Separare la previdenza dall’assistenza @WRicciardi @drsilenzi

Il dibattito sulla sostenibilità del sistema di welfare italiano (sanità, previdenza, assistenza) è guidato da ideologia, strumentalizzazioni e notizie verosimili, ma false. In questo dibattito, il Presidente dell’INPS Boeri spicca per non fare il suo lavoro, ma per assumere posizioni politiche che dovrebbero essere del Governo. La separazione economico-finanziaria del sistema pensionistico da quello di assistenza sociale dovrebbe essere una priorità per uno Stato che non fosse dedito, come il nostro, al gioco delle tre carte!

La previdenza dovrebbe essere sostenuta dai contributi: essa costituisce ancora, almeno formalmente, una retribuzione differita. L’assistenza sociale dovrebbe essere sostenuta dalla tassazione ordinaria alla quale partecipano i cittadini in modo progressivo al crescere del loro reddito.

La maggior parte delle prestazioni dell’INPS sono di tipo assistenziale e sono economicamente sostenute da trasferimenti insufficienti dello Stato e abbondantemente integrate dai contributi che lavoratori e aziende pagano per sostenere la previdenza. Le stime sulla sostenibilità futura del sistema pensionistico vengono “affogate” nel calderone che include l’assistenza. Il risultato è che si presenta come insostenibile il sistema previdenziale, mentre la componente critica è quella assistenziale!

Di qui nasce il battage pubblicitario sulle pensioni d’oro (in un’audizione alla Camera del Deputati, il Commissario alla Spending Review Gutgeld ha affermato che le pensioni d’oro sono quelle superiori ai 2000-2500 euro lordi mensili!!!).

Un gruppo di pensionati sta agendo: https://www.facebook.com/pensionati.uniti?fref=gs&hc_ref=ARSyPNgW2HHQd2x-LuXKIOAUy50QAenWyfZa-rsvZYOF-1McW6c6VlthM9kyc84aXWw&dti=334901093612872&hc_location=group

Lorenzo Stevanato, già magistrato amministrativo, gestisce un’interessante pagina Facebook: https://www.facebook.com/groups/334901093612872/permalink/370881966681451/

Riporto di seguito il suo ultimo post del 30 novembre nel quale illustra una proposta di legge di iniziativa popolare per separare appunto previdenza da assistenza. Dopo le elezioni politiche le azioni si faranno battenti!

Eccolo!

“Parallelamente alla petizione, con cui si chiede che previdenza ed assistenza siano effettivamente separate, per le ovvie ragioni già esposte, si è pensato anche ad un progetto di legge di iniziativa popolare.
Potrebbe essere questo:

PROPOSTA DI LEGGE DI INIZIATIVA POPOLARE RECANTE “ISTITUZIONE DELL’AGENZIA NAZIONALE PER IL WELFARE ASSISTENZIALE”

Articolo unico
In attuazione dell’art. 38, comma 4, della Costituzione è istituita l’agenzia nazionale per il welfare assistenziale (ANWA), dotata di personalità giuridica di diritto pubblico e sottoposta alla vigilanza del Ministero del Lavoro e delle Politiche Sociali, con il compito di assumere tutte le funzioni economiche assistenziali svolte dall’Istituto nazionale della previdenza sociale (INPS).
In particolare l’ANWA ha il compito di:
a) erogare le prestazioni elencate dal comma 3 dell’art. 37 della legge 9 marzo 1989, n. 88, e successive modificazioni;
b) pagare tutte le pensioni totalmente o parzialmente a carico della fiscalità generale;
c) in generale, erogare tutte le prestazioni economiche assistenziali in favore di cittadini non abbienti e/o bisognosi, previste dalla legge;
d) esprimere pareri ed avanzare proposte al Governo in materia di prestazioni assistenziali economiche;
e) svolgere l’attività di controllo dei requisiti che danno titolo alle anzidette prestazioni.
Con decreto del Ministro del Lavoro e delle Politiche Sociali, da emanare nel termine di novanta giorni dalla data di entrata in vigore della presente legge, sono disciplinati l’organizzazione ed il funzionamento dell’agenzia, in modo da realizzare il trasferimento ad essa del personale e delle strutture materiali che l’INPS destina alle funzioni elencate dall’art. 37 della legge 9 marzo 1989, n. 88.
Il direttore dell’agenzia è nominato con decreto del Presidente del Consiglio dei Ministri, su proposta del Ministro del Lavoro e delle Politiche Sociali, tra esperti di riconosciuta competenza in materia di organizzazione e programmazione del welfare, anche estranei all’amministrazione.
Il direttore è assunto con contratto di diritto privato di durata quinquennale, non rinnovabile.
L’agenzia si avvale di personale trasferito dall’INPS. La dotazione organica è fissata con il decreto indicato al precedente comma 3.
La dotazione finanziaria dell’agenzia è determinata dai trasferimenti disposti dallo Stato e fissati annualmente con la legge di bilancio, nonché dai contributi dei datori di lavoro relativamente alle pensioni assistite ed ai trattamenti di integrazione salariale.
Il Governo è delegato ad emanare, entro sei mesi dall’entrata in vigore della presente legge, un decreto legislativo di riordino dei contenuti dell’art. 37 della legge 9 marzo 1989, n. 88, con conseguente abrogazione dell’art. 37 stesso, attenendosi al principio e criterio direttivo secondo cui la separazione di assistenza e previdenza sia completamente attuata ed all’INPS residui la sola funzione previdenziale, mentre all’ANWA sia attribuita interamente la funzione assistenziale.

Questa la relazione accompagnatoria:

RELAZIONE ALLA PROPOSTA DI LEGGE DI INIZIATIVA POPOLARE RECANTE “ISTITUZIONE DELL’AGENZIA NAZIONALE PER IL WELFARE ASSISTENZIALE”

Con l’art. 37 della legge 9 marzo 1989, n. 88, è stato introdotto il principio di separazione, nel bilancio dell’INPS, del sistema della previdenza da quello dell’assistenza, mediante l’istituzione di una gestione dei trattamenti assistenziali (GIAS) finanziato dalla fiscalità generale.
La GIAS ricomprende prestazioni esclusivamente assistenziali (come le pensioni di invalidità) ma anche prestazioni a carattere misto, cioè previdenziali coperte solo parzialmente dai contributi versati, come ad esempio le pensioni integrate al minimo.
L’esigenza della separazione nasceva e nasce dal fatto che entrambe le funzioni sono concentrate in un unico ente, l’INPS, il più grande istituto previdenziale europeo, che tuttavia ha nel suo bilancio anche una spesa assistenziale di oltre trenta miliardi di euro.
Il principio di separazione è certamente indispensabile per garantire trasparenza e chiarezza del bilancio ed evitare la confusione tra i due diversi sistemi.
In realtà, la commistione tra assistenza e previdenza non è stata affatto eliminata, nemmeno dopo l’introduzione dell’art. 37 della legge n. 88 del 1989.
Invero, nel bilancio dell’INPS continuano a circolare cifre poco chiare e, non di rado, le spese assistenziali sono contenute all’interno di voci previdenziali, e viceversa.
Ciò significa che i contributi che vengono versati per garantire in futuro i trattamenti pensionistici finiscono in quest’unico bilancio in cui L’INPS si destreggia per poter erogare anche le prestazioni assistenziali.
Da ciò deriva, inevitabilmente, l’assorbimento di risorse contributive nelle erogazioni assistenziali e sociali.
L’INPS, tuttavia, ha il precipuo compito di garantire che le prestazioni previdenziali siano corrisposte a coloro che hanno versato i relativi contributi confidando nella loro funzione assicurativa e che, quindi, tali contributi siano esclusivamente a ciò destinati; risulta invece del tutto improprio che tali contribuzioni finiscano per essere destinate anche a finanziare prestazioni assistenziali.
Le spese di carattere assistenziale (anche quando si tratti degli incrementi pensionistici non coperti dai contributi, come le integrazioni al minimo) vanno invece poste esclusivamente a carico della fiscalità generale, senza che si attinga ai contributi versati dagli aventi titolo alle prestazioni previdenziali.
Se così non fosse, il principio di uguaglianza fissato dall’art. 3 della Costituzione verrebbe violato, in quanto le prestazioni assistenziali graverebbero ingiustamente su una platea limitata di soggetti, e cioè di coloro che hanno versato e versano contributi per garantirsi il trattamento
previdenziale della vecchiaia.
Inoltre, un tale risultato si rivela altresì in contrasto con altri principi di rango costituzionale, come quello che il trattamento di quiescenza è configurabile quale retribuzione differita, secondo il criterio di proporzionalità alla quantità e qualità del lavoro prestato (art. 36, primo comma, Cost.) nonché con il principio di adeguatezza (art. 38, secondo comma, Cost.) (cfr. le sentenze della Corte costituzionale n. 208 del 2014 e n. 316 del 2010).
I trattamenti pensionistici rappresentano la “restituzione” assicurativa, sotto forma di assegno mensile, di contributi versati e via via incamerati dall’ente erogatore durante la vita lavorativa. A questa “restituzione” assicurativa il pensionato acquisisce un vero e proprio diritto che sarebbe violato se quei contributi venissero (come vengono) dirottati per finanziare anche le erogazioni assistenziali.
Il fenomeno è di entità niente affatto irrilevante.
Si pensi che circa 4 milioni di soggetti ricevono pensioni assistenziali (assegni sociali, di invalidità, etc.) e quasi 5 milioni di soggetti godono delle integrazioni al minimo e delle maggiorazioni sociali, per un totale di circa 9 milioni di beneficiari che rappresentano circa la metà di tutti i pensionati.
Nell’opacità del bilancio INPS onnicomprensivo queste pensioni finiscono per essere parzialmente “pagate” anche da coloro che hanno versato e versano i contributi assicurativi per la propria pensione e ciò, rendendo insostenibile il sistema, ne minaccia paradossalmente la corresponsione.
Questo purtroppo è ciò che avviene quando vi è commistione tra le due funzioni e tra le relative poste di bilancio.
Occorre dunque che le prestazioni di carattere assistenziale (come le integrazioni al minimo, le maggiorazioni sociali e le pensioni di invalidità) non vengano mai confuse nella spesa pensionistica.
Vi è un’ulteriore decisiva ragione che dovrebbe spingere a realizzare la separazione.
Invero, la spesa effettiva per pensioni, al netto delle tasse e delle ingenti somme (oltre 30 miliardi di euro) della gestione assistenziale GIAS, è interamente coperta dalle entrate contributive, a dimostrazione che con le riforme previdenziali via via attuate, fino alla riforma Fornero, il sistema previdenziale italiano non è affatto in passivo ma è perfettamente sostenibile.
Il sistema pensionistico nel nostro Paese poteva definirsi “non sostenibile”, a causa dell’invecchiamento della popolazione e della la bassa età effettiva di uscita dal mercato del lavoro, prima delle riforme Dini e Fornero, ma non certo dopo tali riforme.
Ed infatti, la spesa pensionistica “pura” – detratta anche la tassazione che grava sulle pensioni – con la separazione dalla spesa assistenziale scenderebbe al 10% del PIL, in linea con quella degli altri Paesi comunitari.
Invece, nel confronto con gli altri Paesi europei l’Italia si posiziona, a causa dell’anzidetta commistione, agli ultimi posti delle classifiche OCSE ed Eurostat in tema di spesa pensionistica, con tutte le relative conseguenze negative in termini, non solo di immagine, ma anche di “attenzione” comunitaria alle dinamiche fuori controllo della spesa pubblica ed al bilancio dello Stato, già gravemente zavorrato dal debito pubblico.
Appare quindi opportuno che si proceda ad una riforma radicale della gestione assistenziale svolta dall’INPS.
Per ottenere ciò, è anzitutto necessario che tale funzione sia coerentemente sottratta all’INPS, il quale deve esclusivamente svolgere la funzione previdenziale assicurativa che per legge gli appartiene, e che le erogazioni assistenziali siano invece affidate ad un organismo diverso, convenientemente attrezzato ad occuparsene in maniera equa ed efficace.
La presente proposta di legge popolare è dunque intesa all’istituzione di un’agenzia, posta sotto la vigilanza del Ministero del Lavoro e delle Politiche Sociali, alla quale saranno affidate le prestazioni attualmente elencate nell’art. 37 della legge 9 marzo 1989, n. 88 e ss. mm.
Conseguentemente, l’agenzia avrà altresì funzioni consultive e propositive nonché di controllo circa l’effettiva sussistenza dei requisiti che danno titolo, per i beneficiari, all’erogazione delle prestazioni economiche assistenziali.
Nello stesso tempo, la presente proposta di legge popolare prevede di conferire la delega legislativa al Governo affinché provveda al riordino delle varie voci della GIAS, in modo che i dati della spesa previdenziale e di quella assistenziale divengano certi e trasparenti, passaggio questo prioritario per qualsiasi intervento legislativo di riforma del sistema previdenziale che si voglia consapevolmente intraprendere.”

 

Fatto. Analisi. Impatto di @vitalbaa su newslist.it di @masechi DA LEGGERE!

Come si dovrebbe legiferare e regolamentare in un paese civile, applicando continuamente AIR (analisi di impatto della regolamentazione) e VIR (verifica di impatto della regolamentazione) prima e dopo il processo decisionale.

L’articolo è l’ulteriore dimostrazione dell’interesse della newslist.it del grande Mario Sechi

Una vita sregolata di Vitalba Azzollini Il sottotitolo di questa newsletter  – “Fatto. Analisi. Impatto” (ma anche “Agenda”, come dirò) – è un invito a nozze per chi si occupa di regolamentazione. Quelle tre parole sono, al contempo, presupposto e spinta per l’evoluzione dell’ordinamento. Mi spiego meglio. Il mutamento della realtà è costante, il diritto deve tenere lo stesso ritmo: l’analisi dei fatti, quindi del contesto, così come quella degli impatti delle norme che intervengono sui fatti, è imprescindibile per ogni buon regolatore. Può aggiungersi anche altro. La regolamentazione è un costo, poiché impone oneri e limiti ai soggetti privati, spese di elaborazione ed attuazione a quelli pubblici. Un rule maker realmente accountable deve essere in grado di giustificare in modo trasparente che, tra le diverse opzioni normative a sua disposizione, ha scelto quella più efficace in termini di costi e benefici, dati i fini perseguiti. La scarsa attenzione a questo processo di valutazione ponderata ha determinato nel tempo discipline sovrabbondanti, inutili o poco coerenti. E i conseguenti effetti negativi su produttività, concorrenza, competitività del sistema economico nazionale sono evidenti (e attestati da studi sull’attrattività di diversi Paesi). Dunque, “Fatto. Analisi. Impatto” è, in sintesi, il metodo che i regolatori nazionali – specificamente governo e autorità “tecniche” – dovrebbero  seguire (il condizionale è d’obbligo, come spiegherò oltre), non foss’altro perché è da anni un obbligo di legge. Come si attua in concreto questo metodo? Si attua, da un lato, mediante l’analisi di impatto della regolamentazione (AIR), strumento che serve a definire esattamente il problema da risolvere; individuare gli obiettivi perseguiti e costruire indicatori di carattere quantitativo che consentano di verificarne il grado di raggiungimento; consultare gli stakeholder; esaminare le varie opzioni di intervento (inclusa la cd. “opzione zero”, ossia il non intervento); comparare i vantaggi e gli svantaggi di ognuna di tali opzioni, considerandone gli effetti concorrenziali sul mercato e quantificandone il “prezzo” per cittadini e imprese; delineare un attendibile scenario del futuro funzionamento dell’opzione selezionata, soprattutto dei suoi possibili effetti inattesi o indesiderati, sulla base dei dati disponibili al momento della sua scelta. Dall’altro lato, il metodo citato si attua mediante la verifica di impatto della regolamentazione (VIR), che serve per vagliare il reale grado di raggiungimento degli obiettivi prefissati, misurato sulla base degli indicatori predefiniti; “manutenere” le leggi vigenti, onde permetterne nel tempo la correzione a seguito di eventuali disfunzioni o l’aggiornamento in relazione a sopravvenuti mutamenti fattuali e giuridici; abrogare le norme non più necessarie. Ricapitolando, il metodo riassunto in “Fatto. Analisi. Impatto” – valutazione ex ante dell’adeguatezza della regolamentazione ed ex postdella sua concreta e perdurante efficacia – serve non solo a tenere l’ordinamento al passo di una realtà in costante trasformazione e a imporre ai regolatori di giustificare le proprie scelte in maniera trasparente, ma a garantire il buon funzionamento delle leggi. Quindi, è un metodo idoneo ad assicurare una regolamentazione di qualità. Come il Consiglio di Stato ha evidenziato in un recente parere – ove riassume i numerosi interventi in tema di better regulation da parte del legislatore nazionale, nonché dell’Unione Europea e dell’OCSE – “una norma ‘scritta bene’, che rispetti i requisiti di ‘qualità’ (…) in termini di consapevolezza dell’impatto su cittadini e imprese, reca un beneficio ulteriore – e costi sociali minori – rispetto ai benefici che il suo contenuto ‘di merito’ già prevede”. In altre parole, la valutazione degli impatti, garantendo la qualità delle regole, offre un “valore aggiunto” economicamente stimabile in termini di “maggiore efficacia, efficienza, sostenibilità e ‘durabilità’ delle normative”. “Fatto. Analisi. Impatto” è il metodo che i regolatori nazionali dovrebbero seguire, dicevo usando scientemente il condizionale. Ne spiego la ragione. Come rilevato sempre dal Consiglio di Stato – e come si legge puntualmente nella Relazione sullo stato di attuazione della analisi di impatto della regolamentazione, presentata ogni anno dal Governo al Parlamento – le relazioni AIR sono il più delle volte poco approfondite, prive degli indicatori quantitativi utili a consentire la verifica dell’effettivo impatto delle norme; mancanti dell’analisi economica delle opzioni alternative di regolamentazione e lacunose riguardo all’opzione prescelta; carenti nell’analisi di “fattibilità”, cioè incuranti della successiva fase di attuazione, anche in termini di stima delle risorse – finanziarie e umane – necessarie. Quanto alle VIR, affermare che non ve ne sono molti esempi sarebbe un eufemismo. Questa è la foto del “metodo” – anche per i fallimenti serve metodo – con cui i regolatori nazionali hanno nel tempo affossato ogni italica aspirazione di better regulation. Peraltro, svuotando di significato AIR e VIR, hanno costantemente disatteso anche il c.d. regulatory budget (che impone di non introdurre nuovi oneri amministrativi senza averne prima eliminati altri), reso le consultazioni pubbliche dei meri pro-forma, ossia atti di politica fittizia, e molto altro. Ma qui mi fermo. “Fatto. Analisi. Impatto” è il metodo con cui, in questa newsletter, partendo dai fatti esaminati, vengono tratte conclusioni, fondandole su analisi di dati e impatti svolte trasparentemente. E trasparenza è la caratteristica ineludibile di ognuno degli strumenti di better regulationsopra citati, nonché la chiave di volta per comprendere il loro insufficiente utilizzo, di AIR e VIR soprattutto. La trasparenza delle decisioni di regolazione – cioè la trasparenza delle valutazioni degli impatti, anche attraverso la loro pubblicazione su siti istituzionali – metterebbe i governanti nella condizione di dover rendere conto del proprio operato, consentendo all’elettorato di giudicarli con dati di fatto. Detto in termini più banali, ne disvelerebbe i poco realistici annunci di riforme mirabolanti, così come il mancato ottenimento di effetti previsti con noncurante leggerezza. Dunque, gli strumenti che garantiscono la qualità della regolazione, nonché la trasparenza del processo di rule making, contribuirebbero alla responsabilizzazione democratica dei rule makers stessi, date le conseguenze reputazionali (e soprattutto elettorali) cui potrebbero dar luogo. E’ più chiaro ora il perché in Italia tali strumenti non vengono usati – anzi, sono spesso demonizzati da politici e supporter – con la conseguenza che le leggi sono fatte male e operano ancora peggio? Dimenticavo: nel sottotitolo di questa newsletter vi è anche la parola “Agenda”, cioè il “da farsi”, e ai fini di quanto detto sopra conta anche quella. La trasparente programmazione dell’attività normativa e, quindi, l’elenco delle iniziative di regolamentazione previste in un arco temporale preciso – con pubblicazione sui siti web istituzionali anche dei motivi per cui il programma non viene eventualmente rispettato – rappresenterebbe un impegno, la cui violazione nuocerebbe alla credibilità di chi l’ha assunto. “Fatto. Analisi. Impatto. Agenda”. Così si chiude il cerchio. Chi è l’autore. Vitalba Azzollini, giurista. Lavora presso un’Autorità di vigilanza. Scrive in tema di diritto su riviste on line (tra le altre, La Voce e Noise fron Amerika), blog (Phastidio e Istituto Bruno Leoni) e giornali. Autrice di paper per l’Istituto Bruno Leoni. @vitalbaa

Terremoto e paradossi economici @WRicciardi @drsilenzi @redhenry88

Titolo su Milano Finanza: “Il paradosso del terremoto: le spese per la ricostruzione non incideranno sul deficit e daranno una mano al pil”. E’ l’articolo più interessante e utile pubblicato sui quotidiani. Il passaggio chiave è questo: “La contabilità della ricostruzione ha a che fare con le disposizioni del nuovo articolo 81 della Costituzione, in cui si prevede la deroga all’obbligo del pareggio di bilancio, facendo dunque ricorso all’ indebitamento, solo quando si debbano fronteggiare un ciclo economico o circostanze eccezionali. Tra queste ultime, sono espressamente considerate le gravi calamità naturali. Spetterà al Parlamento, con una conforme deliberazione di Camera e Senato assunta a maggioranza dei rispettivi componenti, dichiarare che si versa in una delle citate situazioni. Anche il Fiscal compact, ma in maniera più generica, considera due circostanze eccezionali che consentono di derogare all’ obbligo di pervenire al pareggio strutturale del bilancio: si tratta degli “eventi inconsueti non soggetti al controllo della parte contraente interessata che abbiano rilevanti ripercussioni sulla situazione finanziaria della pubblica amministrazione”, e quindi nel nostro caso delle gravi calamità naturali. La deviazione temporanea è ammessa, purché non comprometta la sostenibilità del bilancio a medio termine. Nel caso di gravi calamità si attiva la clausola di flessibilità che consente di peggiorare il deficit congiunturale, ma si deve trattare infatti di spese una tantum, che si esauriscono con la soluzione del problema insorto. Tutte le spese pubbliche e le sovvenzioni concesse ai privati a seguito di una calamità naturale concorrono a far aumentare il prodotto, dacché mobilitano risorse materiali e umane che altrimenti sarebbero rimaste inerti. A differenza di qualsiasi investimento, o altra spesa pubblica, di questi interventi non si tiene conto ai fini del rispetto degli obblighi costituzionali ed internazionali sul pareggio di bilancio. La considerazione è ancora più amara se si pensa che le spese edilizie volte alla messa in sicurezza a fini antisismici, sia che derivino da spese pubbliche dirette, sia che dipendano da detrazioni di imposta a favore dei privati che le effettuino, non hanno lo stesso trattamento di favore”. Sì, è un paradosso.

Mario Sechi, Il Foglio List, 25 agosto 2016

How and why do countries vary so much in their use of health services? @WRicciardi @leadmedit @Medici_Manager @pash22

BY ADAM WAGSTAFF , http://bit.ly/1e48HAI

I’ve been struck recently by how little we (or at least I) seem to know about variations in use of health services across the world, and what drives them. Do people in, say, India or Mali use doctors “a lot” or “a little”. Even harder: do they “overuse” or “underuse” doctors? At least we could say whether doctor utilization rates in these countries are low or high compared to the rate for the developing world as a whole. But typically we don’t actually make such comparisons – we don’t have the numbers at our fingertips. Or at least I don’t.

I’m also struck by how strongly people feel about the factors that shape people’s use of services and what the consequences are. There are some who argue that the health problems in the developing world stem from people not getting care, and that people don’t get care because of shortages of doctors and infrastructure. There are others who argue that doctors are in fact quite plentiful – in principle; the problem is that in practice doctors are often absent from their clinic and people don’t get care at the right moment. There are others who argue that doctors are plentiful even in practice and people do get care; the problem is that the quality of the care is shockingly bad. Who’s right?

WHS to the rescue – again

As in a recent post of mine on Let’s Talk Development, I thought the World Health Survey might shed some light on these issues. The WHS was fielded in the early 2000’s in 70 countries – spanning the World Bank’s lower-, middle- and high-income categories. The WHS enumerators asked a randomly-selected adult in each household about his or her use of inpatient care and outpatient care; in the numbers that follow I’ve focused on use in the last 12 months. As I said in the earlier blog post, the WHS does have some drawbacks: it covers some regions fairly fully, other much less fully; it’s 10 years old; and all we can tell is whether inpatient or outpatient care was received, not the number of contacts. But despite these problems, the WHS gets us quite a long way.

A lot of variation – but not necessarily what you’d expect

The maps below show the inpatient admission and outpatient visit rate – actually the fraction of people who had at least one admission or visit in the last 12 months. Green countries are above the developing-country average; red countries are below it.
For IP admissions, most of the OECD countries are above the developing-country average (6.98%). Brazil, Namibia and the European and central Asian countries are also above it. African and Asian countries are mostly below or close to the developing-country average.

The picture is different for outpatient visits. Several OECD countries are actually below the developing-country average (27.52%). And for the most part, the countries below the developing-country average are in Africa: many are considerably below it (Mali stands out dramatically); only a few are above it (Kenya and Zambia stand out). By contrast, several countries in Asia are above the developing-country average: India and Pakistan are dramatically above it, but China and Vietnam are also above it; a few Asian countries are below it – Laos and Myanmar are considerably below it, Malaysia and the Philippines less so.

Do variations in doctor numbers and infrastructure explain variations in utilization?

The maps below show data on doctors and hospital beds per 1,000 persons. I got the data from the World Development Indicators, and took the country averages for the first half of the 2000s. As before, green countries are above the developing-country average; red countries are below it. The countries above the developing-country averages are mostly those in the OECD and Europe and central Asia, though in the case of doctors per 1,000 some of them are also in Latin America and the Caribbean. Except for China, most of Asian countries fall below the developing country average.

Correlating the WHS utilization data with the WDI doctor and beds data shows that doctors and beds per 1,000 persons are positively associated with outpatient visit and inpatient admission rates. A lack of doctors and beds looks like it could indeed be part of the explanation for low utilization rates, though of course we haven’t established causality.

But a lack of doctors and hospital beds is only part of the story. Together they “explain” only 60% of the cross-country variation in inpatient admission rates, while doctors “explain” an even smaller 20% of the cross-country variation in outpatient visit rates.

Some countries – India and Pakistan are examples – are below the developing-country average on doctors per 1,000 persons, but above the developing-country average on the outpatient visit rate. Doctors and hospitals in these countries treat far more patients than one would expect given the number of doctors and hospital beds in these countries. In these countries, it doesn’t look like accessibility is the pressing issue; as research by my colleague Jishnu Das confirms, at least in India, poor quality is the bigger problem.

By contrast, much – but not all – of Africa is in the opposite camp: these countries have inpatient admission and outpatient visit rates that are below what would be expected on the basis of their doctor and beds per 1,000 figures. So it’s not just that these countries lack doctors and beds; it’s also that people are not getting the level of contacts you’d expect from the existing staff and infrastructure. Here it looks like absenteeism could well be part of the story; recent research from my colleague Markus Goldstein confirms it – pregnant women whose first clinic visit coincided with a nurse’s attendance were found to be 46 percent more likely to deliver their baby in a hospital.

Two take away messages

Message #1 is that countries differ considerably in their utilization rates. Much of Asia visits doctors more regularly than both the developing world and the entire world; India’s consultation rate is a third higher than the global average. Africa stands out as the continent where outpatient visits and inpatient admissions lag behind the rest of the world.

Message #2 is that these variations are partly explained by differences in doctors and hospital beds per capita, but only partly. The problem goes deeper than hiring more doctors and building more hospitals. Africa has lower outpatient visit rates than its doctors per 1,000 figures would suggest, while the opposite is true of India and Pakistan. In Africa, it looks like the binding constraint may well be absenteeism, while in S Asia it looks like the first-order problem is the poor quality of care that’s actually delivered.

Vaccines and Autism: CDC Study Says No Connection @Medici_Manager @WRicciardi

Frank DeStefano, MD, MPH http://bit.ly/13g2KgW

New CDC Study of Vaccine Doses and Autism

Concerns about childhood vaccinations and the risk for autism persist for many parents and some members of the public. A new CDC study published in the Journal of Pediatrics ^[1]addressed a current concern about the relationship between autism spectrum disorder (ASD) and vaccination, which centers on the number of vaccines and vaccine antigens given to infants and children, according to the recommended childhood immunization schedule.

The study evaluated the association between the level of immunologic stimuli received from vaccines during the first 2 years of life and the development of ASD. The findings showed that neither the number of antigens from vaccines received on a single day of vaccination, nor the total number of antigens received during the first 2 years of life, is related to the development of autism.

About This CDC Study

This study is the first of its kind to evaluate the issue of “too many vaccines too soon” and the development of ASD. The study was conducted in 3 managed care organizations (MCOs), involving 256 children with ASD and 752 control children matched by birth year, sex, and MCO. In addition to ASD, researchers evaluated autistic disorder and ASD with regression and found no relationship with the number of vaccine antigens received in either of these categories.

Study data were obtained from immunization registries and medical records. The data used in this study had been collected and analyzed previously.^[2] Children eligible for the study were born between January 1, 1994, and December 31, 1999, and were 6-13 years old at the time of data collection.

Each child’s total vaccine antigen exposure was determined by adding the number of different antigens in all vaccines that each child received in 1 day, as well as all vaccine antigens each child received up to 2 years of age. The number of vaccines and number of vaccine doses administered according to type of vaccine are shown in the Table.

Table. Antigens in Vaccines and Total Doses Administered by Vaccine Type

Vaccine Type	Antigens per Dose	Dosesa
Diphtheria toxoid/tetanus-diphtheria (DT/TD)	2	14
Diphtheria-tetanus-pertussis (DTP)	3002	235
DTP – Haemophilus influenzae type B (Hib)	3004	1659
Diphtheria-tetanus-acellular pertussis (DTaP)	4b	1165
DTaP	5b	789
DTaP	6b	492
DTaPHepatitis B	6b	3
Influenza	10	95
Hib	2	2123
Hepatitis A	4	22
Hepatitis B	1	3085
HepatitisB-Hib	3	215
Measles, mumps, rubella (MMR)	24	1093
Measles	10	2
Meningococcusc	2	285
Mumps	9	1
Pneumococcusd	8	698
Polio	15	3385
Rabies	5	1
Rotaviruse	14	57
Rubella	5	2
Typhoid	3000	4
Varicella	69	917
Yellow fever	11	1

aTotal vaccine doses administered in the study population from birth to 2 years of age

bNumber of antigens in DTaP vaccines varied by manufacturer

cMeningococcal C conjugate vaccine administered as part of a clinical trial at 1 MCO

dPneumococcal conjugate (7-valent) vaccine; some doses administered in a clinical trial at 1 MCO

eRotaShield® (no longer marketed)

The number of vaccine antigens has decreased in recent years although the number of recommended vaccines has increased. The routine immunization schedule in 2013 contains more vaccines than the schedule of the late 1990s. The maximum number of vaccine antigens that a child would be exposed to today by 2 years of age is 315, compared with several thousand in the late 1990s. This is the result of changes in vaccines that allow them to more precisely stimulate the immune system. For example, the older whole-cell pertussis vaccine induced the production of approximately 3000 different antibodies, whereas the newer acellular pertussis vaccines (such as DTaP) stimulate the production of 6 or fewer different antibodies.

This study strengthens the conclusion of a 2004 comprehensive review by the Institute of Medicine of the scientific evidence that favored a rejection of the causal association between certain vaccines types and autism.^[3]

Knowledge, Attitudes, and Beliefs About Vaccines and Autism

Some parents are concerned that there is a link between vaccines (such as MMR) or certain vaccine ingredients (such as thimerosal) and autism. However, several large and reliable studies of MMR vaccine have been done in the United States and other countries.^[3,4] None has found a link between autism and MMR vaccination. Furthermore, research^[2] does not show a link between thimerosal in vaccines and autism. Although thimerosal was taken out of childhood vaccines in 2001, autism rates have continued to climb.

Although scientific evidence shows that vaccines do not cause autism, a 2012 HealthStyles survey showed that slightly more than 15% of parents are concerned that they do (LaVail K, Fisher A, CDC; unpublished data). Data from the survey found that 22.8% of parents are concerned that children receive too many vaccines at a single doctor’s visit, and 22.8% of parents are concerned that children receive too many vaccines by the age of 2 years. The vaccines, they believe, can cause learning disabilities, such as autism. In another recent survey,^[5] more than 1 in 10 parents of young children refuse or delay vaccinations in the belief that delaying vaccines is safer than giving vaccines according to the CDC-recommended immunization schedule. Children do not receive any known benefits from delaying vaccines. Delaying vaccines puts children at risk of becoming ill with vaccine-preventable diseases.

What Clinicians Can Do

CDC research with parents about their vaccine attitudes and vaccination behaviors has found that most US parents believe that vaccines are important, and they vaccinate their children. In fact, coverage for most of the routine childhood vaccines remains at or exceeds 90% in children aged 19-35 months. CDC and other agencies and organizations continue to conduct research to learn more about the causes of autism.

Healthcare professionals are the main determinants of parents’ decisions about whether to vaccinate their children. This study provides evidence that clinicians can use to reassure parents that the number of vaccines received early in life is not associated with the development of autism. Clinicians can help parents to learn the signs of ASD and act early so that action can be taken to help their children reach their full potential. Online resources, tools, and educational materials for clinicians to use to communicate with parents and caregivers are found at the end of this article.

Web Resources

CDC. Developmental Milestones

CDC. Autism Spectrum Disorders. Screening and Diagnosis for Healthcare Providers

American Academy of Pediatrics. Community Pediatrics. Act Early on Developmental Concerns: Partnering with Early Intervention

Frank DeStefano, MD, MPH, is Director of the Immunization Safety Office of the Centers for Disease Control and Prevention (CDC). He is a graduate of Cornell University and the University of Pittsburgh School of Medicine. He received training in public health and preventive medicine in the Epidemic Intelligence Service and preventive medicine residency at CDC. He obtained a Masters of Public Health degree at Johns Hopkins University School of Hygiene and Public Health. He has had extensive epidemiologic research experience at CDC, the National Institutes of Health, and at non-governmental research organizations. His areas of research have included immunizations, autism and other developmental disabilities, reproductive health, veterans’ health, diabetes, cardiovascular diseases, and other chronic diseases. Dr. DeStefano is an author on over 150 publications in leading scientific and medical journals. For the past 16 years Dr. DeStefano has had a focus on vaccine safety.

Shared Decision Making to Improve Care and Reduce Costs @Medici_Manager

Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D.

http://www.nejm.org/doi/pdf/10.1056/NEJMp1209500

A sleeper provision of the Affordable Care Act (ACA) encourages greater use of shared decision making in health care. For many health situations in which there’s not one clearly superior course of treatment, shared decision making can ensure that medical care better aligns with patients’ preferences and values. One way to implement this approach is by using patient decision aids — written materials, videos, or interactive electronic presentations designed to inform patients and their families about care options; each option’s outcomes, including benefits and possible side effects; the health care team’s skills; and costs. Shared decision making has the potential to provide numerous benefits for patients, clinicians, and the health care system, including increased patient knowledge, less anxiety over the care process, improved health outcomes, reductions in unwarranted variation in care and costs, and greater alignment of care with patients’ values.

However, more than 2 years after enactment of the ACA, little has been done to promote shared decision making. We believe that the Centers for Medicare and Medicaid Services (CMS) should begin certifying and implementing patient decision aids, aiming to achieve three important goals: promote an ideal approach to clinician–patient decision making, improve the quality of medical decisions, and reduce costs.

In a 2001 report, Crossing the Quality Chasm, the Institute of Medicine recommended redesigning health care processes according to 10 rules, many of which emphasize shared decision making. One rule, for instance, underlines the importance of the patient as the source of control, envisioning a health care system that encourages shared decision making and accommodates patients’ preferences.

Unfortunately, this ideal is inconsistently realized today. The care patients receive doesn’t always align with their preferences. For example, in a study of more than 1000 office visits in which more than 3500 medical decisions were made, less than 10% of decisions met the minimum standards for informed decision making.1 Similarly, a study showed that only 41% of Medicare patients believed that their treatment reflected their preference for palliative care over more aggressive interventions.2

There’s also significant variation in the utilization of procedures, particularly those for preference-sensitive conditions, which suggests that patients may receive care aligned not with their values and preferences, but with their physicians’ payment incentives. Among Medicare patients in more than 300 hospital regions, the rate of joint-replacement procedures for chronic hip arthritis varied by as much as a factor of five, and the use of surgery to treat lower back pain varied by nearly a factor of six. Other studies have found wide regional variation in the treatment of early-stage breast and prostate cancers and in the use of cardiac procedures.

Section 3506 of the ACA aims to facilitate shared decision making. Primarily, it funds an independent entity that would develop consensus-based standards and certify patient decision aids for use by federal health programs and other interested parties. In addition, the secretary of health and human services is empowered to fund, through grants or contracts, the development and evaluation of these tools. Decision aids are meant to be evidence-based and inform patients of the risks and benefits of tests and treatments, their relative effectiveness, and their costs. Health care providers will be eligible for grants to implement these tools and to receive training and technical support for shared decision making at new resource centers. The ACA also authorizes the Center for Medicare and Medicaid Innovation to test shared-decision-making models designed to improve patients’ and caregivers’ understanding of medical decisions and assist them in making informed care decisions. For approaches that provide savings or improve quality of care, implementation can be mandated throughout Medicare without additional legislation.

Randomized trials consistently demonstrate the effectiveness of patient decision aids. A 2011 Cochrane Collaborative review of 86 studies showed that as compared with patients who received usual care, those who used decision aids had increased knowledge, more accurate risk perceptions, reduced internal conflict about decisions, and a greater likelihood of receiving care aligned with their values. Moreover, fewer patients were undecided or passive in the decision-making process — changes that are essential for patients’ adherence to therapies.

Studies also illustrate the potential for wider adoption of shared decision making to reduce costs. Consistently, as many as 20% of patients who participate in shared decision making choose less invasive surgical options and more conservative treatment than do patients who do not use decision aids.3 In 2008, the Lewin Group estimated that implementing shared decision making for just 11 procedures would yield more than $9 billion in savings nationally over 10 years. In addition, a 2012 study by Group Health in Washington State showed that providing decision aids to patients eligible for hip and knee replacements substantially reduced both surgery rates and costs — with up to 38% fewer surgeries and savings of 12 to 21% over 6 months.4 The myriad benefits of this approach argue for more rapid implementation of Section 3506 of the ACA.

The Department of Health and Human Services could quickly launch pilot programs for shared decision making while it works to standardize and certify decision aids. The International Patient Decision Aid Standards Collaboration has developed evidence-based guidelines for certification indicating that decision aids should include questions to help patients clarify their values and understand how those values affect their decisions; information about treatment options, presented in a balanced manner and in plain language; and up-to-date data from published studies on the likelihood of achieving the treatment goal with the proposed intervention and on the nature and frequency of side effects and complications. In addition, it would be helpful to include validated, institution-specific data on how often the specified procedure has been performed, the frequency of side effects and complications, and the cost of the procedure and any associated medication and rehabilitation regimens. We believe that decision aids should be written at an eighth-grade level and should be brief.5

In our view, it seems most critical to begin with the 20 most frequently performed procedures and to require the use of decision aids in those cases. Many decision aids have already been rigorously evaluated, so CMS could rapidly certify these tools and require their use in the Medicare and Medicaid programs. To give such a requirement teeth, full Medicare reimbursement could be made contingent on having documentation in the patient’s file of the proper use of a decision aid for these 20 procedures. Providers who did not document the shared-decision-making process could face a 10% reduction in Medicare payment for claims related to the procedure in year 1, with reductions gradually increasing to 20% over 10 years. This payment scheme is similar to that currently tied to hospital-readmissions metrics.

In addition, the improved quality of care and savings gained through shared decision making can be maximized by integrating this approach into other ACA initiatives. For example, the documented use of patient decision aids could be used as a quality metric in patient-centered medical homes, accountable care organizations, and systems caring for patients eligible for both Medicare and Medicaid. Eligibility criteria for incentives to adopt electronic health record technology might be expanded to include the use of shared decision making and patient decision aids. Moreover, information gathered by the Patient-Centered Outcomes Research Institute (PCORI) could be incorporated into certified decision aids and used to provide physicians and patients with valuable information for making health care decisions. Data about the effectiveness of shared-decision-making techniques could also be collected and disseminated by PCORI for continuous improvement of these approaches.

Unfortunately, implementation of ACA Section 3506 has been slow. More rapid progress on this front would benefit patients and the health care system as a whole.

Selling Proton Therapy to the Public: High Costs Without Benefit @Medici_Manager

In Trentino si sta mettendo in funzione la protonterapia! Auguri per la sostenibilità!

Written by Daniel Wolfson on March 20, 2013 http://bit.ly/WEuqap

Arriving in a train station in a Northeast city the other day, I was struck by the number of advertisements for proton therapy at a local academic medical center (AMC) plastered throughout the station and in local subways. The ads feature a bicycle racer with the tag line: “THE WIND IN YOUR FACE IS WORTH PROTON THERAPY: A cancer treatment that has fewer side effects.”

A bold statement, I thought, considering several studies have shown that proton therapy provides no long-term benefit over traditional radiation and comes with significantly higher cost for most conditions. There are a limited number of conditions—such as pediatric oncology—where proton therapy is shown to be effective.  Most striking, however, was the fact that this ad was specifically created to target a public that is not aware of the proton therapy’s marginal benefit and in what limited conditions it is effective.

“Marginal benefit” is when two procedures have small differences in benefits but large cost differences. Usually the more expensive intervention yields more benefits, like fewer side effects. But in this case, we have a procedure with no added benefits that is a lot more expensive.

Proton therapy uses atomic particles to treat cancer rather than X-rays. The particle accelerator is the size of a football field and costs about $180 million. According to the Yale study, Medicare pays over $32,000 for the treatment compared to under $19,000 for radiation. When applied to treat prostate cancer, outcomes were no different than intensity-modulated radiotherapy. Urinary function side effects were slightly better within six months but those advantages disappeared with 12 months post-therapy.

The ad directly contradicts the findings of this study and claims that proton therapy has fewer side effects than traditional therapy. This claim is true for pediatric cases but not for prostate cancer, the one primarily targeted by these ads.

What bothers me the most is that an AMC is peddling a more expensive procedure with no clear added benefit to the public through a massive advertising campaign. Isn’t there a moral imperative for an AMC to work in the best interest of their community based on the best available clinical evidence? Isn’t this supposed to be the era of value services? If they must advertise the therapy (possibly to recoup some of their costs or at least break even), why not target referring physicians rather than an unsuspecting public that is prone to request the latest and greatest technology just because it’s new? Perhaps referring physicians are wise to the lack of proton therapy’s marginal benefit and the AMC is hoping they will acquiesce to their patients’ demand for this marginal procedure. Is the public to know what cases are best for this type of therapy and for which conditions it is not well suited?

We should expect more and we should demand better. Proton therapy is clearly a more expensive procedure where a just-as-effective procedure exists. Quality and safety has not been raised, only the cost of medicine.

OECD’s Gurria Says Austerity Versus Growth Is a False Dilemma @Medici_Manager @WRicciardi

By Mark Deen, http://bloom.bg/XZQAQ9

Angel Gurria, secretary general of the Organization for Economic Cooperation and Development, said policy makers in the euro area should push ahead with deficit cuts and avoid the “false dilemma” of the austerity debate.

“You need fiscal consolidation in many countries and at the same time you need to plant the seeds of future growth,” Gurria said today in an interview at the World Economic Forum in Davos, Switzerland. “Let’s go for the reforms, accelerate the reforms, so we can consolidate the recovery.”

The International Monetary Fund cut its growth forecast for the 17-nation euro area yesterday, predicting a second year of contraction as the region’s governments seek to reduce public borrowing and revamp their economies in the wake of a sovereign debt crisis. Gurria said that increasing flexibility of both labor and product markets is key to reviving growth.

“If you really want to go for a durable recovery, you really have to go for the fundamental measures,” Gurria said. “Some of these take a long time to get results but today, paradoxically, your best short-term policies may be your best long-term reforms. The announcement and communication of where you want to go may be your best bet.”

To contact the reporter on this story: Mark Deen in Paris at markdeen@bloomberg.net

To contact the editor responsible for this story: Craig Stirling at cstirling1@bloomberg.net

Per salvare il SSN, i politici devono dire ciò che non possono dire! @Medici_Manager @wricciardi

Come in Gran Bretagna, i politici devono dire “l’indicibile” per salvare il SSN: dobbiamo ristrutturate i nostri servizi per malati acuti. In sostanza, bisogna chiudere ospedali!

To fix the NHS politicians must say the unsayable

We need to restructure our acute healthcare services, which will involve district general hospital closures

By Philip Lee http://bit.ly/13EMa52

For a government to aim for constant popularity in a world of 24-hour news is surely pointless, especially when it comes to the NHS. The religiosity surrounding our health system, graphically displayed in the Olympics opening ceremony, has long prevented honest discussion of its shortcomings. Our continual blind faith in a system designed in the shadow of war to serve a stoic nation is perplexing — and has cost lives.

The realities on the ground, along with the poor clinical outcomes when compared with other equivalent countries, can no longer be ignored. The NHS has been showing signs of terminal illness for some time. Yet hospitals that are inadequate continue to be maintained. Any politicians who think that the current system, including the financing model and physical structures, can be sustained in the longer term, under the weight of increasing clinical demands, are deluding themselves.

Indeed, by doing so, they risk further undermining the trust of an increasingly cynical public. Continuing to pay lip service to failed systems is just not acceptable. Neither is a short-termist and timid five-year plan. It is high time that politicians told the truth about the NHS. The system we have is not the envy of the Western world and outcomes are not as good as they should be. It cannot be right that criticism of the status quo is a political taboo. Professional politicians should cease ducking the issue just because it fails to deliver short-term electoral gain.

Lives are worth more than votes. The last Labour government attempted to prop up the NHS by increasing spending significantly. Such financial largesse required the support of Middle England. As measurement was popular with the centre Right, targets were introduced to “guarantee” better care.

The bitter irony for the people affected by the Mid Staffordshire scandal is that this target culture created the environment in which managers chased financial goals at the expense of humane care. Instead of looking for figures to fill election pledge cards, the last administration should have been concentrating on changing the NHS for the longer term. Sadly, it didn’t. A feel-good solution was delivered that left us all feeling worse.

We have long needed to restructure our acute healthcare services. This will involve district general hospital closures, the consolidation of acute specialist services into larger, new hub hospitals and the building of more community clinics. This is not a political decision, but rather a clinically driven necessity, supported by all medical professional organisations. In London, consolidating acute stroke services has already saved hundreds of lives. Of course, closing local hospitals doesn’t go down well with the public, and changing people’s minds on this will be difficult.

But we have no choice. Those of us who want to protect the fundamental principle of access for all need to make the case. The financing of health care also needs reform. I believe that the responsibility for funding should be moving slowly from the state to the individual. Technological advances, ageing, obesity and an increased appetite for medical treatments all load costs on to the taxpayer. New approaches to these challenges often fit poorly within old systems.

I want people to be free to choose any lifestyle they wish, while understanding that their choices may lead to health care costs later in life. I want to be able to give more to the truly deserving because we have spent less on those able to provide for themselves. I also want the very best 21st-century health care to be delivered in safe and appropriate clinical environments.

If politicians like me do not persuade the public of the need for these changes, then the vulnerable in our society will be put at risk. In return for this candour, the British people must accept this new reality. It is an untenable position for the public to demand politicians to tell the truth, only then to vote them out because what they’ve said is unpopular. If you really want a better NHS, then you will have to find the courage to vote for it.

Dr Phillip Lee is Conservative MP for Bracknell and a practising GP

Related Articles

• Tax fizzy drinks to stop Britain becoming the ‘fat man of Europe’ 18 Feb 2013
• Fizzy drink manufacturers hit back over proposed ‘fat tax’ 18 Feb 2013
• NHS boss ‘should resign over country-wide failings’ 08 Feb 2013
• Social care cap to be set at £75,000 08 Feb 2013
• Council knew about widow who starved 08 Feb 2013
• ‘Most nurses are angels, yet the system can just crush the compassion out of them’ 08 Feb 2013

The Future of Health – World Economic Forum @Medici_Manager @IlonaKickbusch

The future of health is being shaped by many global transformations, of which technology and connectivity are the most salient. Hence, “digital technologies and personalized medicines” was an appropriate tag line for this Annual Meeting session.

As an emerging domain – at the intersection of heath and technology – this should be viewed in two contexts:

The first one, centred on personalized technologies, is transforming the way in which patients engage with healthcare in chronic disease management settings; people in general enhance wellness independence. These are important objectives given the likely emphasis on non-communicable disease prevention and incentive-based wellness in the foreseeable future. By linking big data in the cloud with mobile applications, new engagement mechanisms and social media connectivity, a number of health endpoints can now being pursued – from safety, adherence and compliance, to improved access and healthy behaviour change.

The second emerging domain is digital health (eHealth, mHealth, tHealth and cHealth), where its context-specific applications can help achieve broader health systems goals: data management and information for policy can be transformed; e-learning can be enabled; costs and errors can be mitigated through e-solutions in healthcare settings; and transparency and efficiency can be institutionalized in health governance.

Digital health can be the single most important lever to lift heath systems out of their existing systemic problems. By linking entitlements with health data repositories, it can additionally help in the attainment of wider social objectives and universal health coverage goals, which are fast gaining traction as a policy agenda; at the international level as an umbrella post-MDG health goal and at the domestic level as a deterrent against Arab Spring type of social unrest.

The promise within these approaches underscores the need for policies to harness their potential and creates imperatives for global and domestic normative action. Recognition that this promise can only be fulfilled by leveraging the strength of technological tools, which are outside of traditional healthcare, necessitates multisectoral action and effective engagement with the private sector.

An out-of-the box domestic policy appetite needs to be generated for the establishment of an enabling environment for innovation and research. Capacity needs to be built for translating evidence into policy and taking pilots to scale. Governments need to appreciate the “business case” for investment in this area and should create enabling regulations, incentives as well as the necessary infrastructure.

Appropriate investment and partnerships can help achieve double bottom line objectives and a win-win situation for all stakeholders within and beyond the health sector.

http://www.weforum.org/sessions/summary/future-health

Focus on Health-Care Costs Causes More Spending @Medici_Manager @muirgray

By David Goldhill Jan 2, 2013 http://bloom.bg/RMzfNF

In 1983, the Ronald Reagan administration enacted one of the most significant cost reforms in Medicare’s history. The prospective payment system switched inpatient hospital reimbursement from open-ended fee-for-service to fixed fees paid per diagnosis.

In theory, this would give hospitals the incentive to treat patients as quickly and economically as possible.

The new rules did drive big changes. Since 1983, the total number of days spent by Medicare patients in hospitals has fallen 40 percent, even as the number of Medicare enrollees has risen 60 percent. The average inpatient stay is now just over five days, down from 10.

But even an improvement in efficiency of such magnitude failed to slow the cost train. As the number of hospital days declined, the daily charge to Medicare rose to $1,800, from $300.

The prospective payment system is only one obvious example of a long trend. Most major developments in health care — higher doctor productivity, diagnostic scans, new pharmaceuticals, minimally invasive surgery — could be described as increasing health care’s productivity. None of these achievements has lowered prices.

Cost Fallacy

Why not? Strange as it seems, cost is only mildly relevant to the price of care. In the world of health care, cost control is based on the fallacy that there is a fixed amount of care we need. Presumably, the more efficiently it’s performed, the cheaper it will be. This ignores how providers actually respond to changes in their business. By focusing relentlessly on the cost of care, we actually drive it up.

To understand why this is inescapable, ask yourself, What would you rather pay for the items you buy: whatever price a retailer charges or a small amount — say 5 percent — above the retailer’s cost? Take your time; it’s a trick question.

The cost-based pricing seems like the better deal. We imagine going into a store, learning that the merchant paid $10 for a sweater, and buying that sweater for only $10.50. But this assumes that, once you opt for cost-based pricing, the costs will stay the same. In reality, the cost-plus-5-percent system will change the merchant’s economic incentives — so that the next sweater the store buys will “cost” far more than $10.

Imagine the impact cost-plus would have on the world’s simplest business. Your daughter sets up a lemonade stand outside your house and charges a dollar a cup. (That number just seemed right to her.) She sells 50 cups to people passing by each day.

One day the mayor comes along. He’s running for re- election, and he wants to buy a cup of lemonade every week for all 1,000 residents of the town. He doesn’t want to pay $1,000 a week, though, so he suggests paying your daughter a “fair” profit of 50 percent. He knows each cup contains about 10 cents worth of lemons and sugar, so he figures he’ll be paying 15 cents a serving.

The moment your daughter agrees to this deal, however, she will try to increase her costs, because higher costs mean bigger profits. She is better off with more expensive lemons and sugar, larger cups (maybe even glasses), an assistant to run the stand and a new Lemonada 5000 mixer, which guarantees a perfect mix of sugar and lemon in every glass.

The mayor is no idiot. He sees what is happening, so he renegotiates his deal. From now on, he’ll pay her costs plus 5 cents a cup. Unfortunately, this also creates perverse incentives. Your daughter can make more money by reducing the size of each cup. Or she can cut back on customer service, hygiene or speed. Or she can cut side deals with her vendors: The lemon seller can raise his price — passed on to the mayor – – and share the proceeds with your daughter.

Manipulation’s Cost

Bizarrely, a cost-based pricing structure actually adds a new major cost: the effort it takes to track, manipulate and justify costs. In a $2.5 trillion industry such as health care, these activities are a big reason that administrative costs exceed $300 billion a year.

An Economist article on dialysis perfectly illustrates the inflationary impact of cost-plus pricing. Because U.S. clinics are paid on a cost-plus basis, they prefer expensive drugs to cheaper ones. In fact, many appear to order drugs in units that exceed what a standard dosage requires, because they can charge the government for the waste. The article noted that many clinics preferred an injected drug with a price of $4,100 a year over the identical drug in oral form, priced at only $450 a year. Not surprisingly, the manufacturer of the oral drug responded by increasing its price above that of the injected version to make it more competitive.

Our entire health-care system suffers from what I call the cost illusion — the idea that a service has a long-term fixed cost. But every cost is merely someone else’s price. And over time, costs themselves are also determined by prices.

What is the cost of orthopedic surgery? It is the sum of all the costs of the underlying components — the surgeon, anesthesiologist, nurses, hospital, device, tests and drugs. But how are these costs determined?

Let’s look at the orthopedic surgeon. We may believe there is some objective way to measure the cost of her time — a fair return on her years of education or training, say. In reality, the cost of the surgeon’s time depends on the value of orthopedic surgery to patients. If more patients need it, the surgeon’s time becomes more valuable. In a free market, there are two ways the cost of her time could decline: more orthopedic surgeons fighting for business or patients benefiting less from orthopedic surgery.

Protected Costs

In an administered market such as health care, on the other hand, our surrogates — insurers and Medicare — substitute their calculation of cost for the workings of supply and demand. This has the strange effect of preventing costs from ever falling. Let’s say Medicare sets the reimbursement rate for a hip replacement at $15,000. Now say a new drug is invented that makes hip replacements less useful. In a free market, the price would decline. But in an administered system, these prices are viewed as costs, and once set, there is no mechanism to lower them. A hip replacement still takes the same amount of time from surgeons of the same degree of expertise, so the cost must still be $15,000.

In health care, our system is designed to shield patients from even knowing the prices. Unfortunately, a world without prices is also one that can’t achieve the purpose of prices: the allocation of resources to match what consumers want.

Five weeks after my father died from a hospital-borne infection in the intensive-care unit of aNew York City hospital, my mother received a bill for his treatment — $635,695.75! The bill was broken down into 17 items. Had I booked Dad a room at the most expensive hotel in town for the five weeks of his illness, filled the room with a million dollars’ worth of hospital equipment leased for $15,000 a month, given him round-the-clock nursing care, and paid a physician to spend an hour a day with him (roughly 50 minutes more than at the hospital), it would total roughly $150,000.

That leaves $500,000 left over for, say, drugs (billed at $145,431), oxygen ($41,695) and blood ($30,248).

This comparison with actual prices is absurd, of course, because it assumes that the prices on my father’s bill were real prices. No one was actually supposed to pay that bill. The prices didn’t even bear a relationship to the exchange of funds for Dad’s treatment. The hospital billed my mother for her share ($992), which she wisely didn’t pay and the hospital wisely didn’t try to collect. Medicare paid the hospital according to its concept of the hospital’s cost. Of course, there’s no question what the competitive price would be for the service of killing my father: zero.

Prescription Costs

A stunted price system also distorts investment in new treatments. U.S. pharmaceutical companies spent roughly $67 billion in 2010 on research to develop new drugs. But many of these new drugs target conditions for which perfectly good drugs already exist. It is the lack of consumer prices that explains their me-too approach.

Once a new drug is approved, it enters the marketplace at a high reimbursement rate, compensating the manufacturer for its expensive research. So what’s the punishment for entering a crowded market? Very little. Furthermore, even with a promising new entrant, the prices of the existing drugs don’t decline; they have already been set to compensate for their “costs.” In any normal market, a new entrant would bear not only the risk of being rejected but also the risk of a price war.

Administered pricing also explains why our health-care industry has spent far too little on information technology. Your dry cleaner computerized his inventory system because losing a shirt may mean losing a payment or even a customer. But a doctor who invests in state-of-the-art patient data management can’t charge higher prices; insurers won’t pay. Nor is there a market mechanism to force hospitals that use paper records to accept lower prices — they don’t benefit from being more efficient. So the investment is never made.

If we, the consumers, saw and paid prices, we would be looking at a very different industry. My guess is that many of us would pay only for doctors who spend more time talking to us, providers who invest in computerized records, genuinely better treatments rather than me-too drugs for chronic conditions, and hospitals that kill fewer patients.

(David Goldhill is the president and chief executive officer of the cable TV network GSN. This is the first in a series of three excerpts from his new book, “Catastrophic Care: How American Health Care Killed My Father — and How We Can Fix It,” to be published Jan. 8 by Alfred A. Knopf. The opinions expressed are his own. Read Part 2 and Part 3.)

To contact the writer of this article: David Goldhill at dgoldhill@gsn.com.

To contact the editor responsible for this article: Mary Duenwald atmduenwald@bloomberg.net.

La salute va curata meglio, dice N.Dirindin @Medici_Manager

Nerina Dirindin http://bit.ly/WO07t8

Quella che il Governo ha chiamato “manutenzione straordinaria” al Ssn non è stata in grado di incidere, almeno nel breve periodo, sulle incertezze e sulle difficoltà che assillano operatori e assistiti. Apprezzabile l’attenzione a fenomeni come la ludopatia, peraltro non seguita da provvedimenti adeguati.

 Quindici mesi di governo sono troppo pochi per incidere in modo significativo in un settore complesso e delicato come la sanità, soprattutto se il Governo è tecnico e ha poca dimestichezza con i partiti e le lobby parlamentari, la burocrazia statale e le realtà regionali. Anche la crisi economica e gli squilibri della finanza pubblica sono troppo intensi per lasciare spazio a interventi diversi da quelli strettamente necessari per affrontare le emergenze. Pur tenendo conto delle difficili condizioni in cui ha lavorato il Governo, la “manutenzione straordinaria” del Servizio sanitario nazionale messa in atto dal Governo appare deludente.
Il principale impegno è stato “contribuire al contenimento e al risanamento della spesa pubblica” attraverso “la riduzione del finanziamento” pubblico della sanità, “preservando il funzionamento del sistema sanitario, che ha mantenuto invariati i servizi”. Un’affermazione importante, composta di due parti: una reale (la riduzione del finanziamento) e una ipotetica (l’invarianza dei servizi). La riduzione del finanziamento (legge 135/12 e legge di stabilità), che si è aggiunta a quella più consistente disposta dal Governo Berlusconi, è stata reale e tale da rendere praticamente costanti le disponibilità annue per l’intero quinquennio 2010-2014: 112 miliardi di euro all’anno. Una sfida comprensibile in un momento di crisi, ma certamente molto impegnativa, anche perché le regioni non sono più in grado di integrare con risorse proprie i minori finanziamenti statali. L’invarianza dei servizi è per contro una ipotesi di scuola, un auspicio che il Governo si è limitato ad assumere a priori. Vero è che alcuni interventi mirano a ridurre le inefficienze e a contenere le inappropriatezze, ma assumere che la riduzione del finanziamento colpisca solo sprechi e inefficienze, in tutte le regioni e in tutte le aree di intervento, pare ingenuo. E comunque il Governo non può limitarsi a prescrivere “l’invarianza dei servizi”, scaricando sulle regioni la responsabilità di attuare provvedimenti che spesso richiederebbero più gradualità, più flessibilità e più selettività. Con questo non si vuole difendere l’operato delle Regioni, in alcuni casi gravemente responsabili dell’inadeguatezza del proprio sistema sanitario (soprattutto quelle sottoposte a Piano di rientro), ma si vuole sottolineare la necessità di un livello centrale più attento alla fattibilità temporale dei provvedimenti: risparmi di spesa difficili da realizzare nel breve periodo inducono le regioni (anche le più virtuose) a ridurre l’assistenza, in termini quali-quantitativi, e a far gravare i tagli sui cittadini. E di questo il Governo non può non preoccuparsi, a meno che non ritenga comunque accettabile una minore tutela e un aumento delle diseguaglianze nell’accesso ai servizi. Più volte abbiamo sostenuto che i margini di intervento sono ancora consistenti (ad esempio, nel settore della diagnostica, dove si registra un eccesso di tecnologie – spesso male utilizzate – e un ricorso improprio alle prestazioni), ma molti temi sono stati trascurati.
Altri provvedimenti paiono deboli. La riorganizzazione della rete ospedaliera (per molti aspetti sacrosanta) è stata adottata prima della riorganizzazione delle cure primarie (altrettanto sacrosanta, ma di fatto solo annunciata e anch’essa scaricata sulle regioni), mentre dovrebbe essere successiva; e così in molte regioni i cittadini si vedono ridurre l’assistenza ospedaliera prima che sia riqualificato il territorio. Gli interventi sulla sanità elettronica (fascicolo sanitario elettronico, ricetta elettronica, ecc.) costituiscono un piccolo passo in avanti all’interno di un percorso iniziato molti anni fa e che avrebbe richiesto accelerazioni ben più consistenti, anche perché di grande rilevanza per l’innovazione e la “crescita intelligente”; e anche qui il Governo ha chiesto alle regioni di intervenire a costo zero. Significativa al contrario l’attenzione riservata ad alcuni aspetti importanti per la salute delle persone: il consumo di alcol fra i minorenni, la dipendenza da gioco d’azzardo, il cibo spazzatura, provvedimenti che purtroppo non sempre sono riusciti a superare gli ostacoli frapposti da chi ha interessi antitetici alla salute della collettività.
In sintesi, una manutenzione straordinaria non in grado di incidere, almeno nel breve periodo, sulle incertezze e sulle difficoltà che assillano quotidianamente gli operatori e gli assistiti.

Autovalutazione del Governo Salute

Bio dell’autore

Nerina Dirindin: E’ docente di Economia Pubblica e di Scienza delle Finanze presso l’Università di Torino. E’ Presidente del Coripe Piemonte dove coordina il Master in Economia e Politica Sanitaria. Ha ricoperto incarichi istituzionali: è stata Direttore Generale del Dipartimento della Programmazione del Ministero della Sanità (1999-2000) e Assessore della Sanità e dell’Assistenza Sociale della Sardegna (2004-2009).

Multiplicity: il contributo di @richard56 Smith al Convegno per Alessandro Liberati @Medici_Manager

In attesa degli atti completi! Un convegno ispirato a Italo Calvino e le sue “Lezioni americane: sei proposte per il prossimo millennio”.

Quali ispirazioni può ricavare la sanità dalla letteratura! Un libro da leggere, rileggere, studiare.

http://slidesha.re/XiQY2d

Recommended Reading: Reflecting on the Choosing Wisely Journal Articles of 2012 @Medici_Manager @ABIMFoundation

Written by Amy Cunningham on December 21, 2012

Since nine medical specialty societies announced their lists of “Five Things Physicians and Patients Should Question” in April, 55 published journal articles have referenced the Choosing Wisely^® campaign. For the final Recommended Reading post of 2012, we’ve culled a selection of those articles, and will share more in the new year.

In order of publication date:

• ABIM and ABIM Foundation President and CEO Christine K. Cassel, MD, and President and CEO of Consumer Reports, James Guest, JD, helped to kick off the campaign with theJAMA commentary, Choosing Wisely: Helping Physicians and Patients Make Smart Choices about their Care.

• In From an Ethics of Rationing to an Ethics of Waste Avoidance, Howard Brody argued for a stepwise strategy to eliminate unnecessary care given the limitations of comparative-effectiveness research, saying, “it is better first to eliminate interventions for which we have the most solid and indisputable evidence of a lack of benefit.”

• In Application of “Less Is More” to Low Back Pain, the authors found strong evidence supporting the American Academy of Family Physicians’ recommendation as part of theChoosing Wisely campaign, “Don’t do imaging for low back pain within the first 6 weeks unless red flags are present.” The article was accompanied by a commentary by ABIM Foundation Executive Vice President and Chief Operating Officer Daniel Wolfson.

• In the New England Journal of Medicine article, A Systemic Approach to Containing Health Care Spending, Ezekiel Emanuel, MD, PhD and co-authors outlined a number of recommendations for bending the health care cost curve, including the development of credible practice guidelines.

• A British Medical Journal piece on unnecessary care said that a “newly launched movement lead by prominent doctors is challenging the basic assumption in U.S. healthcare that more is better” and cited Choosing Wisely as part of the movement

• Authors of a JAMA commentary mentioned the Choosing Wisely campaign as one of several recent initiatives addressing the physician’s role in health care expenditures. They then call for a new model of medical education that celebrates restraint in ordering health care tests and procedures.

• An Annals of Internal Medicine piece discussed the potential impact of Choosing Wisely recommendations for radiology and argues, “Current campaigns that draw attention to overuse of imaging studies coupled with greater physician knowledge and use of the criteria for appropriate imaging can help to ensure a further reduction in unnecessary testing—a result that would benefit both patients and our health care system.”

• In Choosing Wisely: Low-Value Services, Utilization, and Patient Cost Sharing, researchers from the University of Pennsylvania reflected on the Choosing Wisely campaign and asked, “But if it is difficult in many situations for patients to choose wisely, and if there are significant challenges in getting physicians to choose wisely, then who should be doing the choosing?”

• The Texas Medical Association explored the Choosing Wisely campaign and what it means to their members in Choosing Wisely: More Value, Less Waste, Shared Decision-Making.  (Note, the article begins on page 25.)

We look forward to continuing the conversations on professionalism and Choosing Wisely in 2013, and wish our readers a happy and healthy new year.

I costi della Sanità pubblica in Italia. Ovvero, ce la possiamo ancora permettere? @Medici_Manager @GIMBE

Interessanti spunti di riflessione! Possiamo trasformare questi spunti in domande da fare ai candidati alle prossime elezioni?

http://www.gimbe.org/report_attivita/pubblicazioni/interviste/20121001-Prevenzione_Oggi.pdf