Charting a new territory: health systems vulnerability

Learning from Economic Downturns How to Better Assess, Track, and Mitigate the Impact on the Health Sector

Regarding the measurement of country-specific health system vulnerability to economic crises in comparison to peers and over time, the WB new report says:

Compared to other fields, such as food security (Food Price Watch 2012; Messier et al. 2012) and environmental vulnerability (SOPAC 2010), the health system lags behind in providing standardized definitions, metrics, and applied tools that would help assess crisis-related vulnerabilities. There are no descriptive tools that would allow for retrospective comparison, let alone predictive tools that would enable early warning signals.

The vulnerability assessment that they propose sounds of interest at a first glance. Spain, Cyprus, Italy and Greece are at the top of european ranking of vulnerability (p.60). Data come from 2010, rigth now the position would be a different one, even worse than before. The problem is that variation within each country is huge, comparing countries is an easy way to forget such differences.

Fundamental misconceptions about health economists and economics

Economics: the biggest fraud ever perpetrated on the world?

Twitter is a risky tool. Your short messages are seen worldwide, be careful. Richard Horton, editor of The Lancet, sent 10 tweets about economics and economists. Ten misconceptions, one behind the other. Certain people consider that such sentences doesn't deserve an answer, they only reflect the personality and knowledge of the author. Others, like David Parkin, John Appleby and Alan Maynard think the opposite and they decided to write a comment this week in The Lancet. This is an article for the files. And it fits perfectly as a recommended reading for those that share these controversial views of Richard Horton:

Panel: Tweets from @richardhorton: “Economics, second only to ‘management’, may just be the biggest fraud ever perpetrated on the world.”
The case against economics:
1 The promise economics offers is seductive: how to allocate scarce resources in society.
It’s a false promise.
2 Economists write as if the economy=society, and societal problems=economic problems. The confl ation is false too.
3 Once there was political economy = economics, ethics, politics. Economists have stripped morality from economics, leaving an arid science.
4 The high points of economic thinking are theories, not data. Reliable experimentally derived data are anathema for most economists.
5 Economists see health as an economic good. It is an opportunity cost, with zero intrinsic value.
6 Rationality, for the economist, means subjecting every thought/decision to a cost-benefit analysis. A wholly narrow view of humanity.
7 The big idea in economics is the market. The assumption is that human beings make cost-benefit decisions based only on self-interest.
8 The essence of economics is price. For those in health who argue for access free at point of delivery, we kill the soul of the economist.
9 Economists deny the existence of citizens. They see only consumers.
10 Finally, it’s acceptable to worsen the lives of some provided the gains of others compensate. Economists institutionalise inequality.A sum of nonsense sentences, one behind the other. 

After reading the comment to each of these tweets, it will be difficult to maintain the same position.
And the authors' conclusion:

What motivated Horton’s critical outburst about economics and economists is not clear. More than 40 years ago, an essay by Alan Williams to defend economic evaluation admitted its imperfections, but concluded with Maurice Chevalier’s view on old age: “Well, there is quite a lot I don’t like about it, but it’s not so bad when you consider the alternative!”Economics, like medicine, is imperfect. The challenge for practitioners of each is to ensure that the perfect does not drive out the good. Our practices may at times be imperfect, but that should not inhibit our drive to improve clinical practice and economic activity for the benefit of all our patients and citizens. We all must strive to avoid confused analysis in displays of modest understanding of each other’s work.

Becoming a physician in your country

Once again I have to explain that we live in a weird country. Imagine for a while that you are at the moment of taking the difficult decision about your future professional career. Imagine that you would like to become a physician. You live in a country that still needs new physicians and in the near future a lot of them will retire. If you succeed on that challenge, then you belong to one third (37%) of those that this year have entered into the profession.
The question is why are we not able to fill the remaining 73% with candidates coming from our towns and cities?. There is a perfect messy regulation that blocks any posibility that the students interested in medicine, with excellent curricula and grades, can enter university.
This is a way to constrain career and life development for new generations and restrict access to close professionals for the population. A complete human made disaster. There is only one possibility to survive in such situation, a quick disconnection.

A transactional patient experience

When Seeing The Same Physician, Highly Activated Patients Have Better Care Experiences Than Less Activated Patients

Patient engagement with the treatment of the disease is increasingly relevant. It seems that we have rediscovered that successful outcomes not only depend on the health care system, the patient behaviour may change the course of the disease. The conceptualisation of this trend has come up with a new term: patient activation - a term referring to the knowledge, skills, and confidence a patient has for managing his or her health care-.
A recent article at HA highlights the issue:

Patients at higher levels of activation had more positive experiences than those at lower levels seeing the same clinician. The observed differential was maintained when we controlled for demographic characteristics and health status. We did not find evidence that patients at higher levels of activation selected providers who were more patient centric. The findings suggest that the care experience is transactional, shaped by both providers and patients. Strategies to improve the patient experience, therefore, should focus not only on providers but also on improving patients’ ability to elicit what they need from their providers.

Easier said than done. Anyway, this is not an excuse to put efforts in such direction.

 In addition, a recent study found that patients at higher levels of activation have lower health care costs than those at lower levels.

There is no reason for procrastination, given the current state of resource scarcity.

For another day

The Actress, the Court, and What Needs to Be Done to Guarantee the Future of Clinical Genomics

The introduction of new technologies and benefits in health care is always a perfect chaotic process. It starts with the creation of great expectations that have to be fulfilled (and publicly funded!). In some sense it could be understood as a remake of the Nintendo story of undersupply and artificial scarcity creation. Some genome based biomarkers fits partly with this paradigm.
The case of Angeline Jolie -double mastectomy after BRCA testing positive- was broadcasted worldwide in the weeks before the ruling against gene patenting. Creating uncertainty and scarcity artificially is a heavier combination. And in this situations is when common good has to be protected, and government has the key role.
Two selected messages from this week in PLOS Biology:

If clinical genomics is about to move forward at a more rapid pace due to broader public awareness and a more favorable legal climate then there is still work to be done on the ethical, regulatory, and legal fronts.

Celebrities are now drawing public attention to the utility of genetic testing. With the Supreme Court decision opening the door to more and perhaps cheaper entry into the testing market, the requisite infrastructure for managing risk and the rules for handling risk information must be strengthened. Making testing more widely available will only be morally acceptable if there are rules of the road in place.

 Meanwhile, our regulator is just waiting for another day, then it may be too late.

Music video by Nikki Yanofsky performing For Another Day. 

(C) 2010 Decca Label Group

Neither manipulated, nor influenced

Nudge and the Manipulation of Choice
A Framework for the Responsible Use of the Nudge Approach to Behaviour Change in Public Policy

When thinking on health behaviour change, the nudging approach is the trending topic. Let's remember the origins:

The contribution of Thaler and Sunstein’s Nudge, however, is not that of conveying novel scientific insights or results about previously unknown biases and heuristics (something that Thaler has championed in his academic publications. Instead, it is the notion of “nudge” itself, and the suggestion of this as a viable approach in public policy-making to influence citizens’ behaviour while avoiding the problems and pitfalls of traditional regulatory approaches.

A recent article explains details about two types of nudging:

Type 1 nudges and type 2 nudges. Both types of nudges aim at influencing automatic modes of thinking. But while type 2 nudges are aimed at influencing the attention and premises of – and hence the behaviour anchored in – reflective thinking (i.e. choices), via influencing the automatic system, type 1 nudges are aimed at influencing the behaviour maintained by automatic thinking, or consequences thereof without involving reflective thinking.

And both can be transparent or non-transparent.  An example of a transparent type 1 nudge is one used by the Danish National Railway agency. Speakers in city trains are used to announce “on time” when trains arrive on time. This nudge has been devised in order to get people to easily remember not just the negative, for example, when a train is delayed, but also the positive, when trains are on time. Non-transparent is closely related to manipulation of behavior and choice.

The authors conclude:

The characterization of nudging as the manipulation of choice is too simplistic. Both classical economic theory and behavioural economics describe behaviour as always resulting from choices, but the psychological dual process theory that underpins behavioural economics, used by Thaler and Sunstein, distinguishes between automatic behaviours, and reflective choices. Nudging always influences the former, but it only sometimes affects the latter. The conceptual implication of this is that nudging only sometimes targets choices.

That's a good point. More details inside the article.

PS Understanding the differences between:  Clinical Categorical vs. Regression Based patient classification systems.

PS. Waste vs. value by U. Reinhardt. Must read.

Investing heavily

Global Healthcare Private Equity Report 2013

Healthcare represents about 10% of global private equity in general. Since this is more or less the proportion of health expenditures on the GDP would sound normal. However, since more or less two thirds of this expenditure is public in western countries, we can say that currently private equity may be overweighted in health sector, compared to others. The reason is that private equity may expect better returns in healhcare than in other parts of the economy.
Anyway, if you are interested in the details of what's going on, I suggest you to have a look at: Global Healthcare Private Equity Report 2013.
A key message about who is investing and where:

One clear theme that emerged in 2012, however, was the growing level of private equity firms’ interest in healthcare in China, India and across the Asia-Pacifi c region (see Figure 3). With opportunities abounding and restrictions on foreign direct investment relaxing to some extent, Western funds are building up their presence in Asia-Pacifi c by opening new offi ces, especially in China and Southeast Asia. Over the next several years, deal activity is likely to continue heating up in new geographies as it stabilizes in traditional ones.
Despite the allure of new markets, Western investors face a healthy dose of competition from local investment firms that have already taken root in the regions and strategic players searching for new outlets for growth. At the same time, investors based in the Arabian Gulf region (including sovereign wealth funds) are also investing heavily in emerging markets, with the long-term goal of bringing much-needed healthcare solutions back to their home countries. Given their unconventional investment theme, such investors are often willing to accept lower returns, consequently bidding up valuations across the board.

I always say that if you want to know about the future, it is helpful to have a conversation with a private equity investor and a headhunter. Capital and talent drive the economy, and both are interested in the appropriate allocation of risk and reward.