My keynote speech at Pla de Salut #plasalut14

This is my speech at the conference on Pla de Salut, the health planning process 2011-2015:

Em demanen que parli de les tendències de futur, i quan em van encomanar de venir avui, fet que agraeixo sincerament, els vaig dir que només puc explicar el present, que el futur el construïm cada dia tots plegats i per tant depèn de tots els que som aquí i dels que no.

Tots aquells que alguna vegada s’han dedicat a predir el futur, al final mai no volen mirar l’hemeroteca perquè majoritàriament els posaria en ridícul. Els economistes almenys no ens dediquem a endevinar el futur.

Ningú no hauria pogut preveure que des del 2008 ja portem 6 anys de disminució en el PIB, de menor riquesa. O que el PIB per habitant del 2013 fos inferior al de 7 anys abans, el 2006. En Thomas Piketty diu que la taxa de creixement de l’economia a llarg termini és de l’1,5%, tardarem molts anys en recuperar aquesta mitjana.

La duresa d’aquestes dades, mai vistes excepte en períodes de convulsió social i guerres, ens han recordat novament que els recursos són escassos, que sempre hi ha un dia que els deutes s’han de pagar, que fer dèficit públic indefinidament no és possible sense hipotecar el benestar de les generacions futures.

Que els recursos són escassos per les necessitats i demandes socials existents, és un fet, no és així perquè ho diguin els economistes. Els temps recents ens ha recordat que cal prioritzar, una tasca que sovint és molt feixuga i que força a compromisos entre tots.

Tots aquells que parlaven que la despesa sanitària creixeria indefinidament perquè hi havia factors incontrolables com l’envelliment i la tecnologia, han pogut contrastar que el món no s’ha aturat, malgrat tenir menys recursos, hem envellit més i millor i que tenim més tecnologia.

L’esperança de vida en bona salut ha augmentat en un període de 7 anys, entre 2005 i 2012 de 63 anys a 65,7 en homes, i en dones de 60,6 anys a 66,1. I a més a més sabem que en les dones la proporció d’anys viscuts en bona salut ha augmentat 5 punts percentuals, de 72 a 77%, i que en homes només ho ha fet en un punt, de 81 a 82%. En qualsevol cas en termes marginals i en termes absoluts hi ha una millora substancial. Ningú no hauria estat capaç de preveure canvis d’aquesta magnitud. I fins i tot molts haurien associat amb lleugeresa la disminució del PIB a un menor nivell de salut. Per tant, jo avui no em dedicaré a fer previsions.

El que si que podem fer avui és saber on som, i comprendre millor quin és l’equipatge necessari per al trajecte cap a una millor salut poblacional i individual, cap a un major benestar. La qüestió fonamental al darrera de tot debat de política sanitària és com assolir un millor nivell de salut per a la població i com reduir les desigualtats en salut existents. Podríem també dir-ne en termes estadístics, com augmentar la mitjana i reduir la variança.

I davant del risc d’emmalaltir podem preguntar-nos fins a on arriba la responsabilitat individual i col.lectiva amb la salut. És possible atribuir-ne una responsabilitat?

Resumint-ho molt, la salut depèn de les nostres decisions i comportaments, de factors econòmics i socials, factors físics i mediambientals, de l’assistència sanitària i de la genètica. Quina part correspon a cadascun és complexa d’esbrinar. Un professor de Wisconsin, David Kindig al que segueixo habitualment, sitúa el pes dels comportaments en un 30% del total (decisions individuals). I sabem que fins i tot, en la genètica podem influir en la mesura que els nostre hàbits condicionen també generacions futures, l’herència epigenètica és font d’expressió del genoma dels nostres descendents.

Si el nivell de salut és fruit de tots aquests factors que alhora depenen de cadascú de nosaltres i de la col.lectivitat, aleshores el paradigma clàssic de la producció, on hi ha un que ofereix els serveis –el productor, el sistema de salut- i un que els rep – el consumidor- es troba en lluny del que cal tenir en compte per tal de produir més salut.

I aquí comença el meu relat que pren com a referència 3 preguntes:

-què puc fer jo per la meva salut, la salut dels meus familiars i dels que m’envolten?

-què pot fer el meu país per la meva salut?

-quines eines ha de tenir el meu país per fer-ho possible?

Vull situar un apunt de prudència abans de començar, aquests tres punts obligarien com a mínim a una conferència cadascun. Per tant us prego que m’excuseu la brevetat.

Què puc fer jo per la meva salut?

El compromís amb la pròpia salut significa prendre decisions que contribueixen a mantenir-la i millorar-la. Hi ha riscos que podem evitar i és al nostre abast. La dificultat apareix en la mesura que “som persones humanes”.

La capacitat cognitiva humana ve impulsada per dos "sistemes": (Aquests "sistemes" no existeixen físicament, però el model funciona bé per explicar i predir fenòmens!)

- Sistema 1: funciona de forma automàtica i ràpidament, amb poc o cap esforç i sense sentit de control voluntari (Operacions automàtiques) .La majoria del temps, la nostra capacitat cognitiva ve impulsada pel sistema 1, i de forma prou eficient

- Sistema 2: dedica atenció activitats mentals que requereixen esforç (Operacions que requereixen control). Apareix quan les decisions o accions es tornen complexes i necessiten atenció, amb exigència de «concentració». És molt més lent. Daniel Kahneman.Thinking fast and slow, Penguin, 2012

Ambdós sistemes estan actius quan estem desperts.

• El Sistema 1 s'executa automàticament (sense esforç)

• El Sistema 2 es troba en mode de baix esforç, i només s’utilitza una petita part

• El Sistema 1 genera impressions, intuïcions, sentiments, intencions

• El Sistema 2 en general les accepta

• El Sistema 2 també controla contínuament el comportament.

Però quan el Sistema 1 es troba amb una dificultat, demana al Sistema 2 que l’ajudi:

- Quan es detecta un problema difícil

- Quan es detecta alguna cosa inesperada o improbable

- El Sistema 1 no es pot aturar. Funciona amb una heurística determinada i presenta biaixos.

Tot plegat pot representar un comportament allunyat de la racionalitat que el sistema 2 no necessàriament detecti. Una de les seves principals característiques és la mandra, el rebuig a invertir més esforç que l'estrictament necessari. Mentre no es detecta alguna cosa estranya, es limita a seguir les impressions del Sistema 1.

 Un dels descobriments importants dels psicòlegs cognitius en les últimes dècades és que canviar d'una tasca a una altra representa esforç, i especialment sota la pressió de la immediatesa

Si així es com funcionem, aleshores les estratègies que presuposen la presa de decisions racionals entren en contradicció. Sempre s’ha pensat des de les estratègies de salut pública que un individu ben informat, tractarà de prendre decisions que maximitzin el seu benefici de salut (i en això es fonamenten les actuacions en educació sanitària i difusió d’informació, necessàries però no suficients).

Però les persones humanes tenim molts biaixos cognitius en la presa de decisions, en destacaré només tres, que us sonaran familiars:

• Aversió de pèrdua: És la tendència de les persones a preferir, en major mesura, evitar les pèrdues, en comparació a la possibilitat d‘obtenir guanys.

• Prejudici o biaix de confirmació: És la tendència a buscar o interpretar informació d'una manera que confirmi les nostres pròpies preconcepcions.

• Ancoratge és la tendència humana comuna a confiar massa en la primera peça d'informació que s'ofereix ("àncora") en prendre decisions.

L’economia del comportament ha revisat el paradigma convencional del “consumidor racional” que satisfà els seus interessos, i busca explicar perquè som predictiblement irracionals. Sunstein i Thaler van formular en un llibre controvertit, en diuen “La petita empenta”, i resumint-ho molt em centraria en el que es coneix com arquitectura de l’elecció:

Cada situació d'elecció té una opció per defecte, explícita o no

• El valor per defecte és el que un seleccionador té quan decideix no fer res

• Quan demanem a les persones que trïin un element d'una llista, sovint és útil si l'arquitecte de l’opció especifica una opció per defecte que seria la millor per a la majoria de les persones, especialment aquelles que necessiten ajuda en l'elecció. Exemple: Els menus infantils i les opcions més saludables.

És èticament controvertida aquesta actuació? és paternalisme? Estic convençut que necessitem que ens ajudin, i ens cal saber més sobre com fer-ho. Sols, possiblement no ens en sortirem.

I aquí vull referir-me a la importància de l’estratègia poblacional en un moment que es fa un gran èmfasi en l'estratificació individual del risc. Ens convé apostar per l'estratègia poblacional de reducció de la taxa d'incidència de les malalties, i ens cal fer-ho mitjançant una millor regulació i uns millors comportaments, ambdues qüestions sobre esquemes renovats.

 Recordem Geofrey Rose un moment, a la paradoxa de la prevenció ens diu que “una mesura preventiva que ofereix molts beneficis a la població n’ofereix pocs a cada individu”, malgrat això Rose diu que no podem oblidar-nos d’actuar sobre els determinants de la incidència de les malalties. L’estratègia individual és insuficient. I una vegada sabem les nostres limitacions cognitives, ens cal reconstruir les estratègies de salut poblacional atenent a aquests nous plantejaments.

Per tant, som responsables de la nostra salut pel que fa a decisions i comportament, som responsables d'exposar-nos a riscos evitables, i alhora necessitem una petita empenta.

- que puc fer jo per la salut de la meva família i dels que m’envolten?

La implicació familiar i comunitària en la salut es troba també en el nucli de la millora de la salut. L’adquisició d’hàbits saludables comença a la família. El suport i afecte en cas de malaltia o dependència contribueix decisivament. A l’economia comportamental li preocupa el gregarisme, herd effect, perquè es troba en l’origen de moltes decisions per defecte que prenem. Som responsables doncs de contribuir a crear entorns saludables propers i d’evitar riscos extrems

- què pot fer el meu país per a la meva salut?

No sabem el dia que ens posarem malalts, ni quant costarà l’assistència, ni quant temps durarà la nostra malaltia. Ningú s’imagina al segle XXI que aquest risc pugui ser assumit individualment. A mitjans del segle passat, la majoria de països van començar el procés d’assumir aquest risc financer col.lectivament, és el que coneixem com assegurança social, la cobertura universal. Aquesta és una solució eficient a un problema que altrament no té resposta satisfactòria. En la mesura que el 1% de la població incorre en el 20% de la despesa sanitària anual, o el 5% incorre en el 50%, podem comprendre facilment que posar-se malalt en aquests casos suposaria ser pobre de solemnitat per tota la vida, del malalt i la seva família. Però fins i tot sense pensar en que un any podem ser dels que més gastem en el sistema de salut, considerem el cas d’avui mateix que han nascut nens i nenes La despesa mitjana total d’assistència sanitària – pública i privada- al llarg de tota la seva vida serà de 153 mil euros per les dones i 112 mil euros pels homes (sense tenir en compte els canvis en tecnologia i costos unitaris, dades actualitzades a 2014). Aquesta motxilla tant pesada només la podem assumir de forma col.lectiva.

Per tant, el primer de tot és preservar l’equitat en el finançament, i això s’assoleix mitjançant el mecanisme de l’assegurança social finançat fiscalment.

El segon aspecte a considerar del que pot fer el meu país per a la meva salut és tenir en compte com es distribueix la salut entre la població i que podem fer per millorar-ho. Cal tenir present l’equitat en la provisió. Tenint en compte que tenim dos aspectes, equitat horitzontal, tractar igual a iguals en determinada dimensió rellevant, en una zona geogràfica, mateixa necessitat-mateix accés i tractament, i equitat vertical, tractar desigual a desiguals, una distribució de recursos serà equitativa si en aquella zona geogràfica s’en destinen més a aquells que tenen més necessitat. Amb risc de simplificació diria un exemple, equitat horitzontal: garantia de temps màxim de llista d’espera igual, equitat vertical: priorització de la llista d’espera d’acord amb criteris objectius de necessitat i capacitat de benefici.

Estarem prou d’acord que en aquestes qüestions encara hi ha un llarg camí per recórrer. Un camí que és plagat de paranys que ens posem nosaltres mateixos en algunes ocasions. Admetre la priorització de recursos en base a necessitat i/o capacitat de benefici obliga a prendre decisions compromeses, que en algunes ocasions són més facils i assumibles que en altres. Equitat per tant no és exactament sinònim d’igualtat, ni solidaritat, malgrat que algú ho assimila amb massa facilitat.

El tercer aspecte és l’eficiència en la producció de salut, o com conseguir el màxim valor amb els recursos disponibles. Per tots aquells que tenen alguna reticència al concepte us diria, que des de l’economia ser eficient vol dir assignar recursos allà on podem assolir el màxim valor, i això en alguns casos vol dir reduir i en d’altres augmentar. L’eficiència no es refereix estrictament als costos, es refereix al valor, i per tant no hi ha eficiència possible sense tenir en compte un nivell de qualitat desitjable i assumible.

L’eficiència sorgeix dins de l’organització amb les múltiples decisions clíniques que es prenen, i també de les decisions de gestió, és clar. Eficiència també que sorgeix de la innovació en la tecnologia mèdica i de la informació.

Voldria distingir doncs algunes qüestions clau, del que podem fer per millorar l’organització. Les dues peces són: coordinació i incentius.

Coordinació que evita fragmentació i duplicitats, que obliga a posar-se d’acord i comprometre’s. Coordinació que obliga a proveïdors diversos a establir guies i trajectòries clíniques. Els darrers 12 anys he sigut testimoni d’excepció de l’esforç d’integració assistencial en el cas del Baix Empordà on he col.laborat en la recerca sobre la salut poblacional. Hem pogut publicar com la tasca realitzada en la direcció correcta aporta elevadíssim valor en salut malgrat les mancances en recursos.

La segona peça són els incentius, que ens obliguen a tenir en compte que quan prenem decisions també acceptem riscos, alhora que ens esforcem per assolir uns resultats. Cal compensar l’esforç diferencial, la uniformitat produeix “regressió a la mitjana”, i per tant no reconeix l’excel.lència i redueix oportunitats de millora. Jo sempre m’he preguntat quin és el motiu pel que cal ser majoritàriament funcionari per treballar al sistema de salut. De tota Europa, només Itàlia, Portugal, Espanya, Finlàndia i Suècia desenvolupen l’atenció primària en centres majoritàriament públics segons l’OCDE.

Amb tot això estic assenyalant que cal afrontar dues qüestions:

- un nou marc de desenvolupament de l’activitat assistencial i de l’organització on l’implicació professional estigui a l’arrel de la presa de decisions, on hi hagi assumpció de risc i responsabilitat, no només participació. El risc i la responsabilitat van aparellades al costat de qui assumeix la gestió de les entitats que proveeixen els serveis.

- i un nou sistema retributiu dels professionals de la salut que estimuli l’excel.lència i ajusti per aquells riscos fora del control dels professionals. No podem incorporar variables de les quals un no se’n pot fer responsable.

Però més enllà d’això, els incentius també sorgeixen de:

- mecanismes com la capacitat d’elecció. Si som capaços d’admetre que ens trobem davant pacients cada vegada més informats, també hem d’admetre en determinats casos que l’elecció es una mostra de preferència i per tant que en la mesura que sigui possible i acceptable acabarà en una major satisfacció de pacient i de professional. Ara bé, això també cal ajustar-ho i compensar-ho, altrament es produeixen desajustos inadmissibles.

- competència per comparació. Les publicacions de la central de resultats ens mostren variacions excessives dels indicadors que haurien de provocar una reducció dels intervals fet que fins ara no ha passat. La simple difusió d’informació és insuficient, cal ser valents i introduir mecanismes que evitin compensar per reingressos evitables o atenció inacurada. La competència per comparació és la que es dona en dimensions no-preu, per tant qualitat, i que porta implícita capacitat d’elecció cosa que no hi és per ara.

- professionalisme. Massa gent contraposa amb lleugeresa els incentius que provenen d’estat i mercat (privatització) com dues forces excloents davant una reforma sanitària. Segons el senderi ideològic de cadascú, s’enroca en una o altra opció i no surt d’aquí. Malauradament, aquesta forma de pensar oblida el professionalisme3, al que Freidson atribueix “la tercera lògica”, més enllà de l’estat i el mercat. Qualsevol reforma sanitària que es plantegi al marge de la lògica del professionalisme restarà sense suport ampli. Un professionalisme entès més enllà de l’autonomia, considerant principis de comportament com els que Paul Starr i Paul Freidson han proposat:

- 1) altruisme: cal esperar dels professionals que en la resolució dels conflictes entre els seus interessos i els dels pacients es decantin a favor dels pacients

- 2) compromís de millora: cal esperar dels professionals l’aprenentatge i contribució als nous coneixements i la seva incorporació a la pràctica i

- 3) supervisió mútua; atesa l’especialització en el coneixement, els professionals cal que avaluïn el treball dels seus col·legues per protegir els pacients davant errors potencials.

- Aquesta perspectiva professionalista ens hauria d’obligar a reflexionar més enllà dels debats estèrils sovintejats. Fer les coses bé, i fer bé aquelles que cal fer, és la primera de les exigències i això obliga a un marc ètic professional que cal refermar. I cal refermar-lo perquè altrament el comercialisme fa via, i estic convençut que només més professionalisme evita més comercialisme.

L’eficiència que sorgeix de la innovació tecnológica en salut requeriria un capítol apart. Tant sols assenyalaré que malgrat els esforços en avaluació encara no som capaços de establir criteris clars sobre allò que aporta valor realment i quina quantia de recursos podem aplicar-hi. Més tecnologia no sempre és millor, i el sector salut acumula tecnologia i no la prioritza com caldria, és el que n’he dit recentment en un article el síndrome TMT, too much tecnology.

A les tecnologies de la informació hi hem dipositat moltes expectatives, però el sector salut és extraordinàriament lent en adoptar-les. El 2009 teníem 51,1 milions de visites d’atenció primària, el 2013: 45,1 milions, 6 milions menys, això és moltíssim. No podem atribuir total la reducció del 12% a la recepta electrònica però sens dubte hi ha contribuit. I les alternatives a la visita presencial haurien de ser objecte prioritari d’atenció. La forma com s’organitzen les tasques ha de tenir en compte tots aquest desenvolupaments, una altra forma de treballar. Per cert hem reduit 6 milions de visites sense cap copagament, no afegiré res més.

- quines eines ha de tenir el meu país per fer-ho possible?

Aquesta és una qüestió cabdal, de què ens servirà saber el que cal fer si no tenim les eines d’un estat per fer-ho?

Permeteu-me dir-vos que a mi no em fa por anar a l’hemeroteca, i vull mostrar-vos el que vaig dir ara fa una dècada, si l’any 2004 en un article a Annals de Medicina que es titulava, “D’on no n’hi ha no en pot rajar, repensant l’atenció i el finançament sanitaris”.

“La contradicció està servida. Si Catalunya té més renda que la mitjana espanyola, apareixerà una tensió social per gastar més recursos. Si els recursos es reben en funció de la població, és a dir la mitjana espanyola, aleshores no es pot tancar de cap manera el cercle. La despesa sanitària pública catalana no podrà augmentar si no es modifica el seu finançament autonòmic i, en la meva opinió, si no s’estableix un sistema equivalent al concert econòmic basc i navarrès. De no resoldre’s així, la sortida natural passarà per un progressiu deteriorament de les infrastructures, fallida econòmica i, per defecte, augment de la despesa sanitària privada. Provar qualsevol altra estratègia representa posar pedaços i propines, una estratègia que des de fa 23 anys s’arrossega i que s’ha mostrat insuficient. Cal un sargit profund d’aquesta situació, que només pot oferir el concert econòmic per a Catalunya.

Malauradament, la societat catalana no és encara prou conscient d’aquest fet. I els polítics reflecteixen aquest estat d’opinió. Molts pensen que la Generalitat hi ha de dedicar més recursos i que cal demanar més almoina (crèdits extraordinaris). El problema és molt més de fons i no observo la preocupació en aquesta direcció.

Els propers mesos seran decisius per a debatre la inclusió del concert econòmic en el marc del nou Estatut d’Autonomia. En la mesura que la despesa sanitària representa una tercera part del pressupost de la Generalitat, deixar d’incloure el concert econòmic com a mecanisme de finançament suposa equivocar-se com a mínim en un terç del problema.”

I així va ser, no hi va haver concert econòmic i som on som. Han passat deu anys, que haurien pogut ser molts menys i el benestar dels ciutadans hauria pogut millorar substancialment. Es el cost d’oportunitat que socialment hem de pagar per no haver encertat en un consens que alguns consideràvem imprescindible i que ara una majoria ja el situa en un altre entorn molt més fonamentat.

És per això que si ara hagués d’escriure novament l’article ho faria esperançat. “Encara que no n’hi ha, en pot rajar”, aquest seria el títol. Ho dic sincerament. El país s’ha adonat que la construcció del benestar col.lectiu i individual passa per un nou marc polític on ens permeti satisfer els nostres anhels i desitjos, que en salut passen al final per més esperança de vida en bona salut.

Les entitats clau del país representades al Consell del Servei Català de la Salut han fet un esforç per posar-se d’acord sobre el sistema sanitari que volem, el que vam anomenar Pacte Nacional de Salut, i que de bon grat vaig coordinar. El mes de març passat vam presentar-lo al Parlament. Si bé és cert que van desmarcar-se al darrer moment els grups polítics que no donaven suport al govern-se així com sindicats, també ho és que el document final incorpora elements seus perquè la majoria hi van contribuir decisivament.

Vull dir-vos la meva impressió: més enllà de l’escenificació política no vaig saber veure projectes ni propostes alternatives allunyades que no poguessin ser objecte de debat. És per això que crec que el consens és possible i és necessari. La ciutadania reclama que els serveis de salut estiguin a l’alçada del segle XXI, i per això seria un profund error que en un moment que ja tenim aprop on poguem decidir sobre el sistema de salut no arribéssim a un consens. Les reformes exitoses només són possibles amb consens, només quan la salut i benestar dels ciutadans es posa per davant de qualsevol lluita partidista.

Us convido que llegiu el document del Pacte Nacional de Salut aquells que no el conegueu, i com bé us podeu imaginar, alguns voldríeu més concreció i d’altres el trobareu insuficient. És tant sols un punt d’arrencada.

Hem viscut les passades tres dècades amb una ficció en la política sanitària, hem sentit a parlar sovint de que teníem competència plena en la sanitat. Tant sols un cop d’ull als detalls us pot convèncer que justament hem assolit molt millor salut sense tenir-ne la clau mestre que obre totes les portes. La clau mestre que no hem tingut té quatre vessants:

- la primera és la regulació del finançament. No hem pogut decidir sobre quants dediquem dels recursos fiscals al sector salut, la quantia ha vingut restringida per un sistema de finançament autonòmic premeditadament asfixiant, com diria Trias Fargas.

- la segona és la regulació de les professions. La pedra angular de tot sistema de salut resideix en professionals que en la seva quantia i la seva qualitat i talent són els que necessita un país. No hem pogut decidir sobre això en tots aquests anys, i hem anat a remolc d’un sistema desfasat, desplanificat i desajustat entre oferta i demanda. Avui ens trobem en un moment crític per resoldre-ho, el compte enrera s’ha iniciat i personalment vull dir-vos que de tot el que he dit és el que hem preocupa més. Només si som capaços de decidir sobre això podrem redefinir millor les tasques i papers dels professionals al sistema de salut.

- La tercera és la regulació de les prestacions. En tots aquests anys hem assumit amb el finançament existent la introducció de noves tecnologies, sense poder decidir sobre la seva oportunitat i valor. La incorporació de noves tecnologies s’ha produit en un entorn poc transparent. Si avui us pregunteu quin és el preu dels nous medicaments i com es fixa hi hauria motius per la preocupació.

- La quarta es la regulació de la salut pública, fonamentalment salut internacional i global, però també per exemple aspectes de política alimentària i mediambient. En un món globalitzat, el control del reglament sanitari internacional ha d’estar al nostre abast.

Podria detallar-ho més però, deixem-ho aquí. Hem construit la política sanitària i un nou sistema de salut sense la clau mestre, i això té molt de mèrit. Hem d’estar satisfets dels resultats en salut i alhora compromesos en la seva millora. Hem de conèixer els punts forts i febles que tenim, preservar allò que funciona, canviar tot allò que calgui en la mesura que augmentem l’eficiència i l’equitat del sistema de salut.

En el fons, ja ho he dit al principi, el futur el construim tots, cada dia que passa. Ens equivocaríem si pensessim que els reptes actuals de la política sanitària són cosa tant sols dels polítics, el compromís ciutadà i el compromís professional hi tenen molt a dir. És doncs el moment de compartir i aprendre de l’experiència de tots per tal d’afrontar un futur encoratjador.

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.

Is this the end, my friend?

The last 25 years of publicly funded health care have been marked by the unique ownership structure known as consortium. Consortia allowed a joint venture between ancient non-profit hospitals created by civil society and the public administration. The underlying rationale for such an ownership structure is strictly related to capital investment demand. Since non-profit foundations could not raise enough funds to fulfill new techonology and population health needs, the public sector funded new investments and participated in the boards of directors.
These sounds quite normal, it is a historic evolution and has a clear and common sense argument. However, public sector has not been able to include depreciation and replacement costs in the tariff and this has created greater need for resources.
Unfortunately, those consortia that had management autonomy and public administration in the boards are now being dispossessed from its original owners -the non-profit foundations- and being converted into public organizations.
This is a clear social plundering commited by the spanish Parliament in a recent law. You may have more details in this article (check p.46).
Is this the end? I think so, unless there is a clear mandate to change current regulation. Its impact maybe enormous: disappearing boards of directors, employees converted into "de facto" civil servants and its equivalent remuneration, and the most important: there is no reverse gear.
It is worrying how politicians can accept such a loss of dynamic efficiency before their very eyes. It is unacceptable that social created capital can be plungered this way. Politicians can stop the end of consortia, they should stop it.

PS. Two years ago I was blogging on the same topic. Unfortunately all the alerts were neglected.

PS. Must read, on ebola by I. Hernández.

I've already said that

It is really saddening to explain the same thing again and again. Seventeen years ago I explained the regulatory mess of parallel trade of drugs in Europe. I did it in an article in Información comercial española (unfortunately not available on internet). Two years ago, I insisted on the same disaster in this post.
Now you can see how mafia style practices of well known drug distribution companies were applied, have a look a this news. Surprisingly (!), there is no specific crime in the penal code for such practices.
I said that arbitragists were accumulating impressive amounts of money with international parallel trade and refusing to supply drugs to local pharmacies.It is quite astonishing that it took so long to understand it for justice. Is there anybody doing something to prevent such practices in the future? Where are politicians? On vacation again?.

PS. The government should cancel the license to these drug distribution firms immediately and ban any possibility of a new license in future. This can be done easily without waiting for any european directive.

PS. WSJ: What Catalonia's independence vote means

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).

The role of Public Service Mutuals

PUBLIC SERVICE MUTUALS:The Next Steps

Let's start with the concept:

Public Service Mutuals are organisations which:
1. have left the public sector (also known as ‘spinning out’), and
2. continue to deliver public services, and
3. in which employee control plays a significant role in their operation.

This is exactly the same as"Entitats de Base Associativa" for Primary Care (p.38 of this journal). Only 3% of all primary care teams follow such model after 18 years (11 out of 369). Only 2 new firms were created in the last decade. It seems that there are some constraints on their development but hardly anybody is working to remove such barriers and others are creating new ones. I have always considered that this model fits perfectly with the engagement of the health professionals in the system instead of being civil servants.
In the UK, the taskforce created to analyse the situation has set up clear recommendations for the future (p.29). Maybe, right now we should replicate something similar that could reverse the trend.

PS. Another report from the King's Fund.

PS. Excellent documentary on ebola outbreak, yesterday at TV3 30 minuts, you can watch it until October 19th.

Regulation and low-value care

Swimming against the Current — What Might Work to Reduce Low-Value Care?

While reading this NEJM article on strategies to reduce low value care, I was wondering why the author has not included any regulatory tool. He explains demand and supply side strategies, as usual, and forgets the crucial role of government. It says:

Public acceptance of a role for policy in reducing the use of low value care in the United States is tenuous but increasing with growing awareness of the burden that health care spending places on federal and state budgets and with patients’ increasing exposure to health care costs.

This is a fact or an opinion of the author?. It is not an argument to avoid a key instrument widely recognised by scholars. An appropriate regulatory role is crucial to provide information and signaling the value of health benefits. No regulation or bad quality regulation contributes to a perfectly designed and costly mess.

Fasten seat belts (2)

Let me ask you a question: Do you agree that your government spends 12% of the pharmaceutical budget in a new drug? I understand that if the answer is yes, you also agree to reduce 12% of current expenditures in patented drugs, reducing quantity, price or the benefit. Otherwise you have to explain clearly where to find 12% of additional resources.
This is what is happening in the UK NHS on new Hepatitis C drug. Have a look at this site for the details. And by now the decision is that it is "prohibitive" and "unaffordable".
Last Sunday CBS 60 minutes broadcasted an interesting report on "eye popping" cost of cancer drugs. I suggest you spend 15 minutes of your time watching it:



Don't miss the details on "financial toxicity" as WSJ highlights. How this can be true?
Nearby, new drug benefits are approved without any known cost-effectiveness-budget impact consideration. This is an example of  alleged "responsive government".

PS. My former post on the same issue.

PS. On bribes, again.

PS. Today this blog has reached the 100.000 visits. That's excellent!!!. I really appreciate your interest in my posts.

The seven damaging dilemmas

Rock, Paper, Scissors: Game Theory in Everyday Life

Let me pick the seven deadly social dilemmas from this book:

• Prisonner Dilemma, when communication between two people is not possible and this prevents any cooperation that would end in mutual profit.
• The Tragedy of the Commons, which is logically equivalent to a series of Prisoner’s Dilemmas played out between different pairs of people in a group.
• The Free Rider problem (a variant of the Tragedy of the Commons), which arises when people take advantage of a community resource without contributing to it.
• Chicken (also known as Brinkmanship), in which each side tries to push the other as close to the edge as they can, with each hoping that the other will back down first. It can arise in situations ranging from someone trying to push into a line of traffic to confrontations between nations that could lead to war, and that sometimes do.
• The Volunteer’s Dilemma, in which someone must make a sacrifice on behalf of the group, but if no one does, then everyone loses out. Each person hopes that someone else
will be the one to make the sacrifice, which could be as trivial as making the effort to put the garbage out or as dramatic as one person sacrificing his or her life to save others.
• The Battle of the Sexes, in which two people have different preferences, such as a husband who wants to go to a ball game while his wife would prefer to go to a movie. The catch is that each would rather share the other’s company than pursue their own preference alone.
• Stag Hunt, in which cooperation between members of a group gives them a good chance of success in a risky, highreturn venture, but an individual can win a guaranteed but lower reward by breaking the cooperation and going it alone.

Think for a similar situations in recent cases in close politics and health policy and management. For sure the improvement on the final resolution is related with this statement:

Cooperation would lead to the best overall outcome in all of these cases, but Nash’s trap (which is now called a Nash equilibrium) draws us by the logic of our own self-interest into a situation in which at least one of the parties fares worse but from which they can’t escape without faring worse still.

And if this is so, what then must we do?

• Changing Our Attitudes: If we came to believe that it was immoral to cheat on cooperation, for example, that would obviously help to resolve many social dilemmas.
• Benevolent Authority: Relying on an external authority to enforce cooperation and fair play.
• Self-Enforcing Strategies: Developing strategies that carry their own enforcement so there is no incentive to cheat on cooperation once it has been established. 

And if this is so, how can we implement it?
And so on... 

Fasten seat belts

We have entered into an unknown new world: drug prices -for innovative drugs- are on track to disappear. The NHS has agreed a cap on expenditure for a hepatitis C (sofobusvir) new drug in €125m without disclosing the unit price. Some people may consider it an opaque strategy in times that politicians claim transparency.
In my opinion, such a situation allows to understand better that the pharmaceutical market for innovative drugs is mostly a monopsony (one buyer) in a monopoly (one seller), it is not a competitive market - and this is what I have always considered. Therefore, resource allocation is the result of a bargaining between both parties, and the unit price is irrelevant. The buyer wants to maximize health,  the seller is maximizing income, this is exactly the struggle.
The key question is: How much is NHS willing to pay for better health?. As far as  the budget is limited, the number of treatments times the price is not the right way to proceed to maximize health under constrained resources.
Any government has to set priorities for expenditure according to expected health value created. This information should be public. In any case, when a new drug is available the government should clearly define which benefits are cancelled and which are acceptable. A responsible minister can't  agree new expenditures without any budget.
Therefore, innovative pharmaceutical market is not really a market -right now is clear- and governments should set priorities according to resources available -right now is also clear that they haven't done it-.
Fasten seat belts, we are entering into trying times without any political compass-gps. Citizens are expecting something different. I still remember when Victor Fuchs told long time ago: usually health economists discuss incremental cost-effectiveness in limited marginal terms, the real issue appears when such an amount is enormous. The case of hepatitis C is the example of such a situation, and only health policy and deliberative democracy are the tools to confront it. Unfortunately, this was not the strategy applied nearby.

PS. Catalonia in contention, at Harvard Political Review. Must read, if you are interested on what's going on. Otherwise, try Bloomberg op-ed or LAtimes.

PS. Reading Francesc-Marc Alvaro op-ed I always learn something.

PS. Rating catalans' well-being by OECD.

Ricard Molina. Muntaner-Velódromo. Galeria Barnadas

Bundled payments, update

While I was reading the HA blog I  thought that the word innovation is like a joker, when somebody has a real concern about potential income in the future, any change may harm innovation. The current situation in US of bundled payments is still embryonic and biased towards certain services. Bundled payments need to be holistic, not partial in order to deliver clear results. Otherwise, incentives in non-regulated areas increase. Maybe those that are concerned with innovation will move towards such areas...

Fines, settlements and reputation

Reputation Capital: Building and Maintaining Trust in the 21st Century

In the last decade there has been a proliferation of cases of fraudulent marketing practices and bribery in pharmaceutical industry. In the case of US you may check the details at Propublica. In EU we don't have a similar summary (as far as I know). The latest case in EU involves 6 companies and fines of €427m . In China, the latest case is about $500m fines for bribery. This case was started by an anonymous whistleblower.
While it is no surprise that pharmaceutical industry reputation is weak, corporate social responsibility is still supported by the firms. I can't understand why. In the page 347 of this book you'll find a chapter on this issue: "Is there no prescription? Reputation in the pharmaceutical industry". It says:

If the pharmaceutical industry does not present itself in an active and self-confident way, it cannot expect the situation to improve. For, apart from itself, it has no other advocates

Behavioral Forensics: Why Good People Do Bad Things

A.B.C.'s of Behavioral Forensics: Applying Psychology to Financial Fraud Prevention and Detection

The fraudsters paradigm explained in one book: the bad Apple (rogue executive), the bad Bushel (groups that collude and behave like gangs), and the bad Crop (representing organization-wide or even societally-sanctioned cultures that are toxic and corrosive). As far as fraud and corruption is a nowadays critical issue, understanding what to do about it, is required.
A remarkable statement from the book:

Being curious is indispensable, and asking the right questions is the only way to get to the bottom of things. Once fraudsters realize that they are not dealing with fools, they are usually smart enough to back off. The potential fraud is then nipped in the bud or successfully foiled. The power of asking the right question increases logarithmically as one moves up the organization; indeed, the most important omission is the unasked question.

 Didier Lourenço at Galeria Barnadas                        

Unwarranted variations, what's next?

Geographic Variations in Health CareWhat Do We Know and What Can Be Done to Improve Health System Performance?

We all know that there are unwarranted variations in health care. Unfortunately we haven't the same analysis about the drivers and its impact on health outcomes for such variations. OECD has just released a report on this topic, and suggests the following:

Eight types of policies might be envisaged:
• Public reporting on geographical variations, in order to raise questions among stakeholders and prompt actions, particularly in “outlier” regions.
• Setting targets at the regional level can support public reporting and help promoting  appropriate use.
• The re-allocation of resources to increase (or reduce) supply of resources (e.g., beds, doctors) in regions with low (or high) utilisation rates.
• Establishment and implementation of clinical guidelines in order to promote greater consistency in clinical practice.
• Provider-level reporting and feedback to improve clinical practice and discourage unnecessary provision of health services.
• Changes in payment systems to promote higher (or lower) use when there is high suspicion of underuse (or overuse).
• The measurement of health outcomes, to promote greater consistency in clinical practice that ensures improved patient outcomes.
• The utilisation of decision aids for patients, to promote more informed decisions about benefits and risks of various interventions, and to better respond to patient preferences.

These proposals fall short in my opinion. After a decade of publishing information on variations, public reporting has not raised deep questions for "stakeholders", at least as far as I know. Incentives have not changed substantially in order to reduce differences in utilization. Current payment systems require a redefinition from scratch in order to take into account such issues. Any citizen should be concerned about the results of the report. Something should be done.

PS. By the way, regarding OECD recommendations, they have not explained clearly what Wennberg suggested: shared decision making

PS. Bad journalism at LV. Why CAC doesn't care about complaints on written press.

Ferrando at Galeria Barnadas

How newcomers become bureaucrats?

Becoming Bureaucrats Socialization at the Front Lines of Government Service

It is quite surprising how public service management usually is considered from a reductionist perspective. Some people think that if we understand the rules and incentives that underlie in public service, then we can understand its performance. The constraints to change the factors that drive performance are well known and it seems that nothing can be done to surpass inertia.
A new book provides fresh air on this issue. It argues that:

Bureacratic behavior follows a logic of appropriateness (LOA). This decision-making theory, developed by James March and Johan Olsen, suggests that organizational behavior is associated with norms that individuals develop about what constitutes appropriate, exemplary behavior

A key message:

The traditional understanding that bureacracies change people may be true but beside the point. More important , in this account, is how bureacracies find people and how people find them.

I still don't understand why most physicians-nurses-... in NHS must be civil servants. I have said that many times and nobody has been able to find an argument. In my opinion this is one of the pieces that reflects an outdated system without the possibility to break its inertia.

Outsourcing boards of directors?

BOARDS-R-US:RECONCEPTUALIZING CORPORATE BOARDS

A comment in The Economist suggests a new approach: outsourcing boards of directors. Such a strategy would be justified to solve the current widespread and deep-rooted problems. They provide some examples and we all know some disfunctions. However, such proposal is open to dispute and the conflicts of interest that may arise may not compensate the professional approach of such "firms". On the other hand something should be done and may be this is an interesting approach for publicly owned firms as far as they are not exposed to market competition. Health care could be an example of a sector to experiment and to improve providers' governance.
The original article is in Stanford Law Review.

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?