Risk adjustment, a work in progress

Risk Adjustment, Risk Sharing and Premium Regulation in Health Insurance Markets: Theory and Practice

This is a handbook on an unfinished topic. Risk adjustment is required for any managed competition model to work properly (Enthoven model) and for any funding of plans that tries to promote efficiency and avoid selection:

The Enthoven model has evolved as its ideas have been applied in particular institutional contexts. Today, sophisticated risk adjustment models give a regulator an effective tool to quantify differences among individuals in their expected healthcare costs. Rather than a system of risk-rated premiums, regulators rely more on risk adjustment to pay plans more for higher-risk enrollees. Also, the countries in which the regulated competition model has become dominant (e.g., Germany, the Netherlands) are characterized by separation of the functions of health insurance and healthcare provision. Regulated competition can and has been implemented without the presence of integrated HMO type
risk-bearing delivery systems. In these countries, and in other settings such as Medicare Advantage in the United States, regulated competition is oriented to the health insurers, not the healthcare delivery system.
Throughout this evolution, the key feature of Enthoven’s model remains: an active collective agent on the demand side of health insurance structures and manages the health plan market to overcome market failures. Enthoven calls this agent a “sponsor,” a role that can be fulfilled by various organizations. In health insurance markets today, sponsors are mainly governments (as is common in Europe and the United States) and employers (as is common in the United States). In this volume we will generally refer to a “regulator.”

Therefore, any regulator interested in mitigating health insurance market failures should read it.

Hospital governance: the road not taken

Effective Governance and Hospital Boards Revisited: Reflections on 25 Years of Research

There is a lot of pending work for Hospital Boards to increase its effectiveness. This article shows what has happened in the last years. However, in our close environment, things are still getting worse. Albeit, more research is needed. This is a useful framework that is applied in the article:

Table 1. Board Governance Framework for Mapping the Literature.
Research Themes
Individual actors
•• Board member
•• Board chair/officers
•• CEO/executive director
Governing bodies
•• Governing board as a body
•• Governing board subunits and affiliated
enterprises (e.g., advisory councils)
Organizations
•• Board–CEO relationship
•• Board–Organization relationship
•• Unitary and single-organization hybrids
•• Multitiered organizations
•• Organizations as actors in alliance or
network
Networks, alliances, and multiorganizational initiatives
•• Network or alliance as an organization
•• Interorganizational relationships (IOR;
when IOR is the actual focus)
•• Hybrid nonprofits–government networks
Note. Table adapted by Renz (2015) from Hambrick, Werder, and Zajac (2008) and Renz and Andersson
(2014)

Measuring morbidity vs. measuring episodes: Two parallel views

Clinical risk groups and patient complexity: a case study with a primary care clinic in Alberta

In order to assess the health risk of a population there are two main options: Morbidity adjustment and Episodes of care. The first one can use Clinical Risk Groups, while the latter Patient focused episodes. The morbidity adjustment is useful for adjusting at population level, it is a categorical system, while episode measurement adjusts at patient level .
In this article you'll find an interesting application to a primary care center.

CRGs have definite value with respect to predicting health care utilization, but it is important to note the limitations of the CRG as a stand-alone classification of complexity, particularly for the categorization of patients in the health status 1 through
5 categories. In order to enhance the accuracy, relevance and predictive value of the CRG classification methodology, we see great value in pursuing methods that allow for the careful and systematic inclusion of information from the care record.

The article is trying to use the CRGs for episode measurement, and this is a wrong approach. CRGs are useful as a whole picture, physicians need details, only episodes can provide such information.

Hopper

Why are we waiting? (5)

Waiting Times for Health Services. Next in Line

Long waiting times for health services is an important policy issue in most OECD countries. Reducing the time that people have to wait to get a consultation with a general practitioner, or a diagnostic test or treatment, can go a long way in improving patient experience and avoiding possible deterioration in their health. Governments in many countries have taken various measures to reduce waiting times, often supported by additional funding, with mixed success. This report looks at how waiting times for elective treatment, which is usually the longest wait, have stalled over the past decade in many countries, and have started to rise again in some others. It also analyses the differences in how long people have to wait to get a consultation with general practitioners or specialists across countries. The report reviews a range of policies that countries have used to tackle waiting times for different services, including elective surgery and primary care consultations, but also cancer care and mental health services, with a focus on identifying the most successful ones.

Just a few words. For citizens, this is the hottest topic in our health system. And policymakers are neglecting it, while some citizens are voting with their feed...only those that can.

Bowery men waiting for bread in bread line, New York City, Bain Collection

Primary Care value and physician compensation

Realising the Potential of Primary Health Care

If Primary Care is so important why so few physicians choose it as specialty for the residency programs?. The answer is that there is a difference in perception of value and compensation. Well, this is only the first answer. High value, high effort and low relative compensation compared to other specialties. Governments should care about it and about integrated care is finally organised. This is what OECD report says:

These new models of organisation should be more widely adopted to move away from the traditional and reactive solo-practice model. While there is no one-size-fits-all model of organisation, an integrated model of primary health care often meets the following four characteristics:
 Multi-disciplinary or inter-professional practices with a various mix of primary health care professionals (including GPs or family physicians, registered and advanced nurses, community pharmacists, psychologists, nutritionists, health counsellors, and non-clinical support staff), different models of teamwork, and different target populations (for example as seen in Australia, Canada, the United Kingdom and the United States) (Socha-Dietrich, 2019[101]).
 Comprehensive health services in the community, (for example in Costa Rica), including disease prevention and health promotion, curative services, rehabilitation and management of chronic diseases. Care co-ordination between health professionals is key to enabling the early detection of disease, reducing the exacerbation of diseases, avoiding duplication of services, and increasing provider and patient satisfaction.
 Population health management, generally based on risk stratification using sophisticated IT systems (for example in Canada and Spain), is implemented to better understand the health and risk profiles of the community and to undertake proactive management of patients’ needs. Patients are stratified to identify opportunities for intervention before the occurrence of any adverse outcomes for individual health status.
 Engagement of patients in shared decision making,

Hopper

Why CRISPR is a breakthrough

Programming life: An interview with Jennifer Doudna

‘The Joy of the Discovery’: An Interview with Jennifer Doudna

Precision medicine, here and now

Early Returns from the Era of Precision Medicine

Great article by David Cutler. The time for the returns of precision medicine has arrived in his opinion.

Precision medicine raises hopes for patients and fears for those who try to ride herd on health care spending. Will patients finally live longer and healthier lives? Will society be able to afford it? Surprisingly, at this point, personalized medicine has had less effect on both health and medical spending than either its strongest backers hoped or its most apprehensive actuaries feared.

Albeit,

 To date, total spending on anticancer drugs has been relatively modest. Although inflation-adjusted spending on anticancer drugs increased by $30 billion between 2011 and 2018, this is only 6% of the total increase in personal health care spending over the period. Given that administrative expenses cost an estimated 4 times the amount spent on anticancer drugs, one should be cautious about focusing excessively on the cost of precision medicine.
A better metric than total spending is cost effectiveness: do the benefits of the drugs outweigh the cost? The “drug abacus” tool developed by Memorial Sloan Kettering Cancer Center, which evaluates the cost-effectiveness of 52 anticancer drugs approved between 2001 and 2013, estimates that only a handful of new drugs are worth the cost at conventional valuations of life. If anticancer drugs were priced based on cost-effectiveness criteria, spending would fall by 30%.

This is a US based article, we need some estimates of our health system.

Hopper

Regulating voluntary health insurance

La regulació de l'assegurança voluntària de salut

Market inefficiencies can be eased with proper regulation. In a specific issue of Revista Economica de Catalunya, you'll find an article that I've written on the topic.
There is a specific and actionable proposal to improve the current situation.

Voluntary insurance in Catalonia covers 26% of citizens, possibly the most widely used duplicate insurance in Europe. Given its relevance, the regulator has to decide whether to consider the set of market failures shown in this article and act or, in contrast, put it to one side and watch its impact increase over time. For now, it is clear that government has chosen the second option.
Considering that health is such a highly valued asset individually, surely the public deserves a satisfactory response.

I can't summarise all details here. I suggest a close look at the article and the remaining ones in the same issue.

Or watch this video:

Covid-19 testing landscape

COVID-19 diagnostics in context

This is the best summary of current supply of diagnostic tests for Covid-19:

COVID-19 tests can be grouped as nucleic acid, serological, antigen, and ancillary tests, all of which play distinct roles in hospital, point-of-care, or large-scale population testing.
Table 1 summarizes the existing and emerging tests, current at the time of writing (May 2020). A continuously updated version of this table is available at https://csb.mgh.harvard.edu/covid

Eric Topol says:

There are now *88* @US_FDA  cleared (by EUA) #COVID19 tests so far. Their false negative rates range from 10-48% (by post-release reports).
Might be better to have less tests, more accuracy, with faster turnaround

I agree.

Table 1 Performance comparison of different test types.
Throughput is determined by process type and assay time. In general, automated plate-based assays have higher daily throughputs. Hashtag (#) indicates example systems that have received FDA emergency use authorization (FDA-EUA). See https://csb.mgh.harvard.edu/covid to access continuously updated information. PCR, polymerase chain reaction; PCR-POC, PCR–point-of-care; ddPCR, digital droplet PCR; NEAR, nicking endonuclease amplification reaction; RCA, rolling circle amplification; SHERLOCK, specific high-sensitivity enzymatic reporter; DETECTR, DNA endonuclease-targeted CRISPR transreporter; NGS, next-generation sequencing; μNMR, micro–nuclear magnetic resonance; LFA, lateral flow assay; ELISA, enzyme-linked immunosorbent assay; CLIA, chemiluminescence immunoassay; EIA, enzyme immunoassay; ECLIA, electrochemiluminescence immunoassay; ECS, electrochemical sensing; VAT, viral antigen assay; IFM, immunofluorescence microscopy; WB, Western blot.

Type	Target	Virus	Assay time	Process type	FDA-EUA	Examples
PCR	Viral RNA	SARS-CoV-2	2–8 hours; >12 hours	Plate	56	#Roche, #LabCorp, #BioMerieux, #Qiagen, #Perkin-Elmer, #Becton Dickinson, #Luminex, #Thermo Fisher, others
PCR-POC	Viral RNA	SARS-CoV-2	<1 hour="" td="">	Cartridge	2	#Cepheid, #Mesa, Credo
ddPCR	Viral RNA	SARS-CoV-2	2–4 hours	Manual	1	#BioRAD
NEAR	Viral RNA	SARS-CoV-2	15 min	Cartridge	1	#Abbott
OMEGA	Viral RNA	SARS-CoV-2	1 hour	Plate	1	#Atila BioSystems
RCA	Viral RNA	SARS-CoV	2 hours		0
SHERLOCK	Viral RNA	SARS-CoV-2	1.5 hours	Kit	1	#Sherlock Biosciences (CAS13a)
DETECTR	Viral RNA	SARS-CoV-2	1 hour	Kit	0	Mammoth Biosciences (CAS12a)
NGS	Viral RNA	SARS-CoV-2	Days		1	#IDbyDNA, Vision, Illumina
μNMR	Viral RNA	SARS-CoV-2	2 hours	Cartridge	0	T2 Biosystems
LFA	IgG, IgM	SARS-CoV-2	15 min	Cartridge	3	#Cellex, #Sugentech, #ChemBio, Innovita
ELISA	IgG, IgM	SARS-CoV-2	2–4 hours	Plate	4	#Mount Sinai, #Ortho-Clinical (2), #EUROIMMUN US Inc., BioRAD, Snibe, Zhejiang orient, Creative Dx
CLIA	IgG, IgM	SARS-CoV-2	30 min	Cartridge	2	#Abbott, #DiaSorin
EIA	IgG, IgM	SARS-CoV-2	2 hours	Plate	1	#BioRAD
MIA	IgG, IgM	SARS-CoV-2		Plate	1	#Wadsworth Center
ECLIA	IgG, IgM	SARS-CoV-2	20 min	Plate	1	#Roche
ECS	IgG, cytokine	SARS-CoV-2	1 hour	Cartridge	0	Accure Health
VAT	Viral antigen	SARS-CoV-2	20 min	Cartridge	1	#Quidel, Sona NT, RayBiotech, SD Biosensors, Bioeasy
Microarrays	Ig epitopes	SARS-CoV-2	1.5 hours	Plate	0	RayBiotech, PEPperPRINT
IFM	Viral protein	SARS-CoV	3 hours	Manual	0
WB	IgG, IgM; viral protein	SARS-CoV	4 hours	Manual	0

Intercepting symbiomes

Intercepting pandemics through genomics

It makes sense:

There is an urgent need to establish a global, genomic-based biosurveillance platform, a developmentwhich would be of immense value to biosecurity, biodefense, and the economy. If implemented, this“pandemic interception system” would hugely advance our understanding of the natural world. Three major research programs are poised to support this effort: BIOSCAN, the Earth BioGenome Project (EBP), and the Global Virome Project (GVP). Each of these global programs is now working to develop approaches in comparative genomics that are needed to discover all species and to reveal their interactions. The diversity of infectious agents involved in host–pathogen interactions needs immediate clarification, especially  with regard to those agents that transfect phylogenetically divergent lineages.

A pandemic interception system needs to be based on detailed knowledge of symbiomes, which are the constellations of organisms that interact with all multicellular species. Efforts to describe the structure of symbiomes are motivated by the fact that parasites, parasitoids, and microbes can devastate host populations, especially those that are evolutionarily naïve. Symbiome complexity is governed by rules.

Daido Moriyama

Tackling COVID-19 beyond testing

How We Can Tackle the COVID-19 Crisis Beyond Testing

If you wear a smartwatch or fitness tracker, you can play a role in monitoring the spread of COVID-19 and other viral diseases like the flu. In this Front Row lecture, Eric Topol, MD, and Jennifer Radin, PhD, discuss how they’re calling on the public to share data from wearable devices for a study that’s helping scientists flag the early onset of contagious respiratory illnesses. By harnessing this key data—including heart rates, sleep and activity levels—from hundreds of thousands of individuals, they seek to improve real-time disease surveillance.

Regulating the healthcare bazaar

What to Do about Health-Care Markets?
Policies to Make Health-Care Markets Work

Martin Gaynor in the Brookings Report proposes three types of policy reforms that would increase competition in health care and improve market functioning:

• Reduce or eliminate policies that encourage consolidation or that impede entry and competition.
• Strengthen antitrust enforcement so that federal and state antitrust enforcement agencies can act effectively to prevent and remove harms to competition.
• Create an agency responsible for monitoring and overseeing health-care markets, and give that agency the authority to flexibly intervene when markets are not working

Well, these are only 3 issues, the report highlights the details into the implementation. And if you want to know how far healthcare is from competitive markets, you must start understanding markets. There is a book that may help as a useful guide to start:

Forming beliefs

The Value of Beliefs

Relevant article with key messages:

We construct our beliefs to meet two sometimes conflicting goals: forming accurate beliefs to inform our decisions and forming desirable beliefs that we value for their own sake. In this NeuroView, we consider emerging neuroscience evidence on how the brain motivates itself to form particular beliefs and why it does so.

Our beliefs are fundamental parts of what makes each of us unique. They are a major cause of both harmony and discord; shared beliefs bring people together, while divergent beliefs can spark revolutions. In this age of the internet and social media, the ability of beliefs to both invigorate and polarize is more apparent than ever. This raises a fundamental question: how do people arrive at their beliefs? A traditional approach to studying beliefs is grounded on the idea that people build an internal model of the world for the purpose of informing their decisions to help them achieve external goals, such as gaining rewards and avoiding punishments.

 In particular, individuals often prefer to hold positive beliefs and hold beliefs with high certainty. To achieve this, changes in information seeking and belief updating are motivated by tapping into the same circuits that drive primary reward seeking. However, unlike primary rewards such as food, beliefs on their own do not directly promote survival.

The narrative of pandemics (2)

Información científica especializada, información pública y medios de comunicación durante la crisis del coronavirus

Today you'll find our article on communication in pandemic times in Blog Economía y Salud AES, how markets of attention and radical uncertainty drive current situation.

David Hockney