Who sets the health policy agenda?

Making Health Policy

From this book:

In relation to policy making, the term agenda means: the list of subjects or problems to which government officials and people outside of government closely associated with those officials, are paying some serious attention at any given time . Out of the set of all conceivable subjects or problems to which officials could be paying attention, they do in fact seriously attend to some rather than others.

The crucial issue is who sets the policy agenda, how and why. Two main sources appear as agenda-setting: government and mass media-social networks. There are of course, additional groups and lobbyists that can influence such a process.
Nowadays we could consider that the recession and cutbacks has created a window of opportunity for some to discuss many foundations of our health system. In such a situation, the worst position is the delay on setting the list of topics to be addressed by the government, otherwise non-elected bodies try to mobilise efforts and decisions towards their interests that add to those of the opposition. Therefore, if you are interested on the basics of agenda-setting, have a look at chapter 4 and ask yourself who is in control of it. Are you comfortable with the answer?. If not, something should be done.

Sooner than later

Snake Oil: How Fracking’s False Promise of Plenty Imperils Our Future

Health Impact Assessment of Shale Gas Extraction - Workshop Summary

Applying a Health Lens to Decision Making in Non-Health Sectors - Workshop Summary

Some months ago I suggested a look at PINSAP, the governmental plan to relate health with policy decisions beyond health care and public health. I considered it a real challenge and we have to follow closely what it may deliver. Right now a new pressure on politicians is arising regarding shale gas extraction. Hydrofracturing has wide environmental impacts. Health impact is less known, and this is the reason why IOM released a study last year on that. It says:

The governmental public health system lacks critical information about environmental health impacts of these technologies and is limited in its ability to address concerns raised by federal, state, and local regulators, as well as employees in the shale gas extraction industry and the general public.

If this is so, why hhas the US allowed such extractions?. I suggest you have a look at the book: Snake Oil: How Fracking’s False Promise of Plenty Imperils Our Future,  though it is focused on environmental impact, it provides a clear understanding of the technology and its enormous implications.
If we have to apply health lens to decision making in non-health sectors, this is a clear example for rejecting a technology of tremendous consequences. There are sound reasons to stop such developments sooner than later.

Current expenditure patterns

While looking at the changing economic landscape, you may achieve the conclusion that current trends have never been considered as an option in any forecast. Take for example the total anual expenditure per person. In 2008 it was 13.152€, in 2013 it was 11.710€ (current values, without taking into account CPI). A reduction of 10,9% since the begining of the recession. However, the change in one year (2012-2013) is really high in some categories, people are spending more on pharmaceutical products (9,2%) and less in medical services (-9,8%) (p.4).
If you want to look at individual voluntary health insurance, before the recession the per capita expenditure was 132€ (1.218m€/7,364 m population, 2008) while in 2012 was 137€ (1.445m€/7,571m population), an increase of 5€ . These are the official statistical data.

Health financing on the right track

The Changing Role of Government in Financing Health Care:An International Perspective

If you are looking for a paper that reflects all the issues sorrounding health care finance, you are in luck. A recent article in JEP covers the topics to understand what's going on in developed countries. For example,  I found this statement of interest with regard to our current situation:

The relative efficiency of different types of taxes used to finance health systems has been explored in the public finance and health economics literature. The equity and efficiency properties of general taxation (c.f. Auerbach1985) do not differ depending on whether the money is spent on health or education per se, although, if the level of government that collects revenue differs from the level of government that provides health coverage, there may be equity issues and issues about whether the level of taxation best meets local demand for the services required (c.f. Ahmad and Brosio 2006). Of course, the amount of deadweight loss associated with any revenue generation will depend on the balance and type of taxes  used to raise the revenue.

There are huge equity issues to address in our current system, and have to be corrected very soon. I hope we are on the right track and this is going to be solved in forthcoming months.

Investing heavily (2)

Global Healthcare Private Equity Report 2014

One of the adverse effects of financial repression is that investors may lose their compass in the allocation of risk and the prediction of rewards. This repression period for savers will last longer than anybody would expect, since the size of public debt in some countries is still increasing. Therefore, now it is the time for private equity to invest in sectors with greater uncertainty over profits that would be desirable in normal conditions. This is one reason, among others, why hospitals may appear of interest and this is precisely what happened yesterday.
We know from a recent report that while overall private equity investment increased, capital deployed in healthcare declined in 2013.

Investment levels in the medtech and provider sectors in Europe were down in 2013 compared with 2012, when these sectors saw three $1 billion-plus deals between them. Deal value in the provider sector was especially slow, coming in at only a third of the level seen in 2012, partially due to the dearth of large deals like the previous year’s Mediq (a pharmacy distributor) and Four Seasons (nursing homes) deals.

In 2014 the trend could be the opposite, at least near here. The closed operation (1$ billion-plus) will change the landscape of private health care for decades, and some shocks may appear sooner than later. Let's wait for the strategic responses.

PS. It may seem a paradox, but the unintended effect of financial repression by governments is a misperception of risk. Speculative bubbles before the recession have had the same effect. Beware of that.

PS. Regarding yesterday's case, I understand that antitrust issues will be taken into account properly...

Questions without answer (2)

EESRI. Estadística dels centres hospitalaris de Catalunya, 2012

These are hard times for hospital finances, public and private. In 2012, the deficit of acute care publicly funded hospitals was -29 million €, and -32,7 million € for privately funded ones. In public hospitals, deficit has slightly decreased and the opposite for private ones. Losses appear in both cases,  independent from ownership, however its distribution is for sure of interest, but unavailable. All this data come from a report that I check annually. Last year I posted some questions without answer, and again and updated I reproduce them:

• Why private hospitals have a cesarean rate of 37,2% and public hospitals 22.9%? p.15
• Why "productivity" is double in private than in public hospitals? p.19 (31,52 vs 62,40 UMA/personal sanitari) p.21
• Does size matter for efficiency? Public hospitals average income 80,7m€ , private ones 19,6m €  p.22
• Why ambulatory surgery discharges are 47% in publicly funded and 31,6% in private ones ? (p.15) 
• Why people talk about private profits when there are losses every year?

Why are we waiting? (4)

Patients that are waiting for a health service deserve an explanation about the current situation and its potential solution. In former posts I have made some steps in this direction, but the final and definitive one lies on the resources available.
As far as we are publicly spending 1.095 euros per capita, we could ask if in the same State and under the same tax pressure, some people get more resources than us. Let's have a look at Euskadi,( p.5) any citizen there, will have 1.541 euros per capita for health care in 2014. Therefore, we can increase by 40% our health expenditures without increasing our tax pressure. With such an amount of resources we can forget forever the current waiting lists. In Euskadi, they have 0,8% of population waiting (p.6)  and last year the number of patients was reduced by 2,62%. We have 2,4% of population waiting, 3 more times than them, this is unacceptable and requires immediate action.
Fortunately there is a solution. We need only to disconnect as soon as possible, get all the money of our taxes as they do, and only 60.000 patients will wait instead of 180.000 as it is now. This is good news.

PS. Last Sunday this documentary forgot to tell this relevant information to patients. Once again, I repeat what I said: A wider and sound view about current challenges in health care would allow to understand reality and take better decisions. A new documentary should be recorded to replace it. This is my kind request to TV3.