Incentives and health

Dr James DiNicolantonio writes about the influence of the sugar industry on nutritional guidelines:

Throughout the years, the effects of conflicts of interest with the sugar industry were never quantified, until a recent systematic review of systematic reviews was published in 2013 in the journal PLOS Medicine. The review found that in studies with a conflict of interest with the food industry, 83.3 percent found no evidence linking sugar-sweetened beverages with weight gain/obesity. In contrast, when only studies without conflicts of interest with the food industry were analyzed, the same percentage (83.3 percent) found a positive association—that sugar-sweetened beverages have a definitive connection with weight gain and obesity. This one study provides just a small glimpse of how much science has likely been affected by these types of influences. The Salt Fix: Why the Experts Got it All Wrong and How Eating More Might Save Your Life, Dr. James DiNicolantonio, June 2017

Nothing particularly new, but we do need reminding of the importance of incentives even on hard-working, well-meaning, highly talented members of the medical profession. Of course, financial incentives can reinforce public health as well as degrade it. The Social Policy Bond concept, as applied to health, would align our national health goals with rewards to those who are efficient at achieving them. It's unfortunate that, under our current healthcare systems, there is little to encourage people to seek out those ways of improving our health at least cost. Medical specialists, expert in their field, advocate effectively for their share of limited resources, but the overall health of the nation isn't effectively targeted. Few people have any financial incentive to consider it, and especially not to question the current ways in which funding is allocated.

Health Bonds would be different. They would target our broad health goals, probably in the form of a range of indicators such as longevity and Quality Adjusted Life Years. For the bonds to be redeemed, each indicator would have to fall into a specified range, representing an improvement over the current level. Significant improvements in a nation's health will probably take decades to achieve, but Health Bonds would be tradeable, meaning that any coalition of interests who improve our health, however marginally, can profit from their doing so by virtue of the increased value of their bondholding. By backing and issuing Health Bonds, a government could effectively maximise the health gains per tax dollar spent without having to specify how such gains shall be achieved, nor who shall achieve them. Opportunities for the sort of corruption (whether deliberate or not) hinted at by Dr DiNicolantonio and the authors of the paper he cites, would disappear, to be replaced by a healthcare system in which the interests of practitioners and population would be entirely congruent.

Health: too important to be left to the healthcare industry

Brian Nelson writes: 

That our payment incentives have had the unintended consequence of often harming patients has been recognized by payers (government included) and efforts are underway to change. Can we devise a system that pays for outcomes rather than paying for services regardless of effectiveness? Unless we do, I fear things will not change. A review by Brian W Nelson (orthopaedic surgeon), of Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery, 21 May

There's an idea: pay for favourable health outcomes, rather than activities or institutions purporting to deliver those outcomes, but at least as concerned for their own well-being as those of the people they are supposed to be helping. We see this not only in orthopaedics, but in other areas of physical and mental health. There's nothing particularly startling about this: practitioners have their own families to support, and are reacting perfectly rationally to the incentives on offer. And those incentives encourage over-screening and over-treatment, and the neglect of commercially nonnviable preventive interventions. As the British Medical Association puts it, in a recent paper:

Despite the clear acknowledgement across the UK of the need to prioritise ill-health prevention and public health activities, the data analysed in this briefing show this is not matched by funding commitments. Funding for ill-health prevention and public health in the UK (pdf), British Medical Association, 2017

It's the same, or worse, in the US:

Almost 1.3 million people went to U.S. emergency rooms due to adverse drug effects in 2014, and about 124,000 people died from those events. [R]research suggests that up to half of those events were preventable. ... An estimated $200 billion per year is spent in the U.S. on the unnecessary and improper use of medication, for the drugs themselves and related medical costs.... Too many meds?, Teresa Carr, 'Consumers Reports', dated September 2017

It's time for a new approach. My suggestion is that rather than policymakers' focusing on the means by which they think good health can be achieved, they instead focus on targets for good physical and mental health, and provide incentives for people to achieve those targets. The Social Policy Bond concept, applied to health, would do this, and more: it would inject the market's incentives and efficiencies into all the processes necessary to improve a nation's health. Health Bonds would channel our scarce resources into the most efficient means of improving our health, including those currently neglected or not even considered by our current healthcare bodies, most of which have little incentive or capacity to consider broad health outcomes that fall outside their increasingly specialised remit.

Health Bonds wouldn't stipulate how our health goals shall be achieved, nor who shall achieve them. This allows a broader approach. For example: our current compartmentalised accountancy-driven policy approach would not take into consideration the adverse health impacts of subsidising advanced courses for young drivers of motorbikes or cars. But holders of Health Bonds would look at such measures, investigate their possible health impacts, and make an informed decision as to whether any improvement they might bring to the nation's health is worthwhile, compared to other possible interventions.

Sacrifice on the altar of 'renewable energy'

From the current issue of  New Scientist:

Last week, air pollution in London soared to heights not seen since 2011. The usual suspects were named and shamed, including traffic fumes and a lack of wind. But joining them was a surprising culprit. "We think about half of the peak was from wood smoke," says Timothy Baker, part of a team at King's College London that monitors air pollution. The trendy log-burning stoves producing much of this pollution are marketed as a source of renewable energy that can cut fuel bills while helping reduce global warming. But recent findings suggest they pose a serious threat to the health of their owners, and are also accelerating climate change in the short term. If nothing is done to discourage log burning in homes, it could become the biggest source of air pollution in cities like London. .... Children are especially vulnerable ....  Where theres's smoke, Michael LePage, 'New Scientist', 4 February 

This is just one example showing how our governing institutions cannot deal with broad, long-term social and environmental problems. We have in mind something that sounds like an unarguable benefit: 'renewable energy', say, and target it, explicitly or implicitly. But we fail to take into account the broader, longer-term ramifications. There's no clarity about the distinction between means and ends. Something like 'renewability' - which is anyway a function of our ever-expanding scientific knowledge - is not an end in itself. At best, it's a means to certain ends, which are rarely specified, or specified in such vague terms ('sustainability') as to be subject to bureaucratic or corporate manipulation. The bigger picture is lost: in this instance, the health of vulnerable people and children is sacrificed on the altar of 'renewability'.

It's not good enough. We need to be reward the achievement of goals that are meaningful to ordinary people. 'Physical health' would be a good starting point. Defined in terms of objective criteria, such as longevity or Quality-Adjusted Life Years, a benign and far-sighted government could target the health of its citizens for improvement, and contract out the achievement of such a goal to bodies motivated to, and capable of, keeping up with relevant scientific advances. Our existing institutions and systems of government cannot do this, but Social Policy Bonds targeting health could. I have written about such bonds here. As society grows more complex and the linkages and time lags more intricate, so the scope for problems such as the increased air pollution described above or self-interested deception expands. We need a system that keeps the big picture in mind, and that starts with articulating what, as a society, we want to achieve. Our existing institutions, hard working and well intentioned as they doubtless are, have little incentive to advocate for goals broader than their remit. That worked in times and circumstances when the relationship between cause and effect was easy to identify and address. In today's society, that no longer applies. New organizations with an interest in seeing the big picture are necessary, and a Social Policy Bond regime would see their creation.

Land use and mental well-being

Society's long-term goals often conflict with the short-term, narrow, outlook of our political systems. As well, many of the most valuable things in life are often ignored by our economic and political systems, because they cannot readily be converted into monetary terms. Some contributors to air pollution, for instance, are still disregarded in most countries. The consequences to plant and animal life of loss of habitat are usually ignored too.

But I'll look today at mental health, and specifically the negative impact on it of certain forms of planning and land use. Society's mental health goals are difficult to quantify, but I think we can be reasonably sure that our recent patterns of development of the built environment and land use increase alienation, loneliness, anxiety and depression. A brief extract from a recent article on land use in the US:

[W]alkable communities and co-housing — sound exotic to American ears. Thanks to shifting baselines, most Americans only know single-family dwellings and auto-dependent [ie car-dependent] land use. They cannot even articulate what they are missing and often misidentify the solution as more or different private consumption. But I do not think we should just accept that when we marry and start families, we atomize, and our friendships, like our taste in music, freeze where they were when we were young and single. We shouldn't just accept a way of living that makes interactions with neighbors and friends a burden that requires special planning. How our housing choices make adult friendships more difficult, David Roberts, 'Vox', 16 January

My own belief is that the evidence that US-style suburban patterns of settlement are injurious to mental health is compelling, though perhaps not proven nor provable. But my opinion isn't important. What is important are these points: 

• Few of us have any incentive to find out whether in fact our land use patterns do create or exacerbate psychological problems for large numbers of people, and 


• Even were we to find that suburban living does destroy communities, lead to alienation and atomisation, and so aggravate psychological problems, policymakers have no incentive or capacity to do anything about it.

Acute mental health problems - the sort whose consequences are tragically newsworthy - do get some passing attention. But long-term mental well-being counts for very little in our economic and political systems. Just as policymakers failed to consider most aspects of our physical environment for decades until the consequences of doing so became too difficult to ignore, so too are mental problems and their causes neglected today. And, as the excerpt above implies, if we don't even know what we're missing, there's very little chance of either the market or benign central planners doing anything to help.

Perhaps Social Policy Bonds targeting for improvement the mental well-being of all citizens could be a solution. They could function as a way of representing the interests of people as human beings, as distinct from economic units. Such bonds, in targeting mental health indicators, could act as a countervailing force to the weight given to financial indicators in the property sector. Quantifying mental health might appear difficult, but there is important work being done in this area: examples are here and here.

Mental health is a hugely important issue, but there are others equally important that are similarly ignored by policymakers. There are measures being taken to help avoid nuclear war, for instance, but they are laughably small in relation to the enormity of the problem. The few people charged with conflict reduction - hard working and well meaning though they undoubtedly are - are not paid for their success in doing so, nor do the aggregate funds on offer reflect the urgency and magnitude of the challenge. Which is why I believe we should back Social Policy Bonds that reward the achievement of sustained nuclear peace - an indispensable requirement for humanity and one that is routinely ignored by policymakers. Just like long-term mental health.

Fossilised science is no basis for policy

How do we weight different environmental impacts? Take diesel, lauded at one stage as a way of cutting back greenhouse gas emissions, but known to have lethal effects through emissions of particulates and other pollutants:

Volkswagen’s rigging of emissions tests for diesel cars comes after nearly 20 years of the technology being incentivised in Europe in the knowledge that its adoption would reduce global warming emissions but lead to thousands of extra deaths from increased levels of toxic gases. The rise of diesel in Europe, John Vidal, 'The Guardian', 22 September 2015

Or, take organic food. An organic field will certainly host more wildlife and biodiversity, and decrease or eliminate air and water pollutants. But the same field will most probably yield less than conventional farming. More land would then have to be devoted to supply the same volume of food. And it's likely too that organic food production results in higher greenhouse gas emissions than conventional farming. There are also questions about whether GM crops (foods genetically modified by modern techniques) are better for the environment because they could, for example, require less fertiliser, less land, less water and be more tolerant of salt.

What should policymakers do here? The difficulties of weighing environmental impacts are compounded by our imperfect, but ever-growing knowledge of, say, the effects of pollutants, and more and more research into how to reduce emissions from transport or agriculture. Fossilised science is no basis for sound policy, and getting it wrong, as did those who incentivised European diesel engines, can have disastrous effects.

This is where the Social Policy Bond idea could help. Instead of trying to work out whether, say, less petrol and more diesel is a good idea, or whether organic agriculture is better than conventional, we could instead target social and environmental outcomes, and let a motivated coalition of interested decide how best to achieve them.

How would this work? We first need clarity over what we are trying to achieve. Mostly, we'll be concerned about impacts on plant, animal and human health. Focusing just on human health, we would have broad, national, targets for an array of indicators, such as longevity, infant mortality, quality adjusted life years and others. These would be determined by government, articulating as it does society's goals. But the ways of achieving these goals, and who would achieve them, would be the function of a market in Health Bonds. It would be up to holders of these bonds to decide, on a continuing basis and in response to all new scientific knowledge, what will be the most efficient ways of achieving these goals. The most efficient ways will be those that maximise returns to the bondholders but also to society as a whole. Bondholders' interests will be exactly congruent with those of society, and they will remain so until the bonds are redeemed - which could be decades hence. 

Health Bonds would make it unnecessary for decision makers to try to anticipate new scientific knowledge, or to make decisions on trade-offs that can be, and have been, disastrous. They would stimulate the exploration and implementation of diverse, adaptive ways of improving the nation's health. It's unfortunate that we have very few people or institutions devoted to the healh of an entire country. We have instead organizations like Ministries of Agriculture, Transport, the Environment, and plenty of organizations advocating for solutions to specific health problems: cancer, heart disease, respiratory diseases, and so on. These organizations undoubtedly do good work and are staffed by well meaning, hard working individuals. But they cannot, in good conscience, make the trade-offs between, say carbon dioxide emissions and lung problems in ways that maximise the total health of an entire population. Sadly, that necessary policy perspective falls outside their remit and could even threaten their income and status.

For more about Health Bonds see here. For more about Social Policy Bonds, see here.

Health: better late than never

The Economist looks at the UK's National Health Service

A better model [than the NHS]would be to give health providers a budget based on the population they serve, and pay them according to their ability to meet targets of better public health. This would increase the incentives to use new technology that would give patients more responsibility for their own health. If private outfits can do this with a profit margin to spare, good for them. Bitter Pills, the 'Economist', dated 10 September

Quite right. The current system is staffed by dedicated, well-intentioned, hard-working people, but its goals, explicit or implicit, have little to do with raising the general health of the population. In this the NHS is like many other social services: it began at a time when (1) relationships between cause and effect were easier to identify and (2) resources and expectations were constrained, so that only the most urgent and obvious challenges could be met. Times have changed. Society is more complex, time lags more important, and expectations are higher.

Targeting broad, general, health outcomes, and injecting market incentives into doing so, would greatly improve society's well being, as the Economist (belatedly), suggests. My 2013 essay on applying the Social Policy Bond principle to health goes into more detail.

Health funding needs to be more impartial

Priorities for healthcare funding are heavily influenced by factors other than the ratio of benefit to cost.

[A] review by Cancer Australia (pdf) showed that between 2006 and 2011, breast, colon and prostate cancer all received funding greater than their proportional toll on society — measured in years of healthy life lost. By the same measure, research into lung cancer, along with lymphoma, pancreatic cancer and cancer of the brain were underfunded. Lung cancer research underfunded compared to societal impact, ABC news, 12 August 2015

In this graph, taken from the above link, 'DALYs' on the vertical axis means disability adjusted life years lost to the type of cancer on the horizontal axis. Funding is given in millions of Australian dollars.
 
Some disparities are striking: "Lung cancer, which takes the heaviest toll on years of healthy life, received less than a quarter of the funding given to breast and colon cancer research."

Governments have to make their resource allocation decisions on the basis of data that are necessarily incomplete and constantly changing. So, by default, health expenditure is influenced by groups of medical specialists with little incentive or capacity to see improvements in the general health of the nation as an objective. As a result, funding of these specialities depends to a great and varying extent, on the strength of their lobby groups or on their public profile rather than on what would best meet the needs of society.

The problem is the same sort of top-down, one-size-fits-all, fossilised systems of funding that bedevil other (well-meaning) attempts by government, or any large organisation, to keep track of multiple variables across any but the smallest geographic area. In health, as in education, housing, crime prevention, or environmental pollution we need diverse, adaptive approaches to solving our problems. Society is just too complex now for simple approaches to work effectively, except in those increasingly rare cases were cause and effect can be readily identified and relatively stable over time and space.

The Social Policy Bond principle can be applied to health. Essentially, under a bond regime, government would target for improvement the health of the entire population as measured by (probably) DALYs in combination with other measures. Resources woudl then be allocated impartially according to where they will yield the most benefit per dollar spent. Any target could be long term: if it were several decades bondholders would have an incentive to investigate numerous approaches, including preventive measures, research and education, on a dynamic basis and always with an eye to cost-effectiveness. For more on this, see my brief piece on Health Bonds.

Answering the phone quickly is not a health goal

Another story - this from the UK - shows what happens when we have Mickey Mouse micro-objectives rather than broad meaningful goals:

In January 2016, Lincolnshire Police began an investigation after an allegation that staff within the Force Control Room were calling 999 at quiet times, to ensure calls were picked up quickly to improve performance statistics. ... Today [23 May], five Force Control Room staff have been suspended from duty and have been informed they are under investigation. Source

('999' is the emergency phone number in the UK.) I've been inveighing against these micro-goals for years (here's my first blog post on the subject). Their basic problem is that they arise from the narrow, short-term needs of organizations, rather than the people these organizations are supposed to serve. They're too easy to game, and their achievement is - to put it kindly - not inextricably linked to improvements in the well-being of ordinary people.

A Social Policy Bond regime would be different. We'd target for improvement broad, meaningful goals, such as the health of the entire population. Bondholders would benefit by financing projects that accelerate the achievement of society's targeted outcomes, rather than, as so often today, turning up for work and fulfilling some meaningless quota.

Terrorism and strokes

The website Think by Numbers looks at US government spending on health:

[W]e spend $500 million for every death from terrorism and only $2,000 for every death resulting from strokes. That means we spend 250,000 times more per death on terrorism. Anti-Terrorism Spending 50,000 Times More Than on Any Other Cause of Death, Mike P Sinn, October 2011

We can quibble a bit about the numbers, but these figures do seem to indicate an inefficient way of improving the health outcomes of American citizens. There would be nothing necessarily wrong with such spending patterns if this disparity were the result of an informed populace deciding for itself where its taxpayer dollars should be channelled. But, this isn't the case, and the Economist this week reminds us that 'defence' - that is to say, the military - is one of those industries notorious for cronyism. (Others identified by that journal include telecoms, natural resources, construction, which all 'involve a lot of interaction with the state, or are licensed by it'.)

Of course, it's unrealistic to ask people exactly how every health dollar should be spent. But we can engage the public in such decisions by focusing not on the pathways to improved health - which are complex and ever-changing - but on the outcomes we should like to see. For instance, we could express health goals in terms of Quality Adjusted Life Years, and then answer questions as to whether some x percent improvement in QALYs should be weighted more heavily than others. If the consensus is 'yes', and we judge terrorist deaths, for example, to be more negative than deaths caused by strokes, then we can allocate spending accordingly. Even then, we're unlikely to see the sort of disparities outlined above, which are more a consequence of emotional reactions to television footage, lobbying and cronyism than rational thinking.
My short piece on applying the Social Policy Bond principle to health goes into more detail.

Health is not an accountancy issue

Reading about psychiatry and obesity, and health generally, you can easily get the impresion that the incentives in play conflict with the stated goals of the professionals.

Psychiatry first: Dr Peter Breggin writes copiously and broadcasts about the over-prescription of psychiatric drugs to adults and children, in the US. Often these drugs have little in the way of robust scientific research to justify their use. Research can be shoddy or misrepresented. The organizations that encourage misdiagnosis and overtreatment are captured by powerful interests in, for example, the pharmaceutical industry.

Or obesity: there is an entire weight loss industry dedicated to selling diet books, supplements or food substitutes. There are television shows and exercise programmes, all supposedly aimed at reducing obesity. Yet the long-term results of almost all these interventions are almost invariably small and often negative.

Even in the less cash-driven, more socialized health services of, for instance, the UK, doctors come under pressure to over-prescribe, and defensive medicine - medical care performed primarily to reduce the risk of litigation - is significant.

Let's say that there are arguments on both sides: that some overdiagnosis and overtreatment is going on, but we're not sure how much, or how deleterious are their effects on health. I have no idea how close we are to optimal levels of treatment. Perhaps Dr Breggin and the other sites to which I link above are mistaken, but the important point is that nobody has incentives to find out. Instead, largely by default or historical accident, the major determinants of what interventions get prescribed to whom and how often, are the short-term interests of companies that have goods or other interventions to sell. Their incentives are to overprescribe. It is the narrow, short-term goals of corporations or professional organizations, or government bodies, that largely dictate how we shall tackle our health goals.

So if, say, the best interventions, from the point of view of the unwell person, won't benefit, in cash terms, powerful interest group, it seems likely that they will be under prescribed. (A similar argument applies too to 'negative defensive medicine', where the fear of a cash loss motivates practitioners not to treat patients.) Dr Jason Fung, for instance, recommends fasting as a cure for Type 2 diabetes and obesity.

Again, the point is that there are too few incentives in place that encourage people to look for low- or no-cost ways of treating people that are better, from the patient's point of view, than high-cost ways.

This is where the Social Policy Bond principle can play a part. Health Bonds would target the broad, long-term, general health of an entire population. Bondholders would be rewarded if health outcomes improve, however that occurs. Bondholders would have incentives to research, investigate and exploit only the most efficient ways of improving people's health outcomes. If non-treatment or low-cost treatment is the best way of improving a person's health, then that is what bondholders will be motivated to supply. The important point is that, under a Health Bond regime, it is the ordinary citizen's long-term general health that is the priority for bondholders and not, as in the current system, the accountancy goals of existing organizations, be they public- or private-sector.

Society as a dynamic system

James Lovelock writes:

Cause-and-effect thinking, so often the basis of teaching, fails to provide understandable explanations of real dynamic systems. It fails in physiology, quantum physics and engineering. A rough ride to the future, James Lovelock, 2014

And, I'd say, in policymaking. This links in to my previous post about root causes. Our society and environment are too complex for linear, cause-and-effect thinking to work. That doesn't mean we should give up when faced with supposedly intractable national or global problems as crime, terrorism, war, or poor health. Within each of these problems there will be occasions when cause-and-effect thinking will work well: for instance, improving basic sanitation will probably greatly improve the health of people living in urban slums. But the over-arching policy environment within which decisions such as whether to improve basic sanitation or allocate health funding elsewhere must be one that takes account of the dynamic nature of human society. In other words, it must be adaptive.

A Social Policy Bond regime targeting an array of broad health goals for a population would be adaptive. Under a bond regime government (most probably) would still do what it does best; indeed, what only government can do: articulate society's health goals and raise the revenue for their achievement. But rather than dictate how those goals shall be achieved it would, by issuing (say) Health Bonds, contract out the achievement of those goals to a motivated coalition of bondholders (or people paid by bondholders). The structure and composition of this coalition would probably change over the time period during which the goal are to be achieved - which could be several decades. But at every point in time, bondholders or their agents will have incentives to look for the most efficient ways of raising the population's health. To maximise their returns they will have to respond to changing circumstances, including our rapidly expanding scientific and technical knowledge, and the effects their own activities have on the social and physical environment. By maximising their returns, of course, they would also be maximising society's return on our limited resources.

In short, Social Policy Bonds would take account of the complexities inherent in the dynamic systems that characterise our large societies. They would encourage diverse, adaptive solutions to our social and environmental problems, as articulated by society itself through government. The would inject the market's incentives into the allocation of society's scarce resources at every stage necessary to achieve our goals. By so doing they would maximise the returns on society's investment in our future.

Health screwups

The evidence is necessarily scanty, but the (US) Institute of Medicine in 1999 estimated (pdf) that at least 44 000 and perhaps as many as 98 000 citizens died each year in US hospitals and 1 million patients were injured from a range of mistakes. Since then, according to Joe and Teresa Graedon, there has been little, if any, improvement.

If medical mistakes and misadventures were a disease, there would be a great deal of hand wringing. We would have an organization comparable to the American Heart Association or the American Cancer Society to publicize the problem, and huge sums of tax dollars would be spent researching the causes and seeking solutions to all these screwups. Instead, the medical establishment mostly acts as if this problem were invisible. Top Screwups Doctors Make and How to Avoid Them, Joe Graedon and Teresa Graedon, 2011

My own view is that resources for health care are rarely allocated in ways that optimize returns. It might be that, as I suspect, efficiency counts for little against the charisma or leverage of top specialists, interest groups and celebrities when it comes to deciding which diseases, for instance, shall receive most funding. Or whether preventive medicine should receive more funding. Or, indeed, whether the most efficient ways of improving a population's health have less to do with medicine, and more to do with, as the Graedons persuasively suggest, introducing check lists and rigorous procedures in healthcare facilities. It's only a suspicion, but the point is that there are no incentives in place for people to find out whether it's true.

Applying the Social Policy Bond principle to health might be the solution. To 'health', note, not 'health care'. Why? Because health is not something that arises mainly, or even primarily, from the decisions made by institutions devoted to health care. It may well be the case that relatively costless changes in diet, exercise, tobacco consumption or (one of my pet hates) the frequency and volume at which emergency vehicle sirens are played would do more for health than, say, investments in statins or new technology. As with exposing and tackling the 'screwups' identified by the Graedons, there are no incentives for anyone to find all this out. Instead we have organizations, such as hospitals, health services, charities, interest groups, and corporations which all have their own agendas which might at times coincide with improving the health of the population, but might not, and even if they did, would not necessarily be doing so efficiently. The human and financial costs of such resource misallocation are huge. The Social Policy Bond concept applied to health, by targeting and rewarding improvements in the population's health, however achieved, might be the solution.

The bias against unglamorous diseases

From a letter to the editor of the Economist:

[R]oughly speaking, mental health receives only about half the research funding it should in America, based on its health burden. The problem is that many interest groups lobby Congress vigorously for research funding for their disease. Patients with mental illness do not yet exert that kind of political pressure. letter from Michael Hanna of Mercury Medical Research & Writing, 'the Economist' dated 21 November

It's striking how unrelated is healthcare funding to need. Medical experts have little capacity or incentive to see beyond their own institution or speciality. Government - and not only in the US - responds to pressure from interest groups and allocates funds accordingly. Slipping through the cracks are unglamorous diseases including mental illness. Even within a class of diseases, such as cancer, funding discrepancies are stark: this paper looks at the UK. I think government here is failing in its purpose. It should target for improvement the broad health of all its citizens rather than merely respond to lobbyists, however dedicated, sincere and hard working. It should, as far as possible, be impartial as to the causes of ill health, and direct resources to where they can return the biggest health benefit per dollar spent. Applying the Social Policy Bond principle to health could do this. For more, see my short paper on Health Bonds.

"There's no money in health..."

Suzanne Beachy talks to Dr Peter Breggin about the loss of her son 'due to psychiatry's failure to offer beneficial, caring human services, and indeed due to psychiatry's opposition to them.':

There's no money in health; there's only money in managing illness. Suzanne Beachy, Dr Peter Breggin Hour, 4 November

Ms Beachy is relating her experiences in the US, but the same applies to most western countries. The concept of 'health' is not one that can be readily addressed by our existing institutions. It suffers because it results from a huge number of influences, and because our institutions have grown up during times when that number of influences was much smaller. So these institutions and the systems they embrace aren't as good a fit in today's complex society's as they used to be. Curing short-term illnesses is a relatively visible and quantifiable activity. Treating or managing poor health can also be reduced to a series of procedures that can be performed by our current health care providers. Sure, clinical trials are performed, pills and equipment sold, and a whole array of indicators is measured and targeted. But much about the clinical trials - who performs them, how they're performed and which ones are quietly ignored - is questionable, and many of the targeted indicators are Mickey Mouse at best. They have evolved to measure highly specific rates of activity, rather than outcomes that are meaningful to ordinary people, healthy or sick. The result is exactly what Suzanne Beachy experienced: a system that motivates people and institutions to manage illness rather than optimise health. 

Here's another approach: measure the broad health of society, and target that for improvement. Society is so complex, and our knowledge about society and science is growing so rapidly that no government, however altruistic, generous, or far-sighted, can know how best to maximise our physical and mental well-being. But what a government can do is put in place a system that gives people incentives to find the most efficient ways to maximise society's health continuously. In short, government  can apply the Social Policy Bond principle to society's physical and mental well-being and issue Health Bonds.

Five-year survival rates: another Mickey Mouse indicator

Health statistics are tricky and, when they're used to make a case for increasing or diverting funding, we need to be especially vigilant:

Research published in the European Journal of Cancer shows the UK has the worst survival rates for cancer in western Europe, with rates one third lower than those of Sweden. UK cancer survival worst in western Europe, 'Daily Telegraph', 26 September

The article gives examples:

Five-year breast cancer survival was 79.1 per cent in England, 78.5 per cent in Scotland, and 78.2 per cent in Wales. In Sweden the figure is 86 per cent, with an European average of 81.8 per cent. In England, 80.3 per cent of men with prostate cancer were alive five years later, compared with 90.2 per cent in Austria, 90 per cent in Finland and a European average of 83.4 per cent.

At first glance, this seems an indictment of the UK's approach to diagnosing and treating cancer. But the five-year survival rate needs interpretation: it is the proportion of patients still living five years after diagnosis. We can improve the five-year survival rate by better treatment, which is unambiguously good, or by earlier diagnosis, which is far more questionable. Earlier diagnosis can simply mean more intervention and more treatment (and more side effects), but does not necessarily lead to a reduction in the cancer mortality rate - which is a far better indicator of healthcare efficiency than the five-year survival rate.

A Social Policy Bond regime aiming at improving the overall health of a population would refine and target more-robust indicators, such as mortality and longevity, and would do so impartially. For more about Health Bonds, click here. For more about how misleading are five-year survival rates click here or here.

BMI: the GDP of health

I've railed many times about the inadequacies, and worse, of using Gross Domestic Product as the de facto indicator of social well-being. Which it has become, in the absence of any serious thinking about the social goals we want to achieve and the priorities we give them.

A similar phenomenon seems to have occurred in the world of health, where the body-mass index (BMI) is a long-used measure of obesity. BMI is body mass in kilograms divided by the square of the body height in metres. Apparently, as measured by BMI, obesity in the US plateaued around the year 2004 at 35 percent of the population. But, just as GDP ignores such things as leisure time, state of the environment, income distribution; and counts useless or anti-social economic activities as positives, so too does BMI have its flaws:

It does not consider distribution of fat, type of fat, muscle tone, age, sex, or even big bones. In spite of these flaws, healthcare professionals continue to use BMI as a guideline. A BMI of 20-25 is considered ‘normal’, and anyone larger or smaller is automatically counselled to achieve a healthier weight. .... Obesity is generally understood as a risk factor for heart disease, stroke, cancer, and diabetes, as well as an increase in overall mortality. Excess body weight also increases stress on joints and internal organs. Given these concerns, it’s easy to understand why so many people have celebrated the plateau in BMI. Unfortunately...BMI may not be the best measure of obesity. Your percentage of body fat and waist or abdominal circumference are far more reliable personal indicators of health outcomes than BMI. For example, central obesity, measured by waist circumference, is a more accurate determinant of personal risk and shows an even stronger correlation with poor health outcomes. Caroline Weinberg, Fat but fit?,  'Aeon', 27 August 

There is no clarity about goals. If our intention is to improve the health of people, why not target indicators of people's health, instead of easy-to-calculate but flawed measures such as BMI? If our intention is to prevent disasters arising from adverse climatic events, why not target for reduction the negative impacts of such climatic events, instead of atmospheric carbon dioxide levels or temperatures recorded in weather stations? If our intention is to improve social well-being, why not target indicators of social well-being instead of those economic activities captured by GDP?

BMI, greenhouse gas emissions, GDP per capita: they might answer certain specific questions, but their use as policy instruments is inadequate at best, dangerous at worst. Policymakers need some humility here: neither they nor their advisors know the best ways of improving health, preventing climatic disasters or improving social well-being. Even if they did, at one particular point in space and time, circumstances vary with region and our knowledge grows with time. No government, no single organization can hope to use fossilised knowledge on a one-size-fits-all basis and achieve meaningful results. Instead, policymakers should set broad goals, and let a motivated coalition of interests explore diverse, adaptive approaches aimed at achieving society's broad social and environmental goals. Government can set these goals and, indeed, it is probably the organization best suited to doing so. And, if it concentrated on that, it would come up with a better array of target outcomes than the flawed indicators it now uses, whether explicitly or not.

Government can also raise the revenue to reward the people who achieve these outcomes. But it has no business dictating how they shall be achieved, nor who shall achieve them. We need diverse, adaptive approaches, and those are exactly the sort of approaches that government discourages.

Smoking and obesity; anxiety and sirens

The UK has seen an onslaught against tobacco smoking. At the same time cases of diabetes are soaring, such that 'diabetes medication now accounts for 10% of the NHS [National Health Service] drugs bill'. Research appears to show that people who give up smoking put on weight.

By doing everything possible to suppress smoking has the UK Government unwittingly encouraged obesity and diabetes?  Do the social costs of more obesity and diabetes outweigh the benefits of less smoking? I have no idea, but the important point is how little it is in anybody's interests to answer these questions and use their answers to influence government policy. With smoking the government has had an easy ride: 'everybody knows' that smoking is bad for you, just like 'everybody knows' that taking illegal drugs is bad for you, as is drinking alcohol. You see where I am going here: road traffic kills 1.24 million people annually worldwide, but there are benefits to it as well as costs, as there are for drinking, taking illegal drugs and, yes, smoking, especially, but not only, insofar as people who are denied the opportunity of smoking then may be more likely to be become obese and diabetic. These costs aren't easy to calculate of course, but government has created an environment in which nobody has an interest in doing those calculations. Instead, seeing that smoking directly and obviously causes some diseases, it reacts in the Pavlovian, short-term, one-size-fits-all manner that it, in common with other governments, adopts when they encounter the symptom of a problem. So now, in England: 'work smoking rooms and areas are no longer permitted. All smokers must take their smoke breaks outside.' I've no doubt that rates of lung cancer and other diseases directly related to smoking have fallen as a result. But, as well as the costs to freedoms of the campaign against smoking, there are also the indirect costs to physical health, possibly taking the shape of increased rates of obesity and diabetes. The cancer specialists, and the well-meaning (though perhaps hysterical and self-righteous) anti-smoking lobby have no incentive or capacity to see whether smoking bans help or damage the overall health of people. Nor, under the current policymaking regime, are there any incentives for others to do so. And smokers are an easy target. Car drivers not so much.

We see the same in the area of mental health. The small city in which I currently live is blighted, maybe 20 or 30 times in every 24-hour period, by emergency vehicle sirens. Designed to create alarm and panic, that is what they do, to thousands of people, day and night. I have no doubt that these sirens shave a few seconds off the average journey time of the police, fire and ambulance vehicles. And those few seconds, might, on occasion, make the difference between life and death. But has anybody looked at the costs in terms of mental health of these sirens? It's no surprise that urban living is 'found to raise the risk of anxiety disorders and mood disorders by 21% and 39% respectively'. Physical health too: we may well be at the point where, as well as their reducing the quality of life of thousands of citizens every day, these sirens create more accidents than they help ameliorate by disturbing sleep patterns and inducing panicky responses in other road users and members of the public. Again, under the current policymaking regime, it's in nobody's interests to find out.

If government is to intervene in matters of health, it must look at the overall physical and mental health of its citizens. There have been, and no doubt still are, areas in which relationships between cause and effect are easy to identify. Provision of sanitation for instance, is clearly beneficial. I'd also support bans on smoking in all areas where there will be children and adults who don't choose to be exposed to the fumes. (That would be on aesthetic as well as health grounds.) But society is complex, as are the human body and mind. Most scientific relationships aren't easy to identify; and they vary over space and they change with time. We need policies that allow for diverse, adaptive approaches and that target broad mental and physical health, rather than particular maladies.

I offer my suggestion in this essay, which applies the Social Policy Bond principle to health care. Briefly: governments would target for improvement the health of the population, as measured in Quality (or Disability) Adjusted Life Years. Bonds would be redeemed only after sustained periods of improved health. A bond regime would reward the most efficient ways of improving health by channelling society's scarce resources into the areas where they could do the most good. Unlike today's healthcare systems, it wouldn't assume that a one-size-fits-all approach, based on fossilised science, is good enough for everybody, for all time.

Irrational health funding

This is irrational, but not surprising:

The [US] National Institutes of Health last month published a startling analysis of how it allocates its funding: in 2010, HIV research received nearly $3.1 billion in funding, while a deadly lung disease that has more than six times the health toll in the United States got only $118 million. Two diseases with a similar health burden, breast cancer and chronic liver disease, received wildly different levels of support: $763 million for the cancer best known for iconic pink ribbon awareness efforts, versus $284 million for a disease commonly caused by alcohol abuse. Autism receives more than five times the funding of eating disorders, but their impacts on health, measured in years of disability and premature death, are quite close. Why the diseases that cause the most harm don’t always get the most research money, Carolyn Johnson, washingpost.com, 17 July

I've inveighed against this sort of bias in government policy for years. In health, as in other policy areas, I am sure that government is well meaning and hard working. But it suffers from its inherently uniform, top-down approach. Government can also be short term in its thinking, reactive rather than proactive, and disdainful of innovation while favouring tried, tested but failed approaches. It has to make its resource allocation decisions on the basis of data that are necessarily incomplete. How can it know in detail the effect that spending on, say, cancer diagnostic machinery will have on the overall health of the nation, as compared with subsidising the cost of nicotine chewing gum?

So, by default, health expenditure is influenced by groups of medical specialists with little incentive or capacity to see improvements in the overall health of a large population as an objective. Funding decisions are also heavily influenced by the public profile of a disease or its victims, rather than on what would best meet the needs of society. It’s also a question of diet, exercise, transport, and culture. Recent research shows, for instance, the beneficial effects on health of green spaces in our cities (see here (pdf) for instance). The way government is structured, with its discrete funding bodies, makes it unlikely that such benefits will influence funding decisions.

We cannot expect a government nor any single organization to identify the huge numbers of variables, with all their time lags and interactions, that influence the nation’s health. We can, though, devise a system that rewards people who explore and implement the most cost-effective health solutions, even when circumstances and knowledge are changing continuously. I have tried to do this with my essay on Health Bonds, which would aim to distribute scarce government funds to where they would do most good, as measured by such indicators as Disability Adjusted Life Years. One small caveat though: I'm assuming that most of us - at least in our most rational moments - favour such a distribution of health resources. But there is a possibility that the current (mis)allocation of resources originates in unvoiced but widely held preferences. Ms Johnson quotes one expert: "...we tend to underfund things where we blame the victim". It's unlikely that the large disparities in health funding outlined above do reflect such deliberate choices. But even if they do, it would be better to be explicit about it.

Health: it's complicated

At lower levels of general health we have a good idea about what's needed: basic sanitation, inoculations, and education about hygiene, for starters. A benign government with funds can get things done. It gets a lot more complicated at the health levels prevailing in western countries. Here cause and effect are far more difficult to identify; there are huge numbers of, and possible interactions between, lifestyles and interventions that affect health. And these are changing constantly as our scientific knowledge grows. As well, lobbies are adept at influencing policy in their favour, often at the expense of the general health of the population. This is where an outcome-based approach can succeed where existing policy seems to have lost its way and is likely to be generating diminishing - even negative - returns.

Jerome Burn, here, points out some of the flaws of evidence based medicine as practised in the rich countries. He quotes Dr David Unwin, a general practitioner in Liverpool, UK:

We had to balance evidence based medicine – you come with a problem; I give you a solution – with evidence based practise. That means drawing on my years of clinical experience, rather than just relying on guidelines, and applying it to patient’s own experience. They are the expert on their lives, what they need and what works for them. Without taking that into account you are not going to change anything.

Mr Burn continues:

Even if charities or the government dug deep into their pockets and began to run many more RCT’s [Randomised Control Trials] on lifestyle changes, they are the wrong tool to use. The lifestyle approach we need to integrate much more effectively into medicine doesn’t involve just changing one thing – drug or no drug – it involves doing lots of things at once – for example: different diets and more exercise combined with psychological techniques such as stress reduction. RCTs have difficulties with such multiple interventions. Yet when they are tested they often turn out more effective than drugs.

The existing rich countries' healthcare systems don't encourage the approach that Dr Unwin and Mr Burn are advocating. What's more, they cannot do so. Drug companies' priority is to deliver returns to shareholders. One way of doing this is to influence government, which could not anyway gather, collate and exploit the data necessary to optimise the general health of the population.

Outcome-based policy, and Social Policy Bonds in particular, could be the answer. Improving rich countries' health is complicated and long term in nature. Existing policy isn't working very well. Broad metrics for physical health are fairly well established and robust. A gradual transition in the rich countries to a Social Policy Bond regime would reward efficient existing approaches and channel our limited funding into the most promising new ones. For more, see my essay on Health Bonds.

Demented

The [UK] government’s health policy reached new levels of absurdity last October, when it was announced that GPs would be paid £55 for every diagnosis of dementia they could enter in a patient’s notes. Cash for Diagnoses, Gavin Francis, 'London Review of Books' dated 5 March

I'm convinced policymakers have no idea how to specify societal goals. They don't seem to realize that goals that are narrow and short term can, and most likely will, conflict with those that are broad and long term. So it is with the nonsense described by Mr Francis. From where might the initiative for such incentive payments arise? Mr Francis points the finger:

This debacle is just the latest example of a medical culture, promoted by successive governments over the last twenty years, that rewards over-diagnosis and the prescription of drugs over personalised, professional care.

Our governments seem incapable of looking after society's interests. They seem to think that doing what they can to meet the demands of the most powerful lobby groups, including government agencies, is equivalent to looking after the interests of all their citizens. It isn't. 

A Social Policy Bond regime would be quite different. It would target and reward meaningful improvements in the health of the entire population. It would take a long-term view, and could do so because it would focus exclusively on its target outcomes. It would reward the people who achieve our health goals whoever they are and however they do so. For more on how the Social Policy Bond principle could be applied to health click here.