A transactional patient experience

When Seeing The Same Physician, Highly Activated Patients Have Better Care Experiences Than Less Activated Patients

Patient engagement with the treatment of the disease is increasingly relevant. It seems that we have rediscovered that successful outcomes not only depend on the health care system, the patient behaviour may change the course of the disease. The conceptualisation of this trend has come up with a new term: patient activation - a term referring to the knowledge, skills, and confidence a patient has for managing his or her health care-.
A recent article at HA highlights the issue:

Patients at higher levels of activation had more positive experiences than those at lower levels seeing the same clinician. The observed differential was maintained when we controlled for demographic characteristics and health status. We did not find evidence that patients at higher levels of activation selected providers who were more patient centric. The findings suggest that the care experience is transactional, shaped by both providers and patients. Strategies to improve the patient experience, therefore, should focus not only on providers but also on improving patients’ ability to elicit what they need from their providers.

Easier said than done. Anyway, this is not an excuse to put efforts in such direction.

 In addition, a recent study found that patients at higher levels of activation have lower health care costs than those at lower levels.

There is no reason for procrastination, given the current state of resource scarcity.

For another day

The Actress, the Court, and What Needs to Be Done to Guarantee the Future of Clinical Genomics

The introduction of new technologies and benefits in health care is always a perfect chaotic process. It starts with the creation of great expectations that have to be fulfilled (and publicly funded!). In some sense it could be understood as a remake of the Nintendo story of undersupply and artificial scarcity creation. Some genome based biomarkers fits partly with this paradigm.
The case of Angeline Jolie -double mastectomy after BRCA testing positive- was broadcasted worldwide in the weeks before the ruling against gene patenting. Creating uncertainty and scarcity artificially is a heavier combination. And in this situations is when common good has to be protected, and government has the key role.
Two selected messages from this week in PLOS Biology:

If clinical genomics is about to move forward at a more rapid pace due to broader public awareness and a more favorable legal climate then there is still work to be done on the ethical, regulatory, and legal fronts.

Celebrities are now drawing public attention to the utility of genetic testing. With the Supreme Court decision opening the door to more and perhaps cheaper entry into the testing market, the requisite infrastructure for managing risk and the rules for handling risk information must be strengthened. Making testing more widely available will only be morally acceptable if there are rules of the road in place.

 Meanwhile, our regulator is just waiting for another day, then it may be too late.

Music video by Nikki Yanofsky performing For Another Day. 

(C) 2010 Decca Label Group

Neither manipulated, nor influenced

Nudge and the Manipulation of Choice
A Framework for the Responsible Use of the Nudge Approach to Behaviour Change in Public Policy

When thinking on health behaviour change, the nudging approach is the trending topic. Let's remember the origins:

The contribution of Thaler and Sunstein’s Nudge, however, is not that of conveying novel scientific insights or results about previously unknown biases and heuristics (something that Thaler has championed in his academic publications. Instead, it is the notion of “nudge” itself, and the suggestion of this as a viable approach in public policy-making to influence citizens’ behaviour while avoiding the problems and pitfalls of traditional regulatory approaches.

A recent article explains details about two types of nudging:

Type 1 nudges and type 2 nudges. Both types of nudges aim at influencing automatic modes of thinking. But while type 2 nudges are aimed at influencing the attention and premises of – and hence the behaviour anchored in – reflective thinking (i.e. choices), via influencing the automatic system, type 1 nudges are aimed at influencing the behaviour maintained by automatic thinking, or consequences thereof without involving reflective thinking.

And both can be transparent or non-transparent.  An example of a transparent type 1 nudge is one used by the Danish National Railway agency. Speakers in city trains are used to announce “on time” when trains arrive on time. This nudge has been devised in order to get people to easily remember not just the negative, for example, when a train is delayed, but also the positive, when trains are on time. Non-transparent is closely related to manipulation of behavior and choice.

The authors conclude:

The characterization of nudging as the manipulation of choice is too simplistic. Both classical economic theory and behavioural economics describe behaviour as always resulting from choices, but the psychological dual process theory that underpins behavioural economics, used by Thaler and Sunstein, distinguishes between automatic behaviours, and reflective choices. Nudging always influences the former, but it only sometimes affects the latter. The conceptual implication of this is that nudging only sometimes targets choices.

That's a good point. More details inside the article.

PS Understanding the differences between:  Clinical Categorical vs. Regression Based patient classification systems.

PS. Waste vs. value by U. Reinhardt. Must read.

Investing heavily

Global Healthcare Private Equity Report 2013

Healthcare represents about 10% of global private equity in general. Since this is more or less the proportion of health expenditures on the GDP would sound normal. However, since more or less two thirds of this expenditure is public in western countries, we can say that currently private equity may be overweighted in health sector, compared to others. The reason is that private equity may expect better returns in healhcare than in other parts of the economy.
Anyway, if you are interested in the details of what's going on, I suggest you to have a look at: Global Healthcare Private Equity Report 2013.
A key message about who is investing and where:

One clear theme that emerged in 2012, however, was the growing level of private equity firms’ interest in healthcare in China, India and across the Asia-Pacifi c region (see Figure 3). With opportunities abounding and restrictions on foreign direct investment relaxing to some extent, Western funds are building up their presence in Asia-Pacifi c by opening new offi ces, especially in China and Southeast Asia. Over the next several years, deal activity is likely to continue heating up in new geographies as it stabilizes in traditional ones.
Despite the allure of new markets, Western investors face a healthy dose of competition from local investment firms that have already taken root in the regions and strategic players searching for new outlets for growth. At the same time, investors based in the Arabian Gulf region (including sovereign wealth funds) are also investing heavily in emerging markets, with the long-term goal of bringing much-needed healthcare solutions back to their home countries. Given their unconventional investment theme, such investors are often willing to accept lower returns, consequently bidding up valuations across the board.

I always say that if you want to know about the future, it is helpful to have a conversation with a private equity investor and a headhunter. Capital and talent drive the economy, and both are interested in the appropriate allocation of risk and reward.

Quo vaditis?

Resource allocation in health care is a nightmare for any regulator. Since competitive prices are unavailable, payment systems have to be designed in order to achieve a greater efficiency, better quality and access. Two decades ago a chapter in a book on that topic summarized the knowledge and potential applications. The title was: Hospital Groups and Case-Mix Measurement for Resource Allocation and Payment, and the authors: Pere Ibern, James C. Vertrees, Kenneth G. Manton,Max A. Woodbury. This was the result of my stay as a visiting researcher at Duke University, Center for Demographic Studies. I had the unique opportunity to share knowledge with extraordinarily talented people.
For many years, things moved smoothly. A summary of the state of the art in 2007 is provided in a chapter of this book (p.259).
After twenty years, things have changed, quo vaditis payment systems?. Right now we focus on incentives for integrated care, and accordingly payment systems have to follow a different path. Bundled care and episode of care, these are the crucial topics right now.
However, regulator's inertia and risk avoidance are the greatest constraints for change. It is difficult to leave the confort zone. Although we know that current payment systems require a new design, decisions are being delayed. The latest words of Seamus Heaney, recently passed away, fit perfectly as a key message: Noli timere, don't fear.

A central dilemma

Reconsidering the Politics of Public Health

These are difficult times for public health regulators. JAMA highlights the issue:

A central dilemma in public health is reconciling the role of the individual with the role of the government in promoting health. On the one hand, governmental policy approaches—taxes, bans, and other regulations—are seen as emblematic of “nanny state” overreach. In this view, public health regulation is part of a slippery slope toward escalating government intrusion on individual liberty. On the other hand, regulatory policy is described as a fundamental instrument for a “savvy state” to combat the conditions underlying an inexorable epidemic of chronic diseases. Proponents of public health regulation cite the association of aggressive tobacco control, physical activity, and nutritional interventions with demonstrable increases in life expectancy

The article presents 5 ways towards a solution. The fifth says:

Physicians may bear particular responsibility in addressing the problem that psychologists call “hyperbolic discounting”— the human tendency to discount the value of future conditions bya factor that increases with the length of delay. Physicians bear witness to regrets about prior unhealthy choices in poignant moments— for example, the ex-smoker who wheezes in trying to keep up with grandchildren—and work to prevent other patients from experiencing avoidable fates.Perhaps physicians and other health professionals, as a result, have a special duty to weigh in on how society mitigates the social and environmental conditions that lead toward unhealthy choices

Wishful thinking again?.
Why should physicians bear such huge responsibility? "Nanny physicians"? What about citizens?. As you know, my focus is on shared decision making. Unfortunately the article doesn't mention it.

PS. What's goign on in Catalonia? Have a look at WSJ today. This is not a dilemma, it's a fact.

PS. Are you willing to pay 12.380€ for an additional survival of 36 days -progression free in breast cancer- ?. NICE considers that cost per QALY of Eribulin is 91.778 €. Are you willing to pay this cost? Forget the question,  there is no dilemma, the social insurance will pay it for you as from today. We are rich enough to afford it.

PS. If somebody wants to know how neuromarketing is being applied, have a look at the following documentary: "Don't think, just buy". Public health regulators can learn a lot from this experience to counter commercial efforts on junk foods and beverages.

Humanity cannot be owned

Gene Patenting — The Supreme Court Finally Speaks

In light of recent resolution of US Supreme Court on gene patenting, beyond technicalities, the most important is the final decision. All nine Justices of the Court agreed that the segments of DNA that make up human genes are not patentable subject matter. The Myriad case has raised expectations, now the business model is more clear than yesterday, at least in US. However, nobody talks about those patents already acknowledged and what it happens.
The best summary is in the NEJM article:

The Myriad decision will be an important symbol for those who seek to foster scientific discovery by protecting and expanding the public domain. It also has symbolic resonance with the ideal that our common humanity cannot be owned. The Universal Declaration on the Human Genome and Human Rights declares the human genome to be “the heritage of humanity” and that “the human genome in its natural state shall not give rise to financial gains.”

In Europe the patentability of genetic materially is legally protected by the EU's Biotech Directive, which holds that "biological material which is isolated from its natural environment or produced by means of a technical process" may be patentable "even if it previously occurred in nature." FP says: European firms may now have a lot more leeway than their American counterparts.
Does this make any sense? We should start a review process of genetic patents legislation immediately.

A picture is worth a ...

The World Bank HNP Data

Health expenditure as a share of GDP around the world

Drivers of health cost variation

Variation in Health Care Spending:Target Decision Making, Not Geography

Variations in medical practice are well known and documented. Variations in costs, not so much, at least in our country. Now you can check what happens to geographic cost variations in US. Have a look at IOM report and you'll get the right approach to the issue:

Geographically-based payment policies may have adverse effects if higher costs are caused by other variables like beneficiary burden of illness, or area policies that affect health outcomes. Further, if there are substantial differences in provider practice patterns within regions, cutting payments to all providers within a region would unfairly punish low cost providers in high-spending regions and unfairly reward high cost providers in low spending regions.

A clear alert for any designer of payment systems. The Economist adds more details on this topic and finishes with an additional alert:

The transition from fee-for-service will inevitably be slow. In the meantime, it would help if the millions of Americans with private insurance had any idea what hospitals charge. In May CMS published hospitals’ price lists, showing huge gaps from one hospital to the next. But few patients pay these charges—it would be more useful to know the rate negotiated with their insurers. This transparency does not require restructuring the health system. It just requires hospitals to lift the veil on prices. If they don’t, a regulator may do it for them.

PS. For those that claim that our tax pressure is low. Have a look at taxes over labour costs (41,4%)  OECD average 35,6% (2012), why this figures are not broadcasted? The medium is the message? Who controls the medium? Does anybody consider that competitivenes is possible with such rates?

Where is the problem?

Rafael Nadal said in a recent article:

En el llibre Els mandarins explico que un dia, referint-se als ciclistes, Mariano Rajoy em va dir: "A veure, si tots es dopen, ¿on és el problema? Al final, el que guanya segueix essent el millor".

You'll find the right answer in an excellent article in The Economist: Doping in sport Athlete’s dilemma
The analogy between sports and doping fits quite well with politics and corruption. What next?

Evidence-based market failure

The market may fail to provide the right answer to some citizen's needs. We all know that. If we talk about long term care insurance, the failure is well documented. You may have a look at two NBER academic papers ( A and B ). If you want recent news on the US situation, WSJ provides you a detailed description of this big failure. Still waiting for the right public policy, here and there.

Difference in differences

We all know that the state as a unit of analysis for comparative health policy distorts the whole picture. It forgets that within the country there are huge differences in many key indicators. If you are not still convinced, have a look at the regional european statistics. For sure you'll avoid to achieve any conclusion about health care comparisons without taking into account such data.

A picture is worth a ...

Underestimation of health status

I am strongly convinced that health surveys used to estimate morbidity differ from objective measures. Such large differences are unknown and too often health policy and planning is exclusively based on self-assessed measures. A recent chapter in the book "Active ageing and solidarity between generations in Europe: First results from SHARE after the economic crisis" confirms my impression. Why is this so?. The authors say:

"Being female, older or highly-educated implies a lower probability to underestimate health, and this probability is higher if people are wealthier and have confidants in their social network. Besides, people are more likely to overestimate their health if they are older or wealthier; on the contrary, this probability is lower if they are homeowners or have someone in entourage to talk to."