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?

Dynamic risk adjustment in provider's payment

Prevention and Dynamic Risk Adjustment

Adjusting Medicaid Managed Care Payments for Changes in Health Status

"Risk-adjustment methods have an inherent structural flaw that rewards preventable deterioration in enrollee health status and improved coding of disease burden", this is the key statement in Fuller et al. article. The answer they provide is the introduction of an additional payment adjustment according to changes in health status for similar mix of enrollees. The payment adjustment being proposed is based on changes in aggregate relative payment weights for all enrollees avoiding any individual adjustment.
This is a concrete application of the initial dynamic risk adjustment proposal that Eggleston et al. made in 2007. They suggested a two step payment system: a conventional risk adjustment (for variations in population health outside the provider’s control) and an additional one related to prevention efforts.
There is still a lot to learn about it. Let's keep an eye on this crucial topic.

PS. Have a look at Commonwealth Fund anouncement: "Our initiative recognizes that a wide range of factors influence providers’ choices, beyond financial rewards or penalties, including intrinsic motivation and medical professionalism, organizational influences, and policy" (see Box)

Our health and its determinants (2)

The Relative Contribution of Multiple Determinants to Health Outcomes

There are five major categories of health determinants: genetics, behavior, social circumstances, environmental and physical influences, and medical care. If this is so, do we know the relative importance of each factor?
Last February I posted in this blog a figure by Kindig that explains their contribution. Now a Health Affairs brief summarises different views. Check Exhibit 1, and you'll see there that behaviour represents 35-50% of health status according to different estimates.
The message is clear in our current evironment of mostly non-communicable diseases, we have to find better ways to change behaviour towards healthier people. Decisions and actions, short and long term, risk and responsibility, costs and benefits, trade-offs of every day life.

PS. Must read:  The Ethics of Ebola.

The first three doses of ZMapp were administered to the American medical missionaries Kent Brantly and Nancy Whitebol, who have recovered, and the Spanish priest Miguel Pajares, who has since died. Some offered a practical justification for the widely criticized selection of Brantly and Whitebol: It makes sense to treat health workers first, so that they can continue to help others. But this argument largely fell apart with the selection of the 75-year-old Pajares.

PS.  "Only four companies today make vaccines, compared to 26 companies 50 years ago.". My concerns about a future systemic drug industry are closer than expected (at least in vaccines).

Patient switching-behaviour

Enquesta de salut de Catalunya 2013

Consumer loyalty is a top goal for any maketeer, and the Nielsen Global Survey of Loyalty Sentiment says that to achieve it, offering the best price is the most persuasive tool to motivate consumers to swap devotion to a brand, service provider or retailer. If you enter into healthcare arena, service prices don't play the same role, mandatory insurance coverage is the standard (in developed countries), and voluntary insurance is the option (prices are relevant in this latter case).
What happens when one fourth of the population (~24%) buys voluntary insurance?. They have two options for healthcare access. The last health survey gives the answer (Table 3. p. 44): 57,9% of members go to private services, 29,5% use public services, 12,4% don't use any service. This is the switching behaviour pattern according to access and perceived quality of services, not price.

PS. I suggest a close look to the survey, many interesting things appear inside. Deeper analysis is needed using microdata.

PS. A former post on a related topic.

The impact of information and communication technologies

The number of primary care visits per capita in 2007 was 7,1, nowadays this figure has dropped to 5,9, a reduction of 17% in six years. That's a lot. In absolute terms you get the astonishing figure of 4,5 million visits less! In 2013 the total number of visits in primary care was 44,7 million.
I have taken 2007 as the year for comparison for one reason: there was no electronic drug prescription. I don't know all the reasons behind such huge decrease, however information technology has helped for sure. Righ now, 92% of all prescriptions are electronic. A wide assessment of such period is needed.
Such figures are only a partial evidence of the transformation through technology in one specific area - drug prescription-, now the next step is to go further in other fields: organization of work and communication between physician and the patient. These areas may take advantage of technology and help to change the "production function". However, somebody should also think about the impact on a redefiniton of professional roles and tasks, an issue that is frequently left for another day.

PS. Unfortunately, this good news you'll not find in any newspaper. Nowadays, most of them are interested only in the dark side.

PS. Don't forget that such a decrease in utilization of services has been achieved without any copayment strategy.

The deprivation of human rights and the health crisis

The  situation in northern Irak is critical. More than 1.4 million displaced people, severe human rights abuses and violation of international humanitarian laws. Those people are in need of water and basic sanitation services. Health services are overwhelmed by this situation.
Maybe this is the largest tragedy of our days, innocent people taken out from home and left without anything.
The answer by developed countries is becoming too late and too little. Have a look at EU press release (20 m € in 2014 while Saudi Arabia 500m $, Lancet says). This is an additional reason why I feel very far from european policies and citizenship.

PS. Must read (please beware of potential conflicts of interest): Updating Cost-Effectiveness — The Curious Resilience of the $50,000-per-QALY Threshold

PS. FT :  " the right to vote stands above the decisions of a political tribunal.”

Sisley. From Tita Cervera  St. Feliu exhibition

The people's support for public health care

If you want to know what may drive you to participate in a demonstration, just ask the people. This is precisely what CEO report has done with this question:
"Tell me, please, if the following could have driven or push you to participate in a protest or claim" and the options were: tax increase, improving democracy ,corruption, defense of public education, defense of public health care, evictions, budget cuts, the right to vote.
And the winner is? The defense of public health care with 91,1%.
Good to know, if you didn't before. A clear message for any politician that cares about well-being of the population.

PS. If you want to know how many citizens consider that fundamental changes in health care are necessary, CIS has published the figure: 33%, the highest in the period 1995-2013 (p.10), those who think that  some changes are necessary: 45% (p.9). Something should be done.
Support for public provision of primary care: 60%, on hospital care: 50%. Closer data on 2013 by CEO-CatSalut have not been published, my last comment is here.

Homer. From Tita Cervera  St. Feliu exhibition

Copayments as deterrents

If you want to know if copayments deter drug consumption just ask the people.This is precisely what CEO has done. In their report p.33 they reflect that 85% of citizens have not decreased their consumption, while 13% say yes, and 2 % dont know (?). The posted question maybe is not the best since the word copayments doesn't appear and there is no adjustment over the former copayment regime (retired vs active population). Anyway, we don't know if this 13% of people that say they have reduced it, is for inappropriate medications or appropriate ones. Still looking for the right assessment, this is only the first glance.

PS. How can we measure media power?

 Andrews. From Tita Cervera  St. Feliu exhibition

The uncertainty over genomics sequencing value in clinical decision making

Assessing Genomic Sequencing Information for Health Care Decision Making: Workshop Summary

"The value of genetic sequence information will depend on how it is used in the clinic", key statement that needs some elaboration. This is precisely what the IOM report does, you'll find in their pages the current situation about how genomics may impact in decision making. In chapter 5 you'll understand how an insurer decides about coverage of such tests according to 5 criteria:

1. The test or treatment must have final approval from appropriate governmental regulatory bodies, where required;
2. scientific evidence must permit conclusions about its effect on medical outcomes;
3. technology must improve net health outcomes;
4. the technology must provide as much health benefit as established alternatives; and
5. the improvement in health must be attainable outside investigational settings.

Unfortunately, if you start from the first one, you'll find a complete lack of references by governmental bodies on the approval of such tests. Therefore, I can't understand from the chapter how successful they are on such process.
While reading the book you'll increase your uncertainty about outcomes and value of genomic tests instead of reducing it. This was my impression. Let's wait for future good news, again.

PS. Summary of the report:
"Clinical use of DNA sequencing relies on identifying linkages between diseases and genetic variants or groups of variants. More than 140,000 germline mutations have been submitted to the Human Gene Mutation Database and almost 12,000 single nucleotide polymorphisms have currently been associated with various diseases, including Alzheimer’s and type 2 diabetes, but the majority of associations have not been rigorously confirmed and may play only a minor role in disease. Because of the lack of evidence available for assessing variants, evaluation bodies have made few recommendations for the use of genetic tests in health care."

Consensus in health policy

Some months ago I posted on the same topic. Now you can read my short article in the annual report of the Col.legi de Metges.(text in catalan)

El consens en la política sanitària: el Pacte Nacional de Salut

La política sanitària i els valors socials. La immediatesa i dinamisme del món en que vivim ens porta massa sovint a considerar la política sanitària com el fruit de la decisió puntual, anecdòtica i controvertida del moment. Ens cal una mirada més panoràmica per comprendre que darrera tota política sanitària hi trobarem uns valors socials que li donen fonament. És a dir judicis de valor sobre allò que és bo per a la societat. En ocasions es referiran als objectius o resultats finals i en d’altres als mitjans per assolir-los. Si bé la seva rellevància és determinant per als objectius, en relació als mitjans cal tenir present a més a més la seva efectivitat, i per tant un judici expert sobre allò que de veritat funciona.

L’objectiu final de tota política sanitària descansa sobre la millora de la salut poblacional però va més enllà. L’any 2006 la Unió Europea va considerar que els sistemes de salut són un pilar de la protecció social, de la cohesió i de la justícia social, i assenyala que la universalitat, l’ accés a l’assistència de qualitat, l’ equitat i solidaritat són els valors europeus compartits[i]. En aquest marc i en el seu desenvolupament és on es fonamenta la política sanitària.

El consens en política sanitària. L’adopció de decisions públiques en relació a aquests valors essencials requereix d’un consens polític. Pertoca al parlament i al govern assenyalar què signifiquen exactament aquests valors compartits (objectiu) i quines decisions cal adoptar per assolir-los (mitjans). L’existència d’un consens social sobre aquestes qüestions esdevé una peça clau de l’engranatge. Més enllà de l’acord polític parlamentari, cal que tots els actors que participen en el sistema de salut remin en la mateixa direcció. Precisament un dels elements que es consideren factor d’èxit d’un sistema sanitari és el consens social[ii]. Ens cal doncs una política sanitària basada en el màxim consens possible per tal de tenir un sistema eficient i equitatiu.

La política sanitària basada en l’evidència. Distingir aquells mitjans que poden ser efectius per assolir objectius d’aquells que no ho són, esdevé una prioritat. Disposar d’evidència per tal de contrastar aquelles decisions que produiran el millor resultat és crucial, però alhora complex. La complexitat prové de les singularitats i del context on es desenvolupa cada política. Allò que ha funcionat en un lloc i moment determinat, pot ser difícil de ser reproduït en un altre. Malgrat aquest atenuant, saber allò que funciona amb un criteri expert i objectiu ha d’ajudar a millorar les decisions. Molts informes d’experts sobre reforma sanitària han tractat d’adoptar aquesta perspectiva, si bé amb impacte força limitat. La falta d’aplicació del consell expert té a veure almenys amb les dificultats d’establir consensos amplis i la comprensió del procés polític[iii].

El pacte nacional de salut i els àmbits de consens. La Comissió de Salut del Parlament de Catalunya va acordar el febrer de 2013 impulsar el treballs per assolir un acord per a la salut a Catalunya en el marc d’un model propi. En aquest acord es defineixen les bases del sistema sanitari català, estables i consensuades per tots els agents implicats. Es va precisar que els membres de la comissió serien els representants dels diversos grups parlamentaris i els agents que formen part del Consell Català de la Salut. Els treballs de la comissió es van desenvolupar en vuit grans àmbits temàtics. Es va prendre com a referent els 6 blocs inicials que segons l’Organització Mundial de la Salut han de constituir un sistema sanitari, i s’hi van afegir dos àmbits identificats com a claus pel sistema (la recerca i innovació, i el compromís ciutadà). Els àmbits han estat doncs: finançament i cobertura, professionals, prestacions i catàleg de serveis, model de serveis, avaluació i transparència, recerca i innovació, compromís ciutadà, i governança.

Entrar en el detall del contingut dels 83 acord va més enllà del que es pretén en aquest article, tant sols es farà una breu referència als 2 primers. En l’àmbit de finançament i cobertura s’assenyala amb claredat l’opció per un accés universal de la ciutadania al Sistema Nacional de Salut i alhora s’estableix un criteri de nivell de finançament públic en salut suficient i sostenible, que es relacioni amb el nivell de riquesa del país i que convergeixi amb la despesa de països amb producte interior brut per càpita equivalent i sistema sanitari similar.
En l’àmbit dels professionals s’ha considerat que la planificació de necessitats de professionals, les competències i capacitats acreditades han de ser objecte reconsideració atenent als canvis sociodemògràfics, econòmics i tecnològics. S’explicita l’èmfasi en el professionalisme com a criteri que guia la relació entre professionals amb la ciutadania, amb el sistema sanitari i els proveïdors, i la necessitat d’establir mecanismes per tal de fer efectiva la participació dels professionals en l’elaboració de polítiques i la gestió.

El nivell de consens i els propers passos. El procés per arribar a aquest conjunt d’acords ha estat fruit d’una elevada participació. Diversos motius van impedir que la totalitat dels representants confirmessin el seu acord al darrer moment. Cal assenyalar que en l’elaboració del document hi ha contribucions de tots, també d’entitats i grups polítics que no han pogut donar finalment el seu suport. Cal fer efectiu aquest consens que desitja la ciutadania, les bases perquè això sigui possible hi són, només cal teixir-les acuradament i amb generositat. El Parlament de Catalunya va donar l’opció de mostrar el sistema sanitari que desitgem a una àmplia representació social, ara ja hi ha les bases per a que això pugui transformar-se en realitat.

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[i] Council Conclusions on common values and principles in European Union  health systems, OJ 2006 No. C146/1.

[ii] Balabanova D, Mills A, Conteh L, et al. Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening. Lancet 2013;381:2118-2133

[iii] Black, Nick. "Evidence based policy: proceed with care." BMJ: British Medical Journal 323.7307 (2001): 275.

Statistical vs. identifiable lives

Do We Really Value Identified Lives More Highly Than Statistical Lives?

The recent Ebola evacuated case exemplifies the concept created by Shelling a long time ago, the difference of how a society allocates resources according to 2 different rules:

In 1968, in a paper about valuing ways to reduce the risk of death, Thomas Schelling1 distinguished between “identified lives” and “statistical lives.” Identified lives are the miners trapped in a mine or the child with a terminal disease—specific people who need help now. Statistical lives are those people, unidentifiable before the fact and often after as well, who will be saved by a new safety regulation, public health program, or environmental standard. Schelling observed that people seem to be willing to pay more to save an identified life: “Let a six-year-old girl with brown hair need thousands of dollars for an operation that will prolong her life until Christmas, and the post office will be swamped with nickels and dimes to save her. But let it be reported that without a sales tax the hospital facilities of Massachusetts will deteriorate and cause a barely perceptible increase in preventable deaths—not many will drop a tear or reach for their checkbooks.

Really such a case goes beyond Shelling insight because of uncertainty and unavailability of effective treatment. Bioethics field has argued over what they called "rule of rescue", a different perspective of the same issue. In this respect, NICE statement helps to understand both views:

When there are limited resources for healthcare, applying the ‘rule of rescue’ may mean that other people will not be able to have the care or treatment they need. NICE recognises that when it is making its decisions it should consider the needs of present and future patients of the NHS who are anonymous and who do not necessarily have people to argue their case on their behalf. NICE considers that the principles provided in this document are appropriate to resolve the tension between the needs of an individual patient and the needs of present and future users of the NHS. The Institute has not therefore adopted an additional ‘rule of rescue.

The article by Louise B. Rusell reflects precisely the theoretical and practical controversy and ends with this paragraph:

Adjustments and controversies aside, the evidence provided by VSL estimates suggests that people’s willingness to pay for statistical lives may be consistent with their willingness to pay for identified lives. The apparent existence of 2 different decision rules may have been no more than an artifact of the economic method for valuing statistical lives in use at the time the distinction was proposed. Now that economists’ methods more fully reflect “the interests, preferences and attitudes to risk of those who are likely to be affected by the decisions,” their estimates of the value of a statistical life support the idea that there just may be a single rule: Identified and unidentified lives may be equally valuable. This is good news for decision makers who use cost-benefit and cost-effectiveness analysis to inform decisions.

The theoretical suggestion sounds good, nowadays the political decision making reality goes in the opposite way, at least close.

PS. A must read post on GCS blog about the same topic.

PS. Ebolanomics, the economics of ebola at the New Yorker. Nothing new, prizes instead of patents to promote R&D, a good idea with difficult implementation.

PS. How much would you pay for a quality adjusted life year?

Walt  Khun.  From Tita Cervera  St. Feliu exhibition

Inconvenient reasons

International statistics provide useful information on trends and allow to compare between countries. This is only true if all countries do their homework. In the last edition of  OECD health data, Australia, Japan, New Zealand, Spain and Turkey have "forgotten" to send 2012 expenditure  data. Maybe there are some inconvenient reasons behind that. Anyway, somebody should ask in Parliament about the delay and why they are not delivering the statistics..
Beyond that, I suggest a look at internal 2012 data, coming from Ministry. You'll find that there are some countries with 9.4% public health expenditure over GDP, while others like Catalonia spend 4.9%. Again, somebody should ask in Parliament if there is anybody in charge of the situation. I stop here to avoid any misinterpretation. Disconnecting is the right option, goodbye.

PS. By the way, today you can find in ARA a flawed op-ed. Check the current and right figures and the argument vanishes.

Good Music with Txarango, you may download it free at txarango.com

Health as a shared responsibility

During our lifetime we are exposed to risks, some of them are preventable while others not.
Prevention is a shared responsibility, individuals and society may affect the course of such potential health events. Today, while reading in the press about Ebola controls in the flight Conakry-Casablanca-Madrid I was really concerned about how governments are dealing with such an outbreak. If this is true and only three controls were really made, somebody should request explanations in Parliament. Individual opportunism may avoid to declare "yes" when they were asked if they felt bad.
Sounds naive. A responsible individual should say yes if he really feels bad, but he may also ask himself about cost and benefit of such answer...
On September 24th we are helding a roundtable on such issues: "Individual and collective responsibility on health". It may be of interest for the readers of this blog. If you finally come we may meet at the end of the session, Minorca deserves a yearly visit at least.

PS. Full programme, here

Enough is enough

If there is a grey area in medical devices and services regulation, this is the Laboratory Developed Tests one. Up to now, FDA has refused to define the rules of the game for 11,000 diagnostic tests performed at 2,000 labs in USA. This means that no official or external reviewer has analysed the clinical validity and clinical utility as it is done in any reagent and instrument. I can't understand why we have arrived at such a situation.
Fortunately NYT reports that on July 31st, FDA announced that this will change.

The agency said on Thursday that such discretion must end because circumstances had changed. Lab-developed tests once were fairly simple, often developed by a hospital for tests on its own patients. Now the tests can be complex and are being developed by  companies and marketed widely.

Some widely used commercial tests have never had to be reviewed by the agency. These include Myriad Genetics’ breast cancer risk test, the subject of a Supreme Court patent decision last year; the Oncotype DX test from Genomic Health, which is used to determine if women with early-stage breast cancer need chemotherapy; and noninvasive prenatal tests for Down syndrome that are rapidly catching on.

In this blog I have supported several times for a clear regulation of these tests . Just the other day when looking at the statements of FDA commissioner, I was astonished:

Just as drugs need to be safe and effective for treating diseases, medical devices used to help diagnose disease and direct therapy also need to be safe and effective, Faulty test results could lead patients to seek unnecessary treatment or to delay or to forgo treatment altogether.

These statement raise more concerns about what US regulator has done after all these years. And european regulation is still worse in this sense. I have explained such disaster previously and up to now there is no news. Some times I wonder why do we pay taxes, why do we have to be part of Europe. Enough is enough.

Failures and successes of the engines of democracy: Politics and Policymaking

Why Government Fails So Often: And How It Can Do Better

Our democracy finally has been created to deliver specific outcomes. However, citizens are increasingly unsatisfied with governments. Fortunately we can analyse this fact through a new book that attempts to disentangle the issue going deeper than usual in the roots of the problem:

Americans have a dismal opinion of the federal government’s performance, one that is only getting darker.4 Significantly, this growing antipathy is not antigovernment generally. Instead, it targets only the federal government; respect for state and local governments is both high and stable. Nor is this hostility toward the federal government in Washington a partisan matter. Instead, it is expressed by a majority of Democrats as well as Republicans. And perhaps most revealing, this disaffection long preceded the current political gridlock in Congress that many pundits see (wrongly, as I shall show) as the root of the problem.

You may change the word americans at the begining and place your nationality and this former statement could work. We should question what government failure or success means and the authors look at the literature on policy evaluation and find fewer references than expected.

Understanding government failure, then, presents complex challenges. Its funders, consumers, and ultimate appraisers—“We the People”—are more disgruntled than ever, and the social scientists who assess the evidence most rigorously find that these appraisers’ disapproval is amply warranted.

The author considers that government failures are rooted on recurrent weaknesses that  include unrealistic goals, perverse incentives, poor and distorted information, systemic irrationality, rigidity and lack of credibility, a mediocre bureaucracy, powerful and inescapable markets, and the inherent limits of law. This sounds familiar. Anyway, something should be done, and part 3 is entirely devoted to this issue. I would like to highlight the limits of the law as a constraint, others details are in the book that I strongly recommend. He says:

The very nature of public law places some severe limits—both constitutional and functional—on the effectiveness of the policies that it communicates and governs. Although most of these limits cannot be avoided, some of them might be eased.

I really think that we should explore new options for producing laws and assessing its performance, the current situation of the "democracy engine" is outdated.

PS .A review at WSJ.

 Many of our political debates are about what if anything government should do about the problems our society confronts. The combatants in these battles rarely stop to consider just what government actually can do.

 Peter H. Schuck has written an essential manual for 21st-century policy makers.

When bad science leads to bad policy

The Corruption of Peer Review Is Harming Scientific Credibility

Nothing new, scientific peer review is a process under suspicion. The Guardian illustrated this fact three years ago, and WSJ has repeated the same recently. The potential solution is to put into practice the falsiability process as Popper emphasized long time ago. The main difficulty is data access, however some journals have started to supply such data for researchers in order to confirm the results. My position about it is clear, as a referee I'll refuse to review more papers unless this option is possible for any submitted article. The potential harm is huge in certain fields and circumstances, as the Vioxx case illustrates.
The WSJ op-ed says:

Fixing peer review won't be easy, although exposing its weaknesses is a good place to start. Michael Eisen, a biologist at UC Berkeley, is a co-founder of the Public Library of Science, one of the world's largest nonprofit science publishers. He told me in an email that, "We need to get away from the notion, proven wrong on a daily basis, that peer review of any kind at any journal means that a work of science is correct. What it means is that a few (1-4) people read it over and didn't see any major problems. That's a very low bar in even the best of circumstances."
But even the most rigorous peer review can be effective only if authors provide the data they used to reach their results, something that many still won't do and that few journals require for publication. Some publishers have begun to mandate open data. In March the Public Library of Science began requiring that study data be publicly available. That means anyone with the ability to check should be able to reproduce, validate and understand the findings in a published paper.

Doctor crisis. What crisis?

The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care

Last May I saw this press release about a book by a physician from Kaiser Permanente. Initially I thought that it would be a book for those interested uniquely in US healthcare. I started reading "The Doctor Crisis" last week and still can't stop. It has captured my attention. His observations about the practice of medicine and the pressures that physicians are under, are similar in any developed country, maybe the intensity is not the same. Anyway, in the book there is a reference of a work by Sinsky et al.:  In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices, a must read:

The current practice model in primary care is unsustainable. We question why young people would devote 11 years preparing for a career during which they will spend a substantial portion of their work days, as well as much of their personal time at nights, on form-filling, box-ticking, and other clerical tasks that do not utilize their training. Likewise, we question whether patients benefit when their physicians spend most of their work effort on such tasks.³⁰ Primary care physician burnout threatens the quality of patient care, access, and cost-containment within the US health care system.

We set out in search of joy in practice. What we found were pockets of professional satisfaction.

I missed this article when it appeared last year.What they explain is in my opinion what exactly should be done. As Tom Bodenheimer says, “the Triple Aim should be a quadruple aim, with clinician and staff satisfaction a necessity to achieve the other three aims.”  Considering it as an input and not only as a goal itself is the right approach. More on Berwick's triple aim, at IHI.
I am only at the begining of the book, but I wanted today to reflect this critical issue of our health systems. Something should be done beyond the triple aim. Organizational innovation is required. Right now I am not able to perceive such effort around here.

PS. About the title, focusing only on physicians is a too narrow perspective for those who have to lead a better health care , why not "transdisciplinary professionalism"?

PS. A suggestion: their blog.

Morbidity adjusted life-expectancy

OBTENCIÓN DE LA ESPERANZA DE VIDA Y DESCOMPOSICIÓN EN ESTADOS DE SALUD A PARTIR DE INFORMACIÓN CLÍNICA

I have always considered that any estimate of healthy life expectancy that is build upon many assumptions and coefficients in the end it is difficult to understand. The global burden of disease and its use of DALYs is an extraordinary effort, though if you dig into the results you'll find methological difficulties.
An alternative to such estimates is just to show how the burden of mordibity is distributed across lifetimes. That is precisely what we have presented at the last Health Economics Conference. I believe that such estimation is a promising way to present population life expectancy and health. As far as this is the first attempt, there is still room for improvement.

Healthy and satisfied

Enquesta de salut de Catalunya

Latest data from the 2013 Health Survey shows that 81,1% of the population consider themselves as healthy, slightly better that in 2010 that was 79,3%. Regarding satisfaction, 86,9% of population is satisfied with public health services, again better than 2010 that was 84,7%. Though in 2012 results were a little bit better.
In the details of the results you'll find that obesity and overweight is the biggest issue to address in my opinion. There is still a lot to do on tobacco and alcohol, but data shows some improvement.
This health survey should be broadcast in the media and efforts to promote healthy behaviours should raise. Unfortunately nowadays media is focused on negative messages and this issue lies far from journalists' interests.