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

Clever budget cuts

Disinvestment in the age of cost-cutting sound and fury. Tools for the Spanish National Health System

The government has anounced that it is difficult to apply  new budget cuts again because it would harm citizen's health. However, a close look at this interesting article can provide light to take decisions that would reduce inappropriate care. The authors say:
Articulating the proposed approach to “value for money”, would require 3 basic elements:
(A) The mandate to do it: Regulatory framework
(B) The capacity to identify “low value” interventions and produce guidance on best practice
(C) The capacity to monitor compliance to and effects of “enforced” guidance.
My impression is that light is not enough. Government needs courage for clever reforms, and this means to surpass the existing hurdles. The article explains how. However, I'm uncertain about how many politicians will read this article, and still more uncertain about how many will take the suggested approach.


PS. I should read "Behavioral foundations of public policy".

Why are there high variation rates in procedures?

The Atlas of variations in health care describes what's going on in the real world. Once we know that there are large differences in hospitalization rates between geographic areas, we need to ask about the causes behind them. This is much more complicated.
Have a look at this article and you'll become convinced that it is possible to reduce potential inappropriate care, and hence reduce costs, without harming health. A key paragraph:

Si un área tuviese el comportamiento de las áreas con tasa en el percentil 25 como referencia, el exceso de coste anual oscilaría entre los 89 millones de euros en el caso de proctología hasta los 12 millones en el caso de revisión de artroplastia. En el caso de usar como umbral deseable la tasa del percentil 5, el exceso oscilaría entre los 22 millones atribuibles a revisiones de artroplastia y los 129 millones a procedimientos proctológicos.

This is a clear message for those at the helm of  budget cuts. It's the kind of message that a politician wants to avoid tackling. Anyway, handle with care, this is only a description. There is no clue about causes and consequences.

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.

Dutch crossroads

EVALUATING REFORMS IN THE NETHERLANDS’ COMPETITIVE HEALTH INSURANCE SYSTEM

The quest for introducing systemic competition in health care is plagued with difficulties. This blog has explained its causes several times. There are at least two levels of competition: on the funding side and on the providers side. In my opinion the big issue is on the funding side. Under mandatory insurance, what is the outcome of managed competition (when insurers compete on quality rather than price)?. Although we don't have a case-control assessment, we can have a look at the Netherlands. Latest data confirm that costs are still rising although choice is greater than before. This article says:

Preliminary evidence shows that over the last six years health care costs have kept growing, quality information has become readily available, hospital efficiency has improved, and consumers have had greater choice

It is just a confirmation of my former post. I'm uncertain about the long term acceptance of dutch population for being the country that spends the most  on health in the EU. Can they afford the cost of choice? . Another wave of reform is approaching.

On corruption

These are days with one headline in the journal's front page: corruption. The anomalous funding of parties has created opportunities for "funding" opportunists in those parties. The case of Health Minister may be followed in this police report. The fight against corruption is not that easy. You may check recent proposals by World Bank in this book. I'm not so sure about the effectiveness of Income asset and disclosure as a tool, since we have had this for last 20 years and current news corroborate its failure.

PS. Acemoglu on innovation and growth. And the world of our grandchildren.

Overvaluing expensive drugs

A research from University of York has concluded that NICE is overvaluing expensive treatments because its cost threshold - the price at which a treatment is deemed good value for the NHS - is set too high. The threshold value per quality-adjusted life year (QALY) - a measure of the health benefits of a treatment - should be lowered from £30,000 to just £18,317, their analysis found. It suggests the NHS may be wasting money on treatments that are not as good value as first thought. Professor Sculped said:

It is crucial that the cost effectiveness threshold is seen as representing health forgone as the additional costs of new technologies are imposed on the fixed budgets of local commissioners. For decisions made by NICE and many policy options considered by the NHS and DH, this is the key to establishing the value for money of new services.

This is a strong criticism against QALYs, let's see if it has some impact in the near future. Fortunately, the British have the opportunity to debate on it. Nearer here, the press is saying now that 30% of drugs requested for approval were rejected (7 out of 24). No details available, no website, no transparent process. That's alleged democracy, southern style. NTA=Nothing to add.

PS. If you don't want to read the article, have a look at this presentation. I suggest you save it, it may be useful for the future.

PS. As you can see from my blog, in one week, two officials have said different numbers of rejected drugs for public funding (2 vs 7). Does this make any sense? Is there anybody asking for an explanation in Parliament?

PS. Follow the controversy on DSM-5 at BBC News.

PS. Check here how our drug prices have converged to the european average.

PS. Must read: Uwe Reinhardt blog.

PS. Interesting article on 20 years of economic evaluations of cancer.