Fasten seat belts (4)

The times for drug prescription following prioritisation have arrived. Hepatitis C drugs have paved the way for such a move.There were some informal attempts for certain medicines and it was decided by clinical committees (i.e. for rare diseases), but now it has changed. The government has decided who has to get what and when, this is absolutely new. Have a look at this draft of strategic therapy for Hepatitis C treatment.
Any physician asking for hepatitis C drugs will have to explain the compliance with the criteria and ask for approval.
I said some weeks ago that a new paradigm in drug pricing was starting, right now I have to say that drug prescription priorisation by rules is the new trending topic, at least in our neighbourghood. Wether this prioritisation is based by cost-effectiveness criteria remains to be seen.

On NICE and QALYs

It is quite relevant what's going on with value based pricing by NICE. Recent documents are raising greater controversy and a blog post asks if this is the end of the proposal. Today I suggest you have a look at James Raftery contribution to understand the moment (at least in the UK). No politician is interested in such issues.

Le projet de loi

PROJET DE LOI relatif à la santé

Je regarde le communiqué de presse que la ministre française a préparé pour la présentation de la nouvelle loi et je vois qu'ils ont un long chemin à parcourir, que bon nombre des mesures proposées, nous avons déjà réalisées il y a quelques années et d'autres récemment. Je pense aussi que certaines questions ne sont pas par une loi, nous les avons faites ici avec un plan de santé. Il est bon de voir ce qu'ils font au-delà des Pyrénées, et confirme également que les différences sont significatives dans l'organisation de soins de santé et son financement. Cette loi maintient ces differences.

Efficient health labor markets

Economic, Demographic, and Epidemiological Transitions and the Future of Health Labor Markets

Last April a new working group for human resources strategy in the WHO was created with the following subgroups:
1. Economic, Demographic, and Epidemiological Transitions and the Future of Health Labor Markets
2. Transformative Education
3. HRH Data, Measurement of Impact
4. Positioning of and Accountability for HRH in the Post
5. Public Sector Stewardship/Leadership for Health Systems
6. Addressing Special Needs of LMICs and Fragile States
7. Performance/Quality/ Productivity/Regulation
8. Non-health professionals
The first report has been released recently and it is helpful because:

Summarizes the analysis of available data and studies on health sector employment, taking into consideration the macroeconomic, demographic and epidemiological factors, and the greater mobility of health workforce in a globalizing labor market. Specifically, this paper draws on the key findings from the three background studies that have been commissioned to address the following issues.
1. Examine the macroeconomic context and evidence on the extent to which employment in the health sector contributes to overall economic growth and to productive employment and the general trends in the health labor market 
2. Forecast the health workforce supply and demand to 2030, based on a the estimation of HRH needed to provide essential health services to the population (assuming no change in technology or service delivery model), and the size of health workforce that countries can feasibly produce and employ based on their economic capacities and outlook .
3. Review the trends and impact of globalization and mobility of health workers on national policies on health workforce

Although I'm not a supporter of "wishful thinking" forecasting, I understand that some effort should be made in this direction. WHO is making it with a global perspective, and each country should do its homework. Is there anybody nearby working on that?.
Demand and supply should meet and reach a long-term equilibrium. Regulatory conditions and incentives should be reviewed to achieve better efficiency. This is a precondition for an efficient health system.

PS. Three decades ago I read Marta Harnecker book "The Basic Concepts of Historical Materialism". Then, I could understand the difference between nacionalization and socialization of means of production that Lenin proposed a century ago, and why nationalization was not enough to achieve his political goals. Marx and Lenin forgot the relationship between ownership and efficiency, about how incentives really work. History provides relevant lessons about this oblivion and we should avoid going back in time.

Fasten seat belts (3)

In former posts I have argued that pharmaceutical pricing is forging a new trend. The summary is in this figure (US prices):

The latest FDA approved drug is Harvoni, for hepatitis C. This new drug will compete with Sovaldi, the best drug launch ever made by the same manufacturer, 9.000 million $ in sales in 9 months.
The soaring costs of drugs is also affecting the generics market in US. Have a look at this blog.
As far as the economy is not growing at the same pace, new resources are needed and this may come from reductions on current drug benefits (price or quantity) or less expenditures in non-pharmaceutical goods. Otherwise the option is to delay access. Is this an option for cost-effective therapies?

A milestone for health insurance reform

INFORME Estudio y Propuesta de un Nuevo Marco Jurídico para el Sistema Privado de Salud

If you look at health care financing in OECD countries you'll find an outlier: Chile. This is the country with the largest private financing, 47%. The reason behind such a number is the current system of ISAPRE coverage. A clear explanation of the current situation is shown in this presentation by Camilo Cid, the chairman of the commission for a review of the private health system.
The new chilean government created a commission to get recommendations about what to do with ISAPREs, and the result was that this report was released some days ago.
The trend is clear, opt-out from a single pool is not an option for the future. The Netherlands made the same reform in 2009, Germany constrained its possibilities, and now Chile has decided exactly the same. If there is only a single pool for financing health, this exactly means that the role of the market is going to change at the same time. Insurance price-competition vanishes, and the profit motive is under close scrutiny. Let's see what happens. All this recommendations should be included in the legislation. Anyway, the report is a milestone for the next health reform in Chile. An excellent reference for anyone interested in this topic. Good job.

PS. Values and economic crisis, a report. Have a look at this slide p.31, impressive. Is it possible?

Manuel Castro at Galeria Barnadas 

A healthy recession?

WSJ headlines announce a new economic slowdown. Concerns about the current state of worlwide economy and the financial sector are growing again. A special report by The Economist talks about the third great wave:

A third great wave of invention and economic disruption, set off by advances in computing and information and communication technology (ICT) in the late 20th century, promises to deliver a similar mixture of social stress and economic transformation. It is driven by a handful of technologies—including machine intelligence, the ubiquitous web and advanced robotics—capable of delivering many remarkable innovations: unmanned vehicles; pilotless drones; machines that can instantly translate hundreds of languages; mobile technology that eliminates the distance between doctor and patient, teacher and student. Whether the digital revolution will bring mass job creation to make up for its mass job destruction remains to be seen.

Some years ago  I explained how Iceland economic crisis had no negative effect on health. Now we can confirm the impact in our country in a new report and presentation. The quick answer is that unemployment and poverty have a clear impact on health. As far as the crisis implies raising both determinants, then the result is clear: poor and unemployed population are the target to monitor and improve health. You can discuss over the trend of one specific indicator or its significance. That's a minor issue. In general, average longevity and health is improving, although average doesn't mean everybody. The only way to have a good answer is a cohort study with microdata. I think that somebody should start doing it now, it's crucial.
This report is the best exercise one can do to introduce some common sense in any debate about the crisis and its impact on health: go to the facts and data. Therefore, if somebody talks about negative effects of the crisis on health, now you have to be precise, there is a selective impact.
Some months ago, I considered that what we need is a continuous monitoring of health status in any situation. As far as nobody knows if we are still in crisis, or how many years it will take to recover, monitoring is the right word.
My impression is that we had a crisis in 2008 and a new economic model has emerged. The current situation is unstable, uncertain and unpredictable. That's why the WSJ has anounced a new slowdown today. It's not a crisis, it's a new slowdown (again).