Reading suggestions

Christmas reading suggestions:

'The Humble Economist' by Tony Culyer is now available to download for free in PDF, Kindle and epub formats

Waste, Economists and American Healthcare by Robert G. Evans

Hospital Board Oversight of Quality and Patient Safety: A Narrative Review and Synthesis of Recent Empirical Research

The Healthy NHS Board. A review of guidance and research evidence

Health Policy Basics: Health Insurance Marketplaces

The Optimal Practice of Evidence-Based Medicine Incorporating Patient Preferences in Practice Guidelines

 Fee Increases and Target Income Hypothesis: Data from Quebec on Physicians’ Compensation and Service Volumes

 The influence of cost-effectiveness and other factors on NICE decisions

 NHS Productivity from 2004/5 to 2010/1

 Methods for the estimation of the NICE cost effectiveness threshold

Effectiveness of Medicines and Therapies

 Elaboració d’un sistema universal de priorització de pacients en llista d’espera

La pràctica de la medicina clínica: art i ciència

La mort i l’imperatiu de recerca 

Can Mobile Health Technologies Transform Health Care?

Idoctor. NBC News

Should The Cochrane Collaboration be producing reviews of efficiency?
Mike Drummond, Ian Shemilt & Luke Vale, on behalf of the Campbell and Cochrane Economic Methods Group 

A new stream of work from NICE - Medtech Innovation Briefings

Health systems taxonomy

Five types of OECD healthcare systems: Empirical results of adeductive classification

Once upon a time there were two types of health systems: Beveridge and Bismark based. Social Health Insurance vs National Health Service. This was an easy categorisation. Now, things are much more difficult to classify. Have a look at Health Policy and you'll find an update:

We argue that there is a hierarchical relationship between the three dimensions, led by regulation, followed by financing and finally service provision, where the superior dimension restricts the nature of the subordinate dimensions. This hierarchy rule limits the number of theoretically plausible types to ten. To test our argument, we classify 30 OECD healthcare systems, mainly using OECD Health Data and WHO country reports. The classification results in five system types: the National Health Service, the National Health Insurance, the Social Health Insurance, the Etatist Social Health Insurance, and the Private Health System.

Is there anybody available to guess where we are?. 

We the people

A Constitution of Many Minds: Why the Founding Document Doesn't Mean What It Meant Before

Cass R. Sunstein is a distinguished professor of Law at Harvard. For economists he is well known for his book with R. Tahler on "Nudge". Today I would like to reproduce several statements of his 2009 book: A Constitution of Many Minds: Why the Founding Document Doesn't Mean What It Meant Before. Just for those that consider that law should constraint people's expectations:

I mean to identify and explore three approaches to the founding document: traditionalism, populism, and cosmopolitanism.We shall see that in all three contexts, what is at work is a many minds argument–an argument that if many people think something, their view is entitled to consideration and respect.

Traditionalists insist that if members of a society have long accepted a certain practice, courts should be reluctant to disturb that practice. Some traditionalists go further, urging that even po-litical majority should respect longhstanding practices. Populists believe that if most people believe a certain fact or accept a certain value, judges should show a degree of humility—and respect their view in the face of reasonable doubt. Some populists think that if many people be-lieve something, they are probably right, and elected representatives should defer to them too.Cosmopolitans believe that if many nations, or many democratic nations, reject a practice, or accept a practice, the United States Supreme Court should pay respectful attention. Some cos-mopolitanians believe that if most nations, or most democratic nations, do something, other nations should probably fall in line with them.

Of course the three positions are different, and it is possible to accept one while rejecting the other two. But the structure of the central argument is identical in all three contexts. Nothing in the Constitution itself rules out any of the three approaches that I shall be ex-ploring. The Constitution does not set out the instructions for its own interpretation, and many approaches fall within the domain of the permissible. But traditionalism, populism, and cos-mopolitanism all run into serious obstacles. In the end, much of my argument will therefore be negative and critical. I will try to show why each approach has intuitive appeal – but also why each of them faces powerful objections.

Today is a day to reflect on such issues. Laws are created after a political process, popular sovereignity is above them. I wanted just to reflect on that in a historic day.

It's the budget, stupid

Last week the proposal of health budget was submitted to the Parliament. The expected expenditure will be 1.095 € a level achieved 9 years before (2005) in nominal terms (if we consider the figure in real terms, there is an additional 20% less due to CPI -unfortunately no health CPI available). These are the figures, and this is the reality for those that talk about the end of recession. Next year, we are going to spend actually 20% less in publicly funded health care of what we spent in 2005. If somebody had predicted such trend I'm sure that would be considered a fool.
Now I would like you to suggest you an exercise. Estimate how many years it will take to return to 1.300 € (the peak of 2010). For sure, it will take many, many, many years.
Public Expenditure on health care has been reduced, mostly through salaries.This is a partial measure that has a limit. The review of regulatory and organizational structures is the key issue that is mostly forgotten.

PS. No complains about budget cuts, it's just the reality, we are poorer than before. The option is to work in a different direction, more of the same will get the same result.

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)