Climate change and health

Enviromedics: The Impact of Climate Change on Human Health

These are tough times for the relationship between mankind and the planet. Therefore, this is a good reason to know better the relationship between climate change and health. In this book you'll find the details on each topic.
These are the key issues:

Part I. Climate Change Cascade
2 Climate Change 101: A Primer
3 Heat Waves and Heat Stress
4 Extreme Weather
5 Vector-Borne Diseases
6 Mental Health
Part II. Clear and Present Pathogens
7 Air Degradation
8 Water Security
9 Food Security
10 Allergens
11 Harmful Algal Blooms 

 Many of these modern sources of environmental hazards share a common feature—they derive from human activity as much as or more than from nonhuman sources. Radiation exists in nature, but its concentrated forms on Earth are created by humans. Industries produce the goods that support modern life, while they spin off by-products that can harm the environment and humans. We celebrate the productivity of modern agriculture, but if the runoff of pesticides and antibiotics pollutes the water supply and encourages antimicrobial resistance, we pay a higher price than we realize for food.

Balancing this tradeoff is complicated by the fact that the individuals and interests who typically stand to benefit from a polluting activity are not the same as the ones who will suffer the adverse health and other consequences.

Global externalities and how to fix them. This is one of the greatest challenges nowadays.

Wellbeing economics: a prescription letter

A SPENDING REVIEW TO INCREASE WELLBEING
An open letter to the Chancellor

UK has setup an All-Party Parliamentary Group on Wellbeing Economics. That's great!. If there is one thing that should be on the public agenda is wellbeing. However, after reading the last report it's a little bit disappointing. The have decided 6 priorities to take into account in the spending review according to its importance on wellbeing.

1. Health: Scaling up treatment of mental illness
2. Education: Tackling children’s wellbeing in schools 
3. Further Education: A proper start to working life
4. Social care and community services: Investing in social support networks
5. Work: Better wellbeing leads to better productivity
6. Other priority areas

Not so easy...as they say, It's just a letter...

At a glance

Health at a Glance: Europe 2018

Every two years OECD publishes this report for the European Union on the state of health. The new one has an interesting thematic chapter on mental health. It says:

According to the latest IHME estimates, more than one in six people across EU countries (17.3%) had a mental health problem in 2016  – that is, nearly 84 million people.
The most common mental disorder across EU countries is anxiety disorder, with an estimated 25 million people (or 5.4% of the population) living with anxiety disorders, followed by depressive disorders, which affect over 21 million people (or 4.5% of the
population).An estimated 11 million people across EU countries (2.4%) have drug and alcohol use disorders. Severe mental illnesses such as bipolar disorders affect almost 5 million people (1.0% of the population), while schizophrenic disorders affect another estimated 1.5 million people (0.3%).

And the second thematic chapter is about health expenditure: Strategies to reduce wasteful spending: Turning the lens to hospitals and pharmaceuticals. It says:

For hospitals, reducing or eliminating unnecessary investigations and procedures, many of which expose patients to unnecessary risks without the prospect of clinical benefit, is an obvious target for direct intervention. Expanding the use of day surgery can also be instigated at hospital level. However minimising avoidable admissions, particularly for ambulatory care-sensitive conditions, reducing unnecessary length of stay, and improving discharge processes require broader perspectives. Enhanced primary care services, expanded postacute care facilities, post-discharge care coordination, and in home care services all require health system reforms that cannot be initiated by hospitals  alone.

For pharmaceuticals, creating and supporting competitive markets and promoting the uptake of generics and biosimilars can generate substantial savings. That said, reducing waste does not necessarily mean spending less; it may equally be achieved by gaining better value for money from existing expenditure. Both supply and demand side levers offer scope for better value. Using health technology assessment to inform selection, pricing and procurement of new medicines facilitates an understanding of the true opportunity costs of therapies and helps avoid the displacement of high value interventions with ones of lesser value.

This is not new. We have already heard the same for years. Therefore, current inertia is supported by strong incentives that prevent change (either in policy or management). This is the key challenge.

Mental health: the problem and what can be done

THRIVE: How Better Mental Health Care Transforms Lives and Saves Money

I have to recognise it. Mental health is a difficult issue, and all the efforts to decrease its impact on individual and social welfare are not enough by now. The book by Layard and Clark is a useful reference. I had to read it since long time. It says:

Mental illness is the great hidden problem in our societies, so most people are amazed when they hear the scale of it. In the Western world today one in six of all adults suffers from depression or a crippling anxiety disorder. Roughly a third of households currently include someone who is mentally ill.

I don't know the exact figure, but I agree with the statement.

Mental illness is not just a problem for those it affects directly. It also imposes huge costs on the rest of society. So the case for tackling the problem is not just humanitarian—it is also a matter of plain economics. Mental health problems diminish work, increase crime, and make additional demands on physical health care.

So, what is the cost? The answer is huge. Layard and Clark provide some figures. And in the second part of the book, they review the alternative approaches to the issue. A highly recommended book by one of the greatest economists of our time.

PS Great Tribute to Uwe Reinhardt in NYT by Paul Krugman.

Healthcare Quality Lessons

Caring for Quality in Health

An OECD report provides the lessons on caring for quality, quite general but of interest to dive into each one:

Lesson 1. High-performing health care systems offer primary care as a specialist service
that provides comprehensive care to patients with complex needs
Lesson 2. Patient-centred care requires more effective primary and secondary prevention
in primary care
Lesson 3. High-quality mental health care systems require strong health information systems
and mental health training in primary care
Lesson 4. New models of shared care are required to promote co-ordination across health
and social care systems
Lesson 5. A strong patient voice is a priority to keep health care systems focussed
on quality when financial pressures are acute
Lesson 6. Measuring what matters to people delivers the outcomes that patients expect
Lesson 7. Health literacy helps drive high-value care
Lesson 8. Continuous professional development and evolving practice maximise
the contribution of health professionals
Lesson 9. High-performing health care systems have strong information infrastructures
that are linked to quality-improvement tools
Lesson 10. Linking patient data is a pre-requisite for improving quality across pathways
of care
Lesson 11. External evaluation of health care organisation needs to be fed into continuous
quality-improvement cycles
Lesson 12. Improving patient safety requires greater effort to collect, analyse and learn
from adverse events 

It is like a check list, have you done your homework?

Searching for a book to read

Manel Castro

A prescription for “high-need, high-cost” patients

David Blumenthal presented at the recent  OECD health conference the Commonwealth Fund report: Designing a High-Performing Health Care System for Patients with Complex Needs: Ten Recommendations for Policymakers
These are the recommendations:

1. Make care coordination a high priority for patients with complex needs
2. Identify patients at greatest need of proactive, coordinated care
3. Train more primary care physicians and geriatricians
4. Improve communication between providers, e.g. integrated clinical records
5. Engage patients in decisions about their care
6. Provide better support for carers
7. Redesign funding mechanisms for patients with complex needs
8. Integrate health and social care, and physical and mental healthcare
9. Engage clinicians in change, train and support clinical leaders
10.Learn from experience; scale up successful projects

Once again, the issue is not about what, but about how, according to the specific setting. This is the reason why change implies modify incentives and coordination mechanisms. This is the hardest part, with cost and benefits uneven distributed over time and people. And this is the reason why recommendations fail so often in its implementation.

At Tate Britain, righ now, David Hockney

Common challenges and responses to improve healthcare quality

Caring for quality in health: Lessons learnt from 15 reviews of health care quality

Towards actionable international comparisons of health system performance:expert revision of the OECD framework and quality indicators

Key messages from the last OECD report on quality:

Systemic changes on where and how health care is delivered will optimise both quality and efficiency
Lesson 1: High-performing health care systems offer primary care as a specialist service that provides comprehensive care to patients with complex needs
Lesson 2: Patient-centred care requires more effective primary and secondary prevention in primary care.
Lesson 3: High-quality mental health care systems require strong health information systems and mental health training in primary care
Lesson 4: New models of shared care are required to promote co-ordination across health and social care systems

Health care systems need to engage patients as active players in improving health care, while modernising the role of health professionals
Lesson 5: A strong patient voice is a priority to keep health care systems focussed on quality when financial pressures are acute
Lesson 6: Measuring what matters to people delivers the outcomes that patients expect
Lesson 7: Health literacy helps drive high-value care
Lesson 8: Continuous professional development and evolving practice maximise the contribution of health professionals

Health care systems need to better employ transparency and incentives as key quality-improvement tools
Lesson 9: High-performing health care systems have strong information infrastructures that are linked to quality-improvement tools
Lesson 10: Linking patient data is a pre-requisite for improving quality across pathways of care
Lesson 11: External evaluation of health care organisation needs to be fed into continuous quality-improvement cycles
Lesson 12: Improving patient safety requires greater effort to collect, analyse and learn from adverse events

It may sound as a dejà-vu, and the difficult part is how, not what to do to improve quality. However if you want to read an article on health care quality comparisons, check this one. Comparing quality is crucial because we are used to compare expenditure without a detailed knowledge of quality achievement. We'll have to follow next reports on the issue.

What's health and wellbeing?

Empirical redefinition of comprehensive health and well-being in the older adults of the United States

Once again, we do need a comprehensive definition of what is health and wellbeing,  and the current issue of PNAS provides us with an interesting approach:

The dominant model of health is a disease-centered Medical Model (MM), which actively ignores many relevant domains. In contrast to the MM, we approach this issue through a Comprehensive Model (CM) of health consistent with the WHO definition, giving statistically equal consideration to multiple health domains, including medical, physical, psychological, functional, and sensory measures. We apply a data-driven latent class analysis (LCA) to model 54 specific health variables from the National Social Life, Health, and Aging Project (NSHAP), a nationally representative sample of US community-dwelling older adults.

Although public health campaigns, such as “Choosing Wisely,” rightly emphasize the need to decrease unnecessary health interventions (52), they still accept the basic health conception of the MM as resting on organ system disease. Instead, the CM instantiates comorbidities and the equal importance of mental health, mobility, and sensory function in health and should inform policy redesign. For example, including assessments of sensory function, mental health, broken bones in middle age, and frailty in annual physician visits would enhance risk management. In addition to policies focused on reducing BMI, greater support for preventing loneliness among isolated older adults would be effective. In place of additional (expensive) new medicines for hypertension, helping older adults find social support through home care services or alternative living arrangements could be developed. In summary, taking a broad definition of health seriously and empirically identifying specific constellations of health and comorbidities in the US population provide a new way of assessing health and risk in older adults living in their homes and thereby, may ultimately inform health policy. 

And these are the results:

 The CM of health with six distinct health classes based on 54 health measures across six dimensions (listed in column 1). The column US population (US Pop.) reports the prevalence in 2005 of each disease or condition in the older US Pop. ages 57–85 y old (definitions and validation are in Fig. S1). Within each health class (columns), the prevalence of a given disease or condition indexes the likelihood that any member of the class has that particular disease [rows; n = 54 health measures ordered by prevalence within each health domain (column 2)] and shares similar constellations of disease and health.

We should reckon on something similar with our data, just to check if it fits with the final goal of measuring health and wellbeing. As you may imagine, there are many implications. If we agree on a comprehensive model of health, then we have to focus on how decisions and priorities should be made.

PS. The return of the big questions. JM Colomer opinion;:

The achievement of a human-made plan depends 1/4 on resources, such as money, education or physical strength; 1/4 on skill and decisions; and 1/2 on unpredictable circumstances, usually called luck. A student asked me how luck can be improved: well, I said, if you keep pursuing your goal with perseverance, the probabilities to get it increase (like if you keep playing the lottery, the probability to get the prize also increases)

Infinity Exhibition

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.

Changing health behavior (once again)

World Development Report 2015: Mind, Society, and Behavior

Understanding human behavior is one of the main scientific endevours of our current times. As I have explained before, psychology, economics and neurosciences are making great progress in the last decades. Now the annual report by the World Bank puts all this stuff in one publication:

Three principles stand out as providing the direction for new approaches to  understanding behavior and designing and implementing development policy. First, people make most judgments and most choices automatically, not deliberatively: we call this “thinking automatically.” Second, how people act and think often depends on what others around them do and think: we call this “thinking socially.” Third, individuals in a given society share a common perspective on making sense of the world around them and understanding themselves: we call this “thinking with mental models".

In chapter 8 you'll find the application to health issues. A clear warning:

Telling people that there is a way to improve their health is rarely sufficient to change behavior. In general, successful health promotion campaigns engage people emotionally and activate or change social norms as much as they provide information. The message disseminated should be that others will support you or even applaud you if you do it, not just that something is good for you. Successful campaigns address many or most of the following: information, performance, problem solving, social support, materials, and media . A campaign should tell people that a behavior will improve their health (information), demonstrate and model the behavior (performance), reduce barriers to its adoption (problem solving), create a system for supporting people who choose to adopt it (social support), provide the materials necessary to begin adoption (materials), and provide a background of support through in-person, print, radio, television, and other approaches (media).

As you may imagine, this is much more difficult than simply giving information. This is precisely the greatest challenge.

The value of vaccination

Valuing vaccination

A PNAS article sets a broader perspective on valuing vaccines. It is of interest in light of current difteria case. My position is clear, no doubt about mandatory vaccination if its cost-effectiveness is proven.
Suggestions from the article:

Three general recommendations flow from our arguments and related synthesis of existing evidence on broad benefits of vaccination. First, many economic evaluation studies of vaccinations should be redone to capture the full benefits generated by the vaccination in question. Second, the evidence to date on the full value of vaccination has been focused on measuring the total social benefits generated. It would also be useful to explore the distribution of vaccination’s benefits among different possible beneficiaries. Third, the primary empirical evidence on broad vaccination benefits will need to be considerably expanded and improved

Framework of vaccination benefits

Perspective		Benefit categories	Definition
Broad	Narrow	Health care cost savings	Savings of medical expenditures because vaccination prevents illness episodes
		Care-related productivity gains	Savings of patient’s and caretaker’s productive time because vaccination avoids the need for care and convalescence
		Outcome-related productivity gains	Increased productivity because vaccination improves physical or mental health
		Behavior-related productivity gains	Vaccination improves health and survival, and may thereby change individual behavior, for example by lowering fertility or increasing investment in education
		Community health externalities	Improved outcomes in unvaccinated community members, e.g., through herd effects or reduction in the rate at which resistance to antibiotics develops
		Community economic externalities	Higher vaccination rates can affect macroeconomic performance and social and political stability
		Risk reduction gains	Gains in welfare because uncertainty in future outcomes is reduced
		Health gains	Utilitarian value of reductions in morbidity and mortality above and beyond their instrumental value for productivity and earnings

 

An open mind on mental health

Fit mind, fit job. From Evidence to Practice in Mental Health and Work

The social and economic impact of mental illness requires a new approach. Conventional approaches to the disease are insufficient and a broad involvement of different stakeholders is needed. These are the premises that the OECD has drawn in its new report "Fit mind, job fit. From evidence to practice in mental health and work. " While in previous reports had tried to characterize the state of affairs, now he has been concerned to review successful strategies in different countries.
The total costs of mental illness represent around 3.5% of GDP in European countries. Of this, more than half corresponds to indirect and intangible costs. Among them are productivity losses, an aspect difficult to estimate because the phenomenon of "presenteeism" appears. In the case of mental illness, the fact of going to work despite illness is the rule (over 75%) .
The issue presents differential considerations for other diseases, especially its relationship with the job and productivity. There is evidence of less satisfaction, lower quality jobs and lower pay. All contribute to conditions of work under a mental illness represent a tension for the individual and for the company. And of course in the event of unemployment, even more.
Ssome countries have tried to deal with this situation from an interdisciplinary way. That is, strictly avoiding medicalized view of health policy and trying to involve the various actors in the field of business and social environment of the patient.
The OECD recommendations fall into four areas: youth and education, business, social services and employment and healthcare. Of these, I would like to highlight here those related to the firm, being the most neglected at present.
In the field of business, strategies for supporting employees with mental health problems are crucial to achieve a positive development that avoids the end a loss of jobs and a worsening of the disease. The initial issue to consider is the detection of the problem. Somehow, managers and immediate supervisors need to provide a suitable response to the situation and often do not have the knowledge and training needed. The British example known as "Mental Health First Aid program" is a tipping point to keep in mind despite his limited success in small and medium enterprises.
The adoption of risk prevention strategies also seeks to provide tools to improve psychosocial job conditions. To this, a change of perspective in occupational medicine could contribute decisively.In cases of injury, the management of return to work eventually becomes critical for improving the stage of the disease process. To the extent that the long absences are more complex to address, it is precisely these that require attention consistently. The option of gradual return to work and support by colleagues has proven effective in this regard. The search for a negotiated solution brings more satisfactory exit routes for the disease, the conflict. And finally there are the incentive strategies and the legal obligations of employers in this regard. How to address long-term absenteeism it is a challenge in all countries and there is no rècipe for all cases. Must be combined with adequate monitoring incentives to return to the job.The uniqueness of mental illness is that the successful approach is the one that allows redevelopment activities in the labor and social environment properly. To do this, a modern approach requires among other things that the company and its employees are aware of and responsible for a different perspective and fully involved. In this direction, government and business associations should join hands to tackle an issue that so far we thought belonged only to the health system. The relevance of mental health and its impact on the welfare of citizens and their families, requires a timely response.

Don't think of privatization

Let's do a little thought experiment today.

Close your eyes. Imagine a privatized healthcare consortium as vividly as you can. It is clear! Is it? There are private owners. Or seems to be some officials geting dividends?

Now, I want you to NOT think about privatization. Think of anything else but privatisation. Try it for a few minutes.

What are you thinking of? How many times did the privatization issue cross your mind? Quite a few times, right?

Now, close your eyes again and try to think about what you did for today? Who you met? Where you went? Anything interesting happened when you were traveling? What did you eat for breakfast/lunch? Try it for a few minutes.

How many times did you think of privatization? None? Maybe once or twice especially since I asked this question?

This is an exercise that shows that suppressing your thoughts in your mind doesn't really work. When we try not to think about something and try to suppress it, our minds keep going back to the same thoughts. This is a well known experiment from Wegner et al. (Wegner, D. M., Schneider, D. J., Carter, S. R., & White, T. L. (1987). Paradoxical effects of thoughts suppression. Journal of Personality and Social Psychology, 53, 5–13). As you know, I could also refer to Lakoff mental frames and its: Don't think of an elephant for different evolutive and modern cognitive perspective, but I've done it before.
If you combine deception -about the concept of privatization- and the difficulty of suppressing your thoughts, you'll get the current health policy mess. Distraction is a strategic move that has alleged political profits. For sure, the whole population only receive the losses from such strategy. We have been installed in this paradigm for many years: the privatization devil is here and there, although there is no shareholder getting any dividend. Fortunately, the world stands beyond spaguetti western films. Ownership has impact on efficiency but depends on the context, sometimes public incentives prevail over private ones, and sometimes is the opposite.
If all these sounds weird to you, have a look at our last Parliament resolution and you'll find the astonishing agreement of all parties against the current ruling party on one issue that doesn't exists: a public consortium privatised!!!. If it is public, as it is, can't be private if the owner is the government, as it is. Disappointing, shameful.
I'm really sad that in my country public representatives play with fire in such a way. I just want to say today, that I'm available for those deputies interested in a free private lecture on organizational economics, on what ownership is and what it means for efficiency. Just give me a call or send me an email.

A relaxing cup of café con leche

Mental Health in the policy agenda

Mental Health for Sustainable Development

The need for action in mental health is increasingly recognised. Although relevant improvements have been introduced in developed countries, there is a common view that more should be done. Some diseases like depression are at the top of the burden of disease and bring enormous pain and suffering to individuals and their families and communities. An interesting recent report has been released on the topic. This is the infographic:

PS. UK Health Secretary. Keynote address: the political imperatives to address mental health and depression

Thinking and deciding

World Development Report 2015: Mind, Society, and Behavior

Our decision making patterns are based on multiple foundations. The new WB report summarises them in three sources: automatic, social and mental models.  In chapter 8 you'll find applications to health. Some of them may be naive, while others potentially useful. There is a trial and error process in all this stuff because of cultural implications. If there is a particular area to focus on, it is on health communication for behavioural change. There is a lot to learn from behavioral economics:

Understanding that people think automatically, interpret the world based on implicit mental models, and think socially allows policy makers to make major strides in improving health outcomes. Individuals sometimes value information highly (for example,
when seeking curative care), but at other times providing information is not sufficient to get people to change behaviors that undermine health. Framing effects that make social expectations and social approval more salient can sometimes encourage individuals to seek preventive care and adhere to treatment when they otherwise would not, even though the individual benefits exceed the individual cost.

PS. My former posts on nudging

PS. Post by BIT.

PS. TE on poor behavior.

PS. Excellent "30minuts" documentary about the Snowden's massive information leak ever. (Only until Dec 28th)

Mental health case-mix measurement

Payment by Results in Mental Health: A Review of the International Literature and an Economic Assessment of the Approach in the English NHS

If there is an area where case-mix measurement has been difficult to tackle it is mental health. After all these years, there are several options, but they need an assessment and adaptation to the context of care.
Fortunately there is an excellent review that can be used as starting point. A York University paper commissioned by UK Health Department that tries to compare a UK specific system and its potential application for budgeting and payment:

The Care Pathways and Packages Clusters classification system addresses both clinical  and nonclinical needs. Care pathways have been mapped, although the degree of clinical  consensus for these is unclear. Nonetheless, they offer a starting point from which to  develop consensus. The English approach will require a more systematic approach to data collection and reporting. This offers an opportunity to collect additional data on resource  use and process or outcome measures that can help evaluate quality and cost-effectiveness, and so inform the debate on what constitutes best clinical practice. Over time, it may be possible to introduce Pay-for-Performance (P4P) elements into the system, so that good practice is appropriately rewarded. However, P4P using a target based approach can  encourage ‘tunnel vision’, in which non-incentivised activity is displaced and would counteract the holistic approach embodied in the Care Pathways and Packages Clusters

Is there anybody thinking about this issue nearby?

Our irrational behaviour

The Behavioral Economics of Health and Health Care
Irrationality in Health Care: What Behavioral Economics Reveals About What We Do and Why

Thomas Rice provides an overview of behavioral economics in health in a recent article in Annual review of public health. More or less the same things we already know with some concrete messages. A good starting point for those that want to take first steps in this discipline. The summary:

People often make decisions in health care that are not in their best interest, ranging from failing to enroll in health insurance to which they are entitled, to engaging in extremely harmful behaviors. Traditional economic theory provides a limited tool kit for improving behavior because it assumes that people make decisions in a rational way, have the mental capacity to deal with huge amounts of information and choice, and have tastes endemic to them and not open to manipulation. Melding economics with psychology, behavioral economics acknowledges that people often do not act rationally in the economic sense. It therefore offers a potentially richer set of tools than provided by traditional economic theory to understand and influence behaviors

Right now behavioral economics is still a promise, let's wait until we can really apply it widely.
Thomas Rice says in this respect:

 With the exception of Kahneman & Tversky’s prospect theory, which was developed more than 30 years ago, there has been little in the way of bringing the various tools and policies of behavioral economics under one umbrella. As a result, most of the applications seem to be ad hoc. More development of an overarching theory could aid those interested in designing new interventions when it is clear that traditional economics remedies are insufficient

Regarding the book on Irrationality in Health Care, I haven't had the opportunity to have a look at it. I leave here the reference and 23 anomalies . Maybe in the book there is the answer to solve them.

PS. For those interested in an introductory course, on March 11th starts at Coursera:  A Beginner's Guide to Irrational Behavior

Fresh data

Recently we have known that politicians were spotted while having lunch at a well known Barcelona restaurant. Our crazy world is becoming more unpleasant. At least two options for a politician: no lunch at a restaurant, or silent eating, unless somebody (justice) introduces more costs than benefits on spying. Up to now, spying has been profitable.
In health care, these days is appearing fresh information about hospitals, no spies needed to know P&L data. Data on 2011 hospital costs can be found at Central de Balanços. Those that want to know how money is spent in a consolidated way, can check the latest report. You  can find that outpatient pharmaceutical expenditure in hospitals decreased 5.19%. This is a historical achievement, and pharmaceutical inpatient expenditure lowered 12 % !!!. You may remember my last comment on such data in this post.
Besides a general improvement, hospital deficit in 2011 was 90 m euro, however on p. 36 there is a detailed explanation. Some hospitals account for most of the deficit (5 hospitals - out of 51- represent 64% of the amount of hospitals losses). These details are very important because these are the hospitals where budget cuts have not been effective. May be we can call them free riders? We can't confirm with data available on the report.
If you want to understand recent hospital expenditure, definitely you need to check this report (or mental health report and LTC report) and you'll reassure that the effort to trim costs has been very important, a substantial change in the former trend. Costs are lower, what about efficiency?

PS. ¿Why are there so many wicked  people in politics?. One answer to this question is given by Adolf  Tobeña connecting neurobiology, behaviour and economics. Yesterday I attended a very interesting speach. You may listen Adof Tobeña here in a similar speach (1 hour), or you can go straigth to minute 30 - and get the key messsage-, otherwise you can have a look at this pdf.

PS. A sound criticism towards ACOs, by Mark Pauly. Must read.

The great François Gabart, winner of Vendée Globe 2012

Una recessió saludable?

ARE RECESSIONS GOOD FOR YOUR HEALTH BEHAVIORS? IMPACTS OFTHE ECONOMIC CRISIS IN ICELAND

Els animals s'adapten al medi, els humans també. I si el medi esdevé hostil, aleshores prenem precaucions. Si aquesta recessió ha portat a canviar els comportaments individuals cap a un estil de vida més saludable aquí aprop encara no ho sabem. A Islàndia en canvi ja ho han confirmat. Les conclusions d'un article de NBER són les següents:

The 2008 economic crisis in Iceland led to reductions in all health-compromising
behaviors examined—smoking; heavy drinking; consumption of sugared soft drinks, sweets, and fast food; and indoor tanning. It also led to reductions in certain health-promoting behaviors but increased others. Specifically, the crisis reduced consumption of fruits and vegetables but
increased consumption of fish oil and getting the recommended amount of sleep. Generally, the
effects of the crisis on health-compromising behaviors were stronger for the working-age
population than for the adult population overall.
Changes in hours of work, real household income, wealth, and mental health explained
some of the effects on health-compromising behaviors, ranging from 9% for smoking to 42% for heavy drinking. For health-promoting behaviors, these factors reduced the effects of the crisis only for fish oil and vitamins/supplements, by about one third. We inferred that broad-based factors—such as prices, which increased over 27% in Iceland between 2007 and 2009—played a large role in the effects of the crisis on health behaviors. We exploited our ability to isolate behavioral changes that are likely due, at least in large part, to price changes, to compute participation elasticities for the various goods. We found inelastic responses to price changes for alcohol and sugared soft drinks and elastic responses for smoking, sweets, indoor tanning, and fast food. Health-promoting behaviors revealed less price sensitivity overall compared to health compromising behaviors.

Així doncs semblaria que a Islàndia la recessió és força bona per la salut. En qualsevol cas, això cal agafar-ho amb pinces i no es pot generalitzar ni extendre temporalment més enllà de l'anàlisi feta. Més aviat diria que cal que ens preguntem si cal una recessió per arribar a comportaments saludables o potser ja va sent hora de fer-ho al marge de l'evolució de l'economia.
M'ha agradat això de conèixer l'elasticitat de la demanda abans i després, convindria calcular-ho per aquí aprop. Sabem que el consum retail ha caigut un 9,8% en un any i encara no sabem qué han prioritzat els ciutadans davant aquesta impressionant retallada en el consum domèstic.