VBHS cannot be achieved without reorienting existing fragmented models of care towards one that rests on a strong primary health care foundation (19) with an integrated community care component and underpinned by the principle of people coproducing health. This may encompass a shift from inpatient to outpatient and ambulatory care, where appropriate. It requires investment in holistic and comprehensive care, including health promotion and prevention strategies that support people’s health and well-being (20). It further requires effective referral systems, flexible and multidisciplinary provider networks, and participatory monitoring and evaluation strategies.
In the last 5 years, guidelines have been developed for performing cost-effectiveness analyses (CEAs) for the economic evaluation of vaccination programs against infectious diseases. However, these cost-effectiveness guidelines do not provide specific guidance for including the value of reducing the risk of rare but potentially catastrophic health outcomes, such as mortality or long-term sequelae. Alternative economic evaluation methods, including extended CEA, the impact inventory, cost-benefit analyses, willingness to pay or the value of a statistical life, to capture the value of this risk reduction could provide more complete estimates of the value of vaccination programs for diseases with potentially catastrophic health and nonhealth outcomes. In this commentary, using invasive meningococcal disease as an example, we describe these alternative approaches along with examples to illustrate how the benefits of vaccination in reducing risk of catastrophic health outcomes can be valued. These benefits are not usually captured in CEAs that only include population benefits estimated as the quality adjusted life-years gained and reduced costs from avoided cases.
Care is conceived as all the supporting activities that take place to make, remake, maintain, contain and repair the world we live in and the physical, emotional and intellectual capacities required to do so.1 In this sense, care is at the heart of making and remaking the world. The propensity to care and the work of caring are the lifeblood of our social and economic system. Care is central to the reproduction of society and thus one of its bedrocks, part of a fundamental infrastructure which holds society together. Without care, life could not be sustained.
What happens to affective relations and caring activities when they are subsumed under market forces and turned into services that are sold? As ever more areas of social life and work are directly commercialised, the affective investments of care come into conflict with logics of measure, profitability, time constraints, cost reduction, standardisation, and economies of scale in multiple ways
However, instead of considering efficient ways to provide care, the political views surpass efficiency, a well known paradigm.
Valuing care means allocating resources, not taking them away. There is an urgent need to dismantle the apparatus that allows private wealth extraction from society’s care structures, so that any new funds made available for the public care infrastructures do not simply prop up profits. Care needs to be shielded from the volatilities of financial markets, not be drawn deeper into them. Therefore, the realms of care should not be available to high-risk forms of financial investment, including private equity and debt-based forms of financial engineering, where expectations of high returns on capital are upheld at the expense of quality of employment and quality of care. Nor should public services and the care sector be exposed to free trade agreements that undermine labour, consumer and environmental protections.9 This is a pressing issue in the wake of Britain’s departure from the European Union.
Instead of considering public funding as the main option, and access according to need and not to willingness to pay, she proposes to dismantle private services...
Access to health care relies on the use of available resources in attempts to achieve optimal health outcomes. It is composed of three main components: entry into the health care system, an adequate supply of services available, and timely provision of care
The article provides some useful views on telemedicine. It says,
Frequently cited clinical limitations of telemedicine include the inability to perform comprehensive physical examinations, sacrifice of patient–provider relationships, fragmentation of care, and the potential for overprescribing/excess health care utilization. These concerns are often unsubstantiated, and while it is important to anticipate the potential shortcomings of telemedicine, innovative solutions are continuously being adopted to overcome potential barriers to implementation. Examples of such solutions include the use of user-friendly devices to gather vitals and data to facilitate remote clinical assessment, as well as utilization of interchangeable electronic health records to enable sharing of information among various providers.
Overall, the promise of telemedicine seems encouraging, and we look to further examine notable examples of its efficacy through the lens of four diverse, prototypical medical conditions with the goal of recognizing common themes and identifying areas of needed improvement. These medical conditions include stroke, heart failure, diabetes, and pregnancy.
L’home que sabia mirar el món, Manuel Castro Galeria Jordi Barnadas de l'11 de març al 9 d'abril de 2021
Christopher Belshaw draws on earlier work concerning death, identity, animals, immortality, and extinction, and builds a large-scale argument dealing with questions of both value and meaning. Rejecting suggestions that life is sacred or intrinsically valuable, he argues instead that its value varies, and varies considerably, both within and between different kinds of things. So in some cases we might have reason to improve or save a life, while in others that reason will be lacking.
Therefore qaly is not always a qaly?. So....
This book is about the value and meaning of life. Its focus is on several questions of current and widespread concern, and its aim is to provide answers to at least most of those questions which, as I hope, many will fnd compelling. So we can ask – is life valuable? Or better – which lives, if any, are valuable, and to what extent? What does their being valuable consist in? What sort, or sorts, of value do they have? How, if at all, does this value enjoin us to, or constrain us from, acting in relation to those lives? And then similarly – is life meaningful? But, again, there are better questions to be asked. Can lives have meaning? What sorts of lives? And what sorts of meaning can they have? How is this meaning arrived at? How might it be lost? The two sets of questions are, of course, not altogether distinct. And we can ask both whether a valuable life is, or is likely to be, a meaningful life; and also – different question – whether meaning is itself among the things that we should value.
Cost-effectiveness analysis (CEA) is widely used to evaluate new medical technologies—for example, by the UK’s National Institute for Health and Care Excellence or by the Institute for Clinical and Economic Review. Standard methods calculate the average increase in treatment cost per average quality-adjusted life-year (QALY) gained, also known as the incremental cost-effectiveness ratio (ICER).
Researchers have raised concern that traditional CEA discriminates against the severely ill or disabled.5,6 The U.S. Affordable Care Act forbids using CEA that discriminates against persons with disabilities, both by the Patient-Centered Outcomes Research Institute and in determining Medicare coverage and reimbursement. To address this concern, the Institute for Clinical and Economic Review now calculates the equal value of life-years gained in parallel with standard CEA analyses,7 and other departures from CEA have been proposed as ad hoc ways to repair this problem.6
These exceptions, exclusions, and prohibitions call for deeper examination of CEA’s theoretical foundations. In a new analysis, we develop a generalization of standard CEA methods that resolves many of these issues.
This is precisely what I call it risk-adjusted cost-effectiveness.
McGuire, Schillo and Van Cleef provide an additional perspective to conventional risk-adjustment. They say:
Reinsurance can complement risk adjustment of health plan payments to improve fit of payments to plan spending at the individual and group level. This paper proposes three improvements in health plan payment systems using reinsurance. First, we base reinsurance payments on spending not accounted for by the risk adjustment system, rather than just high spending. Second, we propose pairing reinsurance for individual-level losses with repayments for individual-level profits. Third, we optimize the weights on the risk adjustors taking account of the presence of reinsurance/repayment.
It sounds good, however technical requirements are demanding to be to implemented.
In this article, you'll find a good description of the features of a business ecosystem. Unfortunately, too often this word is misused and abused.
We consider what makes ecosystems different from other business constellations, including markets, alliances, or hierarchically managed supply chains. Ecosystems, we posit, are interacting organizations, enabled by modularity, not hierarchically managed, bound together by the nonredeployability of their collective investment elsewhere. Ecosystems add value as they allow managers to coordinate their multilateral dependence through sets of roles that face similar rules, thus obviating the need to enter into customized contractual agreements with each partner. We explain how different types of complementarities (unique or supermodular, generic or specific, uni‐ or bi‐directional) shape ecosystems and offer a “theory of ecosystems” that can explain what they are, when they emerge, and why alignment occurs.
In WSJ you'll find a good op-ed by Walter Isaacson,
After millions of centuries during which evolution happened “naturally,” humans now can hack the code of life and engineer our own genetic futures. Or, for those who decry gene editing as “playing God,” let’s put it this way: Nature and nature’s God, in their wisdom, have evolved a species that can modify its own genome.
Like any evolutionary trait, this new ability may help our species to thrive—and perhaps even produce successor species. Or it may not. It could be one of those evolutionary traits that leads a species down a path that endangers its survival. Evolution is fickle that way.
This is why it is useful for all of us to try to understand this new room that we are about to enter, one that seems mysterious but can also fill us with hope. Not everything needs to be decided right away. We can begin by asking what type of world we want to leave for our children. Then we can feel our way forward together, step by step, and preferably hand in hand.
A must read speech by Uwe Reinhardt (RIP). Selected statements:
Now, when I listen to all this prattle on value among people of the real world, I ask myself, what the hell do these people actually mean by that? Well, you typically find it defined as outcomes relative to cost, and then encompassing efficiency. Now, you can have fun with this expression in New England as I had, there were all providers, they were all from the supply side and I said, “It’s a great expression, I never thought of it as an economist but let me play with it. See what you can do with this.” So let’s look at this equation. The first thing you’ll know is that quality is multi-dimensional, it’s a vector. We geeks, have a certain aversion to dividing a vector by a dollar figure. Somehow it is hard to teach this, so we invented this little magic machine that can mush up vectors of quality with vectors of utility, feelings, and out comes this thing called a “qaly” (quality adjusted live year). And you know, Bismarck says you should never inquire how laws are made it’s like making sausages. This is worse, this is actually a little bit like making dog food, but you know earnings per share on an income statement is worse in terms of its reliabilities. So let us look at this ratio where we have value equalling qaly over cost, which, by the way, the inverse of that is just what we call cost effectiveness.
The more you think about this ratio, you run into a very famous law, Alfred E. Newman’s. Now, who in this audience knows Alfred E. Newman? You’re the most educated. You know kids nowadays don’t know anything, no wonder they’re so weird. They’re not well-read. We all grew up on Mad Magazine which kept us sane. If you hadn’t read Mad Magazine you’d all be nuts by now because Alfred E. Newman understood the world. Here is this famous law, one person’s healthcare cost is another ones healthcare income. Now that’s worth a Nobel laureate. So following Alfred E. Newman’s law, I’m going to write it like this and you can do that to healthcare providers and you see their little eyes ask, could this be true? Who here has ever served on a hospital board? I have on both for profit and not for profit. At any health clinic, what do they talk about: growth, growth, growth. It means revenue, so they don’t want to hear this. They want more qalys and more revenue, that’s what they really want. So, ask yourself this question; has anyone ever thought that the supply side folks want to create value for the patient by cutting their own revenue? I’ve never heard of that.
Imagine a hospital board with an agenda item: 30 minutes on enhancing value for patients by lowering our revenue. Not thinkable. Has anyone ever seen such a board, or even an agenda item? I have served for over a decade on these boards, and not once. You know growth usually gets an hour; patient safety now gets a half hour. But efficiency, not once have I ever heard of it. It gets worse. We have this equation: revenue equals price times quantity times volume. Can you imagine how obscene that is to a hospital executive? Because they ask, “You mean we can create value by cutting prices? Aren’t prices and quality positively correlated?” And you say, “Why would you say that?” Even if you’re drunk, why would you ever say that? You know, so the hospital raises its price and you get more value.
