Nowadays, those in contact with physicians in publicly funded health care are used to hear about blaming over the politicians and managers, about health system . As this HBR blog states: "Playing the blame game never works". In general, the suggestion is:
Don't blame others for your mistakes.
When you complain, do so constructively.
Set an example by confidently taking ownership for failures.
Always focus on learning.
Reward people for making mistakes.
But what about the system?. If we focus on primary care, I've started reading "La renovación de la atención primaria desde la consulta" . The first chapter explains that innovation should start from the doctor's office, stop complaining. Sounds excellent, however some of our difficulties are systemic and somebody has to fix them.
I really suggest you read it, because when you arrive at chapter 8 and 9 you'll have an overall assessment of the current situation. Don't miss the opportunity to have a look at them.
The anouncement of a potential increase in VAT rate for health care products that currently are under the reduced tax rate, a shift from 10% to 21%, represents the third step in a dangerous growth spiral for health expenditure. From 2010, VAT rates have grown 3 pp (from 7 to 10% the reduced rate) and 5 pp (from 16 to 21%). For public health expenditure, these changes represented an increase in 1,1% or 45 m euro. Right now, the new rate could replicate past events. You can check this information in this recent report. I couldn't find a similar one for private sector.
This is a nonsense. The publicly funded hospitals have to pay a VAT that goes to the government for the goods and services they acquire and they can't put a tax on the services they provide. The hospital resources to pay the tax comes from public funds (the citizens taxes). The result is that hospitals need more funds to pay for more taxes that come from the same body that receives them!
Some years ago, hospitals were asking for VAT rate of 0%, and we all know that this is difficult to achieve under EU rules. Surprisingly a "minor" change in legislation last november has allowed the construction industry for VAT rate of 0%. The final buyer has to pay for the standard VAT amount, but those involved in the process don't have to.
Why does the UK have a reduced tax of 5% or tax exemption in health and we can't apply the same?
Politicians and high level officials often complain about the constraints of the political process. Once they have set up a clear goal, the outcome is subject to a process that it is out of their control. Rather than considering such fact as a failure, this is only a fact that sometimes may happen and others not. The case of tobacco legislation is an interesting political proces that you can check at the latest issue of Journal of Epidemiology and Community Health. Ildefonso Hernández, the former Director General de Salud Pública explains his experience with enacting a law that has had and it is still having strong impact on tobacco consumption and health.
If you want to have a whole picture of the political process in general, I would suggest you this recent book published by the World Bank: Understanding Policy Change. It covers all the critical issues of the political process. A must read for potential politicians and those to blame for policy and politics.
Now we know that 5% of population has paid one third of pharmaceutical copayments that started six months ago (one euro per prescription). About 45 m € have been collected. Just now, when a court from outside says that we have to withdraw such a measure. The issue is not about copayment, that is really working as expected, it's about power, about who sets the rules.
From the begining I considered that was a controversial measure. However, my impression is that it's effects will last. The decline in consumption, number of prescriptions, is a historical achievement: 21% in six months!. The question is, has this lower consumption had an impact on health?, if not, we have a serious problem of not taken such a measure before. Nowadays we don't know wether there were fewer prescriptions or less medicines dispensed. This fact is crucial and requires further scrutiny.
Up to now, over six months the top 5% consuming population has paid 36 € per person, it seems a very reasonable amount. The lemon has been squeezed reasonably.
You can get a clear understanding of the impressive results of road safety policies with a quick look at this excellent article. The summary:
A substantial reduction in deaths from road traffic collisions was observed between 2000 and 2010. Between 2001 and 2010, with the implementation of new road safety policies, there were 26 063 fewer road traffic collisions with victims than expected, 2909 fewer deaths (57%) and 25 444 fewer hospitalizations. The estimated total cost savings were around €18 000 million. Of these, around 97% resulted from reductions in lost productivity. Of the remaining cost savings, 63% were associated with specialized health care, 15% with adapting to disability and 8.1% with hospital care.
In my opinion, next steps for additional reductions in traffic accidents should be adressed with investment in renovation of roads. A clear example of such need is this recent demonstration or the current and tragic situation of N-II and other roads in Girona. You can follow it by twitter at #VergonyaN2. Otherwise, you can watch this documentary, and you'll confirm how politicians can neglect citizens for years. After a decade, Catalonia is still waiting for public investment coming from neighbouring country. Hopefully we will not have to wait for another decade. Soon we'll just keep our taxes and we'll belong to a new State. I't just a compelling argument to prevent mortality.
Inevitably the debates over health reform are rooted in what we currently observe. And our perception is subject to be selected according to our preferences. Decision making under uncertainty has explained how individuals depart from rationality towards multiple biases and this is present everyday in health policy debates.
Currently, the demonstrations against what is called privatization of health services have achieved a difficult tipping point. Both parts, those that are in favour and those that are against are subject to framing effects. In simplest terms, a frame is a model, or lens, for understanding, interpreting, and solving a problem. Politicians have a number of frames that they use to judge people, simplify problems, and make decisions. While framing a concern represents the initial step toward a successful resolution, it is also the first place a decision can go wrong. Because most problems can be framed, or looked at, in more than one way, the lens politicians employ to define an issue can significantly influence how they respond.
And this is exactly what is happening. The frame under the current proposals is that "private management is cheaper". We are not discussing efficiency, lens are focusing on implicitly saving money. Unfortunately this frame should be confronted with the reality. Is it really cheaper? Is being cheaper enough?. Data is scarce and evidence is pending to be provided.
Therefore the recommendation would be: frame the problem from a larger number of reference points and perspectives. A variety of frames allows the decision maker to evaluate the goodness of fit with the specific context. And this is what nobody wants to talk about, about the context. Different ownership alternatives may contribute to efficiency in different ways according to context and the behaviour of the regulator.
Saber de què emmalalteixen i de què moren les poblacions, és la primera preocupació de l'epidemiologia. I també ho ha de ser per a un economista de la salut. La millor forma a data d'avui de saber-ho, és llegir sencer el Lancet del 15 de desembre passat. La publicació del Global Burden of Disease (GBD) per a 2010 ofereix informació detallada sobre la qüestió. M'he guardat especialment l'article referit a l'esperança de vida en bona salut, que confirma allò que sabem: "la geografia forma part també del teu destí". Les diferències són notables, podeu consultar les taules completes. Veureu Andorra i Espanya al top 10 mundial en esperança de vida. Aquest fet hauria de fer-nos reflexionar sobre les causes i les conseqüències que se'n deriven, què cal preservar i què cal millorar. I especialment convindria fer-ho en aquest moment convuls que vivim, on moltes qüestions pengen d'un fil molt prim que es pot trencar en qualsevol moment.
PS. No he trobat per ara cap estimació de l'esperança de vida en bona salut dels catalans més actualitzada.
La darrera és del 2005, 63 anys per als homes (81,5% de la vida), 60,6 per les dones (72,3% de la vida). Algú la deu tenir però al Pla de Salut només surt aquesta i si no hi és potser que algú s'afanyi. Convindria tenir la del 2010 perquè malauradament aquesta vegada no hi és al GBD, però estic convençut que a la propera edició ja hi serà.
PS. Per cert, els de TV3 s'ho han de fer mirar novament. L'enaltiment i l'apologia del risc contrari a la salut hauria d'evitar-se amb diners públics. Em refereixo al reportatge en hora punta de Kilian Jornet. Desconec on és el CAC, però si algú vol emprendre tals aventures que ho faci pel seu propi compte, el pitjor és difondre-les amb recursos públics. Cal rebutjar aquest tipus de promoció de riscos innecessaris per la salut i la vida.
PS. Bon comentari de Sergi Pàmies sobre la qüestió.
PS. Aquí us deixo en David Cutler i la seva lliçó inaugural del curs a la UPF. Haureu de dedicar-hi una hora i mitja del vostre temps.
