Dynamic risk adjustment in provider's payment

Prevention and Dynamic Risk Adjustment

Adjusting Medicaid Managed Care Payments for Changes in Health Status

"Risk-adjustment methods have an inherent structural flaw that rewards preventable deterioration in enrollee health status and improved coding of disease burden", this is the key statement in Fuller et al. article. The answer they provide is the introduction of an additional payment adjustment according to changes in health status for similar mix of enrollees. The payment adjustment being proposed is based on changes in aggregate relative payment weights for all enrollees avoiding any individual adjustment.
This is a concrete application of the initial dynamic risk adjustment proposal that Eggleston et al. made in 2007. They suggested a two step payment system: a conventional risk adjustment (for variations in population health outside the provider’s control) and an additional one related to prevention efforts.
There is still a lot to learn about it. Let's keep an eye on this crucial topic.

PS. Have a look at Commonwealth Fund anouncement: "Our initiative recognizes that a wide range of factors influence providers’ choices, beyond financial rewards or penalties, including intrinsic motivation and medical professionalism, organizational influences, and policy" (see Box)

Doctor crisis. What crisis?

The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care

Last May I saw this press release about a book by a physician from Kaiser Permanente. Initially I thought that it would be a book for those interested uniquely in US healthcare. I started reading "The Doctor Crisis" last week and still can't stop. It has captured my attention. His observations about the practice of medicine and the pressures that physicians are under, are similar in any developed country, maybe the intensity is not the same. Anyway, in the book there is a reference of a work by Sinsky et al.:  In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices, a must read:

The current practice model in primary care is unsustainable. We question why young people would devote 11 years preparing for a career during which they will spend a substantial portion of their work days, as well as much of their personal time at nights, on form-filling, box-ticking, and other clerical tasks that do not utilize their training. Likewise, we question whether patients benefit when their physicians spend most of their work effort on such tasks.³⁰ Primary care physician burnout threatens the quality of patient care, access, and cost-containment within the US health care system.

We set out in search of joy in practice. What we found were pockets of professional satisfaction.

I missed this article when it appeared last year.What they explain is in my opinion what exactly should be done. As Tom Bodenheimer says, “the Triple Aim should be a quadruple aim, with clinician and staff satisfaction a necessity to achieve the other three aims.”  Considering it as an input and not only as a goal itself is the right approach. More on Berwick's triple aim, at IHI.
I am only at the begining of the book, but I wanted today to reflect this critical issue of our health systems. Something should be done beyond the triple aim. Organizational innovation is required. Right now I am not able to perceive such effort around here.

PS. About the title, focusing only on physicians is a too narrow perspective for those who have to lead a better health care , why not "transdisciplinary professionalism"?

PS. A suggestion: their blog.

Commercialism in health and medicine

Buying Health: The Costs of Commercialism and an Alternative Philosophy

There are only three topics of health policy in the newspapers (unfortunately): waiting lists, copayments and privatization. As soon as one topic drops from the agenda, the informational cascade starts with the following one. The last one, privatization is still a concept in need of definition and measurement. I already covered this issue last year and I don't want to repeat it.
Today I would like to insist that beyond a new framing of the concept, maybe we have to change the scope and the term. The right term could be commercialism. We have to understand better how and when commercialism is undermining professionalism.
Jerome Kassirer wrote an excellent piece (US oriented) in Cambridge Quarterly of Healthcare Ethics some years ago that it is still a reference for today. His words:

Professionalism is fundamentally a pact with society. In recognition of certain behaviors and attributes, society confers professional status on us. These privileges are not bestowed, but are earned, and they must be renewed repeatedly for the status to be preserved. Professional behaviors include technical competence that is valued and that adds value, a commitment to self-improvement, a commitment to selfmonitoring and self regulation, and a commitment to use the unique knowledge and competence for the best interests of our patients. This last requirement should include a commitment to resolve conflicts of interest in our patients’ favor.

Is money trumping professionalism? Certainly the pharmaceutical money tsunami is having major adverse effects. It tends to distract faculty into emphasizing profitable research and to neglect their teaching duties. It replaces openness with secrecy, it privatizes knowledge, and it replaces part of the social commons by commercializing discovery. In many instances, it downplays knowledge as a social good. It has also created a culture within which the design of studies is sometimes jiggered to create positive results, in which unfavorable results are sometimes buried, where communication of results is sometimes hindered for commercial reasons, and where bias in publications and educational materials has gone completely unchecked

Maybe there are excessive generalizations, but take it as a general statement to be confirmed by facts and data.
Churchill and Churchill go beyond the usual scope. Their recent article abstract says:

This paper argues that commercial forces have steadily encroached into our understanding of medicine and health in modern industrial societies. The impact on the delivery of personal medical services and on common ideas about food and nutrition is profound and largely deleterious to public health. A key component of commercialization is reductionism of medical services, health products and nutritional components into small, marketable units. This reductive force makes both medical services and nutritional components more costly and is corrosive to more holistic concepts of health. We compare commercial and holistic approaches to nutrition in detail and offer an alternative philosophy. Adopting this alternative will require sound public policies that rely less on marketing as a distribution system and that enfranchise individuals to be reflective on their use of medical services, their food and nutrition choices, and their larger health needs

I deeply agree with such perspective.

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.

Undermining agency theory

The Rhetoric of the Economy and the Polity

Two statements from an excellent article by D. McCloskey:
 
A criticism on agency theory:

The Great Recession gave us all some perspective on how agency theory works. The deepest problem in agency theory in any of its forms (public choice, law-and-economics, finance, whatever) is the same as the problem in prudence-only political theory, subject to the Nussbaum Lemma. The theory declares that one has an “obligation” tomake profit (and further that the economic analyst has an obligation to articulate such a theory, always, and has an obligation not to talk about the ethics of  managerial or scientific obligation, since these are matters of value about which one has an obligation not to dispute). But where does the obligation come from? It comes in fact from the ethical responsibilities of a manager to her professionalism, her stewardship, her stakeholders’ interests, or her promotion of the common good. The agent is not a pure prudence-only, Max U creature after all, just as the Hobbesian selfish individual is not. In the very theory that
denies ethics to the agent, she is imagined to be driven by an ethic, albeit a tacit and abbreviated one. Kant fell into a similar self-contradiction when he claimed to base ethics on reason alone, yet gave no account of the reasons an agent would want to act on reason.

About the crisis:

If we have a crisis, it is one of ethics. Bad People (mainly Bad Men) did it. But the baddest men are the political theorists and business-school professors who recommend an approach to the politics of life that omits the virtues. Is that you, looking at yourself in the mirror?

My understanding is that we have emphasized agency teory beyond its initial purpose. The combination of agency and utilitarism forgets professionalism. I share the view of McCloskey.

PS. 30 years after Fama-Jensen famous article on separation ownership and control.

PS. Another article against agency theory.

PS. Nussbaum Lemma:  I think it implausible to suppose that one can extract justice from a starting point that does not include it in some form, and I believe that the purely prudential starting point is likely to lead in a direction that is simply different from the direction we would take if we focused on ethical norms from the start.
McCloskey interpretation: You have to put the rabbits into the hat if you are going to pull them out.

El professionalisme en la seva màxima expressió

Choosing Wisely. Helping Physicians and Patients Make Smart Decisions About Their Care
Fa poc em demanaven que m'expliqués millor sobre el professionalisme. Els que llegiu aquest blog ja sabeu que em refereixo a tres grans opcions per a millorar l'eficiència: Estat, mercat i professionalisme. Es tracta d'opcions no excloents, sino que són complementàries, només cal triar tant sols la dosi acurada. I precisament en la dosi és on ens podem passar de frenada o quedar-nos curts.
I en referència al professionalisme, ara fa 10 anys que l'American Board of  Medicine va publicar Medical Professionalism in the New Millennium: A Physician Charter. Cal recordar el que diu al principi:

Professionalism is the basis of medicine's contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession.

At present, the medical profession is confronted by an explosion of technology, changing market forces, problems in health care delivery, bioterrorism, and globalization. As a result, physicians find it increasingly difficult to meet their responsibilities to patients and society. In these circumstances, reaffirming the fundamental and universal principles and values of medical professionalism, which remain ideals to be pursued by all physicians, becomes all the more important.

The medical profession everywhere is embedded in diverse cultures and national traditions, but its members share the role of healer, which has roots extending back to Hippocrates. Indeed, the medical profession must contend with complicated political, legal, and market forces. Moreover, there are wide variations in medical delivery and practice through which any general principles may be expressed in both complex and subtle ways. Despite these differences, common themes emerge and form the basis of this charter in the form of three fundamental principles and as a set of definitive professional responsibilities.

I els tres principis:

Principle of primacy of patient welfare. This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician–patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.

Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients' decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.

Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

Doncs bé, ara més que mai crec que el professionalisme ha de suplir l'ineficàcia de l'Estat i els desequilibris del mercat per tal de resoldre les dificultats del sistema de salut. Ho ha de fer ajustant-se a aquests principis i cal aplicar-los en totes les seves implicacions. Quan el dilluns a Els Matins de TV3 preguntaven sobre els pacients que demanen als metges que els precriguin medicaments, la resposta ha de ser només una, aplicar els tres principis, i si no afegeix salut, no cal prescriure perquè ja s'ha saltat el primer. Una actitud condescendent o que hi ha poc temps per visita, esdevenen excuses allunyades d'aquests principis.
Des del JAMA, m'han donat la pista per aquesta reflexió, i aquest primer paràgraf el podeu aplicar també per al nostre país, encaixa la mar de bé:

The polarizing political environment makes it difficult to conduct rational public discussions about this issue, but clinicians and consumers can change the nature of this debate to the potential benefit of patients, the medical profession, and the nation. The initial focus should be on overuse of medical resources, which not only is a leading factor in the high level of spending on health care but also places patients at risk of harm.

PS. En economia de la salut aquest tema del professionalisme es tracta malauradament d'esquitllada. L'econometria cau lluny i per parlar d'eficiència és més còmode pensar en metodologies (DEA et al.) que en decisions clíniques professionals que resulten difícils de modelitzar. Ens caldrà fer un esforç a tots plegats per canviar la situació.

PS. Per tal de conèixer millor què són les Health Insurance Exchanges, mireu aquest blog, el dels estudiants de la BGSE.

PS. Aquells que no vau poder seguir la meva intervenció a Els Matins de TV3, la trobareu aquí.

Quan la tecnologia afegeix disciplina

Disciplined doctors: The electronic medical record and physicians' changing relationship to medical knowledge.

Si encara hi ha algú que té un dubte sobre perquè costa introduir la història clínica informatitzada, ha de llegir aquest article de Social Science and Medicine. L'argument és clar:

The EMR is powerful, this paper argues, not only because of its technical efficiency but also because of its ideological effects, as it changes doctors’ relationship to medical knowledge in such a way that doctors’ understandings of their professional roles become consistent with their subordination to bureaucratic authority.

Es tracta d'un treball qualitatiu suggerent i alhora pot generar controvèrsia. L'autor s'en va anar a una Accountable Care Organization, CalcuCare, va entrevistar metges i va veure què passava amb la història clínica. Per exemple, a l'article explica l'impacte en els protocols-GPC:

While protocols have been an integral part of medical practice for decades (see Berg, 1997), the EMR enhanced their effects in at least three ways. First, protocols were structured into physicians’ interaction with the EMR systemdfor example, once a doctor diagnosed a patient with a certain condition, a particular set of orders was generated automatically (under most circumstances the physician could change the orders, but only after consciously rejecting the protocol). Second, the EMR system allowed physician administrators to easily see which doctors were deviating from the protocols most often. Finally, since the EMR allowed for systemwide comparisons of physician practice and patient outcomes, it was able to combine medical treatment with real-time research in ways that facilitated the ongoing development of new protocols and evaluation of existing ones.

I cap al final diu:

Doctors may continue to feel in control of their profession as professionalism itself becomes more technocratic. Light (2010) discusses this as a transition toward a “new professionalism” based on accountability and value.

Reflexió interessant a tenir en compte.

Wordle del proper article

Els horitzons del professionalisme en medicina

Almenys hi ha dos autors clau, al meu entendre, per a iniciar-se en la comprensió del fenòmen del professionalisme mèdic: Paul Starr i Eliot Freidson. El primer ho tracta a: The Social Transformation of American Medicine, i el segon a Professionalism: The Third Logic. 

Més enllà d'altres consideracions, m'ha interessat la qüestió des de fa temps en la mesura que massa gent contraposa amb lleugeresa Estat i Mercat (privatització) com dues forces excloents davant una reforma sanitària. Segons el senderi ideològic de cadascú, s'enroca en una o altra opció i no en surt d'aquí. Malauradament aquesta forma de pensar oblida el professionalisme, al que Freidson li atribueix "la tercera lògica", més enllà de l'Estat i el Mercat. 

En David Blumenthal escrivia precisament sobre això el 1994 a HA, en ple debat de la reforma sanitària d'en Clinton, destaco:

In most national health care debates the topic has been raised principally by opponents of reform–often organized medicine–and has been used for the explicit purpose of obstructing progress and protecting the self-interested prerogatives of the medical profession. Whatever the reform proposal, it is decried as a threat to medical professionalism and implicitly, therefore, a threat to the quality of care and the satisfaction of patients. This use of the professionalism issue is a great misfortune whose dimensions become apparent if one examines the true role and significance of professionalism in health care reform. The simple fact is that health care reform cannot succeed-politically or substantively–unless it preserves and bolsters the professionalism of physicians and other health care providers.

It should be clear that I am defining professionalism somewhat differently than it is defined in much political discourse. Many doctors equate professionalism with autonomy-to be left alone to do what they want, not only medically but financially. Autonomy, however, is not a divine right of medical or other professionals. Rather, as Paul Starr and Paul Friedson have pointed out, it is a legal, institutional, and moral privilege that is granted by society and that must be earned by health care providers through observing certain standards of behavior, including at least the following.1 (1) Altruism: Professionals are expected to resolve conflicts between their interests and their patients’ interests in favor of the patients. (2) A commitment to self Improvement: Professionals are expected to master new knowledge about their trade and to incorporate it continually into their practice. They also are expected to contribute individually to the knowledge base that informs their discipline. (3) Peer review: Because of their specialized knowledge, professionals are uniquely positioned to supervise the work of their peers, to protect consumers against failures of professionalism.

Aquesta referència hauria d'obligar a pensar a més d'un. Fer les coses bé, és la primera de les exigències, i això obliga a un marc ètic que cal refermar. Però també hi ha més coses a tenir en compte en el professionalisme.
En un article crític, Arnold Relman explicava a JAMA la seva visió sobre la decadença del professionalisme als USA:

This undermining of professional values was an inevitable result of the change in the scientific, economic, legal, and social environment in which medicine is now being practiced. A major reason for the decline of medical professional values is the growing commercialization of the US health care system.

Endangered are the ethical foundations of medicine, including the commitment of physicians to put the needs of patients ahead of personal gain, to deal with patients honestly, competently, and  compassionately, and to avoid conflicts of interest that could undermine public trust in the altruism of medicine.

Si us interessa aprofundir més en el tema, acaba de publicar-se per part del consell britànic de les professions sanitàries un informe que mostra les perspectives de la qüestió mitjançant focus grups amb estudiants. Hi ha detalls suggerents, però l'abast de l'estudi és limitat. Trobo interessant que obrissin el ventall de professions analitzades.
Mentrestant, ara com ara i aquí, el professionalisme és una matèria optativa a la carrera de medicina.
Quant sonen vents de reforma, alguns ho consideren una amenaça al professionalisme mèdic, una amenaça a la qualitat, com deia Blumenthal. Res més lluny quan es fan bé les coses, convé resituar el professionalisme en el seu lloc amb una perspectiva oberta.

PS. Per cert, en Paul Starr acaba de publicar: Remedy and Reaction The Peculiar American Struggle over Health Care Reform. Must-read.

PS. Per a conèixer el sistema sanitari suís aneu a OECD. I sobre Canadà, Indicadors de Salut.