Behavioral health insurance choice

Behavioral hazard in health insurance
Can Consumers Make Affordable Care Affordable? The Value of Choice Architecture

Behavioral Economics is still a great promise for health economics. Anyway, in health insurance some materials are already available. Today I'll bring two articles on the choice of health insurance policy.
Some insights:

People do not misuse care only because the price is below the social marginal cost: they also misuse it because of behavioral biases—because they make mistakes. We call this kind of misutilization behavioral hazard . Many psychologies contribute to behavioral hazard. People may overweight salient symptoms such as back pain or underweight non-salient ones such as high blood pressure or high blood sugar. They may be present-biased (Newhouse 2006) and overweight the immediate costs of care, such as copays and hassle-costs of setting up appointments or filling prescriptions. They may simply forget to take their medications or refill their prescriptions. Or they may have false beliefs about the efficacy of care (Pauly and Blavin 2008).

The key message from the first article:

Incorporating behavioral hazard alongside moral hazard changes the fundamental tradeoff between insurance and incentives. With only moral hazard, lowering copays increases the insurance value of a plan but reduces its efficiency by generating overuse. With the addition of behavioral hazard, lowering copays may potentially both increase insurance value and increase efficiency by reducing underuse. This means that having an estimate of the demand response is no longer enough to set optimal copays; the health response needs to be considered as well. This provides a theoretical foundation for value-based insurance design, where copays should optimally be lower both when price changes have relatively small effects on demand and when they have relatively large effects on health. We show that ignoring behavioral hazard can lead to welfare estimates that are both wrong in sign and off by an order of magnitude.

"Avoidable copayments" , that's it. And about the second:

We examine how well people make these choices, how well they think they do, and what can be done to improve these choices. We conducted 6 experiments asking people to choose the most cost-effective policy using websites modeled on current exchanges. Our results suggest there is significant room for improvement. Without interventions, respondents perform at near chance levels and show a significant bias, overweighting out-of-pocket expenses and deductibles. Financial incentives do not improve performance, and decision-makers do not realize that they are performing poorly. However, performance can be improved quite markedly by providing calculation aids, and by choosing a ‘‘smart’’ default. Implementing these psychologically based principles could save  purchasers of policies and taxpayers approximately 10 billion dollars every year.

That's a lot. glups!

Private health insurance subsidies: the case of Ireland

Unwinding the State subsidisation of private health insurance in Ireland

Taxes may distort individual decisions and hence resource allocation. Subsidies may have the same effect. Ireland had large subsidies for private health until 2013.

In Budget 2014, announced in October 2013, the Minister announced that charges for all beds in public hospitals would be levied on insurers from 2014, raising € 30 m in 2014. Also in Budget 2014, the Minister for Finance announced that the amount of health insurance premium subject to tax relief would be capped at €1000 for an adult and € 500 for a child. This was expected to yield € 94 min savings in 2014 and € 127 m per year thereafter.

The article explains the concrete situation and policies. Its impact on one statement:

Despite the fears about the effect thes emeasures would have on the private health insurance market, the measures do not appear to have caused significant damage to this market. This may be partly due to the introduction of Lifetime Community Rating by the Government in May 2015, and consequent moves by insurers to innovate at the lower-priced end of the market in advance of this.

Ireland is the closer market to us, we share similar features.

Big Data at work in healthcare

Novel Predictive Models for Metabolic Syndrome Risk: A “Big Data” Analytic Approach

Reducing Metabolic Syndrome Risk Using a Personalized Wellness Program

Metabolic syndrome is somewhat fuzzily-defined, let's say it's a concept-frame that can lead to a condition like chronic heart disease, stroke and diabetes. The results of the estimates from a big data application provide clear messages about the need for personalized wellness programs. Both issues are covered in the quoted articles. There is no reason to delay its application.
Let's add the key statement:

The ability of the models to produce highly individualized risk profiles for overall risk of metabolic syndrome and by specific risk factors allows for more successful patient engagement in subsequent care management programs. Figure 2 shows 2 different individual risk profiles. Subject ID 423262 was a 46-year-old male with current out-of-range metabolic syndrome risk factors of high-density lipoprotein (HDL) and waist circumference. He had a 92% predicted probability of developing metabolic syndrome within 12 months, and a 73% probability of developing abnormal blood glucose as a third specific metabolic syndrome risk factor during the study period. Subject ID 107975 presented a contrasting profile. He was a 37-year-old male with 2 out-of-range metabolic syndrome risk factors—HDL and triglycerides—but had only a 40% predicted probability of developing metabolic syndrome within 12 months. For this subject, abnormal blood glucose was also the most likely abnormal factor to develop next, but carried only a 26% likelihood.

Maximizing health and welfare

Maximizing Healthy Life Years: Investments that Pay Off
Future of Healthy How to Realize Returns on Health

Key relationships (click to enlarge)

 



Summary

 

Key tipping points (not exhaustive)

 

Nothing specially new. Good infographics. This report relates to the health determinants literature. Anyway, for your files.

Rethinking drug regulation and health risk mitigation

FDA in the Twenty-First Century. The Challenges of Regulating Drugs and New Technologies

A new book on FDA addresses the  "perennial and new problems and the improvements the agency can make to better serve the public good.". The book would deserve a detailed critique, however, let me skip directly to chapter 25: Device-ive Maneuvers FDA’s Risk Assessment of Bifurcated Direct-to-Consumer Genetic Testing.
In this blog I've written about the same topic. My position is clear: stop direct-to consumer testing. I have explained the rationale here. And what the book says, it is exactly the same:

Three steps are necessary to ensure the safety and effectiveness of DTC
genomic information. First, the underlying data must be analytically  valid—that is, the genomic data sequence must be accurate and precise. Second, the information must be clinically valid—the findings must be causally associated with clinical outcomes. And third, the risks of disclosing the genomic information must be minimized. FDA’s ability to effectively regulate genomic information hinges upon the approach taken to each of these challenges

Meanwhile, in Europe, nobody cares about it. It's a great shame.

 

 

La Lídia Pujol canta l'imne d'Occitània, "Se canta" (apelat tanben "Aqueres montanhes" en la Val d'Aran), dins lo programa de TV3 (Television de Catalonha) 

Learning occitan

Comunicat del 20 de genièr de 2016 del President de l’IEO sul tractament de las lengas regionalas per l’estat francés.
ASSASSINAR SEI LENGAS, ANSIN VÒU LA FRANÇA ?
L’Institut d’Estudis Occitans (IEO) denóncia aut e fòrt que l’Assemblada Nacionala ague fach rebuta a la proposicion de lèi de Paul Molac, relativa a l’Ensenhament immersiu dei lengas regionalas e a sa promocion dins l’espaci public e audiovisuau.
Per memòria, aquesta denegada vèn après : la promessa vana dau candidat Hollande sus la ratificacion de la Carta europenca dei Lengas Regionalas ò Minoritàrias (ambé lo debat mancat a l’Assemblada Nacionala), lo rapòrt Filippetti de julhet 2013 e sei 42 prepausicions passadas per malhas, tornat mai en octòbre de 2015 l’engatjament dau president de la Republica per la Carta, rebutat per la drecha senatoriala e que dire de l’ensenhament dei lengas regionalas assecat…
Convendretz que i a de qué se pausar la question.
Sorda que mai se pòt pas a la demanda populària, la França, es que vòu pas finalament assassinar sei lengas regionalas per de bòn ?
A la veritat, aquesta decision fa chifrar, notadament per son escart d’ambé la demanda sociala, e discredita lo foncionament democratic.
D’escondons, vesèm s’organizar l’eliminacion metodica de nòstrei lengas de l’espaci public republican.
Amb aqueste refús, la França demòra un còp de mai dins lo rodolet dei país reborsiers que donan ges d’estatut a sei lengas. Lo pluralisme linguïstic, pasmens, es una aisina de coësion indispensabla per la Nacion e un element de sa credibilitat internacionala.
Acceptar la postura dau Govèrn actuau de la França que mespresa de lengas que parlan sei ciutadans a milierats se pòt pas mai !
L’IEO demanda per aquò au Govèrn d’iniciativas nòvas que laissan oblidar lei còps que s’es mancat.
Coma lo digueriam encara en octòbre 2015 a Montpelhier, volèm una lèi !
Volèm una lèi que done un estatut vertadier ai lengas regionalas e garantisse sei locutors de tota exclusion e discriminacion.


Pèire Brechet
President de l’IEO

 

Inducing methylation

Nutrition, Exercise and Epigenetics: Ageing Interventions

Epigenetics refers to an inheritable but reversible phenomenon that changes gene expression without altering the underlying DNA sequence. Thus, it is a change in phenotype without a change in genotype. The field of epigenetics is quickly growing especially because environmental and lifestyle factors can epigenetically interact with genes and determine an individual’s susceptibility to disease. Interestingly, aging is associated with substantial changes in epigenetic phenomena. Aging induces global DNA hypomethylation and gene-specific DNA hypermethylation due to the altered expression of DNA methyltransferases (DNMTs).

The evidence of the impact of epigenetics on aging is growing. And nutrition plays a key role on epigenetics through the life course. Thus, there are crucial reasons to focus on nutrition early in life.

It is clear that epigenetic alterations caused by aging may provide a milieu that can develop age-associated diseases such as cancer, cardiovascular diseases, neurocognitive diseases and metabolic diseases. Nutrition is one of the most important environmental factors that can modify epigenetic phenomena. Therefore, one might speculate that nutrition may delay the age-associated epigenetic change and possibly reverse the aberrant epigenetic phenomena that can cause age-associated diseases. Indeed, many nutrients and bioactive food components, which can affect one-carbon metabolism that can regulate methylation of DNA and histone or directly inhibit epigenetic modifying enzymes, are showing promising results in delaying the aging process and preventing age-associated diseases through epigenetic mechanisms.

And beyond nutrition, there is exercise. This is what this book explains and it shows the foundations for better health. If it's "only" an issue of regulating methylation...where are the incentives?

Economic perspectives on public health

Promoting Health, Preventing Disease:The Economic Case

The rethoric behind disease prevention and Health promotion is well known. However, in practice, more needs to be done. A new book by WHO Euro reflects the economic case for such policies

Health promotion and disease prevention have a major role to play in Health policy worldwide, yet they are underused, partly because evidence to suport a strong case for action is difficult to gather. Aimed at a broad audience of policymakers, practitioners and academics, this book is designed to provide an economic perspective on the challenges to better health promotion and chronic disease prevention.

Four diferent considerations:

• The costs of inaction: What are the economic consequences of not taking action to promote and protect the health of the population?
• The costs of action: What would it cost to intervene by providing a promotion or preventive measure?
• The cost-effectiveness of action: What is the balance between what it costs to intervene and what would be achieved in terms of better outcomes – e.g. emotional well-being, physical health, improved quality of life, educational performance?
• The levers for change: What economic incentives can encourage more use of those interventions that are thought to be cost-effective and less use of those interventions which are not?

This book will be a key reference for public health policies, the background and state of the art, pros and cons of each policy, are clearly detailed. Highly recommended.

The quid pro quo at the heart of the international health regulations

Disease Diplomacy. International Norms and Global Health Security

The implementation of international health regulations has its pluses and minuses. Some countries show reluctance to accept a new landscape of global health security. All these issues are reflected in an interesting recent book.

We have seen dramatic changes in the past decade. The engagement of high-level political and security communities with an area that had previously been primarily treated as a technical concern has been a major cause of that change, but it has also meant that the new system is taking time to settle. Prior to 2005, the IHR had not been substantially revised since 1969.

International norms are by their very nature collective ideas, and they rely on that collectivity—the notion of states as forming a cohesive international society—in order to function effectively. When a number of states cannot meet the IHR core capacity requirements and cannot attract the help they need to do so, the entire ethos of the global health security regime is undermined. This, for us, is the challenge facing norm leaders: how to maintain the regime’s political purchase when the security discourse used to establish it is increasingly met with antipathy post-H1N1 and with a lack of financial support to institutionalize the necessary capacities in the domestic structures of the poorest states. Thus, one of the key lessons we draw from the norm-building process examined in this book is that recognizing appropriate behavioral standards and “wanting to do the right thing” are not the same as having the ability to conform to those standards.

A disease-producing organism

Disease Selection. The Way Disease Changed the World


Understanding human life is a great undertaking. After all these years the origins of our cells are not so clear. But let me quote a recent book and its suggested approach:

Evolutionary biologists have looked for some time for a suitable prokaryotic cell that when engulfed by another would form the nucleus of the nascent eukaryotic cell, but none has been identified that matches all the required criteria. However, Luis Villarreal, working with viruses, has come to the astounding conclusion that the primitive cell nucleus could have originated from a complex virus. The vaccinia virus, for example, seems to have all the same mechanisms that are required by a eukaryotic cell nucleus. The virus that formed the nucleus brought with it all the basic genes – thought to number about 324 – that are necessary to form the cell.
It requires a little time, and perhaps rereading of what has just been said, to realize that every cell in our bodies has a nucleus that was derived from a virus. We are the result of a very early disease process!

So not only is the nucleus of our cells derived from a virus but the mitochondria are from a parasitic bacterium. There can be no closer link between us and disease-producing organisms.

Technology, organization and the health system

The digital revolution: eight technologies that will change health and care

A short article by the King's Fund describes key technologies for the future. Really, the future is now:
1. The smartphone
2. At-home or portable diagnostics
3. Smart or implantable drug delivery mechanisms
4. Digital therapeutics
5. Genome sequencing
6. Machine learning
7. Blockchain
8. The connected community
As usual, we need to split technologies according to its value and social willingness to pay. Easier said than done. That's why I would suggest a close look at the report on Better value in NHS. Technology innovation without organizational change to take advantage of its value is extremely costly.
This is the agenda for NHS transformation:

Fragmented regulators in globalized markets

Food and Drug Regulation in an Era of Globalized Markets

The complexities of a globalized world have its impact on food and drug regulation. The options for a collaborative space between different agencies are huge, though the interest is low. Its an issue of power and fear, everybody knows that cooperating would be better, but a lack of commitment is the final result. This is not only an issue for health, of course, but I would like to highlight the fact that this should be the first issue of concern by health politicians worlwide. Meanwhile, you can read this book, though it is partial and limited but shows the current situation.

Public health for the world

Readings in Global Health Essential reviews from the New England Journal of Medicine

The book starts with this statement:

“Global Health” is a relatively recent construct, largely replacing and extending concepts embedded in prior terms such as “Tropical Medicine” and “International Health.” We have adopted a working definition of Global Health as “Public Health for the world”. In this view, everyone in the world is the relevant population, and Global Health seeks to prevent and treat the diseases that compromise good health anywhere in the world. A brief review of the origin and evolution of the concept of Global Health may cast light on some of the institutions and impulses still intrinsic to the study of Public Health for the world.

That's it. A selections of 18 articles from NEJM (plus intro and conclusions) is presented  in the book in order to understand the current change of paradigm:

1. Harvey V. Fineberg and David J. Hunter: A Global View of Health-An Unfolding Series
Part I: Global Disease Patterns and Predictions
2. Christopher J.L. Murray and Alan D. Lopez: Measuring the Global Burden of Disease
3. Anthony J. McMichael: Globalization, Climate Change, and Human Health
Part II: Infectious Diseases
4. Anthony S. Fauci and David M. Morens: The Perpetual Challenge of Infectious Diseases
5. Peter Piot and Thomas C. Quinn: Response to the AIDS Pandemic-A Global Health Model
6. Harvey V. Fineberg: Pandemic Preparedness and Response-Lessons from the H1N1 Influenza of 2009
7. Rupa Kanapathipillai, Armand G Sprecher, and Lindsey R Baden: Ebola Virus Disease: Past and Present
8. Gary J. Nabel: Designing Tomorrow's Vaccines
9. Donald R. Hopkins: Disease Eradication
Part III: Non-Communicable Diseases
10. Majid Ezzati and Elio Riboli: Behavioral and Dietary Risk Factors for Noncommunicable Diseases
11. Prabhat Jha and Richard Peto: Global Effects of Smoking, of Quitting, and of Taxing Tobacco
12. David J. Hunter and K. Srinath Reddy: Noncommunicable Diseases
13. Anne E. Becker and Arthur Kleinman: Mental Health and the Global Agenda
14. Robyn Norton and Olive Kobusingye: Injuries
Part IV: Health System Responses
15. Zulfiqar A. Bhutta and Robert E. Black: Global Maternal, Newborn, and Child Health-So Near and Yet So Far
16. Anne Mills: Health Care Systems in Low- and Middle-Income Countries
17. Jennifer Leaning and Debarati Guha-Sapir: Natural Disasters, Armed Conflict, and Public Health
Part V: Global Institutional Responses
18. Julio Frenk and Suerie Moon: Governance Challenges in Global Health
19. Lawrence O. Gostin and Devi Sridhar: Global Health Law
20. Nigel Crisp and Lincoln Chen: Global Supply of Health Professionals
21. David J. Hunter and Harvey V. Fineberg: Convergence to Common Purpose in Global Health

The book is specially appropriate for any health professional and politician. Clearly written and concrete messages, allows the reader to undestand that public health requires a deeper global coordination.

Health economics of genomics

Genomics and Society: Ethical, Legal, Cultural and Socioeconomic Implications

 Current advances in genomics require an update for health economists. A first reading that  I would recommend is the chapter by James Buchanan titled "Health economics perspectives of genomics" that has been published in a recent book. James is a health economist that works in Oxford University, and his blog is a must read on the topic.

A professional transformation is already under way

THE FUTURE OF THE PROFESSIONS: how technology will transform the work of human experts

The concept of professional job is changing. A new book tries to reflect the impact of technology on professions.This is a key statement:

We are on the brink of a period of fundamental and irreversible change in the way that the expertise of these specialists is made available in society. Technology will be the main driver of this change. And, in the long run, we will neither need nor want professionals to work in the way that they did in the twentieth century and before. There is growing evidence that a transformation is already under way.

Understanding the new scope and implications of such transformation requires an open mind and being aware. It will be a slow change, the authors say, but deep and irreversible towards the post-professional society.

In the long run, increasingly capable machines will transform the work of professionals, giving rise to new ways of sharing practical expertise in society. This is the central thesis of our book. We cannot commit to timeframes, in large part because the speed of change is not in our hands. But we are confident that the change will constitute an incremental transformation rather than an overnight revolution. In the language of the book, the shift itself can be characterized in many ways: as the industrialization and digitization of the professions; as the routinization and commoditization of professional work; as the disintermediation and demystification of professionals.