A non-credible ranking on pandemic preparedness

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See PDF of the report:

2021_GHSindexFullReport_Final

See PDF of the New York Times article:

The World Is Unprepared for the Next Pandemic, Report Says – The New York Times

 

In December 2021, the 2021 Global Health Security Index was made public, a kind of ranking in terms of the preparation of countries to respond to epidemics and pandemics. It is the second time it has been carried out (the first was in 2019, a little before the pandemic) and it analyzes 195 countries.

The report is produced by The Nuclear Threat Initiative, a nonprofit group, and the Johns Hopkins Center for Health Security.

More than 90% of the countries analyzed lack a vaccine or medication distribution plan during an emergency, while 70% show insufficient capacity in hospitals and medical centers.

The average index is 38.9, similar to that of 2019 and there is no adequately prepared country, which would start at 80.1 points.

However, the most surprising thing is that in the 2019 ranking, the first country in the ranking is the United States and the second the United Kingdom, two of the countries with the worst behavior in the face of the pandemic, according to all the analyzes that can be made, which leads us to distrust this ranking.

In the 2021 ranking, the United States maintains number 1, with Australia being second. This year Spain with 60.9 points is in 17th place.

This striking fact is underlined by Dr. Ezekiel J Emanuel, in a statement published in the New York Times, who considers it a non-credible ranking.

One more proof that the rankings must be viewed with a lot of prevention and analyze very well what they consider.

Conversations with healthcare industry leaders (Ramón Berra, General Director of Miranza)

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Roland Berger, a strategic consultancy, intends to organize regular breakfasts with leaders of the health sector in the broad sense. The first of them, December 13, 2021, was with Ramón Berra, General Director of the Miranza ophthalmology company.

 

 

Origin of the company

The Miranza company was born in 2019 and consists of a set of clinics dedicated to ophthalmology, its origin being the merger of the IMO of Barcelona and some Innovaocular clinics (San Sebastián, Madrid, Seville and Cádiz).

It is based on the fact that ophthalmology is a non-hospital specialty, which can be developed without problems in a non-hospital environment and it was possible to consolidate a series of clinics to form a prestigious professional company dedicated to ophthalmology in its entirety and different subspecialties. In this sense, they differ from other ophthalmological chains, dedicated almost exclusively to refractive surgery.

Miranza, today

The company has 20 centers throughout Spain and on Friday, December 17, 2021, it begins its international career with the first center in Andorra.

It is a company that has grown mainly through acquisition, presence in large cities, with medium and high complexity surgery, always led by teams of ophthalmologists with recognized prestige, at least locally.

Acquisition method

Miranza’s approach to a prestigious ophthalmological group is to buy the company (100%), never the property, with which ophthalmologists can continue to receive income as owners of rented properties; with a service provision contract (which specifies a service period and a “non-compete” period) and they are offered the possibility of reinvesting in the parent company and thus becoming minority partners of Miranza.

Miranza has approached the great ophthalmologists of this country, in such a way that it can be said that around 70% of ophthalmology leaders collaborate with Miranza.

An original formula for Medical Management

Miranza has launched an original formula for the group’s Medical Directorate. The key role of medical leadership and the difficulty of forming a recognized medical leadership need not be stressed when there are many medical leaders in the same specialty. The formula is that of the Clínical Leader Forum, a collegiate medical directorate, made up of 9 ophthalmologists.

The pandemic has not impeded the growth of Miranza

Miranza was founded in 2019. Arguably, the onset of the pandemic in early 2020 could have derailed the plan. But nothing further, despite the pandemic, Miranza has grown in the level of billing, number of patients, activity and knowledge.

He doesn’t want to be a “Frankenstein”

Miranza has developed protocols and clinical guidelines, since his intention is not to become a Frankenstein of ophthalmology, but to constitute something of value, beyond the value of the different members.

To do this, it has launched a network, with the idea of ​​sharing knowledge and clinical guidelines for action. This approach has groups of the different subspecialties of ophthalmology (retina, glaucoma, anterior segment, cataracts, etc.)

It also has an Intranet, to share experiences throughout the group.

Miranza Academy

A very interesting experience is the launch of this initiative. In the middle of the pandemic, there were 4 daily training webinars.

They also do two weekly clinical sessions.

Investigation and development

Miranza is aware that the only way to maintain and strengthen its leadership position is through extensive R&D activity. That is why it has a corporate R&D team to which in 2020 it has dedicated 7 million euros.

They have 90 multi-center projects, 2 European projects, public sector funded research, and industry agreements for multi-center trials.

All centers have their R&D coordinator.

The creation of the brand

The Miranza brand was created after a very participatory work with a branding agency (suggests look and hope).

Miranza’s policy with previous brands is to put Miranza as a name, respecting the original names as surnames. Only in the case of IMO and Vissum, due to their great presence, it is done the other way around, those brands are respected as a name and Miranza is given as a surname.

An effort in telemedicine

Apart from online dating, Miranza has made an effort in the development of telemedicine, particularly for second opinions.

It has even been seen that the consultation / surgery conversion ratio is higher in second opinions than in normal consultations.

A concern for quality

The IMO is accredited by the Joint Commission and for its part, Miranza has developed a set of healthcare quality indicators, which are analyzed on a monthly basis.

Patient experience

Miranza is going to launch a patient portal, in order to follow and improve the patient experience in the company

A bit of numbers

73% of Miranza’s billing is to private patients, only 20% is made to insurance companies. It also has a small collaboration with the Administration for issues of the waiting list, but it is an area in which it does not want to grow, given the danger of phagocytization by way of the waiting list of normal activity.

In terms of turnover, it has 80 million euros of sales and 11 million of EBIDTA.

A great effort in operations

Payroll, accounting and treasury are centralized.

A purchasing center has been set up and a catalog of approved materials has been developed, including intraocular lenses. There is an agreement with ophthalmologists by which 70% of the lenses that are placed have to be from the corporate catalog; for the remaining 30% they have freedom of choice.

There is a central contact center, which allows a homogeneous treatment of calls.

An effort has also been made in systems, adding a layer to the pre-existing systems, which allows to have a minimum electronic medical record and a management control panel.

The future

Miranza wants to continue growing, developing in areas of Spain where it is not, also in Portugal, without forgetting future projects in Latin America and North Africa.

Miranza receives many calls from ophthalmological consultations who want to explore joining the company, from which we can deduce that Miranza arouses attraction among these professionals.

Visit to the Command Center of the Sant Joan de Déu Hospital (Barcelona)

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See PDF of the information:

Visit to the Command Center of the Sant Joan de Déu Hospital

Visit to the Command Center of the Sant Joan de Déu Hospital

Thanks to the kindness and long friendship with the Manager, Dr. Manuel del Castillo, and under the effective and detailed explanations of Dr. Francisco García Cuyás, I had the opportunity to visit on November 22, 2021, the Command Center of Hospital Sant Joan de Déu, from Barcelona.

Its start-up was carried out after the hospital’s own development, in which healthcare professionals, bioengineers, computer scientists, data analysts, experts in artificial intelligence, etc. participated. and, of course, the management team.

This center is divided into three main components:

• Command center (monitoring of general hospital activity)
• Contact Center (a space enabled for non-face care)
• eCare (specific telemonitoring of clinical parameters of some patients)

The command center

An overview of the command center is depicted in Figure 1:

Figure 1: Command center overview

 

 

 

In it, we already see that this center is chaired by a large screen, in turn subdivided into 6 components, according to the scheme in Table 1:

 

Table 1. General screen representation of the command center

 

 

The emergency room panel is represented in Figure 2:

Figure 2. Representation of the emergency panel of the command center

 

 

 

The panel of the hospitalization floor has this aspect of Figure 3, which incorporates an artificial intelligence algorithm that predicts the situation of the center for the next day, being able to see, in the lower part, a partial aspect of the monitoring of surgical activity (patient names are deleted):

Figure 3. Panel representation of the hospitalization floors

 

 

The panel with information about the ICU is represented in Figure 4:

 

Figure 4. Representation of the ICU panel

 

 

 

The COVID-specific monitoring panel is in Figure 5:

 

 

Figure 5. COVID-specific monitoring panel

 


In short, the command center provides a snapshot of all hospital activity. It is the evolution of the classic dashboard with real-time data and embedded AI algorithms. It is accessible to the entire steering committee and is evolving to continue incorporating predictive elements that accompany decision-making.

The contact center

Another component is the contact center, which is a place enabled to carry out visits, although each professional who is in this location of the hospital has on his computer the possibility of making visits from anywhere. What facilitates this site is an environment of privacy and adequate space so that these are developed in better conditions. It should be taken into account that the hospital performs about 100 visits / day, corresponding to approximately 45% of hospital visits, having reached, at the peak of the pandemic, 80% of the percentage of visits in the hospital .

A photo of this space is represented in Figure 6.

 

 

Figure 6. Contact center vision

The eCare

Finally, the so-called eCare is possibly the most innovative element, since it monitors cardiology patients on the ward, analyzing 65 variables and using a predictive decompensation algorithm. Logically, it has the potential to monitor patients from many other specialties and not just patients admitted to the hospital.

The eCare screen is represented (with deleted patient names) in the following photo in Figure 7:

Figure 7. eCare Patient Monitoring Screen

 

In short, a breakthrough

The hospital’s plans are to grow the Command Center, gaining in predictability and proactivity.

The challenges that the hospital had to address for this advance are those of work by processes, change management, multidisciplinarity, construction of data environments, etc.

The approach is very original and the concept can be very interesting for Health Departments, private and public hospital networks, pharmaceutical and medical technology companies that need to monitor patients to pay for results, etc.

This experience is unique in Spain and extremely innovative in the world. Another thing that we learn from this excellent and cutting-edge hospital as Sant Joan de Deu, in Barcelona.

The Confederation of Employers of Spain (CEOE) is welcomed to the healthcare debate

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Review the document “Health White Paper”, CEOE, May 24, 2016

Raid on the health sector by the CEOE

A document called “Health White Paper” published by the CEOE has recently come to light. We must congratulate this institution and its main promoter, Carlos González Bosch, for this foray into the health field.

Although there are many associations that exist in the sector, each cares about its specific problems, avoiding general statements. It seems as if they were a little reluctant to discuss general issues and feared that their particular approaches and positions could be weakened if they got into global battles. But this is a mistake; there is no way of defending specific approaches without a general approach to the sector.

Despite development efforts, we note that the “White Paper” is mostly a compilation of the positions of each of the employers’ associations linked to the health sector, and that perhaps an analysis of the problems in the public sector is missing. In this sense the title is perhaps a bit ambitious and instead of ” Health White Paper ” it could be called “White Paper on Private Health”. In any case, it represents a relevant achievement.

However, when rightly asked to reinforce public/private collaboration, perhaps further analysis of the public sector is missing. There can be public/private partnerships if the private sector is not fully aware of the situation, problems, challenges and values of the public sector and the same can be said regarding the public sector with respect to the private sector.

The document is largely an expression of the extraordinary employers’ associations in the sector which are undoubtedly one of its main assets. We refer to Farmaindustria, AESEG, FENIN, Asebío, UNESPA, AESTE, AMAT, to name but a few.

The document is highly descriptive and contains very interesting information. Let’s directly analyze the proposals, which are divided into general and sectoral.

General proposals

Health 

The most important elements in this section are:

  • Depoliticization of health. Although it is understood why this (making decisions for political or electoral reasons) is said, we can hardly ask for the depoliticization of health in a sector with over 75% of public funding. Rather, what we have seen is the near absence of debates on health policies in the last general election campaigns, which is negative. A good healthcare policy and good analysis and proposals for the healthcare sector from politicians are what we  must ask for, not the depoliticization of healthcare.
  • Support for a public, universal and equitable health system, which is very valuable as a Spanish employer statement.
  • To promote cohesion and fairness of the system
  • The need to review budgets and health investment. The significant decline in public health spending entailed by the economic crisis and austerity measures is accurately described in different parts of the document.
  • To support  public/private collaboration formulas. This is a critical issue and considering the strong criticism attracted by the current public/private partnerships, often without knowing the results, employer support is very important.
  • Valuing the drug, medical technology and pharmaceutical services.

Socio-health coordination

  • Integrating social and health resources. To address chronicity as the major challenge facing the health system.
  • Active aging policies.

Social Affairs and dependency

  • Necessary review of the financing of dependency .
  • The need for common requirements for accreditation of health centres in compliance with the Market Guarantee Act. This should be a genuine priority, as this situation is causing serious problems for companies unable to set up a supply globally.

Sectoral proposals

Sectoral proposals are more where the “hand” of the various employers’ associations in the sector is perceived. As befits the difference among associations,  some of the proposals are more strategic, others are more immediate in relation to the interest of the subsector or companies operating in it.

Perhaps the broader approaches are those relating to the pharmaceutical industry, medical technology, insurance and everything related to the development of dependency care.

Pharmaceutical industry

This is one of the most general and strategic proposals, as befits the usual mature approach adopted by Farmaindustria.

  • Recognize the health and pharmaceutical sector as real engines of economic and social development.
  • Consider the fact that more than a third of the pharmaceutical sector’s investments in R & D are carried out in collaboration with public centres
  • Enhance global investment in health, Spain cannot continue to lose relative weight in the public health budget (as proposed in the stability program), as has been occurring in recent years. It should recover in 2020 to 6.5%.
  • Reforming regional funding, so that common and sufficient standards for maintaining a similar level of quality in all regions are guaranteed.

Pharmaceutical distribution

Various technical measures are proposed to improve the functioning of pharmaceutical distribution companies.

Pharmacies

  • Functional integration of pharmacies as  private health facilities in primary care.
  • Regulatory development of a portfolio of services that incorporates a payment mechanism (this approach, so common in the sector, is really difficult to assume given the financial tensions in the public system).

Health technology

In these approaches, the expert input from FENIN is to :

  • Position Spain as an innovative pole in health technology internationally.
  • Improve integration between the field of administration, hospital research and companies.

Biotechnology

  • Maintain access to innovation through long-term cost-efficient formulas
  • Promote bio-entrepreneurship

Orthopaedics

  • Update the orthoprosthetic portfolio through the service portfolio of the National Health System.

Hospitals and private clinics

  • The conclusion of agreements with the public sector is a measure that is mutually beneficial for the sector and the health authorities.
  • Efforts to improve public sector debt and shortening payment terms.
  • The industry claims the consolidation system “fee- for- service” from private insurers, against “per capita”payment systems.

Insurance

Approaches to insurers are very relevant and UNESPA’s contribution is noticeable:

  • The growth of private insurance companies that can provide doses of rationalization in the overall management of healthcare should be enhanced, in the middle of a global scenario of budgetary deterioration and severe shortages in the  Public Health System.
  • Consider expanding the coverage of the “Mutualismo Administrativo” model (Special insurance scheme for Civil Servants of the Central Public Administration) to other civil servants as well as the self-employed groups.
  • The model of administrative concessions, implemented in Valencia, can serve as an example of beneficial formats of public-private partnership in the management of healthcare.
  • You can gradually increase the proportion of the population served by private insurers. For their solvency and specialization, these entities are able to propose a gradual process of replacing public insurance. This is the most important bet placed by healthcare private insurers in our country. This is the most important bet placed by healthcare private insurers in our country.

Mutual societies

  • Disseminate their important social role, little known.
  • To value the contributions of mutual societies in the sense of occupational accidents or diseases that have been avoided.
  • Public authorities must recognize the importance of institutions that manage health care for workers who require it, given that there are over 1.1 million accidents at work and occupational diseases.

Medical transport 

  • Keep linking health transport to the health field, considering that is a benefit.
  • Continue the provision of medical transport in the form of concession agreements between the government and private companies.

Prevention services

  • To influence, even in occupational diseases, promoting prevention rather than rehabilitation.
  • To promote prevention programs in respect of health in the workplace.

Hydrotherapy SPA-social tourism, health and health care to foreigners

  • Regarding health tourism, joint effort to promote the country as a destination for health tourism.
  • Work at European level for the effective implementation of the European Directive on Patients’ Rights to Cross-Border Health Care.

Socio-healthcare sector

  • Effort in achieving a social and healthcare covenant through a joint agreement of the Interterritorial Council of the National Health System and the Territorial Council of Social Services and Dependency
  • Work on defining the profile of the person in need of geriatric care.
  • Use of uniform criteria in the accreditation of centres and geriatric services.

Development of dependency care

This proposed section is one of the most elaborate:

  • The commitments of the Law Unit do not correspond with adequate funding.
  • The Law has been approved as a law of services, not grants, and it is necessary that it is enforced as such.
  • The system requires the homogenization of the professionalization of the teams evaluated.
  • Need for a fair system of accreditation.
  • They should not remain with the title of “residential” centres when they house people with high health needs, but should be considered geriatric centres or intermediate care and not mere home substitutes.
  • Dependent care services (residential centres, day centres, telecare services and home care) and services should be considered as first necessity centres and, as such, a super-reduced VAT rate of 4% should be established.

Dependency insurance

General development of private insurance covering the risk of dependency.

Final assessment

We must make a very positive assessment of this document. It gives an overview of the positions of different employers’ associations linked to the health sector.

Furthermore, after reading the proposals, it can be said that more than 90% of them are subscribable not only from the perspective of employers, but also from the perspective of general sector interests and population health.

Obviously, alongside these general approaches there are others more linked to specific interests (such as when the increase in the portfolio of services paid for pharmacies is defended, or when private hospitals demand that they continue being paid by insurers “by act” and not “per capita”, etc.). But these legitimate claims, though controversial and very specific, are the exception. What predominates are the proposals  based on the interests of the sector as a public service and defending a strategic vision in order to view the National Health System not only as the public part of the system but as the set of medical institutions and resources, publicly or privately owned, engaged in public service.

Congratulations, then, to this incursion by the CEOE into the healthcare sector. Continue.

Farmaindustria agreement with the Ministries of Finance and Health: an example for the health sector

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Report on pharmaceutical policy 2015, published by diariofarma.

Some notable cuts in public health spending

The economic crisis has hit the public health sector whose spending has gone down from 70,579 million euros in 2009 to 61,710 million in 2013, bringing down GDP from 6.5% to 5.9%. This significant decrease in public health spending, more than 12% in just four years, is exceptional in the European context, where health expenditures continued to rise in this period, despite the slow growth over previous periods. Health spending has only declined in 2009-2013 in absolute terms in rescued countries (Greece, Portugal, Ireland) as well as in Spain.

The Government has been very effective in implementing measures to reduce expenditure in the health sector. To achieve this “accomplishment”, the Government used two types of measures: actions on staff, basically reducing wages and the number of employees; and actions on the pharmaceutical industry, reducing the price of medicines. In absolute terms, the impact of the measures taken with respect to staff is slightly higher, but in relative terms of percentage reduction in spending, the most affected was the pharmaceutical industry.

Another feature of this significant reduction in public health spending is that it was carried out in the absence of reform measures to give certain sustainability to the changes (improvements in management, changes in the care model, fighting avoidable costs, emphasis on public / private partnerships, etc.). Perhaps the only exception was the introduction of pharmaceutical co-payment for pensioners, the closest thing to a reform during this period.

All these measures have to be viewed from the perspective of the Stability Programme, which provides that the weight of public health spending stands at 5.3% of GDP in the 2018 horizon.

Limited impact of the measures

Perhaps most surprising, following the sharp decline in public health spending is that health has been almost absent from recent election campaigns which suggests that it was not a priority of the contesting parties, nor was it among the most evident social priorities.

The explanation is not simple, but after the 2010-2013 downturn, spending stabilized in 2014 and grew slightly in 2015. The deterioration in quality is certainly there, but its best-known indicator, waiting lists, does not allow a very disturbing message of the evolution of the sector. In the November CIS survey, health still did not feature as a major problem for citizens.

The question is obvious: if reaction has been low, does this mean that declines in health spending are justified? Perhaps we were spending too much and what is “normal” is the current situation?

A change in health league

The truth is that Spain has never spent much on healthcare compared to other European countries. While it is true that with this reduced spending, Spain’s health league has changed. It has gone from 1,577 euros / citizen / year in 2009, 12% less than the average of the Eurozone-19, to 1,348 euros, 30% below. The same phenomenon occurs in the weight of public health spending. One can say that we have gone from not being too far behind the advanced countries of Europe in public health spending, to meeting the heights of Lithuania and Croatia.

Need to establish a recovery in public health spending

Despite the limited social impact of the measures, several reasons advocate the need for a recovery in public health spending: aging and increase in chronic diseases; renovation needs equipment (totally obsolete as a result of the crisis); increased demand and higher requirements thereof; emergence of new technologies, not only pharmacological but also in the area of medical devices; and finally, the international comparison, primarily with the European Union- 15

Naturally, this growth of public spending must be reconciled with reform measures: only the increase of public resources, together with the promotion of measures to encourage the responsible use of resources and discriminating towards those most in need, can ensure a quality health system, open to the incorporation of innovation, despite the major drivers of upward spending.

In this context, the main priority of public health is the recovery of lost spending in the period 2009-2013, to return to levels closer to the advanced countries of Europe. Surely this cannot be done in one year, given the deficit commitments of our country, but over a parliamentary term.

What agreements represent Farmaindustria

We have seen how the health sector has been hit by the crisis and, within it, the pharmaceutical subsector is the one that has suffered in relative terms. It is logical that the recovery in spending, a priority for the entire health sector is expressed more clearly in the pharmaceutical industry.

It is in this sense that we must view the agreement concluded between Farmaindustria and the Ministries of Finance and Health, on 4 November 2015. Regarding the concern for sustainability, the agreement links the growth of public spending on innovative drugs to the growth of the economy: companies are committed first to compensate the State if this spending grows faster than GDP. The agreement is valid for one year, but renewable for three additional years. It also envisages measures on efficiency and collaboration in terms of patient access to innovation.

Therefore, this agreement is part of the measures necessary for a progressive recovery in health spending, but always from a perspective of sustainability, linking this recovery to economic growth.

Some negative reactions

The agreement, instead of being welcomed and imitated by other industry players, attracted criticism from the Professional Medical Association, which considered it part of a logic zero-sum, so that any rise in pharmaceutical spending would be detrimental to other items, namely the professionals. Rather than joining the efforts to recover health spending that ultimately can only be understood in the long run through a change in some of the forecasts of the Stability Program.

It is hardly understandable that from the highest corporate medical instances constant belligerence against the pharmaceutical industry is maintained, up to the point of challenging the patent system. All this instead of joining the efforts to recover public health spending.

The agreement concluded with Farmaindustria, an example for the sector 

This agreement should be an example for all players in the health sector, to focus their priorities on what really matters: the recovery in health spending. Something that will only be accepted by the economic authorities if at the same time reform measures arise from within the depths of the system, which ensure long-term sustainability. If this does not happen again and spending skyrockets, we very much fear that we will be back to taking the same measures: actions on professionals and the pharmaceutical industry.