To move forward, avoiding false or erroneous comparisons
Better condition and better market
After the fall of the Berlin Wall in 1989, in just a flash, life expectancy at birth in Russia fell from 64 to 58 years for men and from 74 to 71 for women. In that same period, Finland increased its unemployment rate from 2 to 18% without adverse health effects. The unmitigated disaster of the transition of the planned economies of Eastern Europe and Asia towards market economies owes much to an absolutely wrong reading of that fall of the wall, according to which what had triumphed in the world was the market, and the state had failed. The planes to Moscow, Yerevan or Duchambe were filled with preachers of a market that exists both in prisons and in top-macaroon format but that without the institutions of the countries that combine economic and human development simply does not work.
The World Bank reports – in 1995 and 1996 – promoted by Stiglitz, helped restore the importance of the state and correct the ideological trap created by that erroneous interpretation of the fall of the wall. The proper functioning of markets is only a necessary issue, but without an effective state, countries fail. Any income (or welfare) production function combines capital, mainly human and physical, with an efficiency parameter highly influenced by the quality of the institutions of each country.
Currently, many markets are far from being competitive and natural technological monopolies require regulation that allows share prosperity of technological innovations such as artificial intelligence (AI). The lack of competition makes us more unequal and poorer, as they point out Jan Eeckhout or the director of the Federal Trade Commission (FTC) Lina Khan. The states are also clearly better. It is therefore about combining a better state (not more state) with a better market.
The case of healthcare
In health, the extremes of ‘outside the civil service there is no salvation’, or ‘outside the state, public management is oxymoron’, do not lead anywhere either. Private for-profit management (Amazon style) in healthcare can pose problems because its metric (that of return on own resources) is alien to the health value created and the quantity and quality of life produced.
The well-known market failures advise state intervention, but a good state, also free of notable failures, since it is not about replacing the bad with the worse. There are certainly political, union and corporate captures, but They are all vulnerable if the renunciation of competition based on quality comparison is not insisted on, where direct management coexists with adequately evaluated indirect management.
Level the playing field
Leveling the playing field means sharing the legs of the organizational tripod: publicly stated goals, incentives, and evaluation/accountability. Legality obliges us all, but so does effectiveness. Especially when this is the difference in health that citizens achieve.
Every day there is more talk about the (real) increase in the use of private healthcare, and its growing participation in the provision of publicly financed healthcare services. Let us not hope to stir up a priori assumptions about the goodness or legitimacy of this reality driven in one case by spending decisions of users and in another by preferences, conceptions or interests of democratically elected rulers, but rather to point out some perplexities regarding certain differences in treatment between both sectors due to part of the regulators.
Basically it is about pointing out some – among the many existing ones – potholes, slopes or mounds that interfere with the playing field, preventing comparisons or extrapolations that are highly dependent on the peculiar orography of the stadium. If publicly managed healthcare and privately managed healthcare, with or without public financing, must be compared to adopt the decisions that users and politicians consider most appropriate, it must be guaranteed that this competition by comparison does not have the dice loaded or some participants doped.
In the field of selection and hiring of health professionals, current regulations require the title of specialist for all doctors hired for publicly managed centers. However, in the private sector it is enough to prove a degree in Medicine. Obviously, neither the cost of human resources nor the volume of their supply will be the same in both networks, public and private. It is surprising that the state, responsible for basic health legislation, renounces guaranteeing the quality and specificity of the training of professionals in the private sector, imposing higher standards on themselves, even if they seem reasonably generally required. . .
Sometimes, the apparent leveling of the playing field with uniform standards for all areas of management is the result of complaints from professional groups rather than a rigorous and transparent assessment of need. It is exciting to follow the quarrel over the Regulation of minimum nurse ratios.applicable to all centers regardless of their management, which would considerably increase the employment of nurses in this country, and worsen the income statement of many centers.
At another level, in some management environments the seemingly reasonable is proclaimed opinion about the convenience of “money follows the patient.” However, this is a half-truth, because in most cases – from the Alzira-type concessions to the private hospitals in Madrid embedded in the network of the Madrid Health Service (SERMAS) – the money follows the patient to the private providers when you travel to them, but not in the opposite direction, since when a public center serves patients from outside its area it will not effectively receive the symmetrical payment. Whether this is due to the complexities of public budgeting or the lack of legal personality of the directly managed centers does not affect the questioning of a board with an unequal number of black and white squares, or a playing field with potholes next to one of the goals. .
Transparency in information
But the fact that the consequences of patients’ decisions are asymmetrical is almost a minor problem if we compare it with the lack of publicly systematized information to guide their decision-making. Those responsible for health in this country are quite reluctant to disseminate health information useful for making decisions. The “Key Indicators of the National Health System”, accessible in the Ministry of Health website Contains some data aggregated by autonomous communities with limited, if any, usefulness to users. There is also no state regulation on the minimum set of quality indicators for health centers that the autonomous communities must publish for the knowledge of their populations. Only a couple of communities produce and make public part of that information. Catalonia, with its Results Center and Madrid with its Observatory They are honorable exceptions.
It is even more serious that those responsible for basic health regulation do not report any systematized information on activities and results of private centers without links to the public system, beyond the Specialized Care Information System (SIAE), a result of the reform of the previous Statistics of Health Establishments with Boarding Regime (ESCRI). The resources, activity and, above all, the health care quality indicators of these centers remain under the radar and are opaque to citizens and the administration itself. It is paradoxical that the most complete source of information on the private network is an annual report on behalfinvariably titled “Private Healthcare Providing Value”. By dumping into a common repository a minimum part of the information that ALL centers, public and private, handle for their control and management panels, it would be immediate to have comparison systems like those that have existed for decades in less order-oriented countries (see examples of USA.) and that, in addition, are reasonably understandable for citizens who are faced with decisions about their health and healthcare.
Going down to center management, there we also find inappropriate comparisons for putting apples and pears together. In the “management agreements” or similar instruments that some health ministries sign with their departments or health areas, it is not uncommon to find rankings on “efficient and rational purchase of medical supplies” or laboratory in each department, seeking to obtain better prices. In communities where some territories are served by private operators such comparisons are ridiculous or insulting, since comparable results cannot be expected from those who work within the framework of public sector contract legislation – with its notorious loopholes, tricks and tricks to avoid it – compared to those who do it within the common commercial framework.
One step forward to gain momentum
The coexistence of different health management models could stimulate competition by comparison, which in turn is a very powerful activator of quality.
We have enormous potential for extracting wealth to improve health management, thanks to direct and indirect management experiences. The lack of homogeneous information on quality and results prevents comparisons. It is wasteful and as such, it is not only inefficient, it is also immoral.
Comparisons between organizations that play on asymmetrically deformed terrain and with different rules of the game are useless and do not help the population or decision-makers. Changing the rules of the game by making public management management and not mere administration, and leveling the playing field, are essential steps.
The competence over “basic health legislation”, retained by the Ministry of Health, should focus on this leveling instead of insisting on recent attempts to standardize and restrict the management of the centers managed by the autonomous communities.
