The fight between commercialism and professionalism in medicine

Remaking the American Patient
How Madison Avenue and Modern Medicine
Turned Patients into Consumers

I've found this book of interest specially for europeans. Our health systems are currently under pressure. Public budgets are constrained and the private sector is growing. If you want to know what happens next, then this is the book to read. Just to prevent the disaster that comes afterwards, remember that US life expectancy has been declining in the last three years!. Maybe the time to act is now, just to avoid this predictable outcome. Take care.

Risks and benefits of self-testing

 Benefits and Risks of Direct-to-Consumer Testing

These are the pros and cons of two options for the same production process and its impact (a US view only applicable to certain conditions). (Professionalism vs. commercialism).

Conventional:

Self-testing:

And its impact:

Potential and Perceived Benefits of Direct-to-Consumer Testing

Potential Risks of Direct-to-Consumer (DTC) Testing

With DTC testing, consumers may not know the risks or what significance a result has in terms of current and future health. It is challenging for consumers to distinguish tests for health and wellness from entertainment and commercial marketing. This can leave consumers open to misdiagnosis and susceptible to unproven treatments and questionable claims for cancer and disease cures. DTC tests are both an opportunity for an individual to better participate in their health and in the management of chronic diseases, as long as consumers are aware of the risks for inappropriate utilization and inadvertent interpretation that can lead to avoidable follow-up, unnecessary procedures, and additional costs of care. DTC testing is an emerging field and an opportunity for laboratory experts to participate through providing professional advice, consultation on test limitations, interpretive services, and recommendation on optimal test utilization.

My view, now it's time to stop recreational testing and commercialism of lab testing. Later it will be too late. 

Healthcare built around you?

Bezonomics
How Amazon Is Changing Our Lives, and What the World's Companies Are Learning from It

Amazon Care

Atul Gawande departure from Haven, the alliance between Amazon, JP Morgan and Berkshire for developing health services for their workers has created uncertainty about what is really Amazon going to do.
Anyway, if you look at the web you can check what is already doing for their employees: Amazon Care. Here you'll find the FAQS. Up to now everybody was thinking about health goods and businesses that Amazon could provide (details in this report). Right now they have started a pilot of health system that may be developed anywhere. A platform business, that starts slowly with and app and a physicians group.
If you want to undestand what Amazon really means for the economy (and for healthcare) than a new book can provide you some answers: Bezonomics.

The global business world will eventually divide into two camps—those who adopt their own version of Bezonomics, and those who don’t. Alphabet, Facebook, Netflix, Alibaba, JD.com, and Tencent have built huge, powerful businesses based on their ability to collect and analyze data, and keep applying those learnings to make their businesses smarter and their offerings to customers more attractive. In their pursuit of AI-driven technologies such as voice and facial recognition, the Internet of Things, and robotics, they’re creating automated business models that will crush traditional businesses that fail to adapt to this new world. And the emergence of 5G technology, which will replace our current digital networks, will only widen the gap. Experts predict that this next generation of Internet connectivity will be as much as a hundred times faster than today’s web.

The impact that Bezonomics is having on society is just as profound. Some of the big tech companies are sowing discord with fake news, interfering with elections, and violating personal privacy. As Apple CEO Tim Cook put it: “If you’ve built a chaos factory, you can’t dodge responsibility for the chaos.” The global wealth gap has become so out of kilter that politicians in America and Europe have singled out Amazon and other big tech companies for blame. These wealth-creation machines have become so efficient at creating riches for their top employees and shareholders that they’re likely to engender more public outrage and become easy targets for regulators—perhaps in some cases even be broken up.

A must read. In my opinion, what really brings Bezonomics to healthcare is the largest expression of commercialism. In other words, healthcare built around excedent appropriation, not around the patient. If this is so (and Atul Gawande departure is a signal) then we all have to stand up against this model and create value and platforms based on professionalism.

Enciclopèdia de gestió sanitària

 Elgar Encyclopedia of Healthcare Management

 Una enciclopèdia amb aquest índex.

PART I SCENARIOS
1 Big data and artificial intelligence 2
2 Disruptive technology innovations 6
3 Genomics 8
4 Globalization 11
5 Medical tourism 13
6 Precision medicine 16
7 Robotics 19

PART II BASIC MODELS OF HEALTH SYSTEMS
8 Beveridge model 22
9 Bismarck model 24
10 Market-driven model 26

PART III EVOLUTION OF THE PHARMA AND MEDTECH INDUSTRY

11 Market access 30
12 Digital therapeutics 33
13 Biotech 36

PART IV FOUNDATIONS OF HEALTH ECONOMICS

14 Baumol’s cost disease 40
15 Disease mongering 42
16 Moral hazard in health insurance 44
17 Quasi-markets 46
18 Supplier-induced demand 48

PART V FUNDING

19 Payment mechanisms 51
20 Sources of funding 55
21 Tariff vs price 57

PART VI HEALTH POLICY PRINCIPLES

22 Equality and equity 60
23 Universalism 62
24 Well-being 64

PART VII INVESTMENT ANALYSIS

25 Business planning of healthcare services 69
26 Sources of funding for investments 71

PART VIII LEVELS OF CARE

27 Acute, sub-acute and post-acute care 77
28 Chronic care 79
29 Home care and community care 83
30 Hospital 86
31 Long term care 91
32 Prevention 93
33 Screenings 97
34 Primary healthcare 101
35 Secondary vs tertiary vs quaternary care 104

PART IX NEW PARADIGMS

36 Access to healthcare 108
37 Co-production 110
38 Demedicalization 113
39 Evidence-based medicine 115
40 From compliance to concordance 119
41 Gender medicine 121
42 Global health 123
43 Health literacy 125
44 Initiative medicine 127
45 Integrated care 130
46 Population health management 133
47 Skill mix and task shifting in healthcare 136
48 Value-based vs

PART X PLAYERS

49 Boundaryless hospital 142
50 Community and country hospital 144
51 Intermediate and transitional care settings 147
52 Primary care center 150
53 Research hospital 152
54 Teaching hospital 154

PART XI TRENDS

55 Business models 157
56 Decentralization and devolution in healthcare 159
57 Multidisciplinarity and inter- professionality 161
58 Telemedicine 164
59 Vertical and horizontal integration (hub and spoke network) 168

PART XII BEHAVIOURS:

CHALLENGES TO LEADING HEALTH ORGANIZATIONS

60 Accountability 173
61 Accountable care plan and organization 174
62 Iatocracy, professional bureaucracy and corporatization 177
63 Political arena 180
64 Professional vs managerial culture 182
65 Professionalism 184
66 Stakeholder management 186
67 Teamwork 187
68 Turf wars 189

PART XIII PRACTICES

69 Change management 193
70 Disaster management 195
71 Leadership and leadership styles 199

PART XIV ROLES

72 Case manager 203
73 Clinical engineer 205
74 Clinical leader 208
75 Controller 211
76 Family and community nurse 215
77 General practitioner 218
78 Hospitalist 220
79 Medical director 223
80 Operations manager 225
81 Pharmacist 228
82 Quality and risk manager 233

PART XV TOOLS SYSTEM AND

PROCESS: DISEASE MANAGEMENT

83 Clinical governance 237
84 Guidelines and protocols in healthcare systems 239

PART XVI INNOVATION MANAGEMENT

85 Clinical trial 243
86 Health technology assessment 246

PART XVII OPERATIONS

87 Electronic clinical records 251
88 Patient flow logistics 253
89 Patient management 256
90 Supply chain 258
91 Techniques for process and organizations improvement: lean management in healthcare 261

PART XVIII ORGANIZATION

92 Clinical service lines 264
93 Converging trends in hospital transformation 267
94 Divisionalization, clinical directorates and Troika model in healthcare 271
95 Organizational culture 273
96 Organizational design and development for healthcare organizations 276
97 Patient-centered hospital and health organization 281

PART XIX PEOPLE

98 Clinical and professional engagement 285
99 Great Place to Work® 288
100 Magnet hospital 291

PART XX PERFORMANCE

101 Balanced scorecard in healthcare organizations 294
102 Budgeting (financial vs operational) 298
103 Customer satisfaction 301
104 DRG and case mix index 303
105 Length of stay 305
106 Performance measurement and management systems 307
107 PROMs and PREMs 310
108 Strategic control 313

PART XXI PLANNING

109 Strategic planning 318
110 Strategy making 320

PART XXII PROCUREMENT

111 Centralized procurement 324
112 Innovation procurement 327
113 Managed entry agreements (MEA) 330
114 Value-based procurement 333

PART XXIII QUALITY

115 Accreditation in healthcare 337
116 Audit 340
117 Quality management 343

Physician self-referral: a call for action

Physician Self-referral: Regulation by Exceptions

In 2002 a new agreement was published in internal medicine reviews on Medical Professionalism in the New Millennium: A Physician Charter. Some years ago I posted the same issue. Today, I would like to highlight three points again:

• Commitment to professional responsibilities. As members of a profession, physicians are expected to work collaboratively to maximize patient care, be respectful of one another, and participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards. The profession should also define and organize the educational and standard-setting process for current and future members. Physicians have both individual and collective obligations to participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all aspects of their professional performance.

• Commitment to maintaining trust by managing conflicts of interest. Medical professionals and their organizations have many opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage. Such compromises are especially threatening in the pursuit of personal or organizational interactions with for-profit industries, including medical equipment manufacturers, insurance companies, and pharmaceutical firms. Physicians have an obligation to recognize, disclose to the general public, and deal with conflicts of interest that arise in the course of their professional duties and activities. Relationships between industry and opinion leaders should be disclosed, especially when the latter determine the criteria for conducting and reporting clinical trials, writing editorials or therapeutic guidelines, or serving as editors of scientific journals

• Commitment to maintaining appropriate relations with patients. Given the inherent vulnerability and dependency of patients, certain relationships between physicians and patients must be avoided. In particular, physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose.

 After reading JAMA article on physician self-referrals in US, definitely I have to say that this principles are far to be applied. The size of the resources coming from self-referrals is continously increasing despite the existing regulation for decades. The article puts a lot of expectations on changing the payment system, from fee-for-service towards value-based payments to curb the situation. I'm not so confident on this tool, because its implementation is far from optimal.
Anyway this is a difficult issue, and the same happens to dual practice in general. Some weeks ago a new resolution on how to handle conflicts of interest between public and private care was released. Two different concerns appear on my mind. The first is when any patient that decides to start a private treatment, then there is no option to go back to the public sector. He rejects explicitly public coverage. This statement may be appropriate for those patients on public waiting lists, but its application to other situations may be fuzzy. The second relates to information by the healthcare faciliy to patients about benefits and rights. I'm uncertain about how this can be applied without biases, without interference of physicians. My suggestion would be to use more transparent and centralised ways to inform patients through internet.
Unfortunately what I missed is precisely any regulation on physician self-referrals, the core of the problem. This affects publicly funded -in case of dual practice- and private care. Somebody should have a clear position on that. In my opinion, it should start by physicians associations. Self-regulation is a better starting point than any ban on this practice. As you may deduct easily, the general application of the former physician charter would solve this issue.

On rationing (ventilators)

Recomendaciones éticas para tomar decisiones en la situación excepcional de crisis por pandemia Covid-19 en las UCI

These are tough times for mankind. We are social animals and current instructions/recommendations are focused to behave exactly the opposite. Once the coronavirus hits someone, the result may be being hospitalised and one may need intensive care and mechanical ventilation. And if supply is not enough for the demand of ventilators, then starts the most difficult question: who gets the ventilator?. A professional answer is needed. Fortunately the scientific society  Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias has released a document that helps to provide specific recommendations in such situation.
This is exactly what we can expect from a modern society. Professional decisions need guidance and consensus. There is no role for politicians in this issue and in this moment, scientific societies have to coordinate such efforts. Therefore my congratulations for their recommendations.
Basically, the document highlights the criteria of maximizing capability of benefit, and in the current situation and in intensive care, this has to be applied in a general way, for covid-19 and non covid-19 disease requiring such services. And these criteria should be applied in an uniform way.
In this blog I've been supporting the role of professionalism in taking tough decisions. Today I've to say that these is a good example of rationing to keep in mind.

PS. If projects like this one succeed, then tough decisions could be avoided. Great initiative.

Conflicts of interest (in medicine)

I would like to attend this seminar:

Professor George Lowenstein
Behavioural Economics and Conflicts of Interest

“A conflict of interest is a clash between an individual’s professional responsibilities and their personal, typically financial, interests. Traditional economics has not shed much light on conflicts of interest, perhaps in part because it has not recognized the importance of professionalism as a motive in human behaviour. In this talk I will present results from a variety of studies that examine the behavioural economics of conflict of interest. Focusing mainly on conflicts of interest in medicine, some of the research shows how people who care deeply about behaving in a professional fashion can be corrupted by economic incentives. Other research shows how disclosing conflicts of interest, far from helping the recipient of information, can backfire, helping the advice-giver and hurting the advice recipient.”

Lecture Theatre 3, Cambridge Judge Business School. Tuesday 25th February 5-6.30pm. No need to register but arrive early in order to get a seat.

Unfortunately, I can't attend. Any info will be appreciated.
You may follow events on Behavioral Economics, here.

PS. Our public expenditure on health on 2012 gave ground, and was close to 5 years before: 2007. Such expenditure over GDP is still at 2008 position: 5,3% , while our GDP per capita (27.442€) is  at levels before 2006 (!). Therefore we are spending on health (more than) proportionally to our GDP historical trend, however our GDP has shrinked a lot. And we maintain distance to OECD average health expenditure (6,69%) although our per capita GDP is 2,7% larger. That's all right now, it's an issue of months.

PS. Interesting post by Josep Maria Via.

Behavioral contagion

Under the Influence: Putting Peer Pressure to Work

So much has been written on behavioral economics and nudging, and I always think about the implications. Robert Frank in his new book provides new insights to understand the behavioral contagion among all of us. He says:

The argument I will defend in this book, implicit in several of the examples already discussed, is summarized in the following seven premises:
1. Context shapes our choices to a far greater extent than many people consciously realize.
2. The influence of context is sometimes positive (as when people become more likely to exercise regularly and eat sensibly if they live in communities where most of their neighbors do likewise).
3. Other times, the influence of context is negative (as when people who live amidst smokers become more likely to smoke, or when neighboring business owners erect ugly signs).
4. The contexts that shape our choices are themselves the collective result of the individual choices we make.
5. But because each individual choice has only a negligible effect on those contexts, rational, self-interested individuals typically ignore the feedback loops described in premise 4.
6. We could often achieve better outcomes by taking collective steps to encourage choices that promote beneficial contexts and discourage harmful ones.
7. To promote better environments, taxation is often more effective and less intrusive than regulation.

Among behavioral scientists, the first five of these premises are completely uncontroversial. It is only 6 and 7 that provoke disagreement. Regarding 6, even when everyone acknowledges that behavioral contagion causes harm, as in the smoking example, it is often hard to reach consensus on collective actions that would modify the contexts that shape our actions. In part, the difficulty is that individual incentives and collective incentives often diverge so sharply. But objections to premise 6 are also rooted in the long American tradition of hostility toward regulations generally. Nor can there be any presumption that regulation always improves matters. Markets sometimes fail to deliver optimal results, but government interventions are also imperfect. Premise 7 is controversial simply because many people dislike being taxed. Yet a moment’s reflection reveals that the only interesting questions in this domain concern not whether we should tax but rather which things we should tax and at what rates. Whether you’re a small-government conservative or an expansive progressive, tax revenue is necessary to pay for valued public services.

A must read. The book has clear messages for professionalism in Medicine and for pandemics.