Q&A COVID-19, economics and health

 Diálogos en la interfaz de la economía y la salud a propósito de la covid-19

A new book of interest has been released on economics and health perspectives on COVID-19. One message from the introduction: 

En definitiva, resulta controvertido el juzgar la bondad de nuestros sistemas de salud, puestos hoy a prueba con el stress test de la COVID-19. Algunos apuntan a que los recortes presupuestarios son los responsables de que España gaste poco en sanidad. Esto es erróneo; los recortes son coyunturales y responden a procesos normales de consolidación fiscal. El problema es estructural de baja financiación del sistema sanitario, desde la interpretación política de qué parte de la recaudación tributaria se ha de dedicar a cada  una de las parcelas del gasto social o, en su falta, el compromiso a articular medidas complementarias de financiación. Como consecuencia de todo ello, se ha instalado en el sector cierta resistencia contra la contención del gasto sanitario público. El modo en el que los profesionales sanitarios han respondido a la pandemia avalaría dicha posición. Otros piensan que más allá de los recursos disponibles, la razón fundamental de nuestros déficits es la gobernanza con la que las instituciones sanitarias desarrollan su actividad: es la rigidez y no la falta de musculatura lo que dificulta adaptaciones flexibles a las diferentes coyunturas. Dicha percepción pone el foco en la diferente genética de los sistemas públicos, ya organizados como servicios nacionales de salud o como sistemas de aseguramiento social sanitario. Por otra parte, las cifras de gasto como indicadores de buen o mal funcionamiento ofrecen a menudo falsas pistas que no permiten resolver por esta vía las bondades relativas a través de simples indicadores cuantitativos.

There are many more messages in a Q&A format. Inspiring.

 Banksy

Health reform zombies (2)

 THE NEXT GENERATION of HEALTH REFORMS

Three years ago in a OECD Health Ministerial meeting, everyone accepted the statement on the criteria for next health reforms. Now, 3 years later, we can confirm that nothing happened about it.

Inside the document there was also a recommendation on health data governance. And the same, nothing happened.

That's it, an extraordinary built narrative that leads to nowhere. Death and taxes remain as only truths.

Banksy

Health expenditure at a glance, or how Bulgaria spends the same as Catalonia

 Health at a Glance: Europe 2020. STATE OF HEALTH IN THE EU CYCLE

Health expenditure as a share of GDP, 2019 (or nearest year)

Catalonia spends 7,5% of GDP in health, like Bulgaria

Health expenditure as a share of GDP, EU27 and selected countries, 2005-19

Health expenditure by type of financing, 2018 (or nearest year)

Health expenditure from public sources as share of total health spending, 2018 (or nearest year)

Mazzucato as a supplier of a flattering narrative for politicians

 The Myth of the Entrepreneurial State

Some delicious words by Deirdre McCloskey on Mazzucato recent contributions:

Mazzucato, a loyal daughter of the left, is suspicious of private gain, of the sort you pursue when you go shopping, say, and is therefore suspicious of people doing things for a private reward. She wants the State, advised by herself, to decide for you. Yet the private entrepreneur, she would concede, gets a reward if she pleases her customers. And it is in fact what Mazzucato in her own trade has done. She has parachuted herself into the center of the debate about the role of state planning as against private profit-making for innovation and allocation. It is not because she is innovative herself (though that is what her brave rhetoric suggests), but because she is, market-style, giving people what most of them want: magical thinking, mythical certitude, free lunches all around, wise and loving parents guiding the people in a coerced routine from on high. Modern “statism.” Her theory is the illiberal one that has dominated economics since John Maynard Keynes eight decades ago spoke out loud and bold.

 The statists imagine that it is always COVID-19 time, for anything: the legitimate actions by a State to suppress a plague or a forest fire or a military invasion are to be applied to all manner of private matters, always, with no such persuasive claim to legitimacy as fighting plagues, forest fires, or invasions, being technically speaking public goods. Braiding hair for a living is to be regulated by the State. Innovation and allocation, says Mazzucato in particular, are to be socialized.

And we could say that Deirdre is a loyal daughter of the right. And no problem. However, you may imagine what follows...in her book. I have read Mazzucato and part of her arguments are convincing. However, there is a need for a balanced perspective according to the current trends. Deirdre provides such perspective. A book that deserves to be read.

The claims of reason and the imperative of power

The Professor and the Politician. For Max Weber, only the most heroic figures could generate meaning in the world. Does his theory hold up today?

Charisma and Disenchantment: The Vocation Lectures

For Max Weber:

The professor and the politician are not figures to be joined. Each remains a lonely hero of heavy burden, sent to ride against his particular foe: the overly structured institution of the modern mind, the overly structured institution of the modern state.

 The politician needs to convert effort into effect, to “make an impression” on the world. But there’s a fine line between molding the world into a shape and needing to see one’s signature at the base of it. The politician is always at risk of swapping out “actual power”—power tethered to purpose—for “the brilliant appearance of power”—power untethered from purpose. The first is the aim of the true politician; the second, the temptation of vanity, which is “the deadly enemy of any commitment to one’s goals.” When a politician gives in to vanity, amending or adapting his aims in order to perform effectiveness, his power is drained of its design.

 The spectre haunting Weber is neither bureaucracy nor capitalism (although capitalism does play an under-remarked role in these lectures). Instead, it’s an ancient tension between hero and fate, transposed to modern life. Where classical tragedy sees the hero felled by a destiny that he resists, the nemesis of the Weberian actor is absorption in the institutions that he’s meant to oppose. Society is a siren, forever tempting us to forsake our tasks and seek the smaller goods of reputation and status. The scholar becomes a scribe; the politician, a hack. The danger is not defeat of the opposing self from without but corruption of the self from within, where the self’s diminishing desire to oppose comports all too well with society’s needs.

Great op-ed by Corey Robin at The New Yorker.

Joana Biarnés

 

Prioritising the vaccine

 Framework for Equitable Allocation of COVID-19 Vaccine

Health equity is intertwined with the impact of COVID-19 and there are certain populations that are at increased risk of severe illness or death from COVID-19. In the United States and worldwide, the pandemic is having a disproportionate impact on people who are already disadvantaged by virtue of their race and ethnicity, age, health status, residence, occupation, socioeconomic condition, or other contributing factors.

Framework for Equitable Allocation of COVID-19 Vaccine offers an overarching framework for vaccine allocation to assist policy makers in the domestic and global health communities. Built on widely accepted foundational principles and recognizing the distinctive characteristics of COVID-19, this report's recommendations address the commitments needed to implement equitable allocation policies for COVID-19 vaccine.

If vaccines are coming in the next months and we all agree that supply will not fulfill demand, then we need to prioritise. This publication of the National Academy of Medicine provides some usegul insights. However, the most important is to have a concrete application in specific contexts.

Joana Biarnés

Health Reform Zombies

 Better Now. SIX BIG IDEAS TO IMPROVE HEALTH CARE FOR ALL CANADIANS

Morris Barer and Bob Evans first coined the term “health care zombies” in 1998. A health care zombie is a terrible idea about health care that refuses to die. No matter how many times you drive an evidence-based stake through its heart, it rises from the (un)dead to confront you in the newspapers of the nation, ruining a perfectly good morning cup of coffee.

These ideas have often been proposed as solutions to the pressures on our health care system. But they’ve all been shown, time and time again, to weaken health care quality and sustainability. They also undermine our shared values.

These words sound familiar in our context. However it comes from a canadian book.

A canadian physician reflects her views in a well written book about the health reform. It says:

When care is necessary to improve health, every Canadian deserves reasonable access to it. That means solutions to wait times that help everyone, not just people who can afford to pay for their care. And it means finally bringing medicines under medicare. Across the country, people like Ahmed the taxi driver are forced to sacrifice their long-term health because of the short-term crunch of prescription drug costs. Alongside that profound inequity lives the uncomfortable truth that we pay some of the highest prices in the world for our prescription medicines. Only our governments can take the necessary steps to establish a national pharmacare program that would ensure access, safety, and appropriate use of medicines at a cost that is affordable not just for governments, but also for citizens and for employers.

It is quite incredible that canadians don't have drugs in the benefits package. And this is the outline of the book:

THE BASICS

Dr. Martin Goes to Washington

Getting Our Facts Straight

Taking the Pulse of the System

Health Care Zombies

BIG IDEA 1 Abida: The Return to Relationships

Primary Care: When It Works, It Works

Three Relationships for Health

Rewarding What Matters

BIG IDEA 2 Ahmed: A Nation with a Drug Problem

Medicare’s Unfinished Business

The Price Is Wrong

Prescribing Smarter

BIG IDEA 3 Sam: Don’t Just Do Something, Stand There

The Compulsion to Cure

Slow Medicine

BIG IDEA 4 Susan: Doing More with Less

The Revolving Door of Health Care

What Better Looks Like

The F-Word

BIG IDEA 5 Leslie: Basic Income for Basic Health

Sick with Poverty

Curing Income Deficiency

BIG IDEA 6 Jonah: The Anatomy of Change

From Pilot Project to System Solution

Data: The Brain of the System

The Heart of the Matter

Feet to Do the Walking

CONCLUSION Worthy Action

 

Paying for (Artificial) Intelligence

 The US Government Will Pay Doctors to Use These AI Algorithms

The US Centers for Medicare & Medicaid Services (CMS) recently said it would pay for use of two AI systems: one that can diagnose a complication of diabetes that causes blindness, and another that alerts a specialist when a brain scan suggests a patient has suffered a stroke. The decisions are notable for more than just Medicare and Medicaid patients—they could help drive much wider use of AI in health care.

The incentives for technology adoption are related to professionalism, organizational, and economic. In this case are the latter one.Though, FDA must have cleared both algorithms, and this is the case. 

We could also think on using AI for reducing radiation exposure in CT scans for example..

EU is lagging behind developed countries in this (and many other issues)...

Prioritising population health or the economy (2)

  The Pandemic Information Gap. The Brutal Economics of COVID-19

Joshua Gans has updated his former book on covid economics. And says:

Pandemics are an information problem. Solve the information problem and you can defeat the virus. There is a big difference between knowing someone you interact with is infectious and having to make a guess as to whether that person is infectious. In the former case, you can act and limit the interactions. In the latter case, you have to take a risk. And, in evaluating that risk, what we care about is not just whether you become infected but also whether you might pass that infection on to others.

 The difference between perfect knowledge and no knowledge is what causes an infectious disease to have an impact on social and economic interactions. With perfect knowledge, some people get sick, they are isolated, and life is (for most of us) essentially unchanged. With no knowledge at all and no interventions to prevent infections, then for COVID-19, at its peak, about 21 million people in the United States alone would likely be infectious at one time. With no restrictions on activity, the probability that you interact with one of the infectious people on a given day is 21 million divided by 327 million (the US population), or 6.4 percent.4 However, suppose you interact with only 10 people per week. In that situation, the probability that you are able to avoid any of those infected people is about 50-50. When going to public spaces, you may interact with over a hundred people per week. In that case, your probability of avoiding an infected person becomes close to zero. In other words, perfect knowledge allows you to avoid all infected people. No knowledge makes it near certain that you will encounter at least one infected person.

 Without knowledge of how many people are infected and whether particular people are carriers of thecoronavirus, we are forced to take drastic actions.

True. Pandemics are an information problem but information will never be perfect and complete. Uncertainty sorrounds us. And pandemics are more than an information problem. Because you may know who is infected, and not "act and limit interactions". Therefore, emotions, incentives and expectations count. We do have also a behavioral problem. And if it is behavioral, it has ethical implications. And finally, that's life, decisions with or without information and behavioral and ethical implications of such decisions.

Anyway, a useful introductory text.

Measuring covid-19 related deaths

 Excess mortality. Measuring the direct and indirect impact of COVID-19

Estimations of excess mortality can give an overall understanding of the impact of  COVID-19, by not only comparing deaths that are directly attributable to the virus, but also by 
taking into account indirect mortality. There may be, for example, deaths due to health systems not being able to cope with other conditions or to the longer-term impact of the pandemic on population health. There has been preliminary evidence of disruptions to continuity of care, hindering people suffering from heart attacks, strokes and other conditions from seeking necessary treatment in emergency rooms, or of delays in accessing regular preventive or ongoing care in primary care practitioner (GP), surgeries or outpatient departments for chronic conditions.

And a clear message on this OECD report:

 Comparing the number of reported deaths from all causes against the average over the previous five years, Spain recorded a 61% increase in overall mortality over this 10-week period. At the beginning of April (Week 14), Spain also recorded the highest excess mortality for a single week, with a 154% increase in mortality, equating to more than 12 500 additional deaths compared to the 5-year average for the same week.

The politics of care in US

The Politics of Care. From COVID-19 to Black Lives Matter. Edited by Boston Review

After the US elections, now it's time to rebuild. A new book provides some insights.

WHERE DO WE GO from here? Our answer must connect to a broader politics that addresses the deep structural roots of the problems we face in the United States. We must build for a better future, not just climb out of the rubble of this pandemic, brush ourselves off, and return to business as usual. We need a new politics of care, one organized around a commitment to universal provision for human needs; countervailing power for workers, people of color, and the vulnerable; and a rejection of carceral approaches to social problems. The question now is how to connect that vision to programmatic responses that address the needs of the moment and beyond. We need to aim at “non-reformist reforms”—reforms that embody a vision of the different world we want, and that work from a theory of power-building that recognizes that real change requires changing who has a say in our political process.

The proposals from the progressive wing of the Democratic Party, and even those from democratic socialists, are missing what we might call a New Deal for Public Health. Here, social movements are indispensable. In particular, the AIDS movement of the past forty years offers a template for the kinds of mobilization we’ll need to achieve our goals: not only bringing the virus under control, but also building a future where something like this never happens again.

What might that include? The Medicare for All component has been mapped out, but less obvious and just as crucial is a new, robust, long-lasting infrastructure of care. For example, people need to be able to stay home when they are sick. Yet employment in this country systematically undermines our ability to care for ourselves and others. Women have it the worst, especially immigrant women and women of color, for they are the ones with the highest burdens of paid and unpaid care. The truth is stark: more than 32 million workers lack access to paid sick days. While 93 percent of the highest-wage workers have access to paid sick days, only 30 percent of the lowest-wage workers do. The risk of job loss and precarious scheduling all add to employees’ difficulties. Without anything like universal sick pay or income insurance, self-employed and gig economy workers are cast adrift at a time like this.

Diagnostic Testing for the COVID-19 Pandemic (again)

 Rapid Expert Consultation on Critical Issues in Diagnostic Testing for the COVID-19 Pandemic

Yesterday I was thinking about the implications of having spare structural capacity in hospitals for pandemics and disasters. With a larger capacity, the need for lockdown to preserve health system operations would be less important. However, how much capacity is needed is uncertain. Therefore, the cost and benefit of spare capacity of the health system is very difficult to estimate. And I would add, it is really much more difficult to manage such investment, because spare capacity in physical terms is not enough, you would need also spare capacity in human resources!. Maybe there is a technological innovation that I can foresee. Forget it. 

Right now the hotest issue are the tests and the vaccine. And NASEM has released a rapid consultation of interest about tests.

This rapid expert consultation draws attention to four critical areas in developing diagnostic testing and strategies to reduce the number of COVID-19 infections and deaths: (1) advantages and limitations of reverse transcription polymerase chain reaction (RT-PCR) testing for viral RNA; (2) the status of POC testing; (3) testing strategies, namely, considerations in the deployment of types and sequences of tests; and (4) next-generation testing that offers the prospect of highthroughput, rapid, and less expensive testing.

If you want to know the state of the art, this is the document to read. I can't see anywhere any cost-benefit approach of different options...We are still dealing with precision and accuracy, i.e. effectiveness.

PS. Quite surprising that today everybody is talking about a vaccine and its 90% effectiveness without any scientific paper being published. Can you accept that?. Information merchants looking for attention.

 

Editing human genome

 MODERN PROMETHEUS. Editing the Human Genome with Crispr-Cas9

Drug approval and geographic differences

 Approval of Cancer Drugs With Uncertain Therapeutic Value: A Comparison of Regulatory Decisions in Europe and the United States

We know that the regulation of medical devices is quite different between US and Europe, and with COVID tests we have experienced such divide. In drugs, one could expect a closer approach to approval. However, this is not the case. 

Regulatory agencies may have limited evidence on the clinical benefits and harms of new drugs when deciding whether new therapeutic agents are allowed to enter the market and under which conditions, including whether approval is granted under special regulatory pathways and obligations to address knowledge gaps through postmarketing studies are imposed.

In a matched comparison of marketing applications for cancer drugs of uncertain therapeutic value reviewed by both the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA), we found frequent discordance between the two agencies on regulatory outcomes and the use of special regulatory pathways. Both agencies often granted regular approval, even when the other agency judged there to be substantial uncertainty about drug benefits and risks that needed to be resolved through additional studies in the postmarketing period.

Postmarketing studies imposed by regulators under special approval pathways to address remaining questions of efficacy and safety may not be suited to deliver timely, confirmatory evidence due to shortcomings in study design and delays, raising questions over the suitability of the FDA’s Accelerated Approval and the EMA’s Conditional Marketing Authorization as tools for allowing early market access for cancer drugs while maintaining rigorous regulatory standards.

 Hockney