Commercialism in health and medicine

Buying Health: The Costs of Commercialism and an Alternative Philosophy

There are only three topics of health policy in the newspapers (unfortunately): waiting lists, copayments and privatization. As soon as one topic drops from the agenda, the informational cascade starts with the following one. The last one, privatization is still a concept in need of definition and measurement. I already covered this issue last year and I don't want to repeat it.
Today I would like to insist that beyond a new framing of the concept, maybe we have to change the scope and the term. The right term could be commercialism. We have to understand better how and when commercialism is undermining professionalism.
Jerome Kassirer wrote an excellent piece (US oriented) in Cambridge Quarterly of Healthcare Ethics some years ago that it is still a reference for today. His words:

Professionalism is fundamentally a pact with society. In recognition of certain behaviors and attributes, society confers professional status on us. These privileges are not bestowed, but are earned, and they must be renewed repeatedly for the status to be preserved. Professional behaviors include technical competence that is valued and that adds value, a commitment to self-improvement, a commitment to selfmonitoring and self regulation, and a commitment to use the unique knowledge and competence for the best interests of our patients. This last requirement should include a commitment to resolve conflicts of interest in our patients’ favor.

Is money trumping professionalism? Certainly the pharmaceutical money tsunami is having major adverse effects. It tends to distract faculty into emphasizing profitable research and to neglect their teaching duties. It replaces openness with secrecy, it privatizes knowledge, and it replaces part of the social commons by commercializing discovery. In many instances, it downplays knowledge as a social good. It has also created a culture within which the design of studies is sometimes jiggered to create positive results, in which unfavorable results are sometimes buried, where communication of results is sometimes hindered for commercial reasons, and where bias in publications and educational materials has gone completely unchecked

Maybe there are excessive generalizations, but take it as a general statement to be confirmed by facts and data.
Churchill and Churchill go beyond the usual scope. Their recent article abstract says:

This paper argues that commercial forces have steadily encroached into our understanding of medicine and health in modern industrial societies. The impact on the delivery of personal medical services and on common ideas about food and nutrition is profound and largely deleterious to public health. A key component of commercialization is reductionism of medical services, health products and nutritional components into small, marketable units. This reductive force makes both medical services and nutritional components more costly and is corrosive to more holistic concepts of health. We compare commercial and holistic approaches to nutrition in detail and offer an alternative philosophy. Adopting this alternative will require sound public policies that rely less on marketing as a distribution system and that enfranchise individuals to be reflective on their use of medical services, their food and nutrition choices, and their larger health needs

I deeply agree with such perspective.

Against patents, again

Deadly Monopolies: The Shocking Corporate Takeover Of Life Itself – And The Consequences For Your Health And Our Medical Future

I've just finished reading a book on patents in life sciences. As you know from previous posts , I'm convinced that there is an enormous welfare loss from current patent system. If you have the opportunity to read this book, you'll finally will arrive at the same conclusion. Although it was written before the Supreme Court ruling over the Myriad case, the message is still the same: patents contrain innovation and are extremely costly to the society. The case of Hepatitis C is explained in detail. Until some patents were exhausted there was no possibility to start research. Without such patents, new succesful and (costly) treatments have arisen (and afterwards have been patented again).
An interesting interview in Forbes magazine highlights the key issues of the book. Unfortunately times go by and alternatives to patents are not taking off.

Health impact of sugar-sweetened beverages taxation

Averting Obesity and Type 2 Diabetes in India through Sugar-Sweetened Beverage Taxation: An Economic-Epidemiologic Modeling Study

Clever politicians want to know the potential welfare impact of taxation. I said "clever", though this is not always the case. An example of economic modeling for sugar-sweetened beverages to set up the right level of taxation (in India), appears in PLOS Medicine. The summary:

The researchers used survey data relating SSB consumption to price variations to calculate how changes in the price of SSBs affect the demand for SSBs (own-price elasticity) and for other beverages (cross-price elasticity) in India. They combined these elasticities and data on SSB sales trends, BMIs, and diabetes incidence (the frequency of new diabetes cases) into a mathematical microsimulation model to estimate the effect of a 20% tax on SSBs on caloric (energy) consumption, glycemic load (an estimate of how much a food or drink raises blood sugar levels after consumption; low glycemic load diets lower diabetes risk), the prevalence of overweight/obesity, and the incidence of diabetes among Indian subpopulations. According to the model, if SSB sales continue to increase at the current rate, compared to no tax, a 20% SSB tax would reduce overweight/obesity across India by 3.0% and the incidence of type 2 diabetes by 1.6% over the period 2014–2023. In absolute figures, a 20% SSB tax would avert 11.2 million cases of overweight/obesity and 400,000 cases of type 2 diabetes between 2014 and 2023. Notably, if SSB sales increase more steeply as predicted by drinks industry marketing models, the tax would avert 15.8 million cases of overweight/obesity and 600,000 cases of diabetes. Finally, the model predicted that the largest relative effect of an SSB tax would be among young men in rural areas.

The results confirm previous studies, 20% may be the ceiling for a tax . But what happens to health?. Assumptions on a fall in consumption, are just that, assumptions. And former behaviour is extrapolated into the future. This is what happens to any model, and this is the uncertainty and courage that any politician must hold in taking a difficult decision. Such moment is closer than before. If you are not convinced, I would suggest you have a look at this documentary released last week:



The documentary is about weight control, but places special emphasis on sugar (addiction). Please have a look at the quantity of sugar in a beverage!!! (14 sugar cubes). Incredible.

PS. "Superbe" post by Reinhardt: How the Medical Establishment Got the Treasury’s Keys

Cost-effectiveness with uncertain effectiveness

Cost-effectiveness of a gene expression score and myocardial perfusion imaging for diagnosis of coronary artery disease

Gene expression testing is quite different from genetic testing. Gene expression refers to epigenetic regulation of genes that occur without alteration of DNA. I've covered such topics several times in this blog. Today, I would like to focus on a recent published work on a new test  that assesses whether or not a patient's chest discomfort or other symptoms are due to obstructive coronary artery disease. Sounds interesting, since angiography is a costly technology.
A quick look at this recent article will raise new doubts. As you know, there is no need for cost-effectiveness analysis when effectiveness is uncertain. When talking about testing effectiveness means, sensitivity and specificity, AUC and so on. But what happens when the seller (or the model) decides about the threshold and afterwards focuses on negative predictive value of 96% and provides the desired value?. The threshold is only an option in the model. Why not change it?. There is a circular reasoning on that.
My concern is that health economics should look in detail at such issues. It is not an issue of conflicts of interest. In this case any health economist should avoid entering such territory.

When asking your physician is not enough

23andMe and the FDA

Some weeks ago I explained the FDA "closure" of DTC genetic testing business. NEJM analyses with detail the rationale behind such policy:

The goal of the FDA and 23andMe (as well as all clinical geneticists, testing laboratories, and the entire genetics industry) should be to ensure that genomic information is both accurate and clinically useful. Clinicians will be central to helping consumer–patients use genomic information to make health decisions. Any regulatory regime must recognize this reality by doing more than simply adding the tagline on most consumer ads for prescription drugs: “Ask your physician.” That is insufficient guidance unless your physician has ready access to a clinical geneticist or genetic counselor.

European regulation is 15 years old and the new directive is still being discussed. It will not be applied for at least 3 years. Meanwhile, do you know who is protecting us from inaccurate and clinically useless information?

Let's get fit, not fat

Aportaciones de la economía del comportamiento en política sanitaria: Algunas notas en torno al ejemplo de la obesidad
 The influence of obesity and overweight on medical costs: a panel data perspective

In the EJHE you'll find  a clear message:

The results indicate that obesity is associated with substantial healthcare cost increases and there are large differences in costs by degree of obesity. Specifically, severe obesity raises total direct medical costs by an average of 160 € per patient and year. With total medical costs averaging 600 € for normal-weight individuals, this means that severe obesity is associated with an increase in costs of 26 %. The effect of moderate obesity is more modest: it raises medical costs by 97 € or 16 %. Overweight has an even smaller impact, raising costs by 51 € or 8.5 %.

Therefore, if obesity has an economic and health impact, what next?
The EEA article by A. Garcia-Altés reflects current knowledge on behavioral economics and obesity. However there is a long way to go. As I said in a former post we do need a battery of measures to fight obesity: regulatory, social and individual measures.

Our irrational behaviour

The Behavioral Economics of Health and Health Care
Irrationality in Health Care: What Behavioral Economics Reveals About What We Do and Why

Thomas Rice provides an overview of behavioral economics in health in a recent article in Annual review of public health. More or less the same things we already know with some concrete messages. A good starting point for those that want to take first steps in this discipline. The summary:

People often make decisions in health care that are not in their best interest, ranging from failing to enroll in health insurance to which they are entitled, to engaging in extremely harmful behaviors. Traditional economic theory provides a limited tool kit for improving behavior because it assumes that people make decisions in a rational way, have the mental capacity to deal with huge amounts of information and choice, and have tastes endemic to them and not open to manipulation. Melding economics with psychology, behavioral economics acknowledges that people often do not act rationally in the economic sense. It therefore offers a potentially richer set of tools than provided by traditional economic theory to understand and influence behaviors

Right now behavioral economics is still a promise, let's wait until we can really apply it widely.
Thomas Rice says in this respect:

 With the exception of Kahneman & Tversky’s prospect theory, which was developed more than 30 years ago, there has been little in the way of bringing the various tools and policies of behavioral economics under one umbrella. As a result, most of the applications seem to be ad hoc. More development of an overarching theory could aid those interested in designing new interventions when it is clear that traditional economics remedies are insufficient

Regarding the book on Irrationality in Health Care, I haven't had the opportunity to have a look at it. I leave here the reference and 23 anomalies . Maybe in the book there is the answer to solve them.

PS. For those interested in an introductory course, on March 11th starts at Coursera:  A Beginner's Guide to Irrational Behavior

Hostis populi

A plot written by Ibsen in 1882 could reflect current conflicts nowadays. Whats first: Your money or your health?. I went to the theatre last week. Great "mise en escène".
The summary:

Doctor Thomas Stockmann is a popular citizen of a small coastal town in Norway. The town has invested a large amount of public and private money towards the development of baths, a project led by Stockmann and his brother, Peter, the Mayor. The town is expecting a surge in tourism and prosperity from the new baths, which are said to be of great medicinal value, and as such, a source of great local pride. Just as the baths are proving successful, Stockmann discovers that waste products from the town's tannery are contaminating the waters, causing serious illness amongst the tourists. He expects this important discovery to be his greatest achievement, and promptly sends a detailed report to the Mayor, which includes a proposed solution which would come at a considerable cost to the town.
To his surprise, Stockmann finds it difficult to get through to the authorities. They seem unable to appreciate the seriousness of the issue and unwilling to publicly acknowledge and address the problem because it could mean financial ruin for the town. As the conflict develops, the Mayor warns his brother that he should "acquiesce in subordinating himself to the community." Stockmann refuses to accept this, and holds a town meeting at Captain Horster's house in order to persuade people that the baths must be closed.
The townspeople — eagerly anticipating the prosperity that the baths will bring — refuse to accept Stockmann's claims, and his friends and allies, who had explicitly given support for his campaign, turn against him en masse. He is taunted and denounced as a lunatic, an "Enemy of the People." In a scathing rebuttal of both the Victorian notion of community and the principles of democracy, Stockmann proclaims that, in matters of right and wrong, the individual is superior to the multitude, which is easily led by self-advancing demagogues. Stockmann sums up Ibsen's denunciation of the masses with the memorable quote "...the strongest man in the world is the man who stands most alone." He also says: "A minority may be right; a majority is always wrong.

 I deeply disagree with this final generalization. The details are important.

Our health and its determinants

Source: UW.

The quality cure into action

The next David Cutler book: "The Quality Cure. How Focusing on Health Care Quality Can Save Your Life and Lower Spending Too" will appear in April. Meanwhile we can read some pages from Google Books. He sets "quality" at the top of the agenda and he explains that Obamacare is trying to solve access. Focusing on quality means effort on greater value, avoiding waste, and therefore cost containment. At the begining it may seem an already heard message, however I agree with him that the quality chasm must be addressed, as well in our country. The book is a must read beyond US borders for any person involved in health care as it is his former book "Your money or your life" . The first statements from the preface:

For decades, health care was like the weather-everybody talked about it, but nobody did anything about it. Talk was easy, politicians and analysts of all stripe agreed that we wanted a health care system focused on preventing disease and treating it appropriately when necessary. In the past half decade, talk has turned into action.

Let's apply his final words,  it's time to turn talk into action.

PS. A former post on this blog about David Cutler.

PS. On conflicts of interest in medicine. The paper on "The burden of disclosure" by Loewenstein et al. And the comment by Alex Fradera.

The hole for genetic testing market entry

Technology Assessment on Genetic Testing or Molecular Pathology Testing of Cancers with Unknown Primary Site to Determine Origin
Update on Emerging Genetic Tests Currently Available for Clinical Use in Common Cancers

AHRQ has just published two reports of interest. The first is devoted  to assess the evidence on the analytical validity, clinical validity, and clinical utility of commercially available genetic tests for identifying the tissue of origin (TOO) of the cancer in patients with cancer of unknown primary (CUP) site. The second describes genetic tests that have applications in the common solid tumors (breast, lung, colorectal, pancreas, etc.) as well as tests that are used in hematologic cancers (leukemia, lymphoma) and are already available in clinical practice.While the first is an assessment, the second is informative.
There is still a third report to be released and meanwhile NRD explains its conclusions. Having selected 11 prognostic tests, only around half had evidence supporting their prognostic accuracy or clinical validity. Therefore the question is always the same: why these tests without evidence are on the market? Why have they been approved by the FDA?. There is a big regulatory hole to fill in.

Conflicts of interest (in medicine)

I would like to attend this seminar:

Professor George Lowenstein
Behavioural Economics and Conflicts of Interest

“A conflict of interest is a clash between an individual’s professional responsibilities and their personal, typically financial, interests. Traditional economics has not shed much light on conflicts of interest, perhaps in part because it has not recognized the importance of professionalism as a motive in human behaviour. In this talk I will present results from a variety of studies that examine the behavioural economics of conflict of interest. Focusing mainly on conflicts of interest in medicine, some of the research shows how people who care deeply about behaving in a professional fashion can be corrupted by economic incentives. Other research shows how disclosing conflicts of interest, far from helping the recipient of information, can backfire, helping the advice-giver and hurting the advice recipient.”

Lecture Theatre 3, Cambridge Judge Business School. Tuesday 25th February 5-6.30pm. No need to register but arrive early in order to get a seat.

Unfortunately, I can't attend. Any info will be appreciated.
You may follow events on Behavioral Economics, here.

PS. Our public expenditure on health on 2012 gave ground, and was close to 5 years before: 2007. Such expenditure over GDP is still at 2008 position: 5,3% , while our GDP per capita (27.442€) is  at levels before 2006 (!). Therefore we are spending on health (more than) proportionally to our GDP historical trend, however our GDP has shrinked a lot. And we maintain distance to OECD average health expenditure (6,69%) although our per capita GDP is 2,7% larger. That's all right now, it's an issue of months.

PS. Interesting post by Josep Maria Via.

The market size of stratified medicine

Defining and quantifying the use of personalized medicines

There is a lot of noise around the message that the personalised-stratified medicine era has arrived. If you split the clamour from the message, the result is close to 34 medicines at the end of 2012, and in market volume accounted for 3% of the global market by the end of 2009. You'll find this details at NRD and this is the key comment:

First, in terms of characteristics, oncology agents dominate personalized medicine utilization, and disproportionately address unmet medical needs as revealed by priority, accelerated, and orphan disease FDA designations. Second, older drugs that have become personalized medicines post-launch have had a significant impact on the growth of small-molecule personalized medicines; however, the translation from label to clinical practice remains uncertain. Third, per capita usage of personalized medicines in the EU5 markets is greater than in the United States, with usage rates in Japan and the rest of the world growing rapidly

 Affair in Cascais

Club des Belugas- the Chin Chin Sessions

Everything is connected

Pla Interdepartamental de Salut Pública

We all know that improving population health is a task that exceeds the healthcare system. The political debate is too focused on healthcare rather than other determinants to improve health. However, today is a different day. A new plan to introduce health in all policies has been approved and this means a change in the agenda. We'll see how this will be managed, since it is a new approach.
Have a look at the document. The authors have been working hard for months on it. Such policy follows EU criteria and represents an innovation in the current health policy landscape. Let's see how effective it is.