Depression and the burden of disease

The burden of disease in Catalonia, Spain, using disability-adjusted life years (2005-2010)

Depression ranks at the top of the burden of disease in Catalonia measured in DALYs (men 5.7% of total, while women 11.5%) .It is one of the most significant public health problems in the 21st Century.
The current situation requires a closer assessment and intervention. Patients impact and on families and relatives of patients is huge. Next Tuesday The Economist organises a conference on this topic with top speakers from around the world. A good opportunity to review the current situation.

A new frame for measuring hospital efficiency and productivity

Observatori del Sistema de Salut de Catalunya. Central de Resultats. Àmbit hospitalari. Barcelona: Agència de Qualitat i Avaluació Sanitàries de Catalunya. Departament de Salut. Generalitat de Catalunya; 2013

The knowledge about the performance of our health care system is growing every day. It was difficult to foresee such a big change in transparency. Therefore, this is good news.
In the recent released report on hospitals, you'll find many detailed indicators and you can figure out how your hospital is performing according to several dimensions. There is on dimension that needs to be rebuilt, it's called "efficiency" in the report. As far as DRGs are a tool that was created three decades ago and only minor changes have been introduced, any comparison of length of stay by DRG is old fashioned. Measuring production by UME, (unitat de mesura estandarditzada) is another outdated measure. And resulting productivity measures include these biases. Thus, some additional effort should be made to measure efficiency in hospitals, in its services, as the aggregate makes a lot of noise.
Let me suggest a  book by Yasar Ozcan, although it is focused on DEA, maybe some ideas could arise. The basic reference is Measuring Efficiency in Health Care  Analytic Techniques and Health Policy.
An improvement of efficiency measurement is the next step to be taken.

 

PS. Today is one of the saddest days of the democracy. Spain has filed criminal charges over the president of our government and two ministers.This fact represents a lost opportunity to negotiate our exit. From now on, we enter in "terra ignota", things will be tougher.

PS. Two recommended books to understand what's going on: Constitutional violence, (especially chap. 4 legal violence) and Globalization and sovereignty

PS. Newsfeed, here.

A call for a political prescription to tackle obesity (2)

Overcoming obesity: An initial economic analysis


Some days ago, I was asking for a clear determination to our politicians to fight against the obesity epidemics. How? The just released McKinsey report provides 44 measures to implement and its potential impact. Have a look at it, and you'll be convinced that all we need is political will, social consensus and individual commitment to overcome this crucial issue.

Fracking, No Thanks

The Real Cost of Fracking: How America's Shale Gas Boom Is Threatening Our Families, Pets, and Food

Can you imagine a country of 7.5 million citizens that their Parliament agrees to forbid fracking and only 12 judges may decide that this agreement is illegal?. This is just what has happened again.
Last June I explained the health related damages of fracking in this post, today I would like to draw attention to this book: The Real Cost of Fracking: How America's Shale Gas Boom Is Threatening Our Families, Pets, and Food where you'll find detailed explaination of what happens in practice if the government allows such a practice in your neighbourhood. More details in Slate:

In The Real Cost of Fracking, we learn about David, a 14-year-old boy who came down with a mysterious illness shortly after the start of nearby fracking operations. David had arsenic and phenol (a metabolite of the carcinogen benzene) in his blood. When he went to live with friends, the symptoms subsided. But when he returned home to play with his animals, the symptoms came back, even sending him to the hospital again.

We also meet Claire and Jason Wasserman. One day, Jason was outside near a well that was being flared, and he got a nosebleed that stopped after a little while. But the next morning, he went into the bathroom and yelled for Claire. Blood was gushing from his nose. Claire told him to tilt his head back and pinch his nose. But then blood started coming out of his eyes. “Close your eyes! Close your eyes!” she screamed. Then blood came out of his ears.

The moment to disconnect and avoid such damaging extracting strategies for individuals and the landscape has arrived, the Parliament has to enforce its own decision.

A call for a political prescription to tackle obesity

A political prescription is needed to treat obesity
Why Nudge?

Unless there is harm to others, the government cannot exercise power over people. This is the John Stuart Mill's "Harm principle", sometimes called the Liberty Principle. And governments have taken as given that individuals always take decisions in a rational way, fulfilling their preferences. As Cass Sunstein says in his last book "Why Nudge?", such a principle "raises serious doubts about many laws and regulations. Sometimes power is exercised over people in large part to promote their own good, finally people are note entirely sovereign over their body and minds". He argues in favour of paternalism in certain circumstances. We have already explained such details formerly in this blog.
Today I would like to suggest a reading to you, an excellent editorial in the Canadian Medical Association Journal. It is a call for action on obesity and specifically on food policy and taxation on sugar-sweetened beverages.

Our current approach to obesity relies on the assumption that people have choices, often fail to make the right ones, and should be educated and helped to make better choices. This view is simplistic and clearly absurd, given the continued rise in the prevalence of obesity in countries that have been tackling the problem for decades. Are millions of people really choosing to be overweight?

People are not as free to choose as we would like to believe. Neurobiological desires for sweet and high-fat foods gave humans a survival advantage in a world where food was scarce and every calorie counted. Where food is inexpensive and easily available, biological processes related to eating can mirror addiction and will lead to our destruction. We need to change our approach. We need incentives beyond educational messages. Strategies that include individual interventions,  school-based nutrition and activity interventions, incentives for active commuting and changes to the built environment should continue; however, we also need robust ways to restrict portion sizes and reduce the sale of sugar-sweetened beverages and other high-calorie, nutrient-poor food products. Our government needs to consider taxation as a tool to combat the consumption of these addictive foods and beverages, just as it regulates the sale of alcohol and tobacco products for the purposes of population health.

In USA, Berkeley is the first city that will intoduce the soda-tax after a recent ballot. Berkeley’s Measure D proposed imposing a 1-cent-per-ounce general tax on sugar-sweetened beverages and sweeteners used to flavor drinks. The measure will not dedicate funding to a specific cause and did not require only a majority of the vote.
I still remember how a similar measure was discarded some years ago in our country. The times to reconsider the introduction of a soda tax are coming.

Drug pricing 101 (2)

The New Drug Reimbursement Game. A Regulator’s Guide to Playing and Winning

In my former post I was backing a complete review of current drug pricing regulation. Any official that has to perform this task needs some fresh ideas and knowledge and this is precisely what a new book provides. In The New Drug Reimbursement Game by Brita A.K. Pekarsky you'll find the economic foundations for a new drug pricing regulation.
The basic argument:

Higher prices today mean increased economic rent for the pharmaceutical industry (Pharma) otherwise firms would not lobby for them. It is in Pharma’s interest to protect and seek these economic rents. Whether higher prices and more R&D today increase future health remains an empirical question. If higher prices also mean a higher net present value of the population’s health, then it is in the institution’s interest to increase prices. Given the institution’s objectives, the most effective strategy Pharma can use to protect these rents is “the Threat”: lowering prices is against the interest of health funders because it will reduce a population’s future health.

Therefore,

 The regulator’s challenge is to answer the following question:
• “How should rational institutions respond to the Threat?” (A rational response is one that is consistent with a given institution’s stated objective function, whatever this may be.)
This introduction places this research question in the context of current evidence and research, by addressing the following three questions.
• Is it plausible that the Threat exists and that it influences the price of new drugs?
• Is there rigorous empirical evidence that suggests that lower drug prices will result in reduced future health?
• Are economists in agreement as to the value of a decision threshold for new  drugs that accommodates characteristics of the health budget such as allocative and technical inefficiency?

And the conclusion:

When the Institution buys this new drug, it buys the health effects from this drug and the health benefits from future innovation. This is not the case with other health programmes. Therefore, unless the Institution pays a premium for the health effects from the new drug, the population will be worse off because innovation will be suboptimal and the future drug will not be produced.

Unfortunately, when you get to the end you'll miss any consideration about what innovation means. If you look at recent patterns of effectiveness of new drugs, you'll see that the value of innovation is under scrutiny, and most drugs would not pass the test. In my opinion, the regulator has to send signals about the value of health improvement in certain diseases and pharmaceutical companies should focus R+D on such fields and avoid others.
Therefore, a new companion to this book should be written. This is only a regulator's guide to play, but not to win. Take it only as a starting point.

PS. Just FYI, you'll not find the term "Budget impact analysis"  in the book, a close term Programme budgeting marginal analysis PBMA is what you'll find. It is suggested a price effectiveness analysis as a previous requirement for any PBMA, otherwise it makes no sense. This approach seems quite different to  yesterday's news.

Thomas Piketty speech at UPF Oct 2014, it starts at min 8:10. My post, last May.

Drug pricing 101

In his book "Reinventing the bazaar. A natural history of markets", John McMillan says:

Market design consists of the mechanisms that organize buying and selling; channels for the flow of information; state-set laws and regulations that define property rights and sustain contracting; and the market’s culture, its self-regulating norms, codes, and conventions governing behavior. While the design does not control what happens in the market—as already noted, free decision-making is key— it shapes and supports the process of transacting.

If we look at the pharmaceutical market, there are unique features. The government role is at the same time the "market designer" and mostly the monopsonist. The price setting mechanism relies on multiple regulations that evolve according to circumstances. For example, since 2012 there has been no information about patented drug prices accepted for public funding. It sounds quite weird in a moment that everybody is proud of boosting transparency. The debates over the new pricing decree are still more strange. The current mess was explained some months ago in this op-ed. The uncertainty now also embraces pharma-distribution, pharmacists complain about the system.
Such a pricing system is explained in  this presentation (details about pricing in p.6). As far as it is unsatisfactory for everybody, it needs to be rebuilt. My suggestion is that there is a need to start from scratch. John McMillan would say that we have to look for a clever market designer to reinvent drug pricing as soon as possible.