Fiduciary duty in medicine

Professionalism, Fiduciary Duty, and Health-Related Business Leadership

Professionalism is a key concept to understand the practice of medicine. I have emphasized many times this issue in this blog. Today I would like to take one step further and to define the fiduciary duty of all healthcare professionals, specially those at management positions. In JAMA you'll find an article that elaborates the idea:

Fiduciary duty captures the simple idea of an obligation to act in the best interest of another person or party. The fiduciary is entrusted with the care of another person and must ensure that the person’s interests take precedence over the fiduciary’s own interests. Fiduciary duty is familiar to physicians in their relationship to patients, but in business, executives have a fiduciary duty to “the shareholders and the corporation.” A fiduciary relationship contrasts with a contractual one (in which mutual obligations are largely spelled out), and it imposes more extensive expectations of leaders. Fiduciaries are held to a higher standard precisely because of their power to affect the well-being of others who rely on their judgment and cannot adequately monitor and assess the fiduciary’s actions.

PS. Fiduciary duty concept is better developed under common law rather than civil law. Therefore, we need to rethink its implications.

Toni Catany, Photo-Exhibition in Barcelona

Rational emotions

Feeling smart

Game theory is a crucial contribution to science. However it is not that easy to get a clear understanding unless experiments that confirm hypothetical outcomes are well described. And experiments are context dependent.
If you want a good overview of the main insights of Game Theory, have a look at this book "Feeling Smart, why our emotions are more rational than you think" by Eyan Winter. It goes beyond game theory, this is the most fortunate part.You don't need maths to understand it. Mostly it is devoted to applications in a useful way, using behavioral and information views .
Let's take a statement on trust:

Trust is an engine of cooperation between individuals. Cooperation, in turn, is an engine of economic growth and social welfare. Trust cannot be sustained in a society without credibility, the behavioral trait that fosters trust. On the other hand, just as trust cannot survive for long without credibility, credibility is eventually destroyed without trust. If trust is virtually nonexistent in a social setting, then there is no point in trying to develop or sustain credibility; in that situation you are better off adopting selfish and unreliable behavior. Societies and nations can be in one of two equilibria: a “good” equilibrium in which individuals trust each other and behave in a reliable and cooperative manner toward others (justifying the trust), or a “bad” equilibrium in which individuals do not trust each other, with that lack of trust becoming self-justifying as people act without any sense of a need to be trustworthy or reliable. It is easy to guess, even without empirical data, which of these equilibria leads to greater economic growth.

If you are interested in trust games, then go to part II, "On trust and generosity", this is what you should read. I highly recommend it, I've enjoyed reading it.

 

PS. I have a vague feeling these days about what's going on health policy in my country. May be credibility is starting to be undermined? Any health model relies on the credibility and trust of different actors. It is not possible to build a health system without trust among all stakeholders. Instead of creating the conditions for a new health policy based on cooperation, may be the new foundations are departing from conflict?. Is this the way to create a successful health policy?

The building blocks of healthcare payment systems

The Building Blocks of Successful Payment Reform: Designing Payment Systems that Support Higher–Value Health Care

The implementation of healthcare payment systems is a complex task for any insurer, either public or private. Any option for reform is path-dependant and uncertain. The context and the inertia are the sources of lack of support for a change, unless a larger amount of Money -a big carrot- is put on the table.
A new report highlights the building blocks of a payment system. This is the instruction manual, and it refers to 4 issues:

Building Block 1: Services Covered by a Single Payment
Option 1–A: Adding new service–based fees or increasing existing fees.
Option 1–B: Creating a treatment–based bundled payment for a single provider
Option 1–C: Creating a multi–provider treatment–based bundle.
Option 1–D: Creating a condition–based payment.
Option 1–E: Creating a population–based payment.

Building Block 2: Mechanism for Controlling Utilization and Spending
Option 2–A: Adjustments in payment (pay for performance)based on utilization.
Option 2–B: Adjustments in payment (pay for performance)based on spending or savings.
Option 2–C: Bundled payment.

Building Block 3: Mechanism for Assuring Adequate Quality and Outcomes
Option 3–A: Establishing minimum performance standards.
Option 3–B: Payment adjustments (pay for performance) based on quality.
Option 3–C: Warrantied payment

Building Block 4: Mechanisms for Assuring Adequacy of Payment
Option 4–A: Risk adjustment or risk stratification.
Option 4–B: Outlier payments.
Option 4–C: Risk corridors.
Option 4–D: Volume–based adjustments to payment.
Option 4–E: Setting and periodically updating payment amounts to match costs.

A must read, keep it for your files.

 Halley meets Hortal, at Galeria Senda

 

PS. The revolving door of those that claim against revolving doors

Improving physician compensation

A Guide to Physician-Focused Alternative Payment Models

A fixed flat monthly payment to  physicians is a vulgar method to compensate a professional effort. At some initial stages of the career, it may work. As far as experience and knowledge improves results, than some adjustments are needed. In general the publicly funded health system is not able to change the initial stage and remains with more or less the same approach of low-powered incentives. This may work for some individuals, but not for all of them.
Paying on a fee-for service it creates strong incentives to boost volume, and paves the way to overdiagnosis and overtreatment. Privately funded health care is still using mostly this high-powered approach and it is also not able to reform.
Alternative methods of compensating physicians have been described recently in an interesting report. Forget for a while that it is based on the US health system. These are the seven options:

APM #1: Payment for a High-Value Service 
APM #2: Condition-Based Payment for a Physician’s Services

APM #3: Multi-Physician Bundled Payment

APM #4: Physician-Facility Procedure Bundle

APM #5: Warrantied Payment for Physician Services

APM #6: Episode Payment for a Procedure

APM #7: Condition-Based Payment

Food for thought. Something should done to go beyond fee-for service. And do not forget it, changing incentives without any organizational alignment or reform may drive to surprises and poor performance.

PS. Just the opposite to us, NHS expands private care . A controversial trend.

Relative efficacy assesment with mixed treatment comparison

Assessing the relative efficacy of new drugs: an emerging opportunity

"For the majority of new drugs, critical realtive efficacy information is lacking". A strong statement from an article written by EMA officials and a Harvard professor. The article makes two proposals to solve this conundrum:

• One is observational studies, which are comparatively low cost and reflect routine care, as they often involve retrospectively analysing existing data from patient registries, electronic health records or claims databases. By definition, however, they lack randomization and rely on data that are generated in routine care to assess patients’ health states, and on clinical end points that are prone to misclassification or incompleteness

• Mixed treatment comparison (MTC) indirectly assess the relative efficacy of two treatments, A and B, by using existing data from two or more RCTs that have compared each of the treatments to a common comparator (for example, one study comparing A versus placebo and another comparing B versus placebo, although there are more-complex MTC designs, including any available head-to-head RCTs). MTCs are fast and inexpensive as they rely on existing RCT data, some of which is produced even before a drug is marketed

A key requirement for successful mixed treatment comparison should be common end point definitions across RCTs. The article explains the promising COMET initiative, and I wonder why this wasn't created before.

 Ce mercredi à Barcelona nous avons eu la chance d'ecouter an incroyable concert par 

Caravan Palace à la salle Barts

Efficient health systems

The five principles behind the world’s most efficient health systems

I was reading The Guardian this morning and I found this article. Forget for a while if there are five principles or more, its an op-ed. These are the key principles:

1. Integrated care
2. Hospitals as Health Systems
3. Standardise and  simplify
4. Take social care seriously
5. Payer power

You may agree or not, but it is worth checking it out.

PS. If you want to know our research contributions on integrated care, I suggest you attend this workshop.

Caring for humanity

An ambitious agenda for humanity
One Humanity: a shared responsibility

The World Humanitarian summit will take place next May in Istambul. The Lancet  alerts its readers this week:

Worldwide, 60 million people have been forced from their homes by conflict and violence. Additionally, 218 million people are affected by disasters every year. What can be done to prevent and ameliorate this large-scale human suffering and improve our global response?

The UN report sets out five core responsibilities for the international community: political leadership to prevent and end conflicts; strengthen compliance to international law; ensure no one is left behind; move from aid delivery to ending need; and political, institutional, and financial investment into this agenda.
My personal impression is that more should be done, but unfortunately my hope over the impact of UN conferences is really very negligible.

Genome editing: a potential weapon of mass destruction

The Patent Dispute Over Gene Editing Technologies: The Broad Institute, Inc. vs. The Regents of the University of California

Nobody could imagine two decades ago that a small part of wide range of bacteria's immune system could represent so much for genome editing. Known as CRISPR, clustered regularly interspaced short palindromic repeats, such mechanism can recognise and defend against viruses. The other part of the defense mechanism is a set of enzymes called Cas that can cut DNA and avoid the invasion of viruses. Mostly, these research was originated in Les Salines d'Alacant by Francisco Mojica a microbiologist.
As far as this is a natural process Dr. Mojica didn't show interest in patenting it. Now the row over patents is hot between UC Berkeley and the Broad Institute. I will skip details, you may find it in The Economist.
It seems that the fight is only to determine who was the first, and the Court will have to decide on March 9th. However, my question is: why is it still possible to file a patent over human nature?.
Meanwhile the public debate may be moved towards the use of such CRISPR technology for genome editing, and Science was publishing an article about the threat that misuse represents for human beings. Are we facing a new weapon of mass destruction?
Both issues, patents and bioethical implications are crucial at the moment. Former examples provide clear guidance of outcomes that should be avoided. Unfortunately, the race for the biggest size of the pie (billions of $) seems to be a priority over health and humanity.

The failure of replication in economics (and health economics)

Is Economics Research Replicable? Sixty Published Papers from Thirteen Journals Say “Usually Not”

One of the main principles of scientific method is reproducibility. Wikipedia says:

Reproducibility is the ability of an entire experiment or study to be duplicated, either by the same researcher or by someone else working independently. Reproducing an experiment is called replicating it.
The values obtained from distinct experimental trials are said to be commensurate if they are obtained according to the same reproducible experimental description and procedure. The basic idea can be seen in Aristotle's dictum that there is no scientific knowledge of the individual, where the word used for individual in Greek had the connotation of the idiosyncratic, or wholly isolated occurrence. Thus all knowledge, all science, necessarily involves the formation of general concepts and the invocation of their corresponding symbols in language (cf. Turner). Aristotle′s conception about the knowledge of the individual being considered unscientific is due to lack of the field of statistics in his time, so he could not appeal to statistical averaging by the individual.
A particular experimentally obtained value is said to be reproducible if there is a high degree of agreement between measurements or observations conducted on replicate specimens in different locations by different people—that is, if the experimental value is found to have a high precision

If this is so, then somebody could test any specific article and its results. That's precisely what two researchers have done with sixty published papers. The conclusion is specially annoying:

We successfully replicate the key qualitative result of 22 of 67 papers (33%) without contacting the authors. Excluding the 6 papers that use confidential data and the 2 papers that use software we do not possess, we replicate 29 of 59 papers (49%) with assistance from the authors. Because we are able to replicate less than half of the papers in our sample even with help from the authors, we assert that economics research is usually not replicable.

If economics research is usually not replicable, then what about health economics?

PS. Somebody should change immediately the peer review process or othewise close the journal.

PS.  Experience Ai Weiwei at the Royal Academy of Arts online with Ai Weiwei 360.

A taxonomy of health behaviors

Mapping health behaviors: Constructing and validating a commonsense taxonomy of health behaviors