Why are we waiting?

Waiting Time Policies in the Health Sector What Works?

One could say quickly, waiting lists exist in NHS because prices are mostly absent and insurance plays a role. In consumer markets, waiting lists appear when there are creators of scarcity as Brandenburger-Nalebuff explained in his book as a specific strategy, or when there is a temporary mismatch between supply and demand. Since the solution in health care is not to introduce prices and forget insurance, we have to ask about the best practices on tackling such issue. The report by OECD says:

Supply-side waiting time policies, by themselves, are usually not successful. In the earlier OECD study on waiting time policies, the most common policy was to provide increased funding to health providers to decrease waiting times, and this type of policy continues to be a common approach. It has almost invariably been unsuccessful in bringing down waiting times over the long term. Generally, there is a short-term burst of funding that initially reduces waiting times, but then waiting times increase, and occasionally return to even higher levels when the temporary funding runs out. The other main supply-side policy is increasing hospital productivity, by introducing new payment methods such as activitybased financing (ABF) using diagnosis-related groups. This increases hospital productivity, but does not necessarily decrease waiting times.

The most promising tool is prioritisation within a waiting list. The cases of Norway and Australia are interesting examples to check. Nearer here we started with research, and finally a decree was prepared to be released. Unfortunately last April we received a phone call saying it was not possible to rule on waiting lists, that somebody would do it for us. At that moment I said that the intervention of health policy started. The answer today to the initial question - why are we waiting- is at least this one: we have made unnecessary political concessions and we should apply our legislation, we don't need the intervention from outside. That's it.

PS. Data on waiting lists at December 2012.

Why are we waiting? (2)

Yesterday we had the ooportunity of watching a documentary on waiting lists. The message was: there were 180 thousand patients waiting for surgery by the end of 2013 and this is the result of cutbacks on public health budgets.
Unfortunately the most relevant question was not asked. The documentary was created around a prejudice over the crisis and budget cuts, an ideological prejudice. Since they had the answer, why look for a question?
The right question any journalist should ask is: Why are there waiting lists? . And we have to remember that this is a fact and it is independent from economic crisis. You can check in this blog a former post on this issue.
Beyond such question, somebody should ask about the situation in other countries and the potential prescriptions for improvement. But the biased journalistic approach to a topic, requires the focus on a concrete ruling politician not on his policy.
If you want to know what happens in other countries, check here. If you want to know about potential solutions, check here. If you want to know how resources are allocated to providers, check here. (Yesterday somebody was saying that it is completely impossible to know how providers are paid (!), and the journalist was unable to check the internet (!)).
They forgot to say that health expenditure is strictly related to wealth creation. Public expenditure on health has jumped from 5% over GDP (2007) up to 5,6% over GDP (2011). Our government was spending 32% on health od the public budget, and right now is 40%. You may disagree about such level, but you must accept that has increased and we are poorer now than before.
Patients require solutions, and they also forgot in the documentary that avoidable hospitalisations is huge (!) (average 16%, range from 6% to 26%).
They also forgot that a methodology  has been proposed and adopted to prioritise waiting lists on a transparent way.
A wider and sound view about current challenges in health care would allow to understand reality and take better decisions. A new documentary should be recorded to replace it. This is my kind request to TV3.

Why are we waiting? (4)

Patients that are waiting for a health service deserve an explanation about the current situation and its potential solution. In former posts I have made some steps in this direction, but the final and definitive one lies on the resources available.
As far as we are publicly spending 1.095 euros per capita, we could ask if in the same State and under the same tax pressure, some people get more resources than us. Let's have a look at Euskadi,( p.5) any citizen there, will have 1.541 euros per capita for health care in 2014. Therefore, we can increase by 40% our health expenditures without increasing our tax pressure. With such an amount of resources we can forget forever the current waiting lists. In Euskadi, they have 0,8% of population waiting (p.6)  and last year the number of patients was reduced by 2,62%. We have 2,4% of population waiting, 3 more times than them, this is unacceptable and requires immediate action.
Fortunately there is a solution. We need only to disconnect as soon as possible, get all the money of our taxes as they do, and only 60.000 patients will wait instead of 180.000 as it is now. This is good news.

PS. Last Sunday this documentary forgot to tell this relevant information to patients. Once again, I repeat what I said: A wider and sound view about current challenges in health care would allow to understand reality and take better decisions. A new documentary should be recorded to replace it. This is my kind request to TV3.

Why are we waiting? (5)

Waiting Times for Health Services. Next in Line

Long waiting times for health services is an important policy issue in most OECD countries. Reducing the time that people have to wait to get a consultation with a general practitioner, or a diagnostic test or treatment, can go a long way in improving patient experience and avoiding possible deterioration in their health. Governments in many countries have taken various measures to reduce waiting times, often supported by additional funding, with mixed success. This report looks at how waiting times for elective treatment, which is usually the longest wait, have stalled over the past decade in many countries, and have started to rise again in some others. It also analyses the differences in how long people have to wait to get a consultation with general practitioners or specialists across countries. The report reviews a range of policies that countries have used to tackle waiting times for different services, including elective surgery and primary care consultations, but also cancer care and mental health services, with a focus on identifying the most successful ones.

Just a few words. For citizens, this is the hottest topic in our health system. And policymakers are neglecting it, while some citizens are voting with their feed...only those that can.

Bowery men waiting for bread in bread line, New York City, Bain Collection

Using behavioral insights for policy

Social and Behavioral Sciences Team 2015 Annual Report

Some weeks ago, an executive order by President Obama boosted the application of behavioral insights to policy.

To more fully realize the benefits of behavioral insights and deliver better results at a lower cost for the American people, the Federal Government should design its policies and programs to reflect our best understanding of how people engage with, participate in, use, and respond to those policies and programs. By improving the effectiveness and efficiency of Government, behavioral science insights can support a range of national priorities, including helping workers to find better jobs; enabling Americans to lead longer, healthier lives; improving access to educational opportunities and support for success in school; and accelerating the transition to a low-carbon economy.

Sounds interesting. It poses a tweak on the current approaches to policy design. Cass Sunstein says in NYT:

 When government programs fail, it is often because public officials are clueless about how human beings think and act. Federal, state and local governments make it far too hard for small businesses, developers, farmers, veterans and poor people to get permits, licenses, training and economic assistance.

 Behavioral research shows that efforts at simplification, or slight variations in wording, can make all the difference.

The UK and now the USA are introducing this new way to define policies (and health policy). Let's keep an eye on its application and performance. What are we doing in this respect? Why are we waiting to introduce something similar?


 President Barack Obama speaks with members of the Social and Behavioral Sciences Team in the Oval Office in January 2015.

Why are we waiting? (3)

The communication vessels theory says that the pressure exerted on a molecule of a liquid is transmitted in full and with the same intensity in all directions (Pascal). This theory applied to hospital waiting lists is converted into the following one: those patients not attended in public hospitals will go to private ones. In order to increase private market share, the public system has to worsen. This is the malevolent theory partly explained in this documentary.
All theories require some support from facts and data. Private health insurance -duplicate coverage- has increased from 23,0% of population (2007) to 24,3% (2011). And discharges per 1000 inhabitants were 25,9 in private hospitals, and 98,7 in publicly funded ones (2007), on the other hand 26,3 and 89,0 respectively (2011). Therefore, there is a 1,3 points of increase in insurance and 0,4 points in hospital discharges in private hospitals. People may contract more insurance slightly but such increase is not reflected equally in discharges. If you want to look for previous trends you'll find other increases of private insurance of 1 pp without any public cutback.
The efforts to relate crisis and cutbacks to communication vessels between public and private is another example of confusion between concurrent facts and causality. Somebody should demonstrate clearly such relationship before broadcasting it on a TV program, otherwise his reputation is at risk.
The additional argument of unfair competition of public hospitals when the provision of privately funded  services requires once again to be proved. Unfair competition as we know it, it's what law defines. I can't see any provision with such possibility in the current law. Otherwise may be considered a comment without a clear definition of what we are talking about. If you add such comments in a documentary it may seem that it is relevant, and once you check it in detail you'll see that those that talk about unfair competition are asking to be contracted by public funding at the same time. Does this make any sense?.
Once again, I repeat what I said: A wider and sound view about current challenges in health care would allow to understand reality and take better decisions. A new documentary should be recorded to replace it. This is my kind request to TV3.

Cost-effectiveness of public health interventions

The case for investing in public health

The evidence shows that a wide range of preventive  approaches are cost-effective, including interventions that address the environmental and social determinants of health, build resilience and promote healthy behaviours, as well as vaccination and screening. The evidence in this report shows that prevention is cost-effective in both the short and longer term. In addition, investing in públic health generates cost-effective health outcomes and can contribute to wider sustainability, with economic, social and environmental benefits.

Cost-effectiveness studies  are usually focused towards treatments. This report shows some examples related to public health. Unfortunately,  this is not so common. Up to now my reference on this tòpic was this article. Now I'm adding this report by WHO Euro. And the question remains: if these interventions are so cost-effective, why are we waiting for their implementation?

It is recognized that a comprehensive strategy needs to include a combination of population and targeted individual preventive approaches, but it should be noted that, on average, individual-level approaches were found to cost five times more than interventions at the population level (WHO, 2011a). In general, evidence also shows that investing in upstream population-based prevention is more effective at reducing Health inequalities than more downstream prevention (Orton et al., 2011). Meanwhile, the National Institute for Health and Care Excellence in the United Kingdom found thatmany public health interventions were a lot more cost-effective than clinical interventions (using cost per QALY), and many were even cost-saving (Kelly, 2012).

A market that grows

This is the case of voluntary health insurance. Amid the current downturn, in 2012 there was an increase in the number of members (2.04%) and premiums (6.09%). This data confirms previous trends although it reduces its strength. The market serves 1.9 m members and generates €1,300 m  in premiums (close to 8% of health expenditure). The trend towards collectivization is consolidating again. Right  now close to 45% of premiums come from group insurance due to tax-breaks that only to apply to such policies.
The key question then is not regarding the growth of that market, we have to ask ourselves if such growth is in the right direction towards a more competitive and efficient market. My impression is that information asymmetries and current incentives (tax rebates) need to be rebuilt. 
Let's leave it here for today.

PS. Gary Becker on the Breakup of Countries: No Economic Disaster

PS. Carles Boix, on the role of elites.

PS. Yesterday I attended at the conference on economic and legal dimensions of independence:



PS. Extracted from Vilaweb: Message to the elites: independence is viable and inevitable
 
The Wilson Initiative at Cercle d'Economia explains the arguments for a own state
 
'The independence movement goes from bottom to top, from the street to the Circle. And the role of the elite is to provide what is inevitable. There is vibration, there is anxiety ... But we have to make an effort to allow this to happen. " This is the message that Professor Boix has sent on behalf of the Wilson Initiative to representatives of the country's economic and political elites that assembled at the Economic Circle to hear the arguments of this group of distinguished academics . They have appeared amid great excitement and deploying all arguments to show an audience traditionally reluctant to independence process, that is feasible and necessary. 
Savings of 1,800 euros per person per year
The own state is an opportunity, said Jaume Ventura, who presented figures on the balance between the cost and expense to have a state and maintain their structure.
'He says that if we want exactly replicate the structure in Spain that would cost us 383 euros per person per year. And that, assuming we want to maintain the same embassy as many guns and so on. ' This would be the cost per head, said Ventura. But, eliminating the annual fiscal deficit of Catalonia would provide € 16,000 million. 'The Catalans pay 2,251 euros per person per year in excess of contribution to Spain. After paying 100 euros in taxes, only 57 are spent in Catalonia. Why do we pay that extra money? Not because lower pensions than in Spain. The unemployment benefit is also the same. The explanation is that the deficit is not reversed in Catalonia infrastructure. We have the lowest public capital stock '
What could we do with this after saving 1,868 euros? "With a third of the money we could stop the budget cuts, with 1,868 of these would spend $ 500 to be the sixth country with more investment in education, and 550 euros per person per year, we would be the third country in Europe in investment in research and development.

Listen to Lizz Right while waiting for the next concert in Barcelona. 

The lyrics apply to the former text

Rescuing citizens from the "rule of rescue"

People feel a need to rescue identifiable individuals facing avoidable death or harm. This is a well known fact  explained in 1968 by the Nobel laureate Thomas Schelling from an economic perspective  and by Jonsen  in the bioethics context in 1986.

"A single death is a tragedy; a million deaths is a statistic." This quote reflects exactly what we are talking about. However, the issue is: Do you accept the rescue at any price with public money?

These previous posts of this blog: (1) and (2) explain the details. I'll not insist on what I've already said. I suggest you have a look at them.

Today you can asess these three facts:

1. A country spends 38m € in drugs for 249 patients in 2018. A lifetime treatment.

2. A country has a waiting list of 132.025 patients for surgery, 123.249 patients for diagnostic tests, and 424.715 patients waiting for a visit to the specialist. Total people waiting: 679.989 patients in a country with 7.543.825 inhabitants. 9% of the population is in the waiting list for a health service. However, 25% have voluntary duplicate insurance and could jump the list. Therefore the exact figure is 12% of inhabitants waiting.

3. A country knows that spending 10m € in addition every year can increase cardiac surgery by 600 interventions. This means 600 critical patients less in the waiting list. With 38m €, the number of cardiac interventions would be 2.280.

 Ask yourself what to do about it, what would you prefer to do with 38m€ every year ? Just apply them to 249 patients or to 2.280 (you are not on the waiting list, and we'll assume the same adjusted quality of life years for both cases). Anyway, it's too late to have your answer, the government has already decided for you, and maybe you don't agree with it, as I don't agree. The government prefers the rescue of 249 citizens.
Just to finish, check this final fact:

This country spends 1.192 € per capita of public budget on health. Another country under the same mandatory tax system is able to spend 1.635 €, 40% more !!!

More money allows to avoid such dilemmas for this country. Ask yourself if you want to stay in the former tax system that is damaging your health. Once you have the answer, you'll understand why this country wants to leave this unfair tax system as soon as possible.

Now at Brooklyn Museum

Who should get treatment?

Who should receive treatment? An empirical enquiry into the relationship between societal views and preferences concerning healthcare priority setting

The concern for an equitable and fair allocation of healthcare resources requires a prioritisation approach. Otherwise we are going to live in an arbitrary and opaque world.
An article from the Netherlands explains what people think about three perspectives:

The view “Equal right to healthcare” comprises an egalitarian view on health and healthcare. People with this view consider access to healthcare a basic human right. Everyone is equal, hence has an equal right to healthcare. According to people with this view, prioritisation should solely be based on the need for care and prioritisation based on patient, disease, and intervention characteristics, such as the effect of treatment, is opposed. What is considered to be “the right care” is a matter of personal concern for patients and, according to people with this view, patients should be supported in their treatment choices regardless of the costs.

The view “Limits to healthcare” comprises a view with a strong concern for providing “the right care” for patients. People with this view consider health-related quality of life to be an important outcome of treatment. According to people with this view, providing the right care may imply refraining from (life prolonging) treatment. People with this view do not consider cost-effectiveness to be an important criterion for priority setting, although they do consider it important to make good use of money. Hence, providing treatments that generate minimal benefits should be avoided. Priority setting based on patient characteristics is rejected, with an exception made for lifestyle. According to people with this view, patients who are culpable of their own disease should receive lower priority and prevention should receive higher priority in allocation decisions.

The view “Effective and efficient healthcare” comprises a utilitarian view on health and healthcare. People with this view consider it important to generate as much health for society as possible given the budget constraint, and consider a patient’s capacity to benefit from treatment important when setting priorities. Although people with this view focus on the cost-effectiveness of treatments, they do believe it is not possible to “put a [fixed] price on life”. The value of health benefits depends on circumstances and patient characteristics, such as age and culpability, and hence these should be taken into account in priority setting.

 And the result is:

 The majority of respondents was matched to the view “Equal right to healthcare” (64.5%), followed by “Limits to healthcare” (22.5%), and “Effective and efficient healthcare” (7.1%). A minority of respondents (5.9%) could not be matched

My impression is that we change such criteria according to the exact setting we are in a precise moment. That's why beyond societal criteria we do need professional criteria. Sounds too easy to solve the prioritisation exercise according to three principles.

PS. Still waiting for the book:Rationing and Resource Allocation in Healthcare: Essential Readings

 Juan Genovés exhibition at Marlborough gallery

Are Pharmaceutical Companies Earning Too Much?

Are Pharmaceutical Companies Earning Too Much?

Estimated Research and Development Investment Needed to Bring a New Medicine to Market, 2009-2018

The debate about pharmaceutical companies earnings is a never ending story. Now you can find in JAMA an article that reflects the cost of a new drug: $1336 million. This is the summary:

The FDA approved 355 new drugs and biologics over the study period. Research and development expenditures were available for 63 (18%) products, developed by 47 different companies. After accounting for the costs of failed trials, the median capitalized research and development investment to bring a new drug to market was estimated at $985.3 million (95% CI, $683.6 million-$1228.9 million), and the mean investment was estimated at $1335.9 million (95% CI, $1042.5 million-$1637.5 million) in the base case analysis. Median estimates by therapeutic area (for areas with ≥5 drugs) ranged from $765.9 million (95% CI, $323.0 million-$1473.5 million) for nervous system agents to $2771.6 million (95% CI, $2051.8 million-$5366.2 million) for antineoplastic and immunomodulating agents.

Why this new figure is relevant? Because previous estimates said that it was the more than the double!

The mean estimate of $1.3 billion in the present study was lower than the $2.8 billion (in 2018 US dollars) reported by DiMasi et al,

And   my impression is that we have entered in a difficult world to estimate the real cost. Right now many firms are buying research (buying firms that have already a product close to be commercialised) and they are paying a premium for outsourcing research. Therefore, how to estimate the cost in this situations? Uncertain.

David Cutler asks about the earnings of pharma firms and says:

Ledley showed that from 2000 to 2018, the median net income margin in the pharmaceutical industry was 13.8% annually, compared with 7.7% in the S&P 500  sample. This difference was statistically significant, even with controls, although earnings seemed to be declining over time.

Is this positive return differential evidence of too high a return? Not necessarily. The economics of pharmaceuticals are important to consider. Like several other industries (eg, software and motion picture production), the pharmaceutical industry has very high fixed cost and very low marginal cost. It takes substantial investment to discover a drug or develop a complex computer code, but the cost of producing an extra pill or allowing an extra download is minimal. The way that firms recoup these fixed costs is by charging above cost for the product once it is made. If these upfront costs are not accounted for, the return on the marketed good will look very high.

 Paying more than a drug is worth clinically is not a good strategy. Even if a drug is worth a high price socially, pricing patients who need the drug out of the market is a real loss, even if it leads to more innovation in the future. In still another case, price increases for older, generic drugs serve no innovation purpose. But, as a general rule, it is important to be wary of blunt “lower all drug prices” policies.

Cutler doesn't say too much on price according value and about public funding of research. It leaves the initial question open and waiting for adhoc answers. That's it , it's a complicated issue, no general prescriptions, they need to be adjusted to specific conditions without a captured regulator. This last point is the most difficult one to overcome.

Prix Pictet

The new science of contagion

The Rules of Contagion. Why Things Spread — and Why They Stop

In chapter 2 of this book, Adam Kucharski explains the details about R, the crucial parameter in any epidemic. Right now it seems that we are at 2,3 and waiting to decrease below 2.

 R is a more intuitive – and general – way to think about contagion. It simply asks: how many people would we expect a case to pass the infection on to? As we shall see in later chapters, it’s an idea that we can apply to a wide range of outbreaks, from gun violence to online memes.
R is particularly useful because it tells us whether to expect a large outbreak or not. If R is below one, each infectious person will on average generate less than one additional infection. We’d therefore expect the number of cases to decline over time. However, if R is above one, the level of infection will rise on average, creating the potential for a large epidemic.
Some diseases have a relatively low R. For pandemic flu, R is generally around 1–2, which is about the same as Ebola during the early stages of the 2013–16 West Africa epidemic. On average, each Ebola case passed the virus onto a couple of other people. Other infections can spread more easily. The sars virus, which caused outbreaks in Asia in early 2003, had an R of 2–3.
R therefore depends on four factors: the duration of time a person is infectious; the average number of opportunities they have to spread the infection each day they’re infectious; the probability an opportunity results in transmission; and the average susceptibility of the population. I like to call these the ‘DOTS’ for short. Joining them together gives us the value of the reproduction number:
R = Duration × Opportunities × Transmission probability × Susceptibility

PS. The statistics of contagion