Driving evidence-based health policy

Driving Better Health Policy: “It’s the Evidence, Stupid”

Baicker and Chandra are backing an evidence-based health policy. I reviewed it in a previous post. Now the Uwe Reinhardt Memorial Lecture insists on it.

Speaking in favor of evidence-based health policy can be more controversial than one might think. Health policy analysts, health services researchers, and economists in particular often get in trouble by trying to quantify what many hold as unquantifiable and trying to put a price tag on what many think should be priceless.

This is the ouline of the lecture:

WHAT IS AND IS NOT A POLICY
Slogans are Not Policies
Differentiating Between Goals and Policies
EVIDENCE IS INHERENTLY EMPIRICAL
Evidence is Rarely Straightforward
Fact Patterns Alone Do Not Reveal Policy Effects
WORKING TO BASE POLICY ON EVIDENCE
Separating Evidence from Preferences
Using Evidence to Inform Policy

And these are the take-away messages:

• Serious policy assessment requires a detailed description of the policy—slogans are not policies.
• Clearly articulating and differentiating between goals and policies is crucial to evaluating the most effective way to achieve policy goals.
• Evidence is often mixed or ambiguous. Researchers should not let their own policy preferences bias their interpretation or synthesis of the evidence. 
• Evidence does not speak for itself. Researchers need to dedicate effort to timely, accessible, reliable translation.

Agreed. Unfortunately, our close politicians are not interested in evidence if it goes against their ideological criteria. Therefore, claiming evidence for health policy is useless, unless the premise of "politicians will take into account evidence" is really credible. The lecture forgot this "minor" issue, the cognitive biases of health policy.

Josep Segú

On free genetic sequencing, opioids and the Hockney portrait

Selected links

FROM GENE EDITING TO A.I., HOW WILL TECHNOLOGY TRANSFORM HUMANITY?
FIVE BIG THINKERS — REGINA BARZILAY, GEORGE CHURCH, JENNIFER EGAN, CATHERINE MOHR AND SIDDHARTHA MUKHERJEE — PUZZLE OVER THE FUTURE OF THE FUTURE.

Mortality risk, insurance, and the value of life

Opioid nation by Marcia Angell

Genetics Start-Up Wants to Sequence People’s Genomes for Free

THESE DNA STARTUPS WANT TO PUT ALL OF YOU ON THE BLOCKCHAIN

Hockney

In favour of positive discrimination for troublemakers

IN DEFENSE OF TROUBLEMAKERS: The Power of Dissent in Life and Business
L'Illusion du consensus

Charlan Nemeth has done a great job explaining the role of dissent in life and organizations. Her last book shows exactly what happens when we emphasize excessively the consensus.

Rather than worry about appeasing others or making sure we do not offend by disagreeing with them, the message of this book is that there is importance and value in authentic debate. The idea that dissent causes irritation and conflict is only partially accurate. Dissent and debate also bring joy and invigorate discussion. Best of all, genuine dissent and debate not only make us think but make us think well. We become free to “know what we know.” We make better decisions, find more creative solutions, and are better able to render justice.

The topic has strong connections with political correctness and hate. The book by Chantal Mouffe addresses this issue with precision.

Afin d’éviter toute confusion, je devrais peut-être préciser que, contrairement à certains penseurs postmodernes qui envisagent un pluralisme sans aucune frontière, je ne crois pas qu’une politique démocratique doive considérer comme légitimes toutes les revendications formulées dans un société donnée. Le pluralisme que je défends exige de discriminer parmi ces demandes celles que l’on peut accepter comme faisant partie du débat démocratique et celles qui doivent en être exclues. Une société démocratique ne peut pas traiter comme des adversaires légitimes ceux qui remettent en question ses institutions de base. L’approche agonistique ne prétend pas englober toutes les différences ni abolir toutes formes d’exclusion. Mais les exclusions sont envisagées en termes politiques et non pas en termes moraux. Certaines revendications se trouvent exclues de fait, non parce qu’elles sont « mauvaises », mais parce qu’elles défient les institutions constitutives de l’association politique démocratique. Entendons-nous bien, la nature des institutions fait aussi partie du débat agonistique, mais pour qu’un tel débat puisse avoir lieu, l’existence d’un espace symbolique partagé est nécessaire. C’est cette idée que j’ai voulu exprimer quand j’ai soutenu, dans le chapitre 1, que la démocratie nécessitait un « consensus conflictuel » : consensus sur les valeurs éthico-politiques de liberté et d’égalité pour tous mais dissensus sur leur interprétation. Il faut par conséquent tracer une ligne de démarcation entre ceux qui rejettent complètement ces valeurs et ceux qui, tout en les acceptant, en défendent des interprétations opposées.

Troublemakers as dissenters in politics are welcome. Though, if they want to undermine democracy, then forget any positive discrimination. This is not their place.

PS. Bad blood wins the Business book of the year contest.

Oriol Romaní

"Going Dutch" in regulating the mandatory coverage

Can universal access be achieved in a voluntary private health insurance market? Dutch private insurers caught between competing logics

Healthcare in The Netherlands is widely seen as a benchmark for many scholars. Though it is expensive, it combines mandatory coverage with the choice of private insurance coverage. Sounds of interest, though the devil is in the details.
This article explains the main issues surrounding such model:

The Dutch history of voluntary private health insurance shows both the strengths and weaknesses of public–private health insurance systems, especially in the context of a rising demand for (universal) access to health care. As we have explained, social and private health insurance are based on two divergent logics of different institutional orders (the market and the state).
The Dutch case strongly  suggests that universal access can only be achieved in a competitive individual private health insurance market if this market is effectively regulated. The tension between adverse selection and universal access that had vexed the Dutch private health insurance industry throughout its existence was resolved by combining elements from both the insurance logic and the welfare state logic: i.e. an individual mandate, guaranteed issue, community-rated premiums, income-related subsidies and a sophisticated risk equalization scheme .
Achieving universal access in a competitive private health insurance market is institutionally complex and requires broad political and societal support.

Therefore, unless there is a smart regulator, forget it...

PS. Spanish embroglio at Marginal revolution.

PS. How is Obamacare doing?

From Lisa Eckdahl latest album

Provider payment strategies to improve health

Value-based provider payment: towards a theoretically preferred design

The case for improving health is related, among many things, with the incentive structure of the whole system (people, professionals and providers). If we focus our aim towards providers, then we need to reassess current flaws in the system, and ask what do we have to do. A new article tries to address these issues.

In order to tackle the problems related to current payment methods, worldwide, policymakers and purchasers of care are exploring alternative payment strategies to help steering health care systems towards value . A well-known endeavour in this regard is pay-for-performance (P4P), in which providers are explicitly rewarded for ‘doing a better job’. Although P4P is an appealing idea, explicit financial incentives for value should in principle be used only modestly in provider payment methods because of the multitasking problem. Therefore, it is not surprising that in practice, the majority of provider revenues (typically referred to as the base payment) is not explicitly linked to value. This base payment, however, does create implicit (dis)incentives for value, because each payment method influences providers’ behaviour through incentives.

The article reflects a conceptual framework of key components and design features of a theoretically preferred Value Based Payment method. And the key message is:

We conclude that value is ideally conceptualised as a multifaceted concept, comprising not only high quality of care at the lowest possible costs but also efficient cooperation, innovation and health promotion. Second, starting from these value dimensions, we derived various design features of a theoretically preferred VBP model. We conclude that in order to stimulate value in a broad sense, the payment should consist of two main components that must be carefully designed. The first component is a risk-adjusted global base payment with risk-sharing elements paid to a multidisciplinary provider group for the provision of (virtually) the full continuum of care to a certain population. The second component is a relatively low-powered variable payment that explicitly rewards aspects of value that can be adequately measured.

I fully agree with what they say. Close politicians and officials should take this message into consideration regarding the next primary care physicians' strike, and forget the current confusing approach.

Norman Rockwell 

TIRED SALESGIRL ON CHRISTMAS EVE

Estimate $5,000,000 — 7,000,000

(It may be yours, upcoming auction at Sotheby's)

Living with dementia

Care Needed. Improving the lives of people with dementia

Across the OECD, nearly 19 million people are living with dementia. Millions of family members and friends provide care and support to loved ones with dementia throughout their lives. Until a cure or disease-modifying treatment for dementia is developed, the progress of the disease cannot be stopped. 

We all know cases of close relatives with dementia, and we understand the suffering that surrounds the disease. OECD has made a good job coping with this difficult topic.
These are the three key chapters:

• Identifying people with dementia 
• Helping people with dementia live well in the community 
• Health and long-term care services for advanced dementia are poor

As people live at home longer, communities need to be better equipped to meet the needs
of people living with dementia. Post-diagnostic care pathways can help connect people with dementia and their families with available services. But communities themselves must also adapt: community-friendly initiatives that train local populations and businesses to respond more effectively to people with dementia can help to reduce stigma around dementia while making the environment safer and more welcoming. Aging at home also means that informal carers will play an important role in supporting people with dementia. Informal carers should receive the support they need, and governments should assess whether existing services for carers are also adequate for carers of people with dementia, who may have unique needs.

Definitely, every country needs to develop a strategy for this disease. Catalonia has already defined its strategy, though resources are not enough.

Jaume Plensa at Madison Square Park

Next generation sequencing is knocking at the door (and the door is open)

Genetic testing: Opportunities to unlock value in precision medicine
Next-Generation Sequencing to Diagnose Suspected Genetic Disorders
Documento de consenso sobre la implementación de la secuenciación masiva de nueva generación en el diagnóstico genético de la predisposición hereditaria al cáncer

This week I've been reading three pieces on the same topic. First, a McKinsey insight on genetic testing, second a NEJM basic article that reviews the whole state of the issue, and third a consensus by three societies on how to implement next generation sequencing .
All of them are required reading for anyone interested in the topic. You'll notice that technology is knocking at the door and we do need to understand how to manage it. Otherwise it will enter anyway (without knocking) and then it will be more value extraction (by others) than value creation (for patients).
Unfortunately, what you'll not find in these articles is how to manage the introduction of the technology with organizational patterns, allocation and coordination of tasks and decisions. If you want some clues on this, read my previous post on Geisinger, they are applying what it seems to me the most appropriate perspective.

Sense Sal-Fins que surti el sol