May 30, 2016

Giving the priority to the worse off


Finally I've found a book that explains the concept of egalitarianism and its implications with a clear message.
Distributive justice is an area not only of philosophy, but also of several other academic disciplines. For example, the formal analysis of economics is extremely important and valuable for understanding the structure of egalitarian theories of distributive justice. However, it intimidates some people. I believe that the most fruitful way to present theories of distributive justice is to integrate the results of economics and political theory into philosophical analysis.
The concept:
Egalitarianism: a class of distributive principles, which claim that individuals should have equal quantities of well-being or morally relevant factors that affect their life.
What it is not egalitarianism, but maybe you are not aware of:
There are at least four well-known distributive principles that are not egalitarian in the sense I defined above, yet some people think that these are egalitarian in some sense.

The first example is utilitarianism. Utilitarianism can be defined in various ways. Take classical utilitarianism. Classical utilitarianism contends that an act is right if and only if it maximizes the total sum of people’s well-being in a given society. When we calculate the total sum, we assign equal weight to each person’s well-being and simply add up different people’s well-being. Classical utilitarianism endorses assigning equal weight
to every person’s well-being, and it might be claimed that it is egalitarian. However, it is not concerned with how people’s well-being is distributed. Thus, I do not consider it as a form of egalitarianism.

The second example is libertarianism.

The third is the Marxist principle of justice or communism

The fourth is the proportionality principle.
The book reviews several perspectives on egalitarianism with concrete descriptions and comments:
1 Rawlsian egalitarianism
2 Luck egalitarianism
3 Telic egalitarianism
4 Prioritarianism
5 Sufficientarianism
And two specific chapters:
6 Equality and time
7 Equality in health and health care

The chapter on health is specially welcome and is a required reading for health economists, and for supporters of QALYs:
It is obvious that the principle of QALY maximization is utilitarian in spirit. It adds up different people’s good, and claims that we should choose the allocation that maximizes the total good. In the context of health care resource allocation, the good is QALY, which measures health benefit. QALY is added up across individuals to estimate the goodness of different outcomes. Then, the alternative that maximizes the goodness of outcome is chosen. It is not surprising that, according to QALY maximization, it does not matter how QALYs are distributed across individuals. Needless to say, all sorts of objections leveled against utilitarianism are raised against QALY maximization.
Usually, QALY maximization is understood as the unweighted sum of QALYs. However, it does not need to be so.We can make it a weighted sum and give priority to the worse off. If we give priority to the worse off, then it is possible to bring egalitarian concerns to bear on the allocation of health care resources.
One chapter is not enough to disentangle the complexities of QALYs, but it is worth reading.

At the end the author explains his position:
My preferred distributive principle is the aggregate view of telic egalitarianism. I am not
willing to support Rawls’s difference principle, because I agree with Harsanyi(1975) that the difference principle in practice ignores the benefits to the non worst off groups and therefore fails to secure the stability of the basic structure of society. This stands in opposition to Rawls’s claim that the difference principle, together with other principles of justice, guarantees a satisfactory minimum, and therefore secures the stability of the basic structure.
My view is coincidental with the author.

PS The concept of telic (telelological) egalitarianism:

There are two main ways in which we can believe in equality. We may believe that inequality is bad. On such a view, when we should aim for equality, that is because we shall thereby make the outcome better. We can then be called Teleological – or, for short, Telic – Egalitarians. Our view may instead be Deontological or, for short, Deontic. We may believe we should aim for equality, not to make the outcome better, but for some other moral reason. We may believe, for example, that people have rights to equal shares. (Parfit 2000: 84)

May 20, 2016

Taxing the rich to feed the leviathan

Taxing the Rich: A History of Fiscal Fairness in the United States and Europe

In deep endebted states, the endless debate about direct taxes finally relies on one thing, where is the money to raise more resources?. Nowadays, you'll notice a different formulation, focused on redistribution: we want to raise more money to redistribute to those with unfulfilled needs.
A new book is specially welcome to clarify all the concepts in a politicaly troubled moment:
We argue that societies do not tax the rich just because they are democracies where the poor outnumber the rich or because inequality is high. Nor are beliefs about how taxes influence economic performance ultimately decisive. Societies tax the rich when people believe that the state has privileged the wealthy, and so fair compensation demands that the rich be taxed more heavily than the rest.
When it comes to thinking of what tax policy is best, few would disagree with the notion that governments should be-in part guided by fairness. It is a term used frequently by those on both the political left and right.1 How can this be? History suggests that the concept of fairness is up for grabs. Standards of fairness in taxation vary greatly across countries, over time, and from individual to individual.
If we believe that
 Political support for taxing the rich is strongest when doing so ensures that the state treats citizens as equals. Treating citizens as equals means treating them with "equal concern and respect".
Then, we'll agree that the current debate on taxing the rich in our country is absolutely biased and intentionally partisan. With this approach we can't build a new country.
What a country decides about taxes on the rich has profound consequences for its future economic growth and the distribution of economic resources and opportunities
Therefore, this is the book to read for those that have to prepare the next public budget, and for any citizen, a must read.

PS. A good comment on the book.

May 13, 2016

Trade-offs between publicity and secrecy in drug regulation

Secret-Public Voting in FDA Advisory Committees
Secrecy and Publicity in Votes and Debates

Most of us can remember the withdrawal of antiinflamatory drug Vioxx in 2004. And some of us still wonder about the FDA responsibility and its experts committees on that sad affair.
Criticism reached a peak in February 2005 following the work of a committee set up to determine whether or not two of Pfizer’s anti-inflammation medicines, CelebrexR and BextraR , should remain on the market and whether Merck’s anti-inflammation drug VioxxR could be approved again for marketing. The vote – a close one, slightly in favor of the highly controversial BextraR and VioxxR – surprised the informed public and raised suspicions, leading The New York Times to commission a study on committee members’ financial ties. It turned out that ten members (out of thirty-two) had financial ties with one or more drug companies, most with Pfizer (Harris and Berenson 2005; CSPI 2005). As the critics saw it, this was a sign that advisory committees themselves, like FDA’s top management before them, had come under the influence of the drug industry.
After that, the FDA changed its rules for voting to simultaneous and visual methods rather than oral. This option avoids the anchoring effect of first voters. But secret voting was never contemplated.
This is exactly the issue that is addressed in a chapter of the book Secrecy and Publicity in Votes and Debates and now that everybody backs transparency, it's a good moment to stop and read this chapter at least.
So although public voting may be preferred because it allows external actors to monitor expert behavior, secret voting may appear desirable as a means of preventing conformism among experts. Thus, the value of the voting method may depend on of the audience considered: other voters or external actors. There is, however, one procedure that reconciles the benefits of publicity and secrecy, and that is to vote secretly but reveal who voted how after the vote count has been recorded. This method, used in Dominican monasteries in the thirteenth century in a process called the scrutinium (Gaudemet 1979, p. 326) and recommended by Bentham (1999, p. 106), may be termed, following Jon Elster (2013), “secret-public voting.”
 The FDA 2007 reform replaced public voting with secret-public voting, but it also  replaced oral voting, which left ample opportunity for individual members to express
themselves, with “manual” followed by digital voting, which precludes all such expression.
These statements prompt many questions about how our close advisory committees are taking decisions. I don' know any detail about it. And details are important, specially if there are lives at stake.

May 12, 2016

Clap your hands

This is exactly what we have to do after reaching 150.000 visits to this blog!. Thank you so much for your interest!

Today just listen to Parov Stelar: Clap your hands

Clap your hands!
And you swing out wide.
Stomp your feet!
You swing out wide.
Do a bump!
And you swing out wide.
Truck a little bit.
Beat it out and
make it!
Everybody's happy when they're doing the jive.

May 8, 2016

Platforms, a business model (2)

A long long time ago Michael Porter wrote Competitive Strategy a book that has been used as the bible of strategy.
Porter’s model identifies five forces that affect the strategic position of a particular business: the threat of new entrants to the market, the threat of substitute products or services, the bargaining power of customers, the bargaining power of suppliers, and the intensity of competitive rivalry in the industry. The goal of strategy is to control these five forces in such a way as to build a moat around the business and thereby render it unassailable.
Thus, when a firm can erect barriers to entry, it can keep competitors out, and entrants with substitute products cannot storm the castle. When a firm can subjugate suppliers, competition among them weakens their bargaining power so the firm can keep its costs low. When a firm can subjugate buyers by keeping them relatively small, disunited, and powerless, the firm can keep its prices high.
In this model, the firm maximizes profits by avoiding ruinous competition for itself but encouraging it for everyone else in the value chain. Advantage is found in industry structures that create a protective moat—one that enables the firm to segment markets, differentiate products, control resources, avoid price wars, and defend its profit margins.
For decades, companies have studied the five forces model and used it to guide their decisions about which markets to enter and exit, what mergers or acquisitions to consider, what sorts of product innovation to pursue, and what supply chain strategies to employ.
Now platforms add a new perspective,
Enter platforms. Many of the insights embodied in the five forces, resource-based, and hypercompetition models remain valid, but two new realities are now shaking up the world of strategy.
First, firms that understand how platforms work can now intentionally manipulate network effects to remake markets, not just respond to them. The implicit assumption in traditional business strategy that competition is a zero-sum game is far less applicable in the world of platforms. Rather than re-dividing a pie of more-or-less static size, platform businesses often grow the pie (as, for example, Amazon has done by innovating new models, such as self-publishing and publishing on demand, within the traditional book industry) or create an alternative pie that taps new markets and sources of supply (as Airbnb and Uber have done alongside the traditional hotel and taxi industries). Actively managing network effects changes the shape of markets rather than taking them as fixed.
Second, platforms turn businesses inside out, moving managerial influence from inside to outside the firm’s boundaries. Thus, a firm no longer needs to seize every new opportunity on its own; instead, it can pursue only the best opportunities while helping ecosystem partners seize the others, with all partners sharing the value they jointly create.13
These two new realities add a dramatic layer of complexity to business competition. Platform strategy resembles traditional strategy much the way three-dimensional chess resembles the traditional game.14 Within the ecosystem, the lead firm negotiates dynamic tradeoffs involving competition at three levels: platform against platform, platform against partner, and partner against partner.
These are excerpts from the book "Platform revolution" a must read if you want to understand what's going on in value creation in a connected world. In chapter 12 you'll find some comments on health sector, very succint and general.

May 6, 2016

A prescription for pharmaceutical expenditure, is there any one?

Pharmaceutical Expenditure And Policies

If you want to know what's going on in OECD countries on pharmaceuticals, just read this paper. The challenges are huge, and policy answers are delayed. My impression is that beyond the standard approach (the one in the paper), somebody should start talking about priorities for research and innovation according to health needs and potential benefit from recent advances in basic science. There is a need for a dialogue between firms and governments about it. Just a signaling game, saying how much are willing to pay for new innovations if they fit with health needs and potential benefit.

PS.Drug prices: Tweaking the formula excellent article in FT

April 30, 2016

Income and longevity, almost all you need to know

The Association Between Income and Life Expectancy in the United States, 2001-2014 

The estimates of impact of income on longevity are now available for US. And the results are clear. The summary of the article in 4 statements:
First, higher income was associated with greater longevity throughout the income distribution.The gap in life expectancy between the richest 1% and poorest 1% of individuals was 14.6years (95% CI, 14.4to 14.8years) for men and 10.1 years (95% CI,9.9 to 10.3 years) for women.
Second, inequality in life expectancy increased over time. Between 2001 and 2014, life expectancy increased by 2.34 years for men and 2.91 years for women in the top 5%of the income distribution, but by only 0.32 years for men and 0.04 years for women in the bottom 5%(P < .001 for the differences for both sexes).
Third, life expectancy for low-income individuals varied substantially across local areas. In the bottom income quartile, life expectancy differed by approximately 4.5 years between areas with the highest and lowest longevity.Changes in life expectancy between 2001 and 2014 ranged from gains of more than 4 years to losses of more than 2 years across areas.
Fourth, geographic differences in life expectancy for individuals in the lowest income quartile were significantly correlated with health behaviors such as smoking(r = −0.69,P < .001),but were not significantly correlated with access to medical care, physical environmental factors, income inequality, or labor market conditions. Life expectancy for low-income individuals was positively correlated with the local area fraction of immigrants (r = 0.72, P < .001), fraction of college graduates (r = 0.42, P < .001), and government expenditures (r = 0.57, P < .001). 
Differences are huge. Confronting the issue from a policy perspective is not that easy. Individual health behaviors are the key to understand what's going on.

PS. Inequality on income or wealth?. This could be the next article...

Josep Segú
Encants Nous, oli sobre tela, 80 × 220 cm

April 29, 2016

European health regulation on lab tests, the final round? (2)

Last week, Theranos clinical lab has received more bad news. Though the final resolution is still pending, all available informations raise concerns about the acuracy of such lab.Could this happen in Europe? My feeling is that the outdated and obsolete regulation could replicate the story.
In Europe, in vitro diagnostics regulation was decided 18 years ago!. The last proposal debated two years ago in the Parliament got no final agreement. I have explained the inefficiency of european parliament formerly. Health care safety and quality deserves better regulation and specially in lab tests.
Beyond safety issues, the value of lab tests require deeper assessment. Current proposals are not taking into account properly this issue. Now is the moment to introduce it in the final proposal, otherwise it will forgotten for the next two decades.

PS. Have a look at this article: A Systematic Review of Health Economic Evaluations of Diagnostic Biomarkers

Manhattan i Queens (Fragment), oli sobre tela, 60 × 150cm

Platforms, a business model

Platform scale

Platform Scale (n): Business scale powered by the ability to leverage and orchestrate a global connected ecosystem of producers and consumers toward efficient value creation and exchange.

The new hype on business models is around platforms. Well, this is not new, a decade ago David Evans wrote Catalyst Code but its impact was limited. Now "Platform scale" and "Platform revolution" are the two required business books. If you want to understand the economic foundations go to "Platform Economics".
The topic requires more elaboration than a post in a blog. How this trend affects health care in practice remains to be seen.
The Platform Manifesto
1. The ecosystem is the new warehouse
2. The ecosystem is also the new supply chain
3. The network effect is the new driver for scale
4. Data is the new dollar
5. Community management is the new human resources management
6. Liquidity management is the new inventory control
7. Curation and reputation are the new quality control
8. User journeys are the new sales funnels
9. Distribution is the new destination
10. Behavior design is the new loyalty program
11. Data science is the new business process optimization
12. Social feedback is the new sales commission
13. Algorithms are the new decision makers
14. Real-time customization is the new market research
15. Plug-and-play is the new business development
16. The invisible hand is the new iron fist

April 17, 2016

Economic Ethics

Oxford Handbook of Professional Economic Ethics

Some economists, while watching the film Inside job, were astonished by Martin Feldstein statements and justifications of banks with toxic assets. I was one of them. Too many conflicts of interest sorrounded his words. When I saw him, I thought, this is the "health economist" that wrote: Economic Analysis for Health Service Efficiency: Econometric Studies of the British National Health Service. n 1967 (!). This was one of my first readings in health economics many-many years ago.
While I was reading the following paragraph in a new book, I thought that the topic deserved a deeper approach to economists' ethics:
The question of whether there is a profound tension between our professional norms and our self interest deserves careful attention. Conflict of interest in economics gained much  (unwanted) attention after the documentary Inside Job accused some finance economists of doing analysis favorable to financial industry interests while receiving undisclosed  pay from those same interests. Even if you believe, as I do, that Inside Job was unfair to some of its targets, it did fuel a crisis of confidence in economists that we all have a  strong interest in correcting. The response has been to strengthen the norms that we  disclose possible conflict of interests in our research and policy recommendations; this is surely a good thing. An example from my own field of development is that researchers on foreign aid should disclose whether they are employees of or consultants to agencies  dispensing foreign aid (or conversely, recipients of funding from antiaid interests).
Yet the issue of conflict of interest is too complex to be so quickly dismissed by a simple  disclosure requirement.
The handbook by DeMartino and McCloskey is an excellent contribution to shed some light on the issue:
The case for economic ethics is simple and, we think, undeniable. Economists enjoy tremendous influence today over the life chances of others—innumerable others. That is the heart of the matter. The influence of economists arises from their expertise in a field vital to social wellbeing,
freedom, and other valued goals. As economists know better than anyone, when you monopolize a resource that others need, you exert power over them. Moreover, in recent years, economists’ influence has been amplified by institutional developments. Independent central banks, the  multilateral development banks, and other international financial institutions are often in a position to set economic policy and even engage in social engineering without much oversight by elected  officials or the public. Economists are at the helm of such institutions and occupy staff positions in the departments where the actual work gets done. Combined with its intellectual monopoly,  institutional power enhances the ability of the economics profession to alter the course of human affairs—for the better, of course, but also, sometimes, for the worse.
Influence over the lives of others, which can be immense, coupled with the risk of doing even substantial foreseeable and unforeseeable harm, implies that economic practice is ethically fraught. And yet the profession largely manages to ignore the attending burdens. Perhaps because economists understand that harm is universal in economics, the Hippocratic tradition appears to offer no insight into how economists should comport themselves. What does “do no harm” mean in a world where there are no free lunches and where all actions (including doing nothing) entail tradeoffs? And perhaps because economists often paint on big canvases, where they affect the lives of thousands or even millions of people all at once rather than individual clients one by one, clinical ethics seems largely irrelevant. The scale of economic interventions generates among economists a fear that serious and open engagement with professional ethical issues  would paralyze them with doubt in those moments of human need when what is called for instead is focused audacity.
 This is a real call for action into an improvement of practices and behaviors of economists.

Art Basel Hong Kong

April 15, 2016

Where is the trade-off?

The fallacy of the equity-efficiency trade off: rethinking the efficient health system

What goes first? An equitable health system or an efficient one?. You'll see in some textbooks this biased trade-off formulation.
 A more appropriate question would be, “what is more important for a population, a health system that delivers equitable (fairly distributed) health outcomes or a health  system that maximises health gains?” The difference between the meaningless first question (which does not contrast outcomes) and the potentially meaningful second question (which does contrast outcomes) is critical.
 On a continuum of health gains and equity, possible goals of a health system include:
✯ Achieving the greatest health gains for a given input without regard to whether this means concentrating the gains in one (social) group: a traditional health outcomes focus,
✯ Achieving the fairest distribution of health for a given input without regard to the actual level of health achieved: a non-traditional outcome focus on (one form of) health equity, and
✯ Achieving an appropriate balance between the greatest health gains for a given input subject to the constraint of fairly distributing the health gains across social groups: an outcome balancing health equity and health gains
If finally there is a prioritisation on waiting lists, we would focus on the third option. Unfortunately I wrote a post 5 years ago on the same topic...and still waiting for its application.

PS. The trade off started with A. Okun 40 years ago, from a macroeconomics perspective. Have a look at the anniversary at Brookings.

PS. "Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases. Thus, public health is concerned with the total system and not only the eradication of a particular disease." WHO dixit. Can you imagine asking citizens about a Public Health Survey?. The term doesn't make any sense. All over the world the common term is Health Survey if you want to ask people about their health perception, except in Catalonia. So weird, somebody should check it, maybe it's a mistake.

April 14, 2016

The badness and the wrongness of inequality

 On inequality

Two ideas from the philosopher Harry Frankfurt: (1) from a moral point of view, economic equality does not really matter very much, and (2) there is a misunderstanding of the relationship between treating people equally and treating them with respect.

Both ideas are covered in an new book. Some selected statements:
Economic equality is not, as such, of any particular moral importance; and by the same token, economic inequality is not in itself morally objectionable. From the point of view of morality, it is not important that everyone should have the same. What is morally important is that each should have enough. If everyone had enough money, it would be of no special or deliberate concern whether some people had more money than others. I shall call this alternative to egalitarianism the “doctrine of sufficiency”—that is, the doctrine that what is morally important with regard to money is that  everyone should have enough.
Some philosophers believe that an equal distribution of certain valuable resources, just by virtue of being egalitarian, is a significant moral good. Others maintain that what actually is of moral importance is not that the resources be distributed equally but that everyone enjoy the same level of welfare. All of these philosophers agree that there is some type of equality that is morally valuable in itself, quite apart from whatever utility it may possess in supporting efforts to achieve other morally desirable goals.
It is easy to confuse being treated with the sort of respect in question with being treated equally. However, the two are not the same. I believe that the widespread tendency to exaggerate the moral importance of egalitarianism is due, at least in part, to a misunderstanding of the relationship between treating people equally and treating them with respect. The most fundamental difference between equality and respect has to do with focus and intent. With regard to any interesting parameter—whether it pertains to resources, welfare, opportunity, rights,  consideration, concern, or whatever—equality is merely a matterof each person’s having the same as others. Respect is more personal. Treating a person with respect means, in the sense that is germane here, dealing with him exclusively on the basis of those aspects of his particular character or circumstances that are actually relevant to the issue at hand.
Demands for equality have a very different meaning in our lives than do demands for respect. Someone who insists that he be treated equally is calculating his demands on the basis of what other people have rather than on the basis of what will accord with the realities of his own condition and will most suitably provide for his own interests and needs. In his desire for equality, there is no affirmation by a person of himself. On the contrary, a concern for simply being equal to others leads people to define their goals in terms that are set by considerations other than the specific requirements of their own distinctive nature and of their own circumstances. It tends to distract them from recognizing their most authentic ambitions, which are those that derive from the character of their own lives, and not those that are imposed on them by the conditions in which others happen to live.
I found the reference while reading The New Rambler. You'll find there the critical view. Strongly recommended for those interested in this topic and specially those that reject demagogy on using this term.

April 12, 2016

The key piece of gear

La peça clau de l'engranatge

This is the original version of my abridged op-ed in El Punt Avui published last Sunday. (in catalan, you may use Google translator)

Tots aquells que han intentat definir les característiques determinants d’un sistema de salut eficient acaben observant que la coordinació assistencial esdevé una peça cabdal. Això vol dir que la presa de decisions clíniques és més acurada quan diferents professionals i organitzacions treballen en la mateixa direcció, la de millorar la salut i qualitat de vida de les persones. Dit així sembla força elemental, però la realitat és més complexa. Davant d’un procés d’atenció calen moltes aportacions diferents, des de molts àmbits diferents, amb un nivell de qualitat determinat. L’engranatge ha de funcionar sense grinyolar ni una mica.

Hayek fa 70 anys explicava en un article clàssic -“The use of knowledge in society”- com el mecanisme de preus és un instrument extraordinari per coordinar les decisions econòmiques, i com una peça d’informació tant limitada era capaç d’orientar les accions dels que produeixen i dels que consumeixen. En realitat, sabem que és va quedar curt i per tant sense desmerèixer el potencial del mecanisme hi ha prou evidència de les seves mancances si el prenem de forma aïllada.

El sector salut és un exemple de com la formació dels preus és controvertida per la pròpia naturalesa  de l’activitat.  L’oferta i la demanda de serveis assistencial no es coordinen majoritàriament pel mecanisme de preus, són els prescriptors que determinen quins altres professionals i organitzacions han de prendre part en la cadena de valor. És el criteri professional el que guia les decisions en el marc d’unes organitzacions sanitàries que tenen les seves regles de funcionament. I aquesta peça clau de l’engranatge és la fonamental: la de l’organització sanitària integrada que és capaç de definir rutes assistencials davant problemes de salut. Es tracta de definir qui fa què, quan i com. I això esdevé encara més rellevant en el cas de les malalties cròniques, motiu pel qual el Pla de Salut a Catalunya hi ha situat tot l’èmfasi de forma molt encertada.

Substituïm doncs els preus pel professionalisme en la coordinació i assignació de recursos, però no n’hi ha prou. Tota organització té un disseny d’incentius, d’allò que motiva l’acció per part dels seus membres, el professionalisme n’és una part però n’hi ha d’altres. La cultura organitzativa i els valors que la sustenten són determinants del comportament dels diferents actors. El valor que s’atorga al mèrit professional, a l’esforç, i a la qualitat esdevé singular de cada organització. Quan una organització és incapaç de enaltir l’excel·lència i reconèixer-la, aleshores hi ha dues possibilitats: aquells que s’han esforçat no es consideren reconeguts i se’n van – encara que algunes vegades ho fan parcialment-, o tots plegats acaben al que se’n diu regressió a la mitjana. En ambdós casos, hi ha una pèrdua potencial per a tothom. Cal dir que no em refereixo a una qüestió estricta del que se’n diu incentius tipus “pal o pastanaga”, de resposta a un estímul concret. Cal triar entre el context de “mediocràcia” o meritocràcia que és el que defineix l’actitud, el contracte implícit.

Per tal d’assolir la integració assistencial de forma exitosa cal garantir uns incentius acurats. L’enfoc professionalista és necessari però no suficient. I aquests incentius inacurats és precisament la història del que s’ha esdevingut a Catalunya des del 2003, quan va començar la prova pilot de compra poblacional en el sistema sanitari públic.  En aquell moment, determinades zones geogràfiques van assajar d’impulsar organitzacions sanitàries integrades a canvi d’una compensació de l’activitat de forma capitativa. Es trencava doncs des d’aquell moment el criteri de volum, quan més fas més gran és la compensació. S’entrava en una nova dinàmica on el conjunt de serveis de salut poblacionals de proximitat es compensaven pel nombre d’habitants. La innovació era extraordinària i de nivell, anava en la direcció correcta. En alguns casos va mostrar uns resultats excepcionalment bons. Però com sempre, una bona idea aplicada a mitges o sense calibratge fi en el temps, es dilueix. Lluny de reconèixer les mancances en l’aplicació, fins i tot sortien aquells que assenyalaven el desencert del pagament capitatiu.

Ens cal un exercici d’humilitat i aprendre de les realitats recents. El sistema sanitari català té un elevat potencial per desenvolupar l’atenció integrada però té males peces al teler. La primera de totes és el disseny institucional. L’obsessió per la controvèrsia “públic-privat” ens ha fet perdre el guió de la pregunta clau, quins són els valors i quins resultats volem. Si el principi que pretenem preservar és que no hi hagi distribució dels beneficis quan el finançament és públic, aleshores el problema està acotat i no cal donar-hi més voltes. Afecta molt marginalment al conjunt. La segona peça és la següent: si l’objectiu que pretenem és assolir el millor nivell de salut amb els recursos disponibles, aleshores ens hem de preguntar quins són els resultats relatius de les diferents organitzacions i professionals, i  admetre que cal compensar  diferencialment l’esforç per l’excel·lència i la qualitat. Si a tots els professionals i organitzacions se’ls assigna un criteri homogeni de compensació sense ajustar pel valor, aleshores cal alertar la ciutadania que no val queixar-se, tindrem el sistema de salut que no motivarà prou l’assoliment d’objectius. L’equitat s’haurà aigualit en l’igualitarisme. Al final, els incentius sempre treballen en la seva pròpia direcció. Quan algú interpreta uns resultats d’un sistema com erronis, insuficients o millorables, cal que pensi també que són la conseqüència dels incentius. És a dir, que els incentius dissenyats han conduït a un resultat perfectament equivocat.

Ara tenim davant nostre el repte de la integració social i sanitària al costat de la transformació digital del sistema de salut. No es tracta tant sols de la integració assistencial, ara més que mai cal incentivar l’excel·lència i la qualitat en un entorn d’estancament pressupostari profund. El sistema de pagament dels serveis assistencials que s’ha aplicat d’ençà del decret de 2014 i la compensació dels professionals requereix una revisió en profunditat que no es resoldrà amb tímids ajustos segons entorn socioeconòmic. L’entorn està canviant massa ràpid i la regulació ha de refer-se des dels seus fonaments. Altrament tothom resta avisat, tindrem el resultat d’acord amb  els incentius que hem dissenyat. Som a temps d’escollir entre apostar per la “mediocràcia”, un sistema de qualitat mitjana, o d'excel.lència si incorporem la meritocràcia a les organitzacions sanitàries. Tindrem un resultat justet, o un resultat excel·lent, tot depèn de l’opció escollida.

A selection of:

April 8, 2016

Introducing nudging in the law

Nudge and the Law. A European Perspective

Alberto Alemanno is an HEC law professor focused on issues on behavioral policies and regulation. Now he has edited an interesting book. You can check it from this index:

1. The Emergence of Behavioural Policy-Making:A European Perspective

Part I: Integrating Behavioural Sciences into EU Law-Making
2. Behavioural Sciences in Practice: Lessons for EU Rulemakers
3. Nudging and Evidence-Based Policy in Europe: Problems of Normative Legitimacy and Effectiveness
4 . Judge the Nudge: In Search of the Legal Limits of Paternalistic Nudging in the EU

Part II: De-Biasing Through EU Law and Beyond
5. Can Experts be Trusted and what can be done about it? Insights from the Biases and Heuristics Literature
6. Overcoming Illusions of Control: How to Nudge and Teach Regulatory Humility

Part III: The Impact of Behavioural Sciences on EU Policies
7. Behavioural Sciences and EU Data Protection Law: Challenges and Opportunities
8. Behavioural Sciences and the Regulation of Privacy on the Internet
9. EU Consumer Protection and Behavioural Sciences:Revolution or Reform?
10. What can EU Health Law Learn from Behavioural Sciences? The Case of EU Lifestyle Regulation
11. Conduct of Business Rules in EU Financial Services Regulation: Behavioural Rules Devoid of Behavioural Analysis?

Part IV: Problems with Behaviourally Informed Regulation
12 . Making Sense of Nudge-Scepticism: Three Challenges to EU Law ’ s Learning from Behavioural Sciences
13. Behavioural Trade-Offs: Beyond the Land of Nudges Spans the World of Law and Psychology
14. Epilogue: The Legitimacy and Practicability of EU Behavioural Policy-Making

The book deserves time reading it, specially if you are interested in latest trends on nudging and regulation. However, if you don't have enough time, go straight to chapter 10. This is what you should read about implications of nudging on Public Health. He says,
Our previous analysis made a case for more experimentation in behaviourally informed regulation in the EU lifestyle policy. This seems particularly true when examined in light of the limited results attained by self-regulatory schemes led by the food, alcohol, and tobacco industries. While the evidence of what works in terms of behaviour change strategies is limited and too often anecdotal, several success factors have progressively been identified in policy-making.
 These success factors are those we have to check in our close environment and test wether it is worth taking this regulatory approach.