Against the riggers

El enemigo conoce el sistema
Manipulación de ideas, personas e influencias después de la economía de la atención

Uno de los errores recurrentes de la izquierda es pensar que el populismo es la estrategia de los imbéciles, cuando la historia demuestra que no puede ser tan imbécil cuando consigue un éxito arrollador. Ya en Los orígenes del totalitarismo, Hannah Arendt explica que este tipo de estrategia está diseñada deliberadamente para desprender a la sociedad educada de sus recursos intelectuales y espirituales, convirtiendo a la población en cínicos o en niños, dependiendo del ego y el aguante de cada uno. Una doctrina del shock que precede a la escuela de Chicago y que ha sido característica de todos los totalitarismos contemporáneos, del nazismo alemán al estalinismo ruso, pasando por el fascismo italiano.

En un mundo eternamente cambiante e incomprensible, las masas han llegado hasta el punto de que podrían, al mismo tiempo, creer todo o nada, pensar que todo era posible y que nada era verdad... Los líderes de masas totalitarios basaban su propaganda en la correcta premisa psicológica de que, en esas condiciones, uno podía hacer que la gente creyera la declaración más fantasiosa un día, y saber que si al día siguiente les dieran la prueba irrefutable de su falsedad, encontrarían refugio en el cinismo. En lugar de abandonar a los líderes que les habían mentido, clamarían que supieron en todo momento que la declaración era mentira y admirarían a los líderes por su agudeza táctica superior.

How much do countries spend on health?

‌Health at a Glance 2019: OECD Indicators

The european country that spends the most is Switzerland 12,2% over GDP. In Catalonia this figure was 7,6% in 2016 (less than Greece). Per capita income in 2016 was 35% more in Switzerland than in Catalonia, while health expenditure was 60% more in Switzerland.  Where have the catalan taxes gone?. You know it and I know it. And everybody is aware that there is only one solution to have the appropriate public health expenditure. We have to say good bye as soon as possible.

How to identify lab tests of low effectiveness?

Prevalence and Predictability of Low-Yield Inpatient Laboratory Diagnostic Tests

A new approach to understand the size of useless lab tests is to apply: "regularized logistic regression, regress and round, naive Bayes, neural network multilayer perceptrons, decision tree, random forest, AdaBoost, and XGBoost". This means that machine learning has its own space in laboratory medicine. In the article, they show high level of prediction for useless tests.

The best performing machine learning models predicted normal results with an AUROC of 0.90 or greater for 12 stand-alone laboratory tests (eg, sodium AUROC, 0.92 [95%CI, 0.91-0.93]; sensitivity, 98%; specificity, 35%; PPV, 66%; NPV, 93%; lactate dehydrogenase AUROC, 0.93 [95%CI, 0.93-0.94]; sensitivity, 96%; specificity, 65%; PPV, 71%; NPV, 95%; and troponin I AUROC, 0.92 [95%CI, 0.91- 0.93]; sensitivity, 88%; specificity, 79%; PPV, 67%; NPV, 93%) and 10 common laboratory test components (eg, hemoglobin AUROC, 0.94 [95%CI, 0.92-0.95]; sensitivity, 99%; specificity, 17%; PPV, 90%; NPV, 81%; creatinine AUROC, 0.96 [95%CI, 0.96-0.97]; sensitivity, 93%; specificity, 83%; PPV, 79%; NPV, 94%; and urea nitrogen AUROC, 0.95 [95%CI, 0.94, 0.96]; sensitivity, 87%; specificity, 89%; PPV, 77%; NPV 94%).

 This approach goes further than this book:

It's always about quality

La qualité des services de santé. Un impératif mondial en vue de la couverture santé universelle

Improving healthcare quality in Europe. Characteristics, effectiveness and implementation of different strategies

The essential element of access to healthcare overshadows the understanding that better health can only be achieved if accessed services are also of high quality. The Sustainable Development Goals spell this out quite clearly: “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all” (Goal 3, Target 8). Indeed, ensuring that healthcare services are of good quality is an imperative for policy-makers at all levels and an important contributor to health system performance.

Oriol Maspons

Eurohealth

Everything you always wanted to know about European Union health policies but were afraid to ask

I have to say that I am not afraid to ask about health policies in EU because EU is basically a market. Therefore nothing to ask. Social policy is out of the real scope of EU.However, as a regulator of the market for health has clear examples of disfunctioning. For example, implantable medical devices regulation currently applied was enacted in 1990. New regulation will be applied next year, after 30 years of regulatory vacation. Nothing to add. Taxes haven't been on vacation. Shame on Europe. By the way, you'll not find minor details like this one in the book.

The impact of an ageing population (2)

Working Better With Age

WORKING AT OLDER AGES
Why it’s important, how it affects health, and the policy options to support health capacity for work

The message of OECD report:

The number of older inactive people who will need to be supported by each worker could rise by around 40% between 2018 and 2050 on average in the OECD area. This would put a brake on rising living standards as well as enormous pressure on younger generations who will be financing social protection systems. Improving employment prospects of older workers will be crucial. At the same time, taking a life-course approach will be necessary to avoid accumulation of individual disadvantages over work careers that discourage or prevent work at an older age; What can countries do to help? How can they give older people better work incentives and opportunities? This report provides a synthesis of the main challenges and policy recommendations together with a set of international best practices to foster employability, labour demand and incentives to work at an older age.

And the WHO report message:

Dominant policy approaches such as increasing the statutory retirement age are often overshadowed by a lack of attention to two critical questions: firstly, are older workers in sufficiently good health to work longer? And secondly, does increasing the statutory retirement age have consequences, negative or positive, for the health of older workers?

The impact of an ageing population

Will population ageing spell the end of the welfare state? A review of evidence and policy options

Sustainable health financing with an ageing population: implications of different revenue raising mechanisms and policy options

Sustainable health financing with an ageing population: Will population ageing lead to uncontrolled health expenditure growth?

Three documents from WHO Europe are available regarding financing health for an ageing population. You can skip the third, it is about predictions for 2060. This is useless as I've said many times.
However, I agree with this comment:

These analyses find that population ageing is not, and will not become, a major driver of growth in health expenditures. Moreover, they suggest that in countries where age demographics are changing but the size of the older population is not yet large, the costs of improving coverage and access to services for older people is likely to be manageable and now is a good time to begin investing in the health system while the population is relatively young.
However, while population ageing will not become a main driver of health expenditure growth, policy choices related to how health services are delivered, the prices paid (or negotiated) for services, medicines and technologies, and volumes of care will ultimately determine health spending by age trends.

Ouka Lele 

The end of social health insurance

Social Health Insurance in Europe: Basic Concepts and New Principles

During the first decade of this century, health reforms have advocated for universal health coverage in those countries with social health insurance based on contributions. This is a strong trend that needs to be evaluated. A recent article describes in detail these changes and says:

Contrary to some expectations, SHI in Europe has further expanded toward universal coverage, with access to health care considered a right based on either direct or indirect financial contributions. Indeed, Germany is now the only example in Europe where groups of the population can opt out from the main insurance system. And, since 2009, the overall population is required to be covered by either social or private insurance. 

Maria del Mar Bonet als ulls de Toni Catany

The world is fat

 The Heavy Burden of Obesity – The Economics of Prevention

Almost a decade after the publication of the first OECD report on obesity, a new one has been released. This are the facts:

More than half the population is now overweight in 34 out of 36 OECD countries and almost one in four people is obese. Average rates of adult obesity in OECD countries have increased from 21% in 2010 to 24% in 2016, so an additional 50 million people are now obese. Despite a drive in the last decade to deal with increased obesity, more needs to be done amid sedentary lifestyles and an almost 20% increase in calorie supply – i.e. calories available for consumption – in the OECD over the past 50 years.

So what?

The OECD identifies four categories of policies to tackle the problem and gauges the effect of three promising “policy packages” to help countries achieve greater impact and coherence in tackling the obesity epidemic. Food and menu labelling, regulation of advertising of unhealthy foods to children and the promotion of exercise, including by doctors and schools, are among the measures analysed.

Most of the strategies requires a confrontation with the food industry, and governments usually try to avoid it. We'll see what happens.

Gen-ethics (2)

Special Issue: The Ethics Of Human Genome Editing

The CRISPR journal has released a special issue on ethics. You'll find an article with the title "Heritable Genome Editing and the Downsides of a Global Moratorium". This is exactly the opposite argument that Françoise Baylis provides in her book. I think that it is unacceptable a recommendation that nations should "regulate HGE for safety and efficacy only and without distinguishing between therapeutic and enhancing modifications". We can't leave such decisions to scientists and practitioners. I'm really concerned about it.

Gauguin Portraits

Gen-ethics

Altered Inheritance
CRISPR and the Ethics of Human Genome Editing

Our future belongs to all of us. Or maybe not? Maybe somebody could decide for us without noticing it?. The "decisions about the use of genetic technologies in humans are too important to be left to scientists", society has to achieve a broad consensus. Françoise Baylis in her new book sheds light on this issue. She explained his position in an article last spring and now she has published a remarkable book on ethics and genome editing. Her calls for an open and comprehensive international process to reach political, scientific, and social/ethical consensus on regulation of human genome editing have been  unattended up to now. Her ultimate goal:

I want to live in a world that promotes equity and justice and celebrates difference, a world where everyone matters. I want to live in a world where we embrace neighborliness, reciprocity, social solidarity, and community in pursuit of human flourishing and the common good. I want to live in a world where we value collegial as opposed to competitive relations. I don’t want to live in a world where a select, privileged few are able to inscribe their privilege in their DNA and thereby exacerbate unfair class divisions and other social injustices. For these reasons, I want for all of us to reflect on whether heritable human genome editing is a boon or a threat.

I agree. An essential reading highly recommended.

Social differences in health and health systems

Health for Everyone?
Social Inequalities in Health and Health Systems

I still don't know why do we talk about inequalities, I've always thought that we should care about differences. The word inequality drives your mind towards equality, and we all know that this will not happen. Therefore, there are differences that are unfair and avoidable, and these are the ones we have to be concerned.
And when we talk bout social determinants, maybe we should focus on commercial determinants and it would help. Why commercial? Because these factors are more actionable compared to others.
You will not find all these reflections in the new report by OECD. Anywasy it is worth reading to confirm it, though the perspective is the standard one (Marmot) and not new.
What you really have to read is the notice at the begining of each chapter that says:

Note by Turkey:
The information in this document with reference to “Cyprus” relates to the southern part of the Island. There is no single authority representing both Turkish and Greek Cypriot people on the Island. Turkey recognises the Turkish Republic of Northern Cyprus (TRNC). Until a lasting and equitable solution is found within the context of the United
Nations, Turkey shall preserve its position concerning the “Cyprus issue”.
Note by all the European Union Member States of the OECD and the European Union:
The Republic of Cyprus is recognised by all members of the United Nations with the exception of Turkey. The information in this document relates to the area under the effective control of the Government of the Republic of Cyprus.

Shame on Turkey. This notice is an example of the decision that needs to take the OECD urgently: to exclude Turkey from his organization. It is really unacceptable what Turkey has done and it is doing in Cyprus. Europe and OECD are avoiding the conflict saying "The information in this document relates to the area under the effective control of the Government of the Republic of Cyprus". The conflict should be solved as soon as possible with the withdrawal of Turkey from Cyprus. That's all.

PS. What I said in the blog on Cyprus 8 years ago:

PS. Carta de lluny. Tot d'una passejant pel carrer Ledra vaig topar amb una frontera. Em trobava a una capital europea, dividida, envaïda. L'illa de Xipre va quedar escapçada el 1974. Aquella invasió va provocar 200.000 desplaçats que van perdre-ho tot fins el dia d'avui. El genocidi cultural i el saqueig posterior encara dura. He tingut ocasió de visitar dues exposicions que mostren l'espoli que s'està produint a la regió de Morphou (pot visitar-se al Banc de Xipre) i el rescat d'algun botí d'antiquari de l'any passat a Alemanya (Makarios Foundation). Vaig quedar tocat en veure-ho. Tresors artístics destruits per tal que la cultura d'altres desaparegui definitivament. Molt fort.
La situació política és delicada després de l'explosió de l'arsenal de Limassol a mitjans de juliol. Vam assistir a concerts on l'electricitat la subministràven amb generadors, i a Limassol moltes  botigues no tenien llum. Tenen una bombolla urbanística com una catedral i està a punt d'esclatar.
L'escapada cap al Nord va tenir tres destins: Salamina, Famagusta i Kyrenia. Arribar a Salamina suposava fer un visat i assegurança del cotxe però el difícil era arribar-hi perquè no hi havia cap cartell. Salamina és un complex interessant però descuidat i menystingut. Famagusta té una mescla que em va sobtar visualment, catedrals gòtiques escapçades amb minarets. Havia de ser extraordinària però s'han encarregat deliberadament de destruir-la, s'observa clarament quan passeges. Kyrenia va ser un descans, lloc acollidor. Al port amb una calor sofocant vam passar una bona estona. Vam oblidar per pocs moments el país envaït on ens trobàvem.
Crec que els governs que faciliten, impulsen o s'inhibeixen davant del genocidi cultural haurien de ser exclosos del circuit, pena d'infàmia, cosa que per ara no fa ningú.
Hem tingut ocasió de visitar Pafos, els Troodos i les esglésies patrimoni de la humanitat, Kourion, i molts altres llocs. El menjar i en especial la qualitat del peix és envejable. Un bon record i una experiència més per a compartir.

Digitization

Digital Economics

If you want to get a description of what digital economics represents, this article in JEL is the one you have to read.

Digital economics explores how standard economic models change as certain costs fall substantially and perhaps approach zero. We emphasize how this shift in costs can be divided into five types:
(i) Lower search costs
(ii) Lower replication costs
(iii) Lower transportation costs
(iv) Lower tracking costs
(v) Lower verification costs 

Its impact in healthcare is starting right now. Platforms that allow communication between physicians and patients leverage such digital environments. However, all these platforms have admitted that personal contact can't be avoided. Right now, digital represents a small part. Everything will not be digital, at least in healthcare.

Boudin at Mapfre Foundation in Barcelona

Improving population health (2)

References of my speech

Carreras, Marc, et al. "Morbilidad y estado de salud autopercibido, dos aproximaciones diferentes al estado de salud." Gaceta Sanitaria (2019).

Postman, Neil. Amusing ourselves to death: Public discourse in the age of show business. Penguin, 2006.

Lakoff, George. The political mind: why you can't understand 21st-century politics with an 18th-century brain. Penguin, 2008.

Barer, Morris L., et al., eds. An Undisciplined Economist: Robert G. Evans on Health Economics, Health Care Policy, and Population Health. McGill-Queen's Press-MQUP, 2016.

 Pere Ibern, Jordi Calsina. Més enllà de la separació de funcions: organitzacions sanitàries integrades. Fulls econòmics del sistema sanitari, Nº 35, 2001, págs. 17-20

Harris, Jeffrey E. "The internal organization of hospitals: some economic implications." The Bell Journal of Economics (1977): 467-482.

Freidson, Eliot. Professionalism, the third logic: On the practice of knowledge. University of Chicago press, 2001.

Topol, Eric. The patient will see you now: the future of medicine is in your hands. Basic Books, 2015.

Kindig, David, and Greg Stoddart. "What is population health?." American journal of public health 93.3 (2003): 380-383.

Mateu i Serra, Antoni. "Salud en Todas las Políticas e intersectorialidad en la promoción de la salud: el Plan Interdepartamental de Salud Pública (PINSAP) de Cataluña." Medicina Clínica 145.Extr. 1 (2015): 34-37.

Verschuuren, Marieke, and Hans Van Oers, eds. Population Health Monitoring: Climbing the Information Pyramid. Springer, 2018.

Hansen, Pelle Guldborg. "BASIC: Behavioural Insights Toolkit and Ethical Guidelines for Policy Makers." (2018).

Kahneman, Daniel. Thinking, fast and slow. Macmillan, 2011.

Courtwright, David T. The Age of Addiction: How Bad Habits Became Big Business. Harvard University Press, 2019.

Kindig, David A. Purchasing population health: paying for results. University of Michigan Press, 1997.

Baciu, Alina, and Joe Alper, eds. Financing Population Health Improvement: Workshop Summary. National Academies Press, 2015.