Still waiting after all these months

Waiting lists may be considered the most prominent consequence of a publicly funded health system. Without price barriers, the queue for an operation may take months. Data to compare the situation of waiting lists between countries is not that easy to find. However, in the last report by OECD you can get the indicator of how many patients were waiting for more than 4 months in several countries. Take a look at this OECD report (p.42). Only one country in its worst year achieved 41% (UK).
Right now data show that we have the record.  The latest information (p.7) highlights that 100% of interventions for elective surgery required waiting for more than 4 months during 2012. This represents 1,63 more months than in 2011. That's a lot. The number of persons waiting is 93,2 per 10.000 inhabitants (70.814), but 5.000 patients that were on the list and tired of waiting declined the intervention once they were allocated them to a hospital (unfortunately, there is no information about the impact or how they have solved it).
Definitely, waiting lists is a hot topic. they should be fixed and indicators should be close to international standards. Right now we are far, too far away.

The patent cliff is not over

Imagine for a while that the size of a market drops by 290 billion between 2012 and 2018. This is the case of pharmaceuticals. This is not new. Now we can start to check the strategies to cope with this cliff and wether the companies are succesfull or not. Nature RDD explains details, must read. A picture is worth one thousand words:

A startling achievement

INFORME MENSUAL DE SEGUIMENT DE LA PRESTACIÓ FARMACÈUTICA

Pharmaceutical expenditure in 2012 has dropped 14,27%, double of last year. That's unusual, a confirmation of trend reversal started in 2011. The total expenditure was €1.450 m, the decrease in prices 8,2% and on prescriptions 6,5%. The exact reasons behind such a fall are known: the introduction of copayments, the reduction of prices and benefits, and the changes in prescription. We still don't know the size of the impact for each factor.
The question is only one: Has this change affected the population health?. If not, why have we had to wait until now to do it? Unfortunately we can't aswer properly right now. I expect we'll show results in some months time.
Anyway, on one hand my congratulations to the regulator -he has finished vacation at least in pharmaceuticals-, and on the other hand I would like to remind everyone that the expected decrease in the pharmaceutical budget was 27%, therefore the deviation is 13%. I said in this post that it was very difficult to acomplish. The facts confirm my prediction.

PS. January data confirm the trend, on interannual basis a decrease of 15,95%

PS. A non-democratic failed state, yesterday voted to block any potential self-determination referendum, although 78% of its deputees were asking for that. This is a clear message for the international community. Next steps are closer to unilateral declaration.

PS. The beloved princess of the king (not the queen) and lobbyist of the failed state in the press. NTA.

The collapse of managed competition

The colombian Health Minister has just announced the end of competition between insurers under a mandatory health insurance scheme. This is an important announcement, two decades after Ley 100, managed competition will be removed from health policy scene.
We still have to wait for the details, but the application of what Alain Enthoven considered the best efficient option to ensure competition and mandatory coverage is ending in Colombia. The reasons are multiple and difficult to summarise in a post. The explanation deserves a whole book. The breaking point has been the scandals, corruption and fraud in EPS, the insurers side. About 50 companies were intervened and the amounts of embezeled money are impressive. Crime has entered into health care arena.
In my opinion, the most important lesson is that the introduction of social experiments and innovations are not appropriate if regulators don't understand the concept and the tools to manage the system. The policy dynamics and short-term views act against any regulatory stability, unless the country is committed to preserve the underlying principles of the health system. Therefore, be careful on experiments, it can be extremely costly in social terms.

The greater good vs shopping

Engaged Patients Will Need Comparative Physician-Level Quality Data And Information About Their Out-Of-Pocket Costs

Access to quality and cost information for citizens is increasing in certain environments. Right now you can find for example the prevalence of nosocomial infection in acute care hospitals in Catalonia with a simple click (p.69). You can assess in advance the probability of being infected during your hospital stay and if you check the indicator you'll find wide variations. Unfortunately this information is not structured to take decisions.
A recent paper in HA groups two potential approaches, information for greater good vs. information for shopping.

The health care quality and cost reporting programs that fall under the “transparency for the greater good” model tend to be nonprofit and government initiatives focused on improving quality and efficiency, engaging consumers, and increasing awareness of variation in quality and cost. In contrast, the programs that fall under the “one-stop shopping” model tend to be private-sector initiatives that aim to provide personalized, integrated information on cost and quality to support consumers’ decision making regarding care providers and services.

Personnally, I'm not so convinced about the dissemination and use of such information to patients. I'm not so sure about the role of choice in general. I suggest you have a look at the book the Paradox of choice before entering into a dubious land. Anyway, I'm in favour for greater transparency, and initiatives like Central de Resultats are a good example, but I remain uncertain about its usefulness for " doctor shopping".

I should go to Viladecans exhibition on Espriu

The pieces of the puzzle

Charter for healthy living

Since we all agree that in developed world, non-communicable diseases are the greatest challenge for health, we are more and more convinced that the solution lies partly beyond the health care system. The issue is not to be convinced about this, the big question is how. And the answers may be different according to the approach. The World Economic Forum has just released a very interesting report and a toolkit on his topic. Though it is necessary to put together all the pieces of the puzzle, and there is a clear emphasis on a multistakeholder approach, I have the impression of some missing pieces. At least two: incentives and cognitive biases in behaviour and decision making. In this blog, I have pointed out the importance of it - remember Nudge or Mindspace- and I can't see it well reflected in the reports. Although there is a minor reference in the annex, you get the flavour of rational patients and governments, as rational consumers and regulators. The context and our departures from rationality are so important that we have to beware of them. Anyway, the most important is to have a look at the toolkit, not only to the report. The intention is clear, focus on the application.

Cristina Iglesias at Reina Sofia Museum

Patient focused episodes

We all know that no measurement means no management. In health care the measurement of the burden of disease is not that easy. Fortunately at a global level there is the recent study published at Lancet and quoted in this post. If we need to be precise in the measurement with consequences for health care management then we need better tools. Diseases finally appear around episodes, and we may have three type of episodes: event based, disease cohort and population based. The definition of episode needs to be patient-focused rather than disease centered. If you want to know the details of the newest approach to morbidity measurement have a look at this document. It is the evolution of former Clinical Risk Groups towards a new model that will be extremely helpful for management decision making and the definition of appropriate incentives.

PS. Some months ago I explained that new payment systems were in train of being defined. An impact analysis may be found here. My post was titled: A retrofuturist payment system. Now, I would like to change the title once I've seen the details, my proposal is: A complete MESS that needs to be rebuilt from scratch. (to be continued)

PS. Yesterday I attended a book presentation: "I am not Sidney Poitier", by Percival Everett. It was at La Central bookstore. Percival explained the rationale of the book and its subliminal messages.  This is not the kind of novel I'll read.