How to distort priority setting?

Biases distorting priority setting

Why priority setting in health care has so poor outcomes while relevant systems are well developed and readily available? You just have to read this article to understand it.

It starts to identify some rational and structural explanations for the discrepancy between theoretical efforts and practical outcomes in priority setting. However, even if these issues are addressed, practical priority setting may still not obtain its goals. This is because a wide range of irrational effects is hampering priority setting: biases.

Table 1. Overview of various biases and potential implications for priority setting and at which level they may be most prominent.

Bias	Potential Implications	Level
Identifiability and Singularity effect	Undermining principles	Micro
Rejection Dislike	Hamper disinvestment	Micro, meso
Failure Embarrassment effect	Overuse	Micro (primarily)
Prominence Effect (Opportunity Cost Neglect)	Non-warranted use	All
Status Quo Bias	Overuse, Underuse	All
Endowment Effect	Overuse, Underuse	Micro (primarily)
Loss Aversion	Hamper disinvestment	All
Aversion to Risk / Ambiguity	Overuse	Micro, meso
Availability Heuristics	Overuse	Micro, meso
Sacred Values and Taboo trade-offs	Undermining principles	All
Progress bias	Overuse	All
Adoption Addiction	Overuse	Micro, macro
Complexity bias	Undermining principles, overuse	Micro, meso, macro
Extension bias	Overuse	All
Asymmetry of risks and benefits	Overuse	Micro (primarily)
Positive cognitive feedback loops	Undermining principles, overuse	Micro, meso, macro
Prestige bias	Undermining principles, overuse	Micro (primarily)
Imperative of Action	Undermining principles, overuse	Micro (primarily)
Technology Placebo Effect	Undermining principles, overuse	Micro (primarily)
Imperative of Knowledge	Overuse	Micro
Competency Effect	Overuse	Micro
Multiple Replacements	Overuse	Micro
White Elephants	Overinvestment	Micro
Boys and Toys Effect	Unwarranted use	Micro

Episode based payment systems (2)

Value-based provider payment: towards a theoretically preferred design

The details of a payment system methodology are clearly described in this article. I was not surprised to confirm that the proposals we made two decades ago were in the same direction: two-part payment, fix and variable. Unfortunately nowadays we have a retrofuture system that nobody knows exactly how incentives really work. Of course, this is the first best for a discretionary behaviour by a resource allocator. This is a clear step in the wrong direction that started a decade ago. Without proper incentives, efficiency suffers, and to be clear this means less efficient healthcare for the patients. Unfortunately again, nobody cares about it.

The main contribution of this paper is twofold. Inspired by the societal debate on what
stakeholders in health care should ideally strive for, as well as by existing definitions of value, we first described and further specified the concept of value, facilitating the specification of requirements in the design of VBP. We conclude that, in this respect, 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.

The time to fix the current mess has arrived.

Jordi Sàbat

Episode based payment systems

Unraveling the Complexity in the Design and Implementation of Bundled Payments: A Scoping Review of Key Elements From a Payer’s Perspective

After per case based payment systems (DRGs) everybody was waiting for a comprehensive system to measure health services activities. And instead of focusing on episodes, what happened is that bundling was the new frame. Unfortunately, after all these years bundling has not provided the answer because the scope of measurement is related to several diseases and it is not holistic.
When everybody was asking for an alternative to fee-for service, the answer was in my opinion "patient focused episodes of care", but the US government decided otherwise and protected the interests of those that leverage fee-for-service.
Therefore, now it is the time to fix this mistake and take the right  road. In this article you'll find some issues to consider when you have to design a payment system. It still talks about bundling, forget it, substitute it by episodes and it will be fine.

Our framework provides a structured overview of the principal, literature‐based elements of the design and implementation of bundled payment contracts from a payer's perspective. We identified 53 elements that involve all procurement phases and relate to actors on all levels of the health care system. A better understanding of these elements can help payers and other actors devise a strategic approach and reduce the complexity of implementing these contracts. Compared with traditional FFS models, bundled payment contracts introduce an alternative set of financial incentives that affect the entire health care system, involve almost all aspects of governance within organizations, and demand a different type of collaboration among organizations. This is what makes the design and implementation of bundled payment contracts complex and is why they should not be strategically approached by payers as merely the adoption of a new contracting model but, rather, as part of a broader transformation to a more sustainable value‐based health care system, based less on short‐term transactional negotiations and more on long‐term collaborative relationships between payers and providers.

All you need to know about molecular diagnostics

Molecular Diagnostics Fundamentals, Methods, and Clinical Applications

Current advances in health sciences are available at the same time that diagnostic technology and knowledge provide new tools. This book is specially relevant because it summarises all the current state of the art on molecular diagnostics. Therefore a good suggestion for those who want to practice precision medicine.

Table of contents:
I. Fundamentals of Molecular Biology: An Overview
1. Nucleic Acids and Proteins
2. Gene Expression and Epigenetics
II. Common Techniques in Molecular Biology
3. Nucleic Acid Extraction Methods
4. Resolution and Detection of Nucleic Acids
5. Analysis and Characterization of Nucleic Acids and Proteins
6. Nucleic Acid Amplification
7. Chromosomal Structure and Chromosomal Mutations
8. Gene Mutations
9. DNA Sequencing
III. Techniques in the Clinical Laboratory
10. DNA Polymorphisms and Human Identification
11. Detection and Identification of Microorganisms
12. Molecular Detection of Inherited Diseases
13. Molecular Oncology
14. DNA-Based Tissue Typing
15. Quality Assurance and Quality Control in the Molecular Laboratory
Appendices
A. Study Questions Answers
B. Answers to Case Studies
Glossary
Index

Tough days ahead for health policy

Sistema Nacional de Salud: retos y tareas pendientes tras la Gran Recesión

The issue of Revista ICE, a must read for the new health minister:

Presentación

Innovación tecnológica y financiación de prestaciones

La colaboración público-privada en sanidad: hasta dónde y cómo delimitar sus fronteras

Reformas pendientes en la organización de la actividad sanitaria

La atención especilizada del Sistema Nacional de Salud durante la Gran Recesión. Gasto, utilización y variabilidad en el periodo 2004-2015

Atención a la dependencia y cuidados sanitarios: obligados a entenderse

Mirando más allá de los servicios de atención sanitaria: el papel de la salud pública

Diseño institucional y buen gobierno: avances y reformas pendientes

Crisis económica y salud: lecciones aprendidas y recomendaciones para el futuro

Physicians in society

ELS METGES A LA SOCIETAT CATALANA CONTEMPORÀNIA
Borja de Riquer i Permanyer

125th anniversary of Barcelona College of Physicians

The public option for population health improvement

Addressing Social Determinants to Improve Population Health
Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health
The Public Option How to Expand Freedom, Increase Opportunity, and Promote Equality

This is what JAMA article says about population health

While health care organizations may not be equipped to address each of the root causes of their patients’ conditions, they need to broaden their perspective on how to address social determinants of health and use their expertise to influence initiatives on education, housing, employment, and other important health related social issues that take place beyond their immediate clinical purview.

"Need to broaden their perspective", this is the message for health care organizations according to the articoe. I'm not so sure about it. The message is not only for health care organizations, it is for public policies. This is much more difficult to address when there is not a public option for the whole population. A new book sheds light on this topic for the US policy.

PS. The Limits of Private Action: What the Past 40 Years Taught Us About the Perils of Unregulated Markets
PS. There Should Be a Public Option for Everything

How altruistic behaviors reduce pain

Altruistic behaviors relieve physical pain

That's it. You'll find the details in PNAS article:

For centuries, scientists have pondered why people would incur personal costs to help others and the implications for the performers themselves. While most previous studies have suggested that those who perform altruistic actions receive direct or indirect benefits that could compensate for their cost in the future, we offer another take on how this could be understood. We examine how altruistic behaviors may influence the performers’ instant sensation in unpleasant situations, such as physical pain. We find consistent behavioral and neural evidence that in physically threatening situations acting altruistically can relieve painful feelings in human performers. These findings shed light on the psychological and biological mechanisms underlying human prosocial behavior and provide practical insights into pain management.

Parov Stelar 

Fighting against techno-eugenics

A Chinese scientist who shocked the medical community last year when he said he had illegally created the world's first gene-edited babies has been sentenced to three years in prison by a court in southern China.
He Jiankui announced in November 2018 that he had used a powerful technique called CRISPR on a human embryo to edit the genes of twin girls. He said he modified a gene with the intention of protecting the girls against HIV, the virus that causes AIDS. Many scientists expressed concerns about possible unintended side effects of the genetic changes that could be passed down to future generations.
Last fall, He also indicated there might be another pregnancy involving a gene-edited embryo. The court indicated that three genetically edited babies have been born.
The closed court in Shenzhen found He and two colleagues guilty of illegal medical practice by knowingly violating the country's regulations and ethical principles with their experiments, Xinhua news agency reported. It also ordered He to pay a fine of about $430,000.

Such unethical medical behavior is the worst news of 2019. And this article explained last June the reasons:

The link between CCR5 and HIV is fairly well studied. Disabling CCR5 removes the doorway HIV uses to enter and infect cells, but it does so only for some strains of HIV; there are others that don’t need CCR5. Further, the genetic sequence He’s edits produced does not match this well-studied variant of CCR5; in fact, it has never been observed in humans or animals. In other words, no one has any idea whether the variant with which Lulu and Nana are now living will affect HIV immunity or anything else.
That’s a key issue: Genes don’t do just one thing. Most illnesses and traits are influenced by dozens, hundreds, even thousands of DNA variations. Each of our roughly 20,000 genes is linked to many different aspects of our physiology and health. So what else does CCR5 do? A variant that provides protection against HIV also seems to increase susceptibility to a number of more common diseases, like flu and West Nile virus.
CCR5 has also been linked to brain function, which led to some sensational headlines and media speculation that the gene-edited babies might have enhanced brains. There are likely myriad other processes to which CCR5 contributes that we don’t know about yet. To that point: before the recent study, no one had researched whether the CCR5 mutation resulted in better or worse health over a person’s lifetime.
The CCR5 story illustrates a flaw in the logic that underlies gene editing. Efforts to change one gene to affect one illness in a future person ignore the fact that health is the result of infinitely complex interactions within and outside a person’s body. In most cases, the presence or absence of a particular genetic variant is not the sole determinant of a disease or condition.

And this article reminds us that, despite the appearance of agreement, ethical questions that have surrounded human germline editing for years have yet to be properly addressed.

Unnatural Selection: Season 1 | Main Trailer | Netflix

Key issues for Population Health improvement

Aspectos clave para la mejora de la salud poblacional

Gestión Clínica y Sanitaria 72

You'll find inside my article on key issues for population health improvement.

How confirmation bias contributes to polarization

Confirmation bias in the utilization of others’ opinion strength

Humans tend to discount information that undermines past choices and judgments. This confirmation bias has significant impact on domains ranging from politics to science and education. Little is known about the mechanisms underlying this fundamental characteristic of belief formation. Here we report a mechanism underlying the confirmation bias. Specifically, we provide evidence for a failure to use the strength of others’ disconfirming opinions to alter confidence in judgments, but adequate use when opinions are confirmatory. This bias is related to reduced neural sensitivity to the strength of others’ opinions in the posterior medial prefrontal cortex when opinions are disconfirming. Our results demonstrate that existing judgments alter the neural representation of information strength, leaving the individual less likely to alter opinions in the face of disagreement.

The notion that the strength of disconfirming opinion is not necessarily proportionate to its impact on belief change is in accord with anecdotal and ‘real-world’ observations in domains ranging from science to politics. The underlying process is remarkably flexible, with the neural circuitry involved switching on a trial-bytrial basis from high sensitivity to relative neglect, contingent on whether the opinion is confirmatory or disconfirming. This process may leave the individual less likely to alter opinions in the face of disagreement.

Interesting article from Nature. So what? Is there any exercise to train the neural sensitivity of our posterior medial prefrontal cortex? If so, I would suggest these exercise to some guys.

Bloomberg The year in pictures. Police brutality. Barcelona Airport October 2019.

Ethical algorithms like hammers?

Main messages:

All decision-making—including that carried out by human beings—is ultimately algorithmic. The difference is that human decision-making is based on logic or behaviors that we struggle to precisely enunciate. If we humans had the ability to describe our own decision-making processes precisely enough, then we could in fact represent them as computer algorithms. So the choice is not whether to avoid using algorithms or not, but whether or not we should use precisely specified algorithms.

Machine learning is a powerful tool that has many extant and potential benefits.  Technology companies such as Google and Facebook of course rely on products powered by machine learning for much of their revenue—but as these techniques grow in applicability, their scope and societal benefits grow as well.

The result is that, at least for a while, the critics of the algorithmic approach may often be right. There are many consequential domains where algorithmic tools are still too naive and primitive to be fully trusted with decision-making. This is because to model the forest, we need to start with the trees. This book offers a snapshot of exciting strands of research aimed at developing ethical algorithms, many of which are still in their very earliest days.

Global pharmaceutical market vs. local regulators

Regulating Medicines in a Globalized World: The Need for Increased Reliance Among Regulators

As defined by the World Health Organization (WHO), recognition occurs when a regulatory authority accepts the regulatory decision of another authority “as its own decision;”— reliance takes place when a regulatory authority takes into account the work products of another authority (e.g., inspection reports, scientific assessment reports, joint assessment reports produced together with another authority) to help inform the receiving authority's own regulatory decision, which, in the end may differ from the made by the initial authority using the same products. 

Recognition and reliance are the first steps towards an improvement of real coordination between regulatory bodies. If the pharmaceutical market is global, the regulators should cooperate for a coherent global regulation.

Anchoring and adjusting heuristic

Effect of Teaching Bayesian Methods Using Learning by Concept vs Learning by Example on Medical Students’ Ability to Estimate Probability of a Diagnosis

Why do we need more bayesian reasoning?. Can we improve clinical decision making? The answer in this JAMA article.

Although bayesian reasoning has been widely promoted in the literature as a diagnostic strategy, there has been scant evidence that teaching bayesian reasoning actually improves diagnostic accuracy. Providing learners with relatively brief instruction on these abstract concepts appeared to significantly improve their diagnostic performance in comparison with simply providing a number of relevant examples or no relevant instruction.

 The previously reported discrepancy between human probability estimation and optimal bayesian probability estimation has become traditionally accepted in the psychology and medical literature as cognitive biases, including base-rate neglect, anchoring bias, confirmation bias, and representativeness, all of which suggest suboptimal revision and have been purported to be a primary cause of diagnostic error.13,14 However, on closer scrutiny, much of this evidence was derived from situations that were not representative of the typical diagnostic setting. One highly cited study9 used a screening situation in which the base rate was very low and any positive test result, even one with excellent operating characteristics, would have most likely been a false-positive result. Participants in that study also appeared to exhibit semantic confusion by confusing the posttest probability with the conditional probability that was presented in the problem-solving exercise.