Is nudging ethical?

The challenges and opportunities of ‘nudging’

A forthcoming Editorial in the Journal of Epidemiology and Community Health provides some amunition for those interested on nudging.

The answer to the question if nudging is an ethically acceptable way of governing people’s behaviour depends on the ethical principles one adheres to. Our core point is that there is no magic trick, any form of policy intervention will impose a criterion against someone’s will, and democracy requires: (1) transparency from the political system in terms of the values selected in deciding and designing an intervention; (2) and at least an evidence-based justification of choice.

If the preferences of an individual change, then we cannot state that his first choice is better/equal/worse than his second one without introducing a ranking among his preference systems. As a result, value-free interventions cannot be defined.

If no magic bullet is available on the policy side, the same applies to research. In the domain of health, behavioural approaches must cope with the challenge of not neglecting the socioeconomic and contextual determinant of health inequalities

We argue that neglecting socioeconomic variables would be clearly a mistake also in the design of nudge. However, our point is precisely that behavioural science (and nudge as its policy implication) can incorporate an analysis of social and cultural factors, and avoid cognitive universalism.

Easier said than done. For an op-ed, it fits with the audience, for a strict and concrete policy recommendation requires further elaboration. I can't see  a practical and concrete applicable approach nowadays. Let's continue waiting.

PS. Must read, on medical devices in BMJ.A systematic review of new implants in hip and knee replacement

PS. A flawed PNAS article unveiled. Again and again, where is peer-review?

Jordi Pintó at Galeria Banadas

Retrofuturistic payment systems (2)

Long time ago I alerted about a potential payment system that tried to convince everybody and didn't satisfied its goals for equity and efficiency. I was concerned about reproducing the mistakes of the past and creating flaws for the future. What I said more than two years ago, has been recently confirmed more or less by a recent decree. Its detailed analysis goes beyond any post in a blog. The retro part is related to an administrative discretionary classification of hospitals that was initially defined two decades ago (Decree  June 30th, 1992) and failed afterwards. The future part is related to a dual payment system: population and service based that will be defined according to idiosyncratic situations. Both are the pillars of uncertainty in the model.
Right now the most important task to accomplish will be to think about its next reform.

Recruiting and wage bargaining in health care

Wage-setting in the Hospital Sector
Huge differences in physician wages are well-known even after adjusting for PPP. Regulatory design on how recruiting and remuneration is set differs across countries and within them. Now OECD explains such differences for some of them.
If we all agree that health care management requires some autonomy level, the recruiting function should be delegated to managers. This is what happens in most OECD countries, except in Italy, Ireland, Greece, Spain, (and Israel) p. 19. Right now I remember that these are the same countries that needed some bailout... This is not by chance...it's by design...
Somebody should change such status, recruiting and remuneration needs flexibility and adaptation to local conditions.

PS. Paper from ECB  INSTITUTIONAL FEATURES OF WAGE BARGAINING IN 23 EUROPEAN COUNTRIES,THE US AND JAPAN

PS. NYT. For those with melanoma, Will the NHS be able to pay 150,000$ for living one additional year of life with a 69% probability?

Dynamic risk adjustment in provider's payment

Prevention and Dynamic Risk Adjustment

Adjusting Medicaid Managed Care Payments for Changes in Health Status

"Risk-adjustment methods have an inherent structural flaw that rewards preventable deterioration in enrollee health status and improved coding of disease burden", this is the key statement in Fuller et al. article. The answer they provide is the introduction of an additional payment adjustment according to changes in health status for similar mix of enrollees. The payment adjustment being proposed is based on changes in aggregate relative payment weights for all enrollees avoiding any individual adjustment.
This is a concrete application of the initial dynamic risk adjustment proposal that Eggleston et al. made in 2007. They suggested a two step payment system: a conventional risk adjustment (for variations in population health outside the provider’s control) and an additional one related to prevention efforts.
There is still a lot to learn about it. Let's keep an eye on this crucial topic.

PS. Have a look at Commonwealth Fund anouncement: "Our initiative recognizes that a wide range of factors influence providers’ choices, beyond financial rewards or penalties, including intrinsic motivation and medical professionalism, organizational influences, and policy" (see Box)

Our health and its determinants (2)

The Relative Contribution of Multiple Determinants to Health Outcomes

There are five major categories of health determinants: genetics, behavior, social circumstances, environmental and physical influences, and medical care. If this is so, do we know the relative importance of each factor?
Last February I posted in this blog a figure by Kindig that explains their contribution. Now a Health Affairs brief summarises different views. Check Exhibit 1, and you'll see there that behaviour represents 35-50% of health status according to different estimates.
The message is clear in our current evironment of mostly non-communicable diseases, we have to find better ways to change behaviour towards healthier people. Decisions and actions, short and long term, risk and responsibility, costs and benefits, trade-offs of every day life.

PS. Must read:  The Ethics of Ebola.

The first three doses of ZMapp were administered to the American medical missionaries Kent Brantly and Nancy Whitebol, who have recovered, and the Spanish priest Miguel Pajares, who has since died. Some offered a practical justification for the widely criticized selection of Brantly and Whitebol: It makes sense to treat health workers first, so that they can continue to help others. But this argument largely fell apart with the selection of the 75-year-old Pajares.

PS.  "Only four companies today make vaccines, compared to 26 companies 50 years ago.". My concerns about a future systemic drug industry are closer than expected (at least in vaccines).

Patient switching-behaviour

Enquesta de salut de Catalunya 2013

Consumer loyalty is a top goal for any maketeer, and the Nielsen Global Survey of Loyalty Sentiment says that to achieve it, offering the best price is the most persuasive tool to motivate consumers to swap devotion to a brand, service provider or retailer. If you enter into healthcare arena, service prices don't play the same role, mandatory insurance coverage is the standard (in developed countries), and voluntary insurance is the option (prices are relevant in this latter case).
What happens when one fourth of the population (~24%) buys voluntary insurance?. They have two options for healthcare access. The last health survey gives the answer (Table 3. p. 44): 57,9% of members go to private services, 29,5% use public services, 12,4% don't use any service. This is the switching behaviour pattern according to access and perceived quality of services, not price.

PS. I suggest a close look to the survey, many interesting things appear inside. Deeper analysis is needed using microdata.

PS. A former post on a related topic.

The impact of information and communication technologies

The number of primary care visits per capita in 2007 was 7,1, nowadays this figure has dropped to 5,9, a reduction of 17% in six years. That's a lot. In absolute terms you get the astonishing figure of 4,5 million visits less! In 2013 the total number of visits in primary care was 44,7 million.
I have taken 2007 as the year for comparison for one reason: there was no electronic drug prescription. I don't know all the reasons behind such huge decrease, however information technology has helped for sure. Righ now, 92% of all prescriptions are electronic. A wide assessment of such period is needed.
Such figures are only a partial evidence of the transformation through technology in one specific area - drug prescription-, now the next step is to go further in other fields: organization of work and communication between physician and the patient. These areas may take advantage of technology and help to change the "production function". However, somebody should also think about the impact on a redefiniton of professional roles and tasks, an issue that is frequently left for another day.

PS. Unfortunately, this good news you'll not find in any newspaper. Nowadays, most of them are interested only in the dark side.

PS. Don't forget that such a decrease in utilization of services has been achieved without any copayment strategy.