Tag Archives: Spreco

Governare. E non sapere cosa accadrà di @vitalbaa su newslist.it di @masechi DA LEGGERE!

Seconda “puntata” dell’interessante analisi di Vitalba Azzolini: la tecnica e la politica non si incrociano e la misurazione è un’opinione … tutto conduce alla creazione all’italiana del suddito inconsapevole.

La List di Mario Sechi si arricchisce www.newslist.it

In una “puntata” precedente (https://carlofavaretti.wordpress.com/2017/09/17/fatto-analisi-impatto-di-vitalbaa-su-newslist-it-di-masechi-da-leggere/) qui su List ho provato a spiegare la “cultura” degli impatti: vale a dire quel metodo di regolamentazione che impone al governo e ad altre autorità di definire con trasparenza gli obiettivi perseguiti, di valutare ex ante comparativamente gli effetti di diverse opzioni normative (inclusa quella di non intervento), di fissare indicatori di risultato per vagliare ex post se quella prescelta è stata efficace, nonché di redigere un’apposita relazione con tali contenuti. Non è solo un metodo di better regulation, ma anche il modo per inchiodare i governanti alle responsabilità conseguenti ai propri annunci, vincolandoli a rendicontarne i risultati. Sarà per questo che AIR e VIR (analisi e verifica di impatto della regolamentazione) piacciono poco a politici e supporter, nonostante siano obbligatorie ex lege da anni. Detto ciò, può essere utile esporre i settori in cui l’analisi va fatta, verificando se e come “funzioni”: insomma, una verifica di impatto sull’analisi di impatto, e non è un gioco di parole.

Ai sensi di legge, la valutazione ex ante degli impatti va svolta secondo direttrici ben precise: se la futura normativa ha fra i suoi destinatari piccole e medie imprese, ne vanno analizzati gli eventuali effetti distorsivi o sproporzionati rispetto alle imprese di più grandi dimensioni; inoltre, devono essere misurati eventuali nuovi adempimenti a carico di cittadini e imprese; serve altresì stimare l’incidenza delle diverse opzioni di regolazione sulle dinamiche concorrenziali del mercato, scegliendo quella che le sacrifica meno; in caso di recepimento di normative comunitarie, occorre verificare che non siano introdotti obblighi superiori a quelli richiesti da tali normative (c.d. gold-plating). E’ importante poi valutare preventivamente anche le modalità attuative – strumenti, risorse e mezzi – dell’intervento di regolamentazione. Questo è quanto espressamente (e teoricamente) prescritto. Ma i legislatori ne tengono realmente conto?

Partiamo dal primo punto. È’ necessario esaminare che nuove disposizioni non impongano pesi burocratici gravanti in misura maggiore sulle piccole e medie imprese, poiché “l’evidenza empirica mostra in modo inequivocabile come gli oneri (…) legati all’adempimento di una norma siano, in proporzione, molto più elevati per le PMI rispetto alle imprese di taglia media e grande” (Formez PA). Al riguardo, l’Autorità Garante della Concorrenza e del Mercato osserva che “il cammino intrapreso verso l’adozione di regolazioni che ‘pensano in piccolo’ potrà produrre risultati positivi per (…) le piccole e medie imprese, a condizione che i modelli di analisi d’impatto vengano attuati in modo concreto e sostanziale”. E, infatti, l’UE ha predisposto da tempo un test (c.d. test PMI) utile a stimare gli impatti – appunto – degli adempimenti amministrativi sulle imprese di dimensioni minori. Ma di questo test non sembra esservi traccia nelle relazioni AIR nazionali. Le conseguenze sono palesi: un recente studio di Assolombarda in tema di oneri amministrativi nei settori ambiente, edilizia, fisco ecc. dimostra che i costi delle relative procedure (in termini di percentuale sul fatturato e di ore per addetto) continuano a incidere più sulle PMI che sulle grandi imprese. E di studi che attestano queste evidenze ve ne sono comunque molti altri.

Circa il secondo punto, cioè la stima – in sede di elaborazione di nuove normative – degli oneri burocratici gravanti su cittadini e imprese (con quantificazione dei relativi costi), essa è funzionale al c.d. budget regolatorio, previsto ex lege dal 2012. Si tratta di un meccanismo di compensazione c.d. one-in-one-out, per cui non possono essere introdotti nuovi oneri amministrativi senza contestualmente ridurne o eliminarne altri. Questo principio viene osservato? La risposta la fornisce il Consiglio di Stato, il quale pochi mesi fa ha rilevato che, mentre in altri Paesi si stanno sfoltendo molti pesi, elaborando sistemi one-in-two-out o addirittura one-in-three-out, la regola in Italia è pressoché ignorata. Rimando a quanto ho scritto altrove, aggiungendo che, nonostante recenti misure tese a semplificazioni varie, permane “una grave incertezza sul regime amministrativo delle singole attività, sulla stabilità dei titoli abilitativi (impliciti o presunti), sui tempi di definizione delle procedure” (C. Deodato), nonché su molto altro.

Il terzo punto è il full competition assessment, cioè la quantificazione degli impatti concorrenziali, utile a evitare ostacoli ingiustificati all’esercizio delle attività economiche: ma chi l’ha visto? E’ lo stesso Nucleo AIR presso la presidenza del Consiglio ad attestarlo: in sede di elaborazione di nuove regolamentazioni, ci si limita a svolgere “considerazioni apodittiche sull’intervento come ausilio alla competitività e nessuna considerazione specifica laddove l’intervento limiti o distorca il mercato”. Serve altro per dimostrare il senso (mancante) dei regolatori nazionali per la competizione fra privati? Forse sì: ad esempio, ricordare il non lusinghiero 54° posto che l’Italia occupa attualmente nell’Indice Libertà Economiche elaborato dal Fraser Institute (era al 24° posto nel 2000); o la circostanza che per partorire la prima (rachitica) normativa sulla concorrenza sono serviti 8 anni dalla legge istitutiva e circa 900 giorni di discussione.

Per quanto poi attiene al divieto di gold-plating, nelle relazioni AIR i regolatori dovrebbero dare conto del fatto che, nella trasposizione di discipline comunitarie nell’ordinamento interno, non hanno immotivatamente previsto oneri, requisiti, procedure ecc. più gravosi di quelli contenuti nelle discipline medesime. Questo limite viene rispettato? I dati empirici sono chiari: “il 32% (o 3,5% del PIL) dei costi amministrativi di provenienza europea a carico di un’impresa sono da ascriversi, per la stessa Commissione, all’inefficace recepimento del diritto europeo negli Stati membri, e il 4% di essi al solo gold-plating” (E. Ojetti). Inoltre, basta leggere qualche relazione di analisi di impatto nazionale per accertare che non viene fatto un esame attento e puntuale sul gold-plating e che, pertanto, il rischio di violazione è molto alto.

Infine, non mi dilungherò sulla valutazione di strumenti e modalità di implementazione di nuove discipline, rimandando a quanto scritto altrove: in sintesi, come può pensarsi che qualcuno la svolga ex ante, se in Italia non esiste un’autorità preposta a verificare ex post l’effettiva attuazione di “politiche” e relative normative? Né mi dilungherò su analisi di impatto riguardanti profili quali il genere, la salute ecc., svolte in altri Paesi: a cosa servirebbe, se nel nostro le AIR non affrontano neanche quei pochi profili già previsti? A questo punto concludo. Le domande retoriche stanno diventando un po’ troppe.

Annunci

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.

HTA in Italia: pessimismo dell’intelligenza, ottimismo della volontà

Il 24 ottobre scorso sono stato invitato da Giovanni Morana, dinamico direttore della radiologia dell’ospedale di Treviso, ad un convegno sul tema della TAC Dual Energy. Il programma prevedeva una parte dedicata a questa interessante tecnologia ancora in fase di sviluppo e ricerca e una dedicata all’HTA.

hta-venezia-2016hta-2-venezia-2016

L’incontro si è tenuto all’Ateneo Veneto, una fondazione istituita da Napoleone dopo il disfacimento della Serenissima Repubblica di Venezia, in uno splendido palazzo a fianco del Gran Teatro La Fenice.

Per un accidente della storia, il 9 ottobre 1996, nella stessa sede avevo organizzato un workshop, alla presenza dei politici e direttori generali della aziende sanitarie del tempo, dal titolo: “Razionamento o razionalizzazione dell’assistenza sanitaria – il ruolo dell’HTA”, starring Renaldo N. Battista al quale il collega direttore generale di Venezia (il compianto Carlo Crepas) aveva tributato gli onori che la Serenissima Repubblica tributava ai Capi di Stato e agli Ambasciatori in visita a Venezia: il corteo in barca lungo il Canal Grande.

hta-venezia-1996

L’invito di Giovanni Morana ha suscitato in me due sentimenti: il piacere di discutere oggi con i clinici (italiani, stranieri e un brillante giovane collega italiano che lavora a Charleston, Carlo De Cecco) e i produttori di tecnologia i metodi e le opportunità offerte dall’HTA; l’amarezza di toccare con mano la lentezza con la quale in questi vent’anni l’HTA si è diffusa in Italia!

Quanta strada ancora da percorrere! Se smettessimo di buttarci a pesce sulle cose urgenti e ci occupassimo un po’ di più delle cose importanti (De Gaulle) …..!!!

Il XXI secolo non ci ha portato ancora superare lo storicismo gramsciano: “Tutti i più ridicoli fantasticatori che nei loro nascondigli di geni incompresi fanno scoperte strabilianti e definitive, si precipitano su ogni movimento nuovo persuasi di poter spacciare le loro fanfaluche. D’altronde ogni collasso porta con sé disordine intellettuale e morale. Pessimismo dell’intelligenza, ottimismo della volontà”. (Q28, III)

Anzi…..

 

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

Cost Containment: The Importance of Nurses @Medici_Manager @helenbevan @pash22

by September Wallingford, RN, BSN http://bit.ly/1aBpqvv

Due to ever increasing healthcare costs, stakeholders in the healthcare system rely heavily upon front-line workers to assist in containing costs to help make healthcare more affordable. Since nursing is the largest sector of front-line workers, the field has an opportunity to greatly impact cost containment. Currently, there are 2.7 million nurses in the workforce, with an expected growth rate of 26% over the next decade; however, there has been limited discussion on how nurses can help contain healthcare costs.

Why are nurses not usually integrated into the cost containment discussion? Why have we not been invited to the table? Likely, it is because we don’t have the power to order (or discontinue) tests, labs, or medications, all of which are major factors in the rising costs of care. Even so, a nursing perspective can be important and should be considered when doctors make treatment decisions.

For example, I recently treated a patient who had undergone abdominal surgery. Despite uncomplicated post-operative days 1 and 2, on day 3, he developed nausea, vomiting, and an increasingly distended abdomen. I administered intravenous anti-nausea medications, along with back rubs and cool cloths on his forehead. None of the treatments worked. While waiting for the doctor, I sat with the patient and spoke to him about the possibility of receiving a nasogastric tube to alleviate his symptoms. Given an understanding of the process, the patient agreed to this possibility and I paged the doctor once again. The doctor eventually placed the nasogastric tube, the tube was connected to suction, and out came a liter of gastric contents.

I then noticed that the doctor had put in an order for an abdominal x-ray to “check nasogastric tube placement.” Seeing this, I initiated a conversation with the doctor to discuss the patient’s symptomatic improvement as well as his current state of exhaustion. I assured the doctor that nurses would be at the patient’s bedside to monitor for signs and symptoms of tube malfunction. As a result, the doctor cancelled the x-ray, which not only eliminated an unnecessary test for the patient, but also reduced the cost associated with his care.

Situations like these are commonplace to nurses across the country. We witness daily that more is not necessarily better, and we are in a position to help make decisions that lower costs without negatively impacting the patient’s care. Nurses bring a unique perspective to the healthcare cost conversation, so include us in the discussions, give us a seat at the table, and utilize us as active participants in the fight against rising healthcare costs.

September Wallingford is a registered nurse at an academic medical center in Boston, Massachusetts. She is currently completing her graduate nursing education to become an Acute Care Clinical Nurse specialist.

Doing what’s right for patients demands a culture change @muirgray @Medici_Manager @pash22 @helenbevan

We are pleased to announce the dates of our 2013 Lown Conference:
From Avoidable Care to Right Care 

For more information on the 2013 conference, please visit our website:
http://lowninstitute.org/project/2013-lown-conference/

2013 LOWN CONFERENCE: FROM AVOIDABLE CARE TO RIGHT CARE

June 24, 2013   Avoidable Care Admin   

This year’s Lown Conference, From Avoidable Care to Right Care, will take place on December 3-4, 2013 in Boston, MA.

The 2013 invitation only conference will gather clinicians, patient advocates, and civic leaders to deepen our mutual understanding of the cultural, scientific, and ethical issues surrounding the overuse of medical services.

Attendees will leave this meeting with priorities for addressing this pervasive problem, and collaborators who are prepared to begin building bridges to the right care in their communities.

Major themes at this year’s event:

  • fostering a new kind of conversation among clinicians, patients, and civil society
  • envisioning health and health care 25 years from now
  • the global epidemic of overuse

Speakers include:

  • Don Berwick, MD, MPH, Former Administrator, Centers for Medicare and Medicaid Services (invited)
  • Katy Butler, Author of Knocking on Heaven’s Door
  • Bernard Lown, MD, Professor Emeritus, Harvard School of Public Health; Senior Physician (ret.), Brigham and Women’s Hospital, Boston
  • Richard Smith, MD, Former Editor BMJ
  • Rabbi Richard Address, D.Min, Senior Rabbi, Congregation Mkor Shalom

Our working groups for Medical Education, Community Engagement, International Collaboration, and Setting the Research Agenda will convene for a working session on December 5, 2013 following the conference. If you are interested in participating on one of these working groups, please email us for more information atinfo@lowninstitute.org.

For more information on the conference, including how to register, please visit the Lown Institute website at www.lowninstitute.org.

More Treatments Equal Better Care? @Medici_Manager @pash22 @helenbevan

by

American HealthScare : 

How the healthcare industry’s scare tactics have screwed up our economy — and our future http://bit.ly/18TFCaf

There are multiple lines of evidence that doing more things to patients doesn’t always result in better health. I summarize a few examples here.

Dartmouth Studies

Researchers at Dartmouth University examined the relationship between medical resources used and the resulting health outcomes in people nearing the end of their lives in two California regions, Los Angeles and Sacramento.

In Los Angeles, the patients used 61% more hospital beds, 128% more intensive care unit (ICU) beds, and 89% more physician labor in the management of chronically ill patients during the last two years of life compared to Sacramento. In spite of this intense use of medical resources, the quality of care for patients with heart attacks, heart failure, and pneumonia was worse in Los Angeles. Patients did not enjoy this aggressive care either. Patients rated 57% of Los Angeles hospitals as below average compared to 13% of Sacramento hospitals.

What are the cost implications of the overly aggressive care in Los Angeles? If the Los Angeles hospitals had functioned at the same level as the Sacramento hospitals over the five years of the study measuring these differences, the savings to the Medicare system would have been approximately $1.7 billion.

Brain Aneurysms

Researchers studied immediate family members of patients who had symptomatic brain aneurysms. The researchers wanted to know if finding and surgically fixing aneurysms in the healthy family members who had no aneurysm symptoms would prevent strokes and deaths. The results were basically that many people were injured as a result of the surgery, which the researchers didn’t feel justified the few saved lives.

The Medical Outcomes Studies

In the late 1980s and early 1990s a series of studies called the Medical Outcomes Studies were completed. Their purpose was to measure differences in medical resources used and health outcomes in patients with common conditions who saw different kinds of doctors. They wanted to know if ologist care led to better health compared to primary care, and how the doctors differed in practice styles. The researchers studied patients with high blood pressure and diabetes.

For high blood pressure, patients of cardiologists had more office visits, more prescriptions, more lab tests per physician visit, and were more likely to be hospitalized. There was no difference between the three physician types for average blood pressure, complications, or physical function.

For diabetes, patients of endocrinologists were found to have higher hospitalization rates, more office visits, more prescription drugs, and more lab tests per physician visit than family physicians. There was no difference between the three physicians for average sugar levels, physical functioning, and almost all diabetic complications.

Summary

These are just a few examples of how more aggressive medical care doesn’t always result in better health. All of the GIMeC members typically support the notion that more is better. Overcoming this aggression bias will be one of our big challenges in reforming our healthcare system.

References

Wennberg DE, Fisher ES, Goodman DC, Skinner JS, Bronner KK, Sharp SM. Taking care of patients with severe chronic disease: the Dartmouth atlas of health care 2008. The Dartmouth Institute for Health Policy and Clinical Practice Center for Health Policy Research [online]2008 [cited 2009 May 2]. Available from: http://www.dartmouthatlas.org/atlases/2008_Chronic_Care_Atlas.pdf.

Risks and benefits of screening for intracranial aneurysms in first-degree relatives of patients with sporadic subarachnoid hemorrhage. N Engl J Med. Oct 28 1999;341(18):1344-1350.

Vernooij MW, Ikram MA, Tanghe HL, et al. Incidental findings on brain MRI in the general population. N Engl J Med. Nov 1 2007;357(18):1821-1828.

Greenfield S, Nelson EC, Zubkoff M, et al. Variations in resource utilization among medical specialties and systems of care. Results from the medical outcomes study. JAMA. Mar 25 1992;267(12):1624-1630.

Greenfield S, Rogers W, Mangotich M, Carney MF, Tarlov AR. Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and specialties. Results from the medical outcomes study. JAMA. Nov 8 1995;274(18):1436-1444.

6° Congresso Nazionale SIHTA – Bari, 7-9 novembre 2013 @Medici_Manager @SIHTA_Italia

Segnate la data del 6° Congresso di SIHTA: per la prima volta organizzato al Sud, a Bari; per la prima volta analizzata la metodologia della valutazione etica e d’impatto sociale nell’HTA; per la prima volta focalizzati i temi del cambiamento di cultura dei professionisti e degli stakeholder a sostegno dei cambiamenti organizzativi e strutturali.

Dal 7 al 9 novembre 2013

Quattro sessioni plenarie dedicate a: la valutazione etica e di impatto sociale in HTA; HTA come leva per lo sviluppo economico del Paese; HTA tra innovazione e disinvestimento; equità e sostenibilità del Servizio Sanitario Nazionale.

Sessioni parallele e workshops.

Sessioni posters.

Eventi precongressuali tra cui la sessione autunnale dell’Health Policy Forum (a invito).

Quote d’iscrizione molto ridotte rispetto alle edizioni precedenti.

DOVETE ESSERE PRESENTI

http://slidesha.re/14VpOjH

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

Up to 50pc of deaths at Mid-Staffs NHS trust on Care Pathway

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.

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

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Costi standard in sanità: i documento del Convegno N.I. San. @Medici_Manager

Ecco i documenti del II Workshop Nazionale sui Costi Standard tenutosi il 18 Ottobre 2012 aSan Giovanni Rotondo, a cura del N.I.SAN.

http://bit.ly/YmOKuR

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.