més enllà de l’acord polític parlamentari, cal que tots els actors que participen en el sistema de salut remin en la mateixa direcció. Precisament un dels elements que es consideren factor d’èxit d’un sistema sanitari és el consens social[ii]. Ens cal doncs una política sanitària basada en el màxim consens possible per tal de tenir un sistema eficient i equitatiu.

La política sanitària basada en l’evidència. Distingir aquells mitjans que poden ser efectius per assolir objectius d’aquells que no ho són, esdevé una prioritat. Disposar d’evidència per tal de contrastar aquelles decisions que produiran el millor resultat és crucial, però alhora complex. La complexitat prové de les singularitats i del context on es desenvolupa cada política. Allò que ha funcionat en un lloc i moment determinat, pot ser difícil de ser reproduït en un altre. Malgrat aquest atenuant, saber allò que funciona amb un criteri expert i objectiu ha d’ajudar a millorar les decisions. Molts informes d’experts sobre reforma sanitària han tractat d’adoptar aquesta perspectiva, si bé amb impacte força limitat. La falta d’aplicació del consell expert té a veure almenys amb les dificultats d’establir consensos amplis i la comprensió del procés polític[iii].

El pacte nacional de salut i els àmbits de consens. La Comissió de Salut del Parlament de Catalunya va acordar el febrer de 2013 impulsar el treballs per assolir un acord per a la salut a Catalunya en el marc d’un model propi. En aquest acord es defineixen les bases del sistema sanitari català, estables i consensuades per tots els agents implicats. Es va precisar que els membres de la comissió serien els representants dels diversos grups parlamentaris i els agents que formen part del Consell Català de la Salut. Els treballs de la comissió es van desenvolupar en vuit grans àmbits temàtics. Es va prendre com a referent els 6 blocs inicials que segons l’Organització Mundial de la Salut han de constituir un sistema sanitari, i s’hi van afegir dos àmbits identificats com a claus pel sistema (la recerca i innovació, i el compromís ciutadà). Els àmbits han estat doncs: finançament i cobertura, professionals, prestacions i catàleg de serveis, model de serveis, avaluació i transparència, recerca i innovació, compromís ciutadà, i governança.

Entrar en el detall del contingut dels 83 acord va més enllà del que es pretén en aquest article, tant sols es farà una breu referència als 2 primers. En l’àmbit de finançament i cobertura s’assenyala amb claredat l’opció per un accés universal de la ciutadania al Sistema Nacional de Salut i alhora s’estableix un criteri de nivell de finançament públic en salut suficient i sostenible, que es relacioni amb el nivell de riquesa del país i que convergeixi amb la despesa de països amb producte interior brut per càpita equivalent i sistema sanitari similar.
En l’àmbit dels professionals s’ha considerat que la planificació de necessitats de professionals, les competències i capacitats acreditades han de ser objecte reconsideració atenent als canvis sociodemògràfics, econòmics i tecnològics. S’explicita l’èmfasi en el professionalisme com a criteri que guia la relació entre professionals amb la ciutadania, amb el sistema sanitari i els proveïdors, i la necessitat d’establir mecanismes per tal de fer efectiva la participació dels professionals en l’elaboració de polítiques i la gestió.

El nivell de consens i els propers passos. El procés per arribar a aquest conjunt d’acords ha estat fruit d’una elevada participació. Diversos motius van impedir que la totalitat dels representants confirmessin el seu acord al darrer moment. Cal assenyalar que en l’elaboració del document hi ha contribucions de tots, també d’entitats i grups polítics que no han pogut donar finalment el seu suport. Cal fer efectiu aquest consens que desitja la ciutadania, les bases perquè això sigui possible hi són, només cal teixir-les acuradament i amb generositat. El Parlament de Catalunya va donar l’opció de mostrar el sistema sanitari que desitgem a una àmplia representació social, ara ja hi ha les bases per a que això pugui transformar-se en realitat.

---

[i] Council Conclusions on common values and principles in European Union  health systems, OJ 2006 No. C146/1.

[ii] Balabanova D, Mills A, Conteh L, et al. Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening. Lancet 2013;381:2118-2133

[iii] Black, Nick. "Evidence based policy: proceed with care." BMJ: British Medical Journal 323.7307 (2001): 275.