We don't know what we 're doing in medicine.... or yes we know!

This sentence was expressed by Dr. Eddy on February, 4 1990 in Detroit Free Press. He recognized the importance of the gaps in medical decision making and the effect in the efficent use of healtch care resourses.

The empirical work of Dr. John Wennberg  and various colleagues tried to find some arguments to explain that. They focused on the study of "Small Area Variations (SAV)" the phenomenom that refers to the wide variations in the per-capita utilization rates for many medical and surgical procedures that are commonly found in comparing small, contiguus hospital service markets.

They have argued that much of the observed variation is closely related to the degree of physician uncertainty with respect to diagnosis and treatment and the differences in local opinions. He's the founder editor of  The Dartmouth Atlas of Health Care 

Is there any small area variations (SAV) evidence in Spain?: Take a look at ATLAS VPM a brilliant initiative coordinated by Enrique Bernal Delgado PhD in Medicine. Senior Researcher of the Research Unit in Health Services and Policies of Aragon Institute of Health Science.

They have published 8 Atlas:

8 Potentially Preventable Hospitalizations related to exacerbation of chronic diseases
7 Variability in Hospitalizations of older people in the NHS
6 Variability in Hospitalizations due to oncological surgery in the NHS
5 Variability in Hospitalizations due to mental health problems in acute care hospitals.
4 Variability in Hospitalization due to cardiovascular problems and procedures in the NHS
3 Variability in Pediatric Hospitalizations due to surgical and diagnostic procedures selected
2 Variability in General Surgery Interventions in the NHS
1 Variability in Orthopaedic Surgery and Traumatology. Hip fracture, knee replacement and hip replacement

photo: (*) Photosolde
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copagament-copago-copayment: evidence data in Catalonia

 

Co-payments (Co-pay, user charge): A fixed monetary payment that is made by the patient to the provider at the time of service.

PAYING FOR FORMERLY FREE MEDICINES IN SPAIN (july 2013). This working paper is the first attempt to provide accurate estimates of the overall impact at the regional level of a cost sharing reform on pharmaceutical prescriptions with regional variants established in Spain since July 2012 in the framework of heavy austerity reforms on public financing.

Conclusions:
It would be a mistake to increase cost sharing on medication across chronic and effective treatments. If one thing is clear from randomised and natural experiments, it is that cost sharing should be lower the greater the need for the treatment and the more effective that treatment is.

The high concentration of expenditure in patients with chronic conditions suggests the maintenance of low rates, together with the application of upper limits to the amount payable out of the patient’s pocket, either as a monetary amount that would be the same for all, or – a finer adjustment – as a percentage of each patient’s income. Otherwise, the cost in the form of greater use of emergency and hospital services may more than cancel out the savings made through cost sharing for chronic patients.

After decades trying unsuccessfully to reduce drug spending in the Spanish national health system through actions on prices and prescribers, the copayment established in mid 2012 led to a dramatic reduction in the use of drugs whose effect on health is not known.

Although the new copayment is modulated by income, a small portion of patients supports a large part of the expense.

Without disaggregated data is not possible to know who have reduced their use or what medicines are being left to take. Perhaps the moral abuse is reduced without adverse health effects, or even improving. But certain groups of patients may be enduring a financial burden or reducing the use of treatments needed, with high cost in terms of health loss.

Authors:
Jaume Puig-Junoy
University Lecturer at the Department of Economics and Business at Universitat Pompeu Fabra, Main Researcher of the Centre for Research in Health and Economics (CRES). Interesting to visit his blog: pilleconomics

Beatriz González López-Valcárcel
Full Professor of Quantitative Methods in Economics from University of Las Palmas de Gran Canaria, Associate Researcher of Centre for Research in Health and Economics (CRES).

Santiago Rodríguez Feijoo
Full Professor of Quantitative Methods in Economics from University of Las Palmas de Gran Canaria.

W. Eugene Smith—Time & Life Pictures/Getty Images (1951)
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