Being transparent

Central de Resultats. Àmbit d’atenció primària. Dades 2012 

Today a new health budget is going to be presented. The focus will be on cutbacks. I'm really tired about talking always about the same in the Parliament. If public income is decreasing, public expenditure follows, changing priorities or more debt are not an option. Therefore, it may be better to know how money is spent and what are the outcomes.
You may check excellent information about primary care performance in this report, an example of transparency. The number of primary care visits in the public system is still falling (-2,5%, 1,1 m less). Instead of decreasing human resources there was a slight increase in full time employees in primary care. The aggregated impact has been a reduction in the number of physician visits per day in 3,2%  (average 2012: 24,5 visits).
One fact to highlight is that less visits have been performed, and we don't know exactly if this means anything special in health terms. In the next future, an update on morbidity will be introduced in the report.

PS. Good news. A new registry of health professionals will be created. Unfortunately we can't project the needs for the future and regulate access. It's only an issue of time, things are going in the right way.

PS. LSE Conference: Behavioral Economics and Diet. It is worth watching it. 

Reference pricing entering into terra incognita

If the regulatory reform proposal for drug reference pricing really succeeds, we can confirm that the end of reference pricing as we have known, has started. From this moment on, we enter in terra incognita.
I would suggest a look at the non-binding report by the Antitrust Commission. Two issues emerge: (1) a minimum threshold for reference pricing updating, and (2) only drugs with  monthly discount beyond 10% will be taken into account for minor prices.
Forget technicalities, the general issue is about competition. The concerns of the report are related to anticompetitive effects, if government doesn't ammend it, it will be another example of poor quality regulation.

Putting brakes on health expenditure

Health at a Glance 2013

We already know it. Health expenditures are stagnating across OECD countries. The size of such stagnation and its potential impact is what really counts. About the size we may check it at the new report with 2011 data, and with this figure:

Now is a good moment to remember the arguments of inevitability of health expenditure: demography, income and the residual (technology, relative prices and institutions). Check this paper for the projections (a useless effort in my opinion). The income reduction and specially the drop in public income is the factor that explains such decrease. Therefore, those that consider health expenditure will always increase because there are forces "out of control" - ageing and technology- (as Bob Evans said and criticised) have been left without argument. They have been surpassed by the decision making of politicians and citizens when income falls. They have put the brakes on health expenditure and we don't know how long it will last. The issue is right now about the impact, are we destroying value or waste? Maybe in our country we are simply increasing "productivity" with labour cost cuts. A founded answer is needed.

PS. Detailed data in excel file, here

PS. More data, here. And the ppt, here.

PS. Per capita public health expenditure next year will be 1.095€ and this is a drop of 15,5% in the last 5 years. Definitely, such reality is underrepresented in the figure, in other words we may be outliers, do you know why?.

PS. If there is a cut on labour costs by 10% and at the same time a reduction in the "production" of visits by 10% (p.25), what happens to productivity?. Following standard methods...productivity stagnates! (a nonsense)

Desperate discounts started

After the change of pharmaceutical pricing schemes in April 2012, the same product may have two prices, one for the National Health System and another for the citizen paying out of pocket. This scheme was put in place last January. Now it's a good moment to have a look at how it works.
For drugs sold on community pharmacies, NHS discounts range is 6-63%, and for specialty drugs 1-74% (!!!). You can check this statement in this table.
Does this make any sense?. I don't want to go further. I'm just confirming the situation after the regulator has paved the way: a desperate discounts process has started.

PS. Thinking critically, the former interpretation is wrong, discounts are not the issue. In order to be publicly funded, a discount gives higher satisfaction to the officials (anchoring). If this discount is confidential, still greater "satisfaction", because of fine tuning in the process of adjusting the cost per QALY to its expectations. A useless effort by the regulator (funded by our taxes), a successful effort for market access. As a citizen it is sad to be subject to such poor quality regulator, we can only expect to disconnect as soon as possible.

PS. Early impact of copayments, have a look at this post.

A healthier population (after all this years)

Enquesta de salut de Catalunya 2012. Informe dels principals resultats 

It is just a fact. The authors of The Lancet article were unable to have a look at the last Catalan Health Survey. In 2006, 78,6% of population considered their health as good, in 2012 (p54) this figure has moved up to 82,8%. The Lancet only emphasized negative issues without clear evidence. It seems that this is the selling argument of our times.
The most relevant thing from the health survey is that citizens view themselves healthier than before the recession, you'll find additional details inside the report.
However, a closer look may highlight some doubts about individual health behaviours, smoking by young people and specially the obesity epidemics. Therefore, a short applause and a clear public health alert for an improvement of health behaviours.

Internalities, habit formation and healthy individuals

Healthy Habits: Some Thoughts on The Role Of Public Policy in Healthful Eating and Exercise Under Limited Rationality

Selected statements from a chapter of new book presented recently: Behavioral Public Policy, a must read.

About unhealthy habits:

Neither self-control problems per se nor naivety about future self-control problems necessarily lead to special mistakes in light of habit formation. People over-indulge in un-healthful behaviors because of self-control problems. But it is primarily the unhealthfulness per se not the habit component that causes the problem. Self-control problems predict that people overconsume unhealthy goods and activities, but by themselves there is no simple prediction that overconsumption is worse for habit-forming goods than for non-habit-forming goods.

Message:

First, unless we believe that it is likely that people are making mistakes, the fact that some activities are habit forming does not (in any way that I can understand) heighten the case for policy intervention, regulation, or paternalism. Second, if we decide we'd like to deter some activity, we should never forget the power of prices. The most practical policy we may employ if we reach the conclusion that people are doing too much of bad habits or too little of good habits: tax or otherwise deter the bad habits, and subsidize or otherwise support the good habits. If we want to get people to do less unhealthy eating, we should make it more costly; if we want people to do more exercise, we ought to make it cheaper

Tool, a life cycle adjusted taxes on unhealthy behavior:

Instead of (say) 10% tax on unhealthy items for a persons entire life, consider heavy taxes for young people for these items, and no taxes when older, in a way calculated to leave the total tax burden the same overall if people do not change their behavior. What would happen, according to di§erent theories of motivation? If young people are acting according to fully rational models, fully realizing the habits they are forming and the costs they are incurring, then they will be made no worse off. Indeed, there is a behavioral prediction of the rational model: they will either keep consuming a lot in their youth and in their adulthood just like they did before, or they will stop in their youth and then start in their adulthood. But either way, economic theory based on full rationality says they will be just as well as before. How might people who have self-control problems or projection bias behave? The prediction is that they are very likely to decrease consumption dramatically both in their youth and thereafter. This is because the prediction of these alternative models is that those who were forming these habits when young (at least the ones who were close to indi§erent before) were not planning to do so. If people don't realize they will develop a lifelong habit as strong as they will, then they never thought they were going to pay taxes later in life just because of early consumption.

Wether this is possible to apply remains uncertain. I suggest looking at Acemoglu-Robinson paper to shed some light.

How much does healthcare cost during your life?

Estimating lifetime healthcare costs with morbidity data

We don't know when we can get an illness, how much it will cost to treat and how much time will last. Thats the rationale for being  insured. However, if you were born in 2007 your lifetime healthcare costs in Baix Empordà were 111.936 € for women and 81.566 € for men (on average and without any additional assumption about changes in unit costs). As far as this is the average, mandatory insurance allows for compensating those in ill health by those that are healthy. This is an unique efficient result, any departure from such option would require individual savings and potential debt when having an illness.
We have just published such estimation in BMC Health Services Research, those of you that follow this blog will remember this 2011 post. Lifetime health trajectories is a challenge for research, our contribution is just one of the first steps in such direction.

PS. Must read (as usual), Uwe Reinhardt blog on Angus Deaton.

PS. Economic and financial conditions are again "bubble-like.". WSJ dixit today. I agree.

PS. Toni Catany, exhibition at Galeria Trama.