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where you stand . . . depends on where you sit

17 May

Living with Open Hands

“Where you stand . . . depends on where you sit . . .” The viewpoints you are most likely to advance (your stance politically, your opinions) are decisively determined by the place you occupy economically, in your career, in your community, in your organization, in society. We must not ever presume to speak for others; especially those outside of our scope, like the poor, the battered and bruised, the broken hearted, the “least of these.” We must ‘live’ there . . . and listen.

Three years ago, I sat in a very different place in life with very different viewpoints.
An entrepreneur, a social entrepreneur at that, making enough money to actually pay the bills.
Two income family.
Home owner.
Living in a middle class neighborhood.
Going to a middle class church in a poor neighborhood. (Made me feel better about church)
Wondering why those people in that poor…

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Geography is destiny in medicine

6 Apr

Heraclitus of Ephesus (Ἡράκλειτος, Herakleitos; c. 535 BC – 475 BC), a Greek philosopher, is known for having said: character is destiny (otherwise said A man’s character is his fate.)
The two main reasons why the derived adage “geography is destiny” applies to medicine are first that exposure to diseases risk factors varies from one region to another in a same country with the same health services and health insurance coverage :

http://earthsky.org/human-world/bill-davenhall-your-doctor-needs-to-know-your-place-history

and second that the pattern of care chosen by practitioners to treat the population for a given condition also greatly varies depending of the place of abode (still at a same health services and health insurance coverage level):

“A study of the geographic distribution in elementary school children discloses no correlation between Tonsillectomy and any other factor, such as overcrowding, poverty, bad housing, or climate. In fact it defies any explanation, save that of variation of medical opinion on the indications for operation.”

Quoted from:
http://proceedings.esri.com/library/userconf/health09/docs/plenary/goodman.pdf

There is tremendous unexplained variation in rates of surgical procedures from hospital catchment area to hospital catchment area, and region to region that cannot be explained by epidemiologic factors. For example, colleagues and I discovered in 1992 (see Spine, 1992) that the 15 fold difference in surgical procedures on the spine in Washington State was inexplicable by almost all population and diagnostic factors.

Quoted from:
https://depts.washington.edu/geog/2011/03/in-health-care-geography-is-destiny/

From the citations quoted above we could even go further in completing the adage by saying: in medicine geography is not only destiny it is also the caregiver.

Lessons from Medicare

17 Mar

Are disease management, patient education or value based payment cost efficient?

In the medicare experience results were mitigated and barely paid the program’s fees. You can read the brief that has been issued by the  Congressional Budget Office‘s health and Human Resources division:

http://www.cbo.gov/sites/default/files/cbofiles/attachments/01-18-12-MedicareDemoBrief.pdf

and the blog that discusses the report:

http://theincidentaleconomist.com/wordpress/can-the-better-care-lower-cost-act-live-up-to-its-name/

In France  a program of disease management and care coordination has been implemented. Its name is Sophia and it targets two chronic diseases, asthma and diabetes mellitus. More information here:

http://www.ameli-sophia.fr/le-service-sophia

But I can’t find any evaluation of the kind of the CBO report that searches if the health care cost savings, inherent to the program, balance the program’s fees. If you have found such a report let me know.

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The effects of Expanding health coverage

8 Feb

The Affordable Care Act (aka Obamacare) is practically a laboratory experiment at the scale of a continent that allows health economists to observe the effects of expending the health coverage to a whole population (a thing that Europeans have done and that they call modestly Universal Disease Coverage, in French couverture maladie universelle or CMU). Starting from his reading of a
Congressional Budget Office (CBO) report the health economist Austin Frakt lists the incentives and disincentives to work that a mandatory health coverage creates. But in my view the point is: does the labor market need workers anymore, with or without health coverage? If it really needs workers then it would be better that they could afford care and rehabilitation, it is the interest of both the employer and the employee. If it doesn’t, the labor market will always consider that the costs are to high.
The blog the incidental economist is about health economics, below is the post with a link to the CBO report:
http://theincidentaleconomist.com/wordpress/cut-out-the-noise-and-read-the-cbo-report/

Who is the caregiver?

26 Dec
English: Healthy Life Years and Life Expectanc...

English: Healthy Life Years and Life Expectancy with Disability in the 25 EU Member States, 2006, both sexes (Photo credit: Wikipedia)

 

The end of life is not the same for women and men. It is common to think that women are more healthy, live longer and thereof can support their partner. But in fact, at birth, the difference for one individual between his Life Expectancy (acronym LE) and his Healthy Adjusted Life Expectancy (acronym HALE) is larger in average for women than it is for Men. So there is some chances that the care giver could not be the one we thought of at the first sight.
The link below is the address for a very sensitive article posted by France Woolley.

 

http://worthwhile.typepad.com/worthwhile_canadian_initi/2012/12/who-is-the-caregiver.html#more

 

 

 

Hospital Spending Intensity and Patient Outcomes

25 Dec
English: Data Source http://www.irdes.fr/EcoSa...

English: Data Source http://www.irdes.fr/EcoSante/DownLoad/OECDHealthData_FrequentlyRequestedData.xls (OECD Health Data 2009). Health care cost rise based on total expenditure on health as % of GDP. Countries are USA, Germany, Austria, Switzerland, United Kingdom and Canada. (Photo credit: Wikipedia)

An amazing study implemented by Canadian health services researchers and published in the Journal of American Medical Association, suggests that depending which side of the border between Canada and the USA you live on, the consumption of the same expensive acute health cares results in different outcomes in term of patient’s health and quality of care. In other words, it is not so a matter of “how much” but rather a matter of “how” when it comes to question the legitimacy of a nation’s health care expenditures. The authors schedule to extend the field of their study to European countries and also to the long-term cares of chronic conditions.

http://m.youtube.com/#/watch?sns=fb&v=EOm2Ommqq5c&desktop_uri=%2Fwatch%3Fv%3DEOm2Ommqq5c%26sns%3Dfb&gl=FR

Changing Mindsets -Strategy on health Policy and Systems research

22 Dec

The report referenced below with its internet link reflects the strong incentives given by the WHO to enhance the articulation between research in health systems and research in health policy in one hand and the decision making at the political level in the other hand in the realm of health care and health coverage. Nine countries are studied, including China, Thailand and Nepal for the Asian part of the World.

http://www.who.int/alliance-hpsr/alliancehpsr_changingmindsets_strategyhpsr.pdf

Health Policy Analysis Institutes: India, Thailand, and Vietnam Case Studies

11 Dec

Each country, especially the emerging ones, have to back their health policy on the evidence brought by the research focused on health systems in order to implement  sound, balanced health services for their citizens. Thailand Vietnam and India present in the video below their national institutes devoted to health systems research.

 

International Health Policy: Comparative Health Care Systems

10 Dec

How to explain the differences across North America and Western Europe regarding the policies of health coverage (mandatory in one hand, private initiative in the other hand)? The response has to be searched in the past history on both side of the Atlantic Ocean. Feudalism in Europe made government to be considered by people as a good thing which liberated them from oppression of the King and feudal lords while in North America, Government rules are associated in people’s mind with the oppression of the English government which imposed taxes before the independence. At least it is the theory exposed by Henry J. Kaiser Jr. Professor of Health and Research Policy Emeritus at Stanford.

A congress in Padova

16 Jun

Social insurance medicine specialists gathered in Padova

So it is the last day of my first international medical congress. Saturday 6:00 AM, i’m waiting for the bus for the Marco Polo Airport at the Padova railway-station.
The participants were a majority of Italian health services Doctors, all of them talking fluently English (lectures were in this language ). Then came attendees from the Eastern European countries (Romania, Slovenia…), the Northern Europe: Norway, Netherlands, German, Belgium, Swiss. Given the size of its population, France was under represented, not to mention Spain, Portugal or Greece which sent nobody (despite the social difficulties those countries are confronted with). Since Bismarck and Beveridge Social Security is more a Protestant than Catholic countries affair although Italian social insurance Doctors were greatly represented in the Padova congress (mainly those from the INAIL a.k.a. the Italian National Insurance Institute for Industrial Accidents).
It’s simple, in Padova palazzio are everywhere , even at the railway-station there is a palazzio.
All the congress sessions where in palazios which is a little bit strange for a congress dedicated mainly to social security and social difficulties endured by people insured to healthcare and pension funds (May I can recall that the congress topic was the social security challenges in Europe?). But I admitt that it would be utterly snobbish to refuse to enter in a palazzio in a town like Padova given that such facilities are not the exception but the rule overthere! Anyway, all was perfect, Italian people have an innate way to be always elegant and handsome and the Dolce Vita (douceur de Vivre) is not an empty word here. People move with an elegance you can not find anywhere else. Astonishingly for an Italian town bicycles seems to be a habitual and usual mode of transportation which contradict the reputation of car fan the Italians bear since Fangio.
I shared thoughts and ideas with the Director of Medical Assessment Division of the Pension and Invalidity Insurance Institute of Slovenia who heartily invited me for an eventual lecture at the 3rd International Congress of Medical Assessors which would take place in Maribor, Slovenia (a little brother of the EUMASS congress we could say in one sense).

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