The greater good vs shopping

Engaged Patients Will Need Comparative Physician-Level Quality Data And Information About Their Out-Of-Pocket Costs

Access to quality and cost information for citizens is increasing in certain environments. Right now you can find for example the prevalence of nosocomial infection in acute care hospitals in Catalonia with a simple click (p.69). You can assess in advance the probability of being infected during your hospital stay and if you check the indicator you'll find wide variations. Unfortunately this information is not structured to take decisions.
A recent paper in HA groups two potential approaches, information for greater good vs. information for shopping.

The health care quality and cost reporting programs that fall under the “transparency for the greater good” model tend to be nonprofit and government initiatives focused on improving quality and efficiency, engaging consumers, and increasing awareness of variation in quality and cost. In contrast, the programs that fall under the “one-stop shopping” model tend to be private-sector initiatives that aim to provide personalized, integrated information on cost and quality to support consumers’ decision making regarding care providers and services.

Personnally, I'm not so convinced about the dissemination and use of such information to patients. I'm not so sure about the role of choice in general. I suggest you have a look at the book the Paradox of choice before entering into a dubious land. Anyway, I'm in favour for greater transparency, and initiatives like Central de Resultats are a good example, but I remain uncertain about its usefulness for " doctor shopping".

I should go to Viladecans exhibition on Espriu

The pieces of the puzzle

Charter for healthy living

Since we all agree that in developed world, non-communicable diseases are the greatest challenge for health, we are more and more convinced that the solution lies partly beyond the health care system. The issue is not to be convinced about this, the big question is how. And the answers may be different according to the approach. The World Economic Forum has just released a very interesting report and a toolkit on his topic. Though it is necessary to put together all the pieces of the puzzle, and there is a clear emphasis on a multistakeholder approach, I have the impression of some missing pieces. At least two: incentives and cognitive biases in behaviour and decision making. In this blog, I have pointed out the importance of it - remember Nudge or Mindspace- and I can't see it well reflected in the reports. Although there is a minor reference in the annex, you get the flavour of rational patients and governments, as rational consumers and regulators. The context and our departures from rationality are so important that we have to beware of them. Anyway, the most important is to have a look at the toolkit, not only to the report. The intention is clear, focus on the application.

Cristina Iglesias at Reina Sofia Museum

Patient focused episodes

We all know that no measurement means no management. In health care the measurement of the burden of disease is not that easy. Fortunately at a global level there is the recent study published at Lancet and quoted in this post. If we need to be precise in the measurement with consequences for health care management then we need better tools. Diseases finally appear around episodes, and we may have three type of episodes: event based, disease cohort and population based. The definition of episode needs to be patient-focused rather than disease centered. If you want to know the details of the newest approach to morbidity measurement have a look at this document. It is the evolution of former Clinical Risk Groups towards a new model that will be extremely helpful for management decision making and the definition of appropriate incentives.

PS. Some months ago I explained that new payment systems were in train of being defined. An impact analysis may be found here. My post was titled: A retrofuturist payment system. Now, I would like to change the title once I've seen the details, my proposal is: A complete MESS that needs to be rebuilt from scratch. (to be continued)

PS. Yesterday I attended a book presentation: "I am not Sidney Poitier", by Percival Everett. It was at La Central bookstore. Percival explained the rationale of the book and its subliminal messages.  This is not the kind of novel I'll read.

An active life ruled by reason

The humble economist

The works by Tony Culyer are so familiar for every health economist that we couldn't live without them. Those that have arrived a little bit late, now have the opportunity to read all his contributions in one book. My impression is that any university professor could create a syllabus following only this reader: Social Scientists and Social Science, Extra-Welfarism, Ethics, Need and Equity,Health Policy,Health Technology Assessment.
The introduction highlights his academic life, 250 articles, more than two dozens of books and a strong public impact of his works.
I still remember the first time I was reading about the extra-welfarist approach. In those days, the individual utility paradigm was the basis for any article you could read. I was feeling uncomfortable on the assumptions, Culyer gave the opportunity to open the windows for fresh air. Unfortunately his message has not always been understood and applied. Let me reproduce some paragraphs from the introduction:

Culyer’s concept of “extra-welfarism” helps to liberate health economists from the confines of the traditional “Paretian” or “welfarist” approach to evaluating alternative policies and institutions that dominated economic thinking in the nineteenth and twentieth centuries. Traditional “welfarist” economic analysis assumes that subjective individual preferences or “utilities” (understood either as the desires that motivate individual decisions or the feelings of happiness that may or may not follow those decisions) are the be all and end all of the social good when it comes to doing “economic” analysis properly. Culyer’s “extrawelfarist” approach allows economists to use additional sources of information about individual wellbeing or lourishing – i.e. additional to subjective desires and feelings – for evaluating alternative policies and institutions. In keeping with his professional humility, of course, he does not endorse any specific view of what constitutes a flourishing life: “Flourishing may mean different things to different people; all I require is that it be a high goal whose accomplishment gives a deep satisfaction to the one living it, and perhaps others too, as when it is said of someone who has died ‘that was a life well-lived’.

The concept of “extra-welfarism” builds upon the work of Amartya Sen, who first coined the term “welfarism” and wrote of the need to use “non-welfare” or “non-utility” information when assessing individual wellbeing. Culyer developed and refined this idea in the specific context of health care, showing in particular how non-welfare information about people’s health – and not merely people’s health-related preferences or desires – could be fruitfully used in the health care field. The three essays in turn set out the basic idea; develop and refine the distinction between “welfarist” and “extra-welfarist” approaches to health economics, in a multiauthor essay originally lead authored by the eminent Dutch health economist, Werner Brouwer; and then explore a range of different practical applications of both “welfarist” and “extra-welfarist” approaches in the health sector, showing how both can be fruitful in different contexts.

In this post I made some reviews of his recent work and here you'll find an interesting article that it is pending to be read and commented in this blog. 
Right now I only would like to share with all of you the opportunity to read the whole book again, some articles are not easy to find. Definitely, it is a reference book for any person interested in Health, Health Care and Social Decision Making, as it says the subtitle.
Congratulations!

PS. Check the extra-welfarist approach in p.59 of this excellent book of Vicente Ortún.

A new quality measurement paradigm

Quality Measure, Based On Health Outcomes, That Compares Current Care To A Target Level Of Care

The works by David Eddy et al. are a must read always. The latest one at HA February is specially relevant because it represents the introduction of new tools for measuring quality. The abstract says:

The quality of health care is measured today using performance measures that calculate the percentage of people whose health conditions are managed according to specified processes or who meet specified treatment goals. This approach has several limitations. For instance, each measure looks at a particular process, risk factor, or biomarker one by one, and each uses sharp thresholds for defining “success” versus “failure.” We describe a new measure of quality called the Global Outcomes Score (GO Score), which represents the proportion of adverse outcomes expected to be prevented in a population under current levels of care compared to a target level of care, such as 100 percent performance on certain clinical guidelines.

The tool-kit of this Global Outcomes Score is the Archimedes Model. Some months ago I devoted several posts to it. I'm absolutely sure that this approach has wide implications for our health system and I don't understand why we should delay its application. Eddy explains that in several specific situations -mostly population based- more quality represents less costs (-38%!!! p.2446). This is another excellent example of clever budget cuts. Are there any intelligent readers able to apply it? How long will we have to wait for it?

PS. If you don't have access to HA, go through Archimedes webpage.

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".