Failures and successes of the engines of democracy: Politics and Policymaking

Why Government Fails So Often: And How It Can Do Better

Our democracy finally has been created to deliver specific outcomes. However, citizens are increasingly unsatisfied with governments. Fortunately we can analyse this fact through a new book that attempts to disentangle the issue going deeper than usual in the roots of the problem:

Americans have a dismal opinion of the federal government’s performance, one that is only getting darker.4 Significantly, this growing antipathy is not antigovernment generally. Instead, it targets only the federal government; respect for state and local governments is both high and stable. Nor is this hostility toward the federal government in Washington a partisan matter. Instead, it is expressed by a majority of Democrats as well as Republicans. And perhaps most revealing, this disaffection long preceded the current political gridlock in Congress that many pundits see (wrongly, as I shall show) as the root of the problem.

You may change the word americans at the begining and place your nationality and this former statement could work. We should question what government failure or success means and the authors look at the literature on policy evaluation and find fewer references than expected.

Understanding government failure, then, presents complex challenges. Its funders, consumers, and ultimate appraisers—“We the People”—are more disgruntled than ever, and the social scientists who assess the evidence most rigorously find that these appraisers’ disapproval is amply warranted.

The author considers that government failures are rooted on recurrent weaknesses that  include unrealistic goals, perverse incentives, poor and distorted information, systemic irrationality, rigidity and lack of credibility, a mediocre bureaucracy, powerful and inescapable markets, and the inherent limits of law. This sounds familiar. Anyway, something should be done, and part 3 is entirely devoted to this issue. I would like to highlight the limits of the law as a constraint, others details are in the book that I strongly recommend. He says:

The very nature of public law places some severe limits—both constitutional and functional—on the effectiveness of the policies that it communicates and governs. Although most of these limits cannot be avoided, some of them might be eased.

I really think that we should explore new options for producing laws and assessing its performance, the current situation of the "democracy engine" is outdated.

PS .A review at WSJ.

 Many of our political debates are about what if anything government should do about the problems our society confronts. The combatants in these battles rarely stop to consider just what government actually can do.

 Peter H. Schuck has written an essential manual for 21st-century policy makers.

When bad science leads to bad policy

The Corruption of Peer Review Is Harming Scientific Credibility

Nothing new, scientific peer review is a process under suspicion. The Guardian illustrated this fact three years ago, and WSJ has repeated the same recently. The potential solution is to put into practice the falsiability process as Popper emphasized long time ago. The main difficulty is data access, however some journals have started to supply such data for researchers in order to confirm the results. My position about it is clear, as a referee I'll refuse to review more papers unless this option is possible for any submitted article. The potential harm is huge in certain fields and circumstances, as the Vioxx case illustrates.
The WSJ op-ed says:

Fixing peer review won't be easy, although exposing its weaknesses is a good place to start. Michael Eisen, a biologist at UC Berkeley, is a co-founder of the Public Library of Science, one of the world's largest nonprofit science publishers. He told me in an email that, "We need to get away from the notion, proven wrong on a daily basis, that peer review of any kind at any journal means that a work of science is correct. What it means is that a few (1-4) people read it over and didn't see any major problems. That's a very low bar in even the best of circumstances."
But even the most rigorous peer review can be effective only if authors provide the data they used to reach their results, something that many still won't do and that few journals require for publication. Some publishers have begun to mandate open data. In March the Public Library of Science began requiring that study data be publicly available. That means anyone with the ability to check should be able to reproduce, validate and understand the findings in a published paper.

Doctor crisis. What crisis?

The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care

Last May I saw this press release about a book by a physician from Kaiser Permanente. Initially I thought that it would be a book for those interested uniquely in US healthcare. I started reading "The Doctor Crisis" last week and still can't stop. It has captured my attention. His observations about the practice of medicine and the pressures that physicians are under, are similar in any developed country, maybe the intensity is not the same. Anyway, in the book there is a reference of a work by Sinsky et al.:  In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices, a must read:

The current practice model in primary care is unsustainable. We question why young people would devote 11 years preparing for a career during which they will spend a substantial portion of their work days, as well as much of their personal time at nights, on form-filling, box-ticking, and other clerical tasks that do not utilize their training. Likewise, we question whether patients benefit when their physicians spend most of their work effort on such tasks.³⁰ Primary care physician burnout threatens the quality of patient care, access, and cost-containment within the US health care system.

We set out in search of joy in practice. What we found were pockets of professional satisfaction.

I missed this article when it appeared last year.What they explain is in my opinion what exactly should be done. As Tom Bodenheimer says, “the Triple Aim should be a quadruple aim, with clinician and staff satisfaction a necessity to achieve the other three aims.”  Considering it as an input and not only as a goal itself is the right approach. More on Berwick's triple aim, at IHI.
I am only at the begining of the book, but I wanted today to reflect this critical issue of our health systems. Something should be done beyond the triple aim. Organizational innovation is required. Right now I am not able to perceive such effort around here.

PS. About the title, focusing only on physicians is a too narrow perspective for those who have to lead a better health care , why not "transdisciplinary professionalism"?

PS. A suggestion: their blog.

Morbidity adjusted life-expectancy

OBTENCIÓN DE LA ESPERANZA DE VIDA Y DESCOMPOSICIÓN EN ESTADOS DE SALUD A PARTIR DE INFORMACIÓN CLÍNICA

I have always considered that any estimate of healthy life expectancy that is build upon many assumptions and coefficients in the end it is difficult to understand. The global burden of disease and its use of DALYs is an extraordinary effort, though if you dig into the results you'll find methological difficulties.
An alternative to such estimates is just to show how the burden of mordibity is distributed across lifetimes. That is precisely what we have presented at the last Health Economics Conference. I believe that such estimation is a promising way to present population life expectancy and health. As far as this is the first attempt, there is still room for improvement.

Healthy and satisfied

Enquesta de salut de Catalunya

Latest data from the 2013 Health Survey shows that 81,1% of the population consider themselves as healthy, slightly better that in 2010 that was 79,3%. Regarding satisfaction, 86,9% of population is satisfied with public health services, again better than 2010 that was 84,7%. Though in 2012 results were a little bit better.
In the details of the results you'll find that obesity and overweight is the biggest issue to address in my opinion. There is still a lot to do on tobacco and alcohol, but data shows some improvement.
This health survey should be broadcast in the media and efforts to promote healthy behaviours should raise. Unfortunately nowadays media is focused on negative messages and this issue lies far from journalists' interests.

Positive and negative risk cultures

Risk Savvy

While reading The Guardian I find out that Nudge theories could fall from the mainstream.:

Though nudge-economics remains seductive, what once seemed like a panacea has come to look a bit more like a series of sticking plasters. Earlier this year the nudge unit was removed from direct government control, partly sold to the Nesta innovation charity run by New Labour guru Geoff Mulgan, a move which seemed to suggest the prime minister no longer viewed it as quite so central to his philosophy. That move has coincided with a backlash, or at least a critical analysis, of some of the tenets on which its brand of behavioural economics is based.

You already know from this blog I have devoted many posts to it. And I've said many times that its application is still in its beginings. However, if you look at the new book by Gerd Gigerenzer "Risk Savvy", maybe the perspective could be otherwise. He examines Kahneman works and gives a different view. The issue of two systems of the brain, A and B, when taking decisions is under criticism. He defends heuristics that in some sense use both when taking some difficult decisions.
His work goes beyond such criticism and it is an additional perspective on how we take decisions and the role of risk and uncertainty.
He considers that health sector is dominated by a negative risk culture, a way of doing that tries to hide errors and in such situations learning is much more difficult. On the other end of the spectrum are "positive error cultures that make error transparent, encorage good errors and learn from bad errors to create a safer environment". This is the case of commercial aviation. From his view, the use of check lists and safety measures should be boosted in many settings to improve efficiency.
Gigerenzer work is a good recommendation for summer reading. Wether he is able to convince you more than Kahneman, it's uncertain right now.

Big data, big opportunity

Learning from Big Health Care Data

Big Data is more than a buzzword, it raises high expectations about how the massive treatment of data may deliver new results. At NEJM you'll find an article that explains general implications for health care:

Two key “learning” applications of big health care data that hold the promise of improving patient care are the generation of new knowledge about the effectiveness of treatments and the prediction of outcomes. Both these functions exceed the bounds of most computer applications currently used in health care, which tend to offer physicians such tools as context-sensitive warning messages, reminders, suggestions for economical prescribing, and results of mandated quality-improvement activities

At JEP, you'll find an article by Hal Varian that shows the new challenges for econometrics:

Conventional statistical and econometric techniques such as regression often work well, but there are issues unique to big datasets that may require different tools. First, the sheer size of the data involved may require more powerful data manipulation tools. Second, we may have more potential predictors than appropriate for estimation, so we need to do some kind of variable selection. Third, large datasets may allow for more flexible relationships than simple linear models.

All in all, you'll be convinced that it is more than a buzzword.

PS. You may find an example of application of big data in our recent article in Gaceta Sanitaria.

Who sets the health policy agenda?

Making Health Policy

From this book:

In relation to policy making, the term agenda means: the list of subjects or problems to which government officials and people outside of government closely associated with those officials, are paying some serious attention at any given time . Out of the set of all conceivable subjects or problems to which officials could be paying attention, they do in fact seriously attend to some rather than others.

The crucial issue is who sets the policy agenda, how and why. Two main sources appear as agenda-setting: government and mass media-social networks. There are of course, additional groups and lobbyists that can influence such a process.
Nowadays we could consider that the recession and cutbacks has created a window of opportunity for some to discuss many foundations of our health system. In such a situation, the worst position is the delay on setting the list of topics to be addressed by the government, otherwise non-elected bodies try to mobilise efforts and decisions towards their interests that add to those of the opposition. Therefore, if you are interested on the basics of agenda-setting, have a look at chapter 4 and ask yourself who is in control of it. Are you comfortable with the answer?. If not, something should be done.

Sooner than later

Snake Oil: How Fracking’s False Promise of Plenty Imperils Our Future

Health Impact Assessment of Shale Gas Extraction - Workshop Summary

Applying a Health Lens to Decision Making in Non-Health Sectors - Workshop Summary

Some months ago I suggested a look at PINSAP, the governmental plan to relate health with policy decisions beyond health care and public health. I considered it a real challenge and we have to follow closely what it may deliver. Right now a new pressure on politicians is arising regarding shale gas extraction. Hydrofracturing has wide environmental impacts. Health impact is less known, and this is the reason why IOM released a study last year on that. It says:

The governmental public health system lacks critical information about environmental health impacts of these technologies and is limited in its ability to address concerns raised by federal, state, and local regulators, as well as employees in the shale gas extraction industry and the general public.

If this is so, why hhas the US allowed such extractions?. I suggest you have a look at the book: Snake Oil: How Fracking’s False Promise of Plenty Imperils Our Future,  though it is focused on environmental impact, it provides a clear understanding of the technology and its enormous implications.
If we have to apply health lens to decision making in non-health sectors, this is a clear example for rejecting a technology of tremendous consequences. There are sound reasons to stop such developments sooner than later.

Current expenditure patterns

While looking at the changing economic landscape, you may achieve the conclusion that current trends have never been considered as an option in any forecast. Take for example the total anual expenditure per person. In 2008 it was 13.152€, in 2013 it was 11.710€ (current values, without taking into account CPI). A reduction of 10,9% since the begining of the recession. However, the change in one year (2012-2013) is really high in some categories, people are spending more on pharmaceutical products (9,2%) and less in medical services (-9,8%) (p.4).
If you want to look at individual voluntary health insurance, before the recession the per capita expenditure was 132€ (1.218m€/7,364 m population, 2008) while in 2012 was 137€ (1.445m€/7,571m population), an increase of 5€ . These are the official statistical data.

Health financing on the right track

The Changing Role of Government in Financing Health Care:An International Perspective

If you are looking for a paper that reflects all the issues sorrounding health care finance, you are in luck. A recent article in JEP covers the topics to understand what's going on in developed countries. For example,  I found this statement of interest with regard to our current situation:

The relative efficiency of different types of taxes used to finance health systems has been explored in the public finance and health economics literature. The equity and efficiency properties of general taxation (c.f. Auerbach1985) do not differ depending on whether the money is spent on health or education per se, although, if the level of government that collects revenue differs from the level of government that provides health coverage, there may be equity issues and issues about whether the level of taxation best meets local demand for the services required (c.f. Ahmad and Brosio 2006). Of course, the amount of deadweight loss associated with any revenue generation will depend on the balance and type of taxes  used to raise the revenue.

There are huge equity issues to address in our current system, and have to be corrected very soon. I hope we are on the right track and this is going to be solved in forthcoming months.

Investing heavily (2)

Global Healthcare Private Equity Report 2014

One of the adverse effects of financial repression is that investors may lose their compass in the allocation of risk and the prediction of rewards. This repression period for savers will last longer than anybody would expect, since the size of public debt in some countries is still increasing. Therefore, now it is the time for private equity to invest in sectors with greater uncertainty over profits that would be desirable in normal conditions. This is one reason, among others, why hospitals may appear of interest and this is precisely what happened yesterday.
We know from a recent report that while overall private equity investment increased, capital deployed in healthcare declined in 2013.

Investment levels in the medtech and provider sectors in Europe were down in 2013 compared with 2012, when these sectors saw three $1 billion-plus deals between them. Deal value in the provider sector was especially slow, coming in at only a third of the level seen in 2012, partially due to the dearth of large deals like the previous year’s Mediq (a pharmacy distributor) and Four Seasons (nursing homes) deals.

In 2014 the trend could be the opposite, at least near here. The closed operation (1$ billion-plus) will change the landscape of private health care for decades, and some shocks may appear sooner than later. Let's wait for the strategic responses.

PS. It may seem a paradox, but the unintended effect of financial repression by governments is a misperception of risk. Speculative bubbles before the recession have had the same effect. Beware of that.

PS. Regarding yesterday's case, I understand that antitrust issues will be taken into account properly...

Questions without answer (2)

EESRI. Estadística dels centres hospitalaris de Catalunya, 2012

These are hard times for hospital finances, public and private. In 2012, the deficit of acute care publicly funded hospitals was -29 million €, and -32,7 million € for privately funded ones. In public hospitals, deficit has slightly decreased and the opposite for private ones. Losses appear in both cases,  independent from ownership, however its distribution is for sure of interest, but unavailable. All this data come from a report that I check annually. Last year I posted some questions without answer, and again and updated I reproduce them:

• Why private hospitals have a cesarean rate of 37,2% and public hospitals 22.9%? p.15
• Why "productivity" is double in private than in public hospitals? p.19 (31,52 vs 62,40 UMA/personal sanitari) p.21
• Does size matter for efficiency? Public hospitals average income 80,7m€ , private ones 19,6m €  p.22
• Why ambulatory surgery discharges are 47% in publicly funded and 31,6% in private ones ? (p.15) 
• Why people talk about private profits when there are losses every year?

Why are we waiting? (4)

Patients that are waiting for a health service deserve an explanation about the current situation and its potential solution. In former posts I have made some steps in this direction, but the final and definitive one lies on the resources available.
As far as we are publicly spending 1.095 euros per capita, we could ask if in the same State and under the same tax pressure, some people get more resources than us. Let's have a look at Euskadi,( p.5) any citizen there, will have 1.541 euros per capita for health care in 2014. Therefore, we can increase by 40% our health expenditures without increasing our tax pressure. With such an amount of resources we can forget forever the current waiting lists. In Euskadi, they have 0,8% of population waiting (p.6)  and last year the number of patients was reduced by 2,62%. We have 2,4% of population waiting, 3 more times than them, this is unacceptable and requires immediate action.
Fortunately there is a solution. We need only to disconnect as soon as possible, get all the money of our taxes as they do, and only 60.000 patients will wait instead of 180.000 as it is now. This is good news.

PS. Last Sunday this documentary forgot to tell this relevant information to patients. Once again, I repeat what I said: A wider and sound view about current challenges in health care would allow to understand reality and take better decisions. A new documentary should be recorded to replace it. This is my kind request to TV3.