Monday, 14 January 2019

Could the American Health System Become the Best in the World?

Josep M. Picas



The title of this paper is the same as one recently published in the "Perspective" section of The New England Journal of Medicine (NEJM), "From Last to First. Could the U.S. Health Care System Become Best in the World?" This article seemed to me to be an interesting example of introspection and critical analysis, and at the same time an excellent formulation of future challenges. I must confess that I feel admiration and envy for these types of approaches and advances that we frequently observe in the Anglo-Saxon environment.

In summary, the article is based on a report from the Common-wealth Fund which compares health expen-diture and results across several countries of the world with a high economic level. It’s said that in the United States, despite offering a high level of ad-vanced, specialized technical treatment, the results, from the populations’ point of view, leaves much to be desired. The authors attribute the causes of the problems to several factors:
  • Deficiencies in accessibility in its various nuances (linked to the subject of coverage).
  • Necessary commitment to primary care (expose their hope in the Medical Home).
  • Administrative inefficiency (linked to payment systems).
  • Inequity in the provision of services (associated, among others, with the necessary commitment to increase the financing of social services).

They end the article with the proposal to overcome these challenges and place their hopes on maintaining and improving their health laws despite of the existing threats.

But the aspect that more reflection provokes is that this article appears in a moment of maximum confusion. In particular, if we want to predict how the American health system will evolve, as in many other fields, it will suffer from the actions of the current presidency. In any case, it seems to me of interest to comment that the various attempts at repeal & replace the so-called Obamacare have failed until now, even with the opposition of prominent Republican senators. Many of these attempts relate to the level of coverage and to insurance aspects, but not so much to the organizational model.

At this level, it should be noted that the number of ACOs (accountable care organizations, probably the paradigm of integrated health systems) has continued to rise and their two best-known programs have expanded their success: Medicare Shared Savings recently communicated a total savings of 652 million dollars in 2016 (for example, the Cleveland Clinic ACO has saved 42.2 million, of which 19.9 million will be returned) and the other program, Bundled Payments ), continues to move forward with nuances, especially by introducing concepts related to value payment, led, among others, by Michael Porter.

Success has impacted most global health systems, for example in New Zealand (see "Developing accoun-table care systems, Lessons from Canterbury, New Zealand"). And perhaps the most surprising case is Germany, where, after the success-ful and little-known Gesundes Kinzigtal, OptiMedis AG is expan-ding by applying the model in the Netherlands and even in the United Kingdom.

In order to finish and emphasize this approach to "wanting to be" despite unfavourable environments, two recent documents are advisable for people who may be interested. In one of them, from the National Academies: Global Health and the Future Role of the United States, a large number of authors are positioned in the face of health globalization, and in another, published by NEJM Catalyst under the title The New Marketplace of Health Care: Impacts and Incentives of Payment Reform brings together a collection of articles and expert conversations that lead the reform of the payment system along with clinical practitioners, among many other relevant professionals.

A final comment is that, sadly, our country is not mentioned in this article of the NEJM and that the detail of our involvement in Global Health is insignificant (0.12% of GDP and 25th place among 28 countries, when the average is in 0.41% and the UN target is 0.7%). Maybe someday someone would have to pose some questions.


Monday, 7 January 2019

Focusing on the daily life of frail people








The PACE (Program for All-Inclusive Care for the Elderly) model was born in 1971 when a dentist and a social worker working for the San Francisco Department of Public Health in Chinatown-North Beach realized that older people were reluctant to move to a social residence when, instead, with some complementary services, they could continue to live in their own homes, in a more friendly and stimulating environment. Nearly fifty years later, PACE enjoys good health and "The Commonwealth Fund" has published a "Case Study" analysing its operation and results.

Monday, 31 December 2018

Who’ll talk about us when we’re dead?

Antoni Peris



First of all, allow me to recommend that you rush out to see A ghost story (D. Lowery, 2017). It's not a ghost movie. It's a movie with ghosts. It's not a movie about grief. It’s a film about permanence, about memory, about the permanence of memory and our will to endure as human beings. We are asked, what will remain of the Ninth Symphony of Beethoven when a thousand years have passed. And what will remain of us? Who will remember our passing through this world? The presence of A ghost story (ironically presented as one of those phantasms of children's stories, with a bed sheet and holes to see through) is something that refuses to disappear, perhaps the boy that appears at the beginning of the movie, perhaps the ghost of the house, or of the place, or perhaps the accumulation of experiences that take form whilst trying to continue their existence; It’s a beautiful and serene film exploring whether our existence and memory make any sense.

Monday, 24 December 2018

On the subject of continuity of care in hospitals








Last week we debated how the longitudinal continuity of primary care affects the comings and goings of chronic patients to emergency services. Along this line, I would like to explore the difficulties that hospitals have in guaranteeing ongoing health care services especially at night and at weekends, and how this problem weighs on services when taking care of the most vulnerable groups.

Imagine that a frail person enters a hospital due to acute decom-pensation, according to the known evidence, a global geriatric eva-luation and an individualized therapeutic plan should be deve-loped in agreement with the primary care team, if the desired outcome is to have a reasonable chance of returning home as soon as possible and in the best possible condition. The problem originates in that the hospitals, not even the best of them, are able to give a continuous response to patients as described, since the usual medical equipment usually offers a continuous coverage of only 27% (From a 5 day week of 8 to 5). What happens in the remaining 73% of time (evenings, nights and weekends)? As our imaginary patient, although you would enjoy medical coverage on duty, the service you will receive is very likely far from guaranteeing the continuity necessary for the fulfilment of your personalized plan.

Monday, 17 December 2018

Dysphagia and "minimal mass interventions": ethics, management and value

Marco Inzitari





In recent times there is an increased risk that the relevant becomes unseen. I understand that readers are mainly from the world of health but did you know that in Barcelona, ​​at the end of September 2017, the European and world congress on swallowing disorders was organized? And that the current president of the European Society of Swallowing Disorders is very close to us because he’s Dr. Pere Clavé, gastroenterologist and academic director, teaching and innovation at the Hospital de Mataró?

I was fortunate to be invited to talk about Dysphagia in older people in this meeting, with the opportunity to review the advances in this area. I don’t aim to venture into any clinical treatise on Dysphagia, but I think it’s useful to disseminate some aspects that are in line with the "value practices" advocated by this blog.

Monday, 10 December 2018

Innovation or decadence. There’s no middle ground

Josep Maria Monguet



Innovation is not a fad; it’s a structural phenomenon of the future, largely a product of the acceleration in the production of new knowledge. Innovation was always part of our world, but there are two new factors nowadays:
  1. Accelerated innovation: more novelty in products and services are observed more frequently.
  2. It's everyone's business: each one of us are protagonists of innovation.

Monday, 3 December 2018

The status of the patient's experience throughout the world

Anna Sant



"The State of Patient Experience 2017" is a study carried out by The Beryl Institute, were officially published to expose a global patient's experience. The conclusions have changed with respect to the study presented in 2015.

The Beryl Institute and "The State of Patient Experience 2017" 

The Beryl Institute that I referred to earlier in this blog, is a community dedicated to improving the patient experience around the world through collaboration and shared knowledge. The organization, based in the United States, prepares this study biennially since 2011 to share the challenges and opportunities that health organizations around the world are finding in their approach to improving the patient experience.