Le mécontentement des médecins liberaux

Les médecins libéraux français ont initié une grève jusqu'au 31 Décembre. Les raisons sont dans le projet de loi de santé qui disent l'"etatalisation" du système de santé. Ils demandent vraiment une augmentation de 8,6% des prix de visites de 23 à 25 € . Aujourd'hui, je ai lu l'éditorial de Le Monde:  

Le revenu annuel moyen brut d'un generaliste est de 76.600 euros et celui d'un spécialiste de 121.00 euros. Ces revenus restent inférieurs de 25% à 30% à ceux de leurs homologues européens.

Pas mal. Les médecins urgence de l'hôpital ont déclaré une autre grève, le ministre a admis de baisser de 20% le nombre d'heures travaillées par an (!). Cela on peut dire que est un parfait opportunisme, selon le dictionnaire.
L'agitation pour la nouvelle loi est servi. De même en France se plaignent d'un projet de loi de nationalisation inexistante, près d'ici il ya des gens qui parlent de privatisation lorsque toutes les entités sont sous le contrôle publique. La perversion du langage a atteint les limites de l'empoisonnement de l'environnement. 

Juan Luis Guerra - En el Cielo No Hay Hospital

Mental Health in the policy agenda

Mental Health for Sustainable Development

The need for action in mental health is increasingly recognised. Although relevant improvements have been introduced in developed countries, there is a common view that more should be done. Some diseases like depression are at the top of the burden of disease and bring enormous pain and suffering to individuals and their families and communities. An interesting recent report has been released on the topic. This is the infographic:

PS. UK Health Secretary. Keynote address: the political imperatives to address mental health and depression

European health regulator on holiday

After Canada, the first european country that has allowed recreational genetic testing is UK. Some weeks ago the Ethics Research Committee approved the commercialisation of 23andme test that provides 100 genetic reports. Wired says:

The £125 spit test kit is not a diagnostic test, but instead identifies genes that are associated with inherited conditions including cystic fibrosis, Alzheimer's disease, Parkinson's disease and sickle cell anaemia. It's not just health information that can be discovered within the results of the test though -- there is also the opportunity for customers to learn more about their inherited traits and genetic ancestry.

Why has the UK approved it and the FDA has restricted the same test in the US?.  Some months ago I explained that european legislation was outdated. Now the genetic testing firm has profited from bad regulation to enter into european market with CE mark. Does anybody know where the regulator is spending their holiday?

PS. While being  so easy to regulate recreational genetic testing under current false advertising rules, why is only the US doing that?. You should know that closer than you think similar tests are available for you. Where is the catalan health regulator?

PS. Why is the tax regulator not on vacation?

Emile Claire Barlow - Jardin d'Hiver

Thinking and deciding

World Development Report 2015: Mind, Society, and Behavior

Our decision making patterns are based on multiple foundations. The new WB report summarises them in three sources: automatic, social and mental models.  In chapter 8 you'll find applications to health. Some of them may be naive, while others potentially useful. There is a trial and error process in all this stuff because of cultural implications. If there is a particular area to focus on, it is on health communication for behavioural change. There is a lot to learn from behavioral economics:

Understanding that people think automatically, interpret the world based on implicit mental models, and think socially allows policy makers to make major strides in improving health outcomes. Individuals sometimes value information highly (for example,
when seeking curative care), but at other times providing information is not sufficient to get people to change behaviors that undermine health. Framing effects that make social expectations and social approval more salient can sometimes encourage individuals to seek preventive care and adhere to treatment when they otherwise would not, even though the individual benefits exceed the individual cost.

PS. My former posts on nudging

PS. Post by BIT.

PS. TE on poor behavior.

PS. Excellent "30minuts" documentary about the Snowden's massive information leak ever. (Only until Dec 28th)

Global health surveillance

Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Is there any health convergence across countries?. You'll find the answer using the Global Burden of Disease study in a recent Lancet article (a must read).

Part of the answer depends on how the goals are framed—for example, what does convergence mean? In the development literature on economic convergence, convergence has been framed in terms of poverty rates or in terms of income inequality measured by the Gini coefficient or other measures of inequality. Work on convergence in life expectancy has tended to focus on measures of absolute difference rather than relative difference. We found unequivocal divergence in mortality rates for women aged 25–39 years and older than 80 years and for men aged 20–44 years and 65 years and older, similar to previous estimates of divergence of life expectancy at birth since the 1980s. In these age groups, both the Gini coefficient and the mean absolute diff erence in death rates are rising. In all other age groups, except girls aged 10–14 years, relative inequality is increasing but the absolute gap is  narrowing.

For most countries, the general pattern of reductions in age-sex specific mortality has been associated with a progressive shift towards a larger share of the remaining deaths caused by non-communicable disease and injuries. Assessing epidemiological convergence across countries depends on whether an absolute or relative measure of inequality is used. Nevertheless, age-standardised death rates for seven substantial causes are increasing, suggesting the potential for reversals in some countries.

If longevity is mostly improving everywhere, now the key issue should be to analyse global convergence on quality of additional years of life. 

PS. Check p.3499 of the supplementary information. And p. 150 for changes in total Life Expectancy 1990-2013,  (5,6 y men, 3,9 y women). If you read my previous post, you'll find interesting differences about what is going on with healthy life years for women.

Rethinking the practice of medicine

Team-Based Care: Saving Time and Improving Efficiency

When two years ago Eric Topol published a book on "The creative destruction of Medicine", many people thought it was a provocation. He was just borrowing the term keyed by Joseph Shumpeter for the economy as a whole. However, his message in my opinion still falls short. He was focusing strictly on changes that rely on technological innovations and he forgot organizational innovation.
Now, have a look at this recent article at FPM 

Drs. Hopkins, Sinsky and Peter Anderson all state that most outpatient visits can be divided into four distinct stages: 1) gathering data, 2) the physical exam, 3) medical decision-making, and 4) patient education/ plan of care implementation. Rather than the physician being responsible for all four stages, they recommend that a clinical assistant (a registered nurse, licensed practical nurse, or highly skilled medical assistant) perform the more clerical stages, one and four, while the physician focuses primarily on stages two and three. The clinical assistant stays in the room with the patient during the entire visit, gathering the history and doing all the documentation. The physician joins them for stages two and three before moving on to the next exam room where a second clinical assistant has set the stage by performing stage one. This allows the physician to see more patients, thus covering the costs of additional clinical assistants.

This proposal requires coordination and a reallocation of resources, roles and tasks. In certain diseases such a model has already been implemented. Is anybody able to extend it and amplify its impact on efficiency of the whole healthcare system?

PS. FT books of the year

PS. In UK some hospital mergers are prohibited. What a difference on the rule of law compared to ours!

Vertical equity in waiting lists

Three years ago I explained that it was good to know that prioritisation was going to start on the waiting lists. It was only the anouncement. Afterwards, it came the uncertainty after a phone call. On March 7th, 2013 the headline post of this blog was: Still waiting after all these months.
Many theoretical efforts have been devoted to improve vertical equity in waiting lists, now it's time to apply them. The moment of truth arrives when somebody has to apply objective criteria, and this raises concerns on the  status quo. This is precisely what it comes to my mind when reading this document. I can't find any reference to shared decision-making with patients, taking into account their interests and social preferences. It emphasizes the autonomy of the physicians for waiting lists management, but this is absolutely not enough.
Finally, the document says that budget cuts have to finish. Is this a political or a professional statement?. Everybody should know that budget cuts are related to our critical economic situation, with an unacceptable fiscal deficit. Why is there no reference to this constraint?. Is this a political or a professional option?

Overcoming political decay

Political Order and Political Decay: From the Industrial Revolution to the Globalization of Democracy

If I had to highlight two books of 2014 that will be considered classics in the near future, the first would be Piketty's on Capital in XXI century, and the second would be the Francis Fukuyama one: Political Order and Political Decay.
Both are worth reading. I've just finished the Fukuyama one, and covers one topic that appears in everyday headline news: corruption. In chapter 5 you'll find a wider explanation of patronage and clientelism and its impact on democracy.

Patronage is sometimes distinguished from clientelism by scale; patronage relationships are typically face-to-face ones and exist in all regimes wether authoritarian or democratic; whereas clientelism involves larger-scale exchanges of favors between patrons and clients, often requiring a hierarchy of intermediaries.

Clientelism is very different from a purer form of corruption where an official steals from the public treasury and sends the money to a Swiss bank account for the benefit of himself and his family alone. This type of corruption is sometimes labeled, following Weber,  prebendalism.

Fukuyama gave a speech to present his book last October at Harvard. Comments on his book appeared at FT, WSJ, The Guardian.or The Economist :

Political decay can take away the great advantages that political order has delivered: a stable, prosperous and harmonious society.

In my opinion, there are many signs of political decay. The question is wether we will be able to overcome such a situation in a disconnected state. Meanwhile, a better understanding in a historical perspective as the Fukuyama one, is highly recommended.

PS. Video of the Presentation at Harvard Institute of Politics

PS. Just released. OECD Foreign Bribery Report. An Analysis of the Crime of Bribery of Foreign Public Officials

Bribes are generally paid to win contracts from state-owned or controlled companies in advanced economies, rather than in the developing world, and most bribe payers and takers are from wealthy countries.

Bribes were promised, offered or given most frequently to employees of state-owned enterprises (27%), followed by customs officials (11%), health officials (7%) and defence officials (6%). Heads of state and ministers were bribed in 5% of cases but received 11% of total bribes.

PS. An example of how excess of transparency may inhibit some talented individuals to commit to public service as officials. We are creating strong barriers for a future high performing public service.

The successful recent trends in healthy life expectancy (3)

The Cost of an Additional Disability-Free Life Year for Older Americans: 1992–2005

We already know that the trend of healthy life expectancy is on the right track. If we all agree that under a universal coverage system, the aim should focus on being efficient and equitable at purchasing population health,  then a crucial question would be: how much does it cost an additional healthy life year?.
We do have such estimates for USA. A quite recent article says that the average discounted cost per additional disability-free life year is $71,000, assuming that half of the gains in healthy life expectancy were attributable to increases in spending.
Is this more or less than you would be willing to pay for it?. Recall how much we are spending per month of survival with cancer treatments. You can check it on p.254 of this article. As a society, currently we are paying from €562 (Erlotinib+Chemotherapy) up to €66,164 (Ipilimumab) for one month of additional survival and nobody cares about it. That's life!. Glups!

Where is value created in hospital mergers?

Hospitals, Market Share, and Consolidation

In the current wake of private hospital mergers, somebody should ask the right question. Where is value created?. If the goal is to reduce competition and create an environment close to a monopoly, than we can understand that market rivalry will decrease, prices will be higher, consumers will lose. In my opinion, the current mergers process shows signs of value destruction or value redistribution rather than value creation. Antitrust authority has been condescendent with the recent events and its resolution has forgotten the basics. Once you approve the merger, there is no way out, no easy reversal of a "quasi-monopoly" as it is the case of Barcelona private hospitals from today, that 64% of beds will belong to one firm.
Cutler and Morton published a JAMA article stating that something should be done to prevent such situations.

Antitrust authorities are examining these consolidated systems as they form, but broad conclusions are difficult to draw because typically the creation of a system will generate both benefit and harm and each set of facts will be different. Moreover, the remedies traditionally used (eg, blocking the transaction or requiring that the parties divest assets) by antitrust authorities in cases of net harm are limited. For this reason, local governments may want to introduce new policies that help ensure consumers gain protection in the event of consolidation, such as insurance products that charge consumers more for high-priced clinicians and health care centers, bundling payments to clinicians and health care organizations to eliminate the incentives of big institutions to simply provide more care, and establishing area-specific price or spending target

And their point is: local governments. Antitrust authorities are unable to understand the unique conditions of local competition. Unfortunately, local governments have no authority over such matters here. Meanwhile, the harm (to competition) has already been made.

PS. As far as the poor quality regulation is the norm in our current state, the only way out is to escape from this disordered world. To disconnect asap, there is no other option.

PS. If you want to know the answer to my today's question, have a look at this article: The Impact of Hospital Mergers on Treatment Intensity and Health Outcomes. You'll find strong reasons to be concerned:

The primary specification results indicate that mergers increase the use of bypass surgery and angioplasty by 3.7 percent and inpatient mortality by 1.7 percent above averages in the year 2000 for the average zip code. Isolating the competition mechanism mutes the treatment intensity result slightly, but more than doubles the merger exposure effect on inpatient mortality to an increase of 3.9 percent.The competition mechanism is associated with a sizeable increase in number of procedures.

PS. If Antitrust economics helps to support these processes, then somebody should rethink the theory and its application from scratch.

Cartier-Bresson. Rome Exhibition. Must see.

The successful recent trends in healthy life expectancy (2)

Health at a Glance: Europe 2014

A new european health report by OECD has been released. It includes key data and information regarding how health systems are performing and citizen's health. Some days ago I was highlighting the successful achievement in healthy life expectancy in our country (as a temporal trend). Now we can compare these data with other countries and we can see that we are at the top 10 of EU-28.
Data can raise many comments. If you want to know the big change in health expenditure, look at p. 121. In 2000-2009 european expenditure growth rate was 4.7%, in 2009-2012 is -0.6%. In our specific case is still less. Now is the moment to remember those that some years ago said that health expenditure would never collapse because there were some factors (technology and ageing,...) beyond the control of decision makers.
In summary, we can confirm that healthy life expectancy has increased and resources have shrunk. That's all folks (up to now).

PS. On cross-fertilization between health economics and management.

 

Norman Rockwell. Rome exhibition. Must see.

How much does it cost (a drug)?

Once again you can check the cost of developing a new drug ($2.6 billion in years 1995-2007), a jump in real terms of 145% from its former 2003 estimate $802m. These figures were widely criticised. And now as you may imagine this is again a huge nonsense. The Economist and Forbes joke about this numbers and my view is even more sceptical.
I'm still waiting for an estimate of new drugs costs adjusted by value. Unless somebody is able to provide such a figure, I will avoid analysing in detail any cost accounting exercise.

Risky lifestyle regulation, what's new?

Regulating Lifestyle Risks The EU, Alcohol, Tobacco and Unhealthy Diets

Since we all agree that lifestyles affect health, then more evidence is needed on what to do and how to do it. Fortunately, a new book summarises the state of the art on regulating lifestyles. Selected sentences from two selected chapters 14 and 15:
Nudging healthier lifestyles: Informing the non-communicable diseases agenda with behavioural insights
by Alberto Alemanno

In sum, most behavioural insights consist of ‘mechanisms rather than law-like generalizations’.66 For purposes of policy, it would therefore be valuable to have a better understanding of how the major findings of behavioural research apply within heterogeneous groups. Unfortunately, due to methodological and empirical complexity, current variety of behavioural studies.71 A number of different types of studies are possible, such as (a) experiments, (b) randomized controlled trials (RCTs) and (c) surveys. 

Using outcome regulation to contend with lifestyle risks in Europe Tobacco, unhealthy diets, and alcohol
by Stephen d. Sugarman

In conclusion, outcome regulation offers a new way to deal with lifestyle risks – risks that people now take but at a deep level want reduced. That is, mature peoplemostly do not want to smoke or get drunk or eat unhealthily. They have been enticed into doing so in substantial part because of marketing efforts by sellers of these products who have created social norms in support of their consumption. People also drink, smoke, and eat the wrong things because they provide short-termpleasure, even if they also bring with them long-term serious harms.

There are some debatable conclusions, however this book is a required reading for any health regulator.

PS, NYT article on mediterranean diet, original in BMJ..

The opportunity cost of delay in applying HTA

Some weeks ago I attended the meeting of the Spanish Health Techonology Assessment Association. The presentations and communications highlighted the current status on economic evaluation, and to be honest, an uncertain application and usefulness for public policy in our country. The reason?. There is a fear, a deep fear, that economic evaluation could guide some coverage decisions. Since this represents a reduction of discretionary powers, politicians prefer the status quo. Any change that represents an introduction of health technology assessment will reduce the degrees of freedom in their decisions. Is this fair for society? I would like somebody to calculate the opportunity cost for such a delay.

PS. I suggest you have a look at Sculpher, Peiró and Culyer presentations. My presentation was about stratified medicine, and J. Pons about the state of the art in HTA.

PS. Tomorrow, Conference at Fundació Grifols: Personal and collective determinants of health ailments, Whose responsibility is it?. Determinantes personales y colectivos de los problemas de salud, ¿de quién es la responsabilidad? I'll give a speech in the first session.