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RethinkingValue-BasedHealthcareScalingThroughPractice
RETHINKING VALUE-BASED
HEALTHCARE
Scaling Through Practice
Text © Future Agenda 2020
Images © istockimages.com
Graphs © As referenced
First published February 2020 by:
Future Agenda Limited
84 Brook Street
London
W1K 5EH
www.futureagenda.org
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RethinkingValue-BasedHealthcareScalingThroughPractice
Rethinking Value-Based Healthcare
Scaling Through Practice
Lars Dahl Allerup
Sam Kondo Steffensen
Tim Jones
Caroline Dewing
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RethinkingValue-BasedHealthcareScalingThroughPractice
National healthcare providers have long had to
battle with how to narrow the gap between need
and demand on the one hand and available
resources on the other. In some ways they are
victims of their own success. The global population
is growing, and people are living longer, largely
because many are able to access better healthcare
than ever before. However, at the same time, and
in particular in Europe, SE Asia and the US, ageing
populations have led to a shift from the treatment of
acute illnesses towards having to manage chronic
disease and deliver more complex treatment
processes. This increased pressure has meant
that many health and social care organisations
constantly face a shortage in financial, personnel
and material resources. This has come into sharp
focus since the western financial collapse of 2007,
as some countries have sought to scale back
annual increases in funding in health services.
Health systems charged with maintaining a balance
between cost and quality, face a big problem.
A number of different approaches have been
explored including evidence-based decision
making (to ensure that only interventions with
strong evidence of cost effectiveness are used),
quality improvement (to improve outcomes), and, of
course, cost reduction. They have all delivered some
success, but healthcare spend is still growing faster
than inflation and, in many developed economies,
higher costs have not necessarily correlated with
an increase in life expectancy. Beyond this, the
complexity within healthcare systems means that
inefficiencies remain rife – so much so that some
calculate that up to a third of current healthcare
spend is wasted.1
,2
Alternative healthcare models
are being sought. One possible solution is Value-
Based Healthcare (VBHC). This focuses on the
outcomes that matter to patients as well as
the costs of delivering them. Around the world
healthcare providers are busy exploring how VBHC
can both improve the efficiency and effectiveness of
healthcare delivery and seed new opportunities
for innovation.
Context
Input: Health expenditure per capita (PPP US$)
Outcome: Health-adjusted life expectancy (years)
Emerging economies
Developed economies
Health expenditure as %
of GDP
Ideal path
Path to avoid
Life Expectancy vs Spend
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RethinkingValue-BasedHealthcareScalingThroughPractice
Global organisations such as the OECD and
WHO, G20 and World Economic Forum (WEF)
are beginning to recognise the benefits of VBHC.
Indeed, Rethink Value recently briefed the G20
on its potential to solve future healthcare issues
around VBHC. To be clear, however, there are no
easy answers. Indeed, many organisations are still
struggling with the question of where to start, how
to scale and how to make the value of healthcare
more transparent. To review key lessons from the
practice frontline, explore what obstacles and
highlight which approaches may have greatest
future impact, Rethink Value convened an expert
conference at Danish Technical University in
Copenhagen in late November 2019.Facilitated by
Future Agenda, this event integrated views from
philosophers, patient representatives, physicians,
medical device manufacturers, pharma companies,
payers and hospital managers with debate and
discussion between participants drawn from across
the healthcare system. This article is a summary of
the pivotal insights that were shared and debated
with some key quotes from the event highlighted
in blue text. It explores some of the associated
implications for healthcare systems worldwide.
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RethinkingValue-BasedHealthcareScalingThroughPractice
Rethink Value: Towards value-based transactions
At Danish Technical University
Agenda: Speakers and subject matter
Pondering on the concept of value in a transactional perspective
•	 Mickey Gjerris, Bioethicist, PhD
Value in healthcare research - from the patient perspective
•	 Henrik Vincentz, Founder of the James Lind Institute
Value-Based Healthcare - from catchphrase to projects
•	 Niels Lund, Vice President, Novo Nordisk
New Patient Pathway for Renal Cancer - Roche Pharma and Herlev University Hospital
The strategic Value-Based Healthcare perspective of a large MedTech company
•	 Maarten Akkerman, VP Medical Affairs & Value-Based Healthcare EMEA, Medtronic
Panel discussion about understanding and assessing patient value – the clinicians’
perspective on today’s agenda
•	 Jens Hillingsø, Head of Department (Surgery and Transplantation), Rigshospitalet
•	 Henrik Røgind, Head of Department (Rheumatology), Rigshospitalet.
•	 Steen Mejdahl, Head of Department (Joint and Bone Surgery), Hospital of Herlev and Gentofte.
Implementing the Strategy of Value-Based Health Care
•	 Scott Wallace, Co- Founder and Managing Director, Value Institute for Health and Care,
University of Texas at Austin
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RethinkingValue-BasedHealthcareScalingThroughPractice
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RethinkingValue-BasedHealthcareScalingThroughPractice
In 2004 Elizabeth Teisberg and Michael Porter
published an article, “Value-Based Healthcare” which
set in motion the transition to a value-based delivery
model.3
This proposed that “patient value is defined
as patient-relevant outcomes, divided by the costs
per patient across the full cycle of care in order to
achieve these outcomes. Value-Based Healthcare
focuses on maximising the value of care for patients
and reducing the cost of healthcare.” They introduced
a two-fold strategy:
•	First, health care should be reorganised into value-
based care pathways around patient groups.
These pathways should no longer be merely
focused on increasing production, while shifting
costs to other providers, but they should strive for
the highest value for patients, i.e. the best possible
outcomes for acceptable costs.
•	Second, these pathways should compete for the
favour of patients and health care purchasers.
Patients should – in turn – behave more as
critical health care consumers, while purchasers
‘buy’ the best possible health care for the lowest
possible costs.4
Most health systems agree that, in principle,
Value-Based Healthcare could deliver access to
better care that provides more benefit to patients but
at a lower-cost to the system. However, in practice,
as yet there is no single agreed definition of what it is
or even of what value means (and for whom) in the
health context.
Different organisations have grappled with finding a
definition that suits their needs. For example, in the
UK, one perspective is that “Value-based healthcare
is the equitable, sustainable and transparent use of
the available resources to achieve better outcomes
and experiences for every person.”5
In contrast, in
Singapore, which is often rated as having one of the
best healthcare systems in terms of efficiency and
satisfaction, the view is that value-based care is a
care delivery model where providers are paid based
on patient health outcomes rather than the amount of
healthcare services that they provide.6
When we talk about outcomes that deliver value there
is a fundamental question of who decides the right
outcomes. A treatment may not be worth it for the
patient – as the way we run healthcare today not all
patients understand the choices that they are making.
We need to progressively focus on a pyramid of value
encompassing societal value, patient value and clinical
value. Moreover, the criteria will change. For instance,
as patients age, physicians are often called upon to
shift their priorities as end-of-life support can differ
significantly from healthcare in earlier years.
The challenge of gaining consensus around value and
value-based healthcare is a priority. “The absence of
an agreed definition of ‘value-based healthcare’ in the
NHS, the lack of skills required to deliver value-based
healthcare and a clear understanding of the barriers
to effective development and implementation inhibits
the health system in addressing problems such as
overdiagnosis, too much medicine, poor allocation
of resources and the introduction of inadequately
evidenced technologies.”7
To help enable better understanding, in 2019, an
EC expert panel proposed to define VBHC more
clearly as a comprehensive concept built on four
value-pillars:
1.	Appropriate care to achieve patients’ personal
goals (personal value),
The Evolution of Value-Based
Healthcare
Apple
18,3%
Amazon
15,0%
Facebook
13,1%
Organise into
integrated
practice units
(IPUs)
1
Measure
outcomes and
costs for every
patient
2
Expand
excellent
services across
geography
5
Integrate care
delivery across
separate
facilities
4
Move to
bundled
payments for
care cycles
3
Build an enabling information
technology platform6
The Six Components of VBHC
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RethinkingValue-BasedHealthcareScalingThroughPractice
2.	Achievement of best possible outcomes with
available resources (technical value),
3.	Equitable resource distribution across all patient
groups (allocative value) and
4.	Contribution of healthcare to social participation
and connectedness (societal value).8
The WEF has also been working on an appropriate
definition and suggests Value-Based Healthcare to
be a holistic approach to delivering health results that
matter to patients at a lower cost by;
•	Measuring health outcomes that truly matter to
specified patient groups;
•	Comparing results achieved by different health
systems;
•	Shifting payment away from volume (e.g. fee-for-
service) to models that encourage prevention,
integration of caregivers and high quality such as
bundled payment or capitation; and
•	Reconfigure care delivery to improve coordination
across the health system.
What is agreed is that the principle of VBHC begins
by measuring outcomes that matter to a particular
patient. These are consolidated on a population
segment level, and then the insights that are revealed
are used to tailor and improve interventions all along
the care pathway for those with similar conditions.
It sounds simple but gathering valid and actionable
health data is a challenge. There are remarkable
differences in clinical practises even in the most
advanced healthcare markets. Often when they
do exist, health data are frequently uncoordinated,
and stuck in legacy non-interoperable systems.
Furthermore, the medical profession is by nature
conservative and change averse, not to mention
sometimes under-resourced and time-pressured, so
the additional administrative burden of data collection
may simply be too overwhelming for many clinicians.
All of this explains why as yet very few have a
rigorous approach to either measuring patient-
centred outcomes or the cost of care. This is true
even in countries such as Denmark and Sweden
where the healthcare systems are underpinned by
social democratic traditions; equal rights are explicitly
protected in healthcare legislation; and measuring
performance and benchmarking is very much part of
the health tradition.
The International Consortium of for Health Outcomes
Measurement (ICOHM), and others are working to
address this and to identify on what are the best
measures for VBHC including definitions around
value. In many countries there is not only a shift
to ranking different hospitals, providers and health
insurers but also compiling and sharing tables of how
individual physicians perform. Some consider that
this is going too far, others see that it is inevitable and
far better to occur in a transparent, trusted manner
rather than informally via social networks and some
sort of medical trip advisor ratings.
This suggests that there is some way to go before
there is consensus on a shared universal definition.
What is also clear is that in order for VBHC to be
a success there needs to be a cultural adjustment
in the public understanding of healthcare delivery
and so consensus around what this should mean
is a priority. VBHC requires a strong system of
governance and orientation towards more relational
and explorative contracts to support a new paradigm
that shifts resources from (intrinsically assumed) low
to (demonstrated) high value. It needs to steer public
research; stimulate appropriate regulation to ensure
there is appropriate accountability; support targeted
actions by member states; and work with industry to
deliver appropriate pricing models.
Given its significance it is useful to look at how VBHC
is being viewed through four pivotal lenses – patients,
physicians, providers and payers.
 
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RethinkingValue-BasedHealthcareScalingThroughPractice
Despite the lack of precise definitions, there was
consensus in Copenhagen that VBHC is “all about
being relevant to the patient.” The focus is on
delivering a truly holistic form of care which goes
beyond the traditional clinical environment and
provides care and wellness services that extend into
our daily lives, homes, and communities. It reminds
us that, above all, patients are individual human
beings with varying needs and, rather than consider
health as a process commodity, the best way to
achieve high-quality, cost-effective care is to consult
with them - because most patients are best placed
to determine what really matters with regard to their
own health.
Alongside this, better consumer engagement is key
to obtaining a long-term view. Consumer data is
becoming the foundation for predicting health risks
and making social interventions into day to day life.
Furthermore, regulatory pressures, highly competitive
markets and advances in technology and healthcare
delivery models increasingly support this approach.
Value-based health goes beyond traditional
clinical care in hospitals and doctors’ surgeries - it
also entails prevention. While primary care has
often been the first point of contact for patients,
technology has now opened the door to more
touchpoints beyond the physical facility. Online
and app-based interaction are quite suitable for
engaging patients in conversation around their
health needs, conditions, values and preferences.
Patients can now participate in multiple ways that
facilitate communication, inform, monitor / deliver
treatment at home and, importantly, build trust.
As the spotlight turns away from quantity and
onto value, different aspects of care gain more
significance. Access to more health information
gives patients the power to focus on the type
of outcomes that matters to them. This typically
includes pain-free diagnosis and treatment,
fast recovery, a low chance of side effects and,
ultimately, a better quality of life. It also enables
patients to make informed decisions about the
medications and care they want to receive and
the doctors and care centres through which health
services are delivered.
Patients increasingly also expect diagnostic
procedures and treatment paths to be personalised
to incorporate their preferences, ideally in the
comfort of their own home. Sensors, smartphone
apps and data analytics allows more primary care
to be delivered online. Even those who are suffering
from chronic illnesses are able to accept treatments
at home, reducing healthcare costs while at the
same time increasing quality of life for patients.
For patients the shifts towards wellness helps
reduce the instance of unnecessary diagnostic and
therapeutic treatments they might have to undergo.
This can increase both the cost of care and risk
of exposing patients to unnecessary risk. Patients
also expect continued and reliable access to
caregivers for advice and support while also wanting
control over the availability of their personal health
information to others. To move practice forward, in
Singapore and elsewhere, VBHC analysis has been
combined with design thinking to identify how and
where healthcare support can best be provided in
ways that better suit the patients’ life and needs as
well as manages costs.
The Patient View
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RethinkingValue-BasedHealthcareScalingThroughPractice
VBHC and Clinical Trials
Looking ahead some also see that combining the
thinking from VBHC with upcoming technologies for
virtual clinical trials technologies could both reduce
the time and cost of Phase 1 trials and improve the
matching of patients for Phase 2 and 3. This could,
it is argued, improve ratios of patients participating
in new medicine development and accelerate the
time to impact.
Patients on early stage trials often become
advocates of the new approaches. Organisations,
such as the James Lind Institute, which works
with patient communities on clinical trials, see that
those who take part gain greater insight into the
progress of their own disease but without significant
inconvenience and minimal intervention; they also
have the opportunity to become more informed
about potential treatments through contact with
expert medical staff which in turn may incentivise
them to make improvements in their lifestyles. For
terminal patients, or those with chronic conditions,
this involvement can also affect their mental health,
allowing them a sense of purpose and control.9
However, while an increased focus on the patient
is important, some caution that, in terms of overall
value, maximising satisfaction in the ‘customer
experience’ should be balanced with the needs and
interests of the other parties involved.
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RethinkingValue-BasedHealthcareScalingThroughPractice
Doctors are at the frontline of the healthcare value
debate and face challenges from all sides. In
many countries, most are nonetheless still paid
according to the traditional fee-for-service model.
The problem is not only that activity-based payment
models lack incentives for improving healthcare
value, sometimes doctors are also disincentivised
to deliver care. For example, in 2019 research by
the BCG suggested that privately insured surgical
patients with one or more health complications
provided a US hospital with a 330% higher profit
margin (an additional $39,000 per patient, on
average) than the margin from similarly insured
patients who had no complications. This meant
that there was little financial incentive for physicians
to improve health care value by minimizing
complications.10
Doctors are also challenged by having to deal
with outdated regulation. Sometimes outdated
national guidelines are holding back meaningful
progress towards VBHC due to their generalized
and retrospective character. One doctor said; “if
I were a journalist my headline would be uproar
against national guidelines”. Some are too stringent
and have not kept pace with technological change.
This means that doctors are obliged to make
patients undergo unnecessary treatments and
which they may not want or need simply to satisfy
the regulators. Consider for example the number
of blood tests required for terminal cancer patients.
Often these are precautionary, however time is
wasted discussing the result for both patient and
doctor when the better provision of care may well be
a conversation about how to improve quality of life.
We heard a suggestion that “with a cancer patient
we should spend less time discussing the results of
a blood test and instead focus on how to improve
their present and future quality of life.” Many agree
that new technologies can help patients take more
The Physician’s Perspective
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RethinkingValue-BasedHealthcareScalingThroughPractice
responsibility for their own health, cut waste in the
system and better track the cost-effectiveness
of personalised treatments over time. They also
concur that improvements in health outcomes are
greatest when clinicians themselves are responsible
both for collecting and interpreting data and for
leading efforts aimed at clinical improvement.
However, as a group, healthcare professionals are
naturally conservative, so some find it hard to adjust
their consultancy practices to new methods of
treatment. For example, although acknowledging
video consultations are convenient, economic and
can improve quality of life, one physician admitted
that “sometimes it’s difficult for us to realise that a
patient can take care of their own conditions.”
Aligning a health system with a VBHC model
represents a tremendous shift in culture for all
stakeholders, doctors in particular. However, there
is a general recognition that there is a need to
transition away from what has become siloed and
wasteful care delivery to a more patient-centric
and especially productive healthcare. At the
forefront of this is the desire to impact patient well-
being, through supporting health education and
encouraging healthier behaviours. Fundamental to
this is the collection of good metrics.
Identifying and improving access to relevant data
allows healthcare providers of all kinds to better
understand the most important aspects of the
patient journey and then consider ways in which
this could be improved. We heard that “we have a
lot of data which is measured a lot - but we don’t
measure the data that matters a lot.” It is certainly
true that until recently the medical profession has
measured its effectiveness largely by one metric:
clinical outcomes. Process measures are often used
in health care quality assessment, yet these, while
often easy to measure, do not always correlate with
clinical outcomes. Similarly, structural measures,
patient experience, and other indicators are often
substituted for outcomes. Going forward there will
be increased emphasis on tracking and improving
not just patient outcomes but the entire human
experience of being a patient.
Once metrics around value have been established
there can be greater clarity on what appropriate
targets should be and adjustments made. For
example, although doctors might in principle
support VBHC and agree that limiting the number
of out-patient visits and instead using video
consultation would both reduce system costs and
benefit patients they may be unwilling to support
change in that direction if their salary is based on
the number of out-patients they actually see. It
provides no advantage to them and, in their view,
the lack of a real consultation may possibly increase
risk for the patient.
Although most doctors agree that standardised
clinical guidelines and treatment plans are
important, the challenge of building and maintaining
a suitably flexible and accurate database is almost
too much. However, in Denmark some questioned
whether a one-size fits all strategy is practical. In
addition, despite the appetite to use technology
to improve patient care and reduce costs, the
siloed nature of health records made some at our
conference question the practicality of creating a
national health database - not least because of the
heavy administrative burden it places on already
stretched physicians. Alongside being responsible
for the communication with the patient and helping
them through their course of treatment doctors
are obliged to update medical records, code the
activities and order treatments and tests directly in
the system.
 
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RethinkingValue-BasedHealthcareScalingThroughPractice
The Provider Point of View
VBHC is dependent on all those involved in the
delivery of healthcare collaborating around the
common objective of putting the patient at the
centre of all decision making. There are multiple
options for how this can be achieved - for example
by incorporating patient reported outcomes in
clinical trials and real-world data studies to give a
holistic view of the benefits of a particular medicine.
This process is already well established in oncology,
rare diseases and allergies, and is growing in the
autoimmune and gastrointestinal areas. But equally
there are any number of ways in which design
and implementation of VBHC initiatives can be
challenging -particularly when trust is at a low ebb.
“Mistrust between pharma and government is at
an all-time high. It’s difficult to have transformation
systems on the basis of mistrust.”
Participation in the VBHC model requires hospitals
and other care facilities to create and follow
comprehensive benchmarking plans. This, for
instance, allows facility leaders to find weak points
in financial, clinical, or quality performance and set
measurable goals for improvement. However, it
needs a range of organisations to collaborate. In
spite of a growing pool of pilots and visible pockets
of excellence, many are proceeding with caution,
and it has not always been a positive experience;
“some people join initiatives to make sure they don’t
go anywhere.” Electronic health records companies
have sometimes deliberately designed systems to
prevent easy data-sharing, locking users into their
services while several private healthcare providers
have been known to hoard proprietary data because
of its commercial value. Despite this, during our
conference, we heard strong support for the VBHC
approach. “The lack of progress is not for lack of
engagement or willpower.”
For the pharmaceutical industry adapting to
VBHC essentially means a move from a “payment
per pill to payment per outcome” model. This
is a fundamental step change. Historically most
innovation in pharma has taken place at the
beginning of the value chain in drug discovery. In
the future, several see that innovation will have to
have to be far more holistic and occur across the
value chain. Introducing true value-based metrics
into R&D processes would help to do this, as would
enhancing existing medicines in order to improve
the patient experience. Decreasing the number of
instances when a patient needs to take a certain
medication, reducing its side effects and improving
the way a drug is administered - such as moving
from an injectable to an oral administration - are all
ways to improve outcomes, increase adherence
and reduce unnecessary spend. Further research
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RethinkingValue-BasedHealthcareScalingThroughPractice
around personalisation may also enhance patient
segmentation and increase the odds of positive
health outcomes. Roche is one company already
making big bets in this area - around half of its
late-stage pipeline have companion diagnostics
to determine whether specific patients are
genetically disposed to respond to therapies. More
pharmaceutical firms are now also supporting
patients with better health education about the
treatment and the ongoing management of
their conditions.
As health systems increasingly focus on a
comprehensive range of factors that affect health
outcomes – drugs, technology, health information,
care management and delivery, there is a huge
co-ordination role to play. Also, the information
associated with the development, use and impact of
medication is fast becoming a very valuable asset so
the organizations that can capitalise on this and use
it to deliver new insights and value adding services
are likely to reap rewards. This is a new opportunity
for some of the established providers. However, it
is also possible that several of the growing number
of new players - health information companies, IT
vendors and tech firms - will step up to the mark.
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RethinkingValue-BasedHealthcareScalingThroughPractice
One of the main challenges for healthcare providers
and managers is how to maintain the delicate
balance between costs and quality. Around the
world, many collaborative efforts are underway
to explore how VBHC can have greater impact
on this by shifting the business model to become
more patient-centric: “we need to buy solutions
not services and devices”. As procurement in
healthcare moves away from traditional lowest-price
strategies towards quality, service and solutions, the
possibility for stakeholders to align views increases.
In addition, value-based purchasing links specific
objectives to reimbursement incentives and can
consequently reduce the incidence of medical errors
by rewarding the best performing care provider
organisations.
Key to success is to establish principles around the
measurement of outcomes so that payers can be
comfortable about what it is they have contracted,
and providers can agree what it is they should
deliver. Several at our conference agreed that “there
is no silver bullet in healthcare, but survival alone
is not a good metric.” However, the capture and
reporting of data between systems processes and
stakeholders is difficult to achieve, certainly without
considerable administrative effort. It requires trust,
collaboration and a full-ecosystem approach.
Suppliers contribute analytics, providers are best
placed to measure outcomes and payers are pivotal
in identifying the outcomes that matter most.
The WEF is working hard to bring relevant
stakeholders together to establish global metrics
but it is a long journey. “There needs to be more
organisational backbone about this.” In the
meantime, a number of specific pilots are now
generating good results. For example, in the
Netherlands there is an initiative around end-
stage renal cancer and another in Atlanta around
the measurement of diabetes outcomes which
has brought together 30 local partners across
government, health systems, pharma and suppliers.
The Payer Perspective
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RethinkingValue-BasedHealthcareScalingThroughPractice
Elsewhere different payment approaches being
trialled. These are, for example, commercial
arrangements where a medicine’s price is linked
to the outcomes achieved for patients receiving
the medicine in real-world clinical practice.
Medicines that perform as expected and deliver
pre-agreed outcomes are reimbursed at the pre-
agreed price, while medicines that do not deliver
the outcomes are reimbursed at a lower price or
not at all. An early adopter of this in the US was
Amgen for its cholesterol drug Repatha, where
many patients were treated for six months before
full reimbursement was made available: It was
initially provided with a 60% discount.11
Risk-sharing
schemes are also gaining popularity, even in the
private sector. As outcomes are also dependent
on patient behaviour, patient compliance and
adherence are often taken into account here.
In the UK, different types of cost sharing
agreements around cancer care are being explored.
These include treatments that are initially discounted
until it is clear whether a patient is responding to a
medicine; payment by results - where payers are
reimbursed by manufacturers if a patient does not
respond to treatment; and pay for performance
- where refunds and rebates are provided if a
medicine fails to meet pre-agreed outcome targets
for individual patients.12
From a cost-saving perspective, it is apparent
that the motivation has to be right – it cannot be
just about spending less and reducing healthcare
budgets without an upside. In Finland, for example,
when a company within the public system delivers
improvements, they keep 40% of the savings but
the other 60% are put back into the healthcare
system for others to use and benefit from. Equally,
some ask “should the indirect cost-savings for
the patient, their employers or insurers from, for
instance, remote consultation rather than face-to-
face be considered? Can a share of these savings
be handed back to the hospital?”
As with other industries, such as the automotive
sector, more holistic models of cost and value
are also emerging covering the ‘total cost of
care’. Several therefore expect that Medtech
players will increasingly need to deliver ‘beyond
the product’ solutions that integrate education,
service, consultation, and finance with the products
themselves to deliver greater value for payers.
Support for this approach is in part due to a
response for stricter quality and safety requirements
but for providers it also reduces compatibility
risks as devices and their related services can be
sourced from the same supplier which then become
responsible for follow-up and compliance.
On occasion payers (and care providers) can
be distracted from considering what could be
the best way to treat a patient because of the
pressure to focus on the management of costs.
“There is such a rush to the bottom all the time.”
Initiatives such as the MedTech Europe Code of
Ethical Business Practice (2017) lays out guidelines
on cost transparency aims to address this. At
the same time, low-cost players are challenging
traditional pricing approaches; together with an
increasing uptake of online tools and social media,
this is leading to procurers becoming more price
conscious.
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Exemplar Approaches
Historically two Europeans in particular have been seen as leading examples of VBHC progress: Sweden and
the Netherlands. However within recent years individual regional healthcare systems such as Catalonia, Wales
and the Capital Region of Denmark have also come on board; particularly when using public procurement as
leverage. Many believe that it is this which is the key to ensuring VBHC at scale.
Sweden
One country that has achieved higher quality
healthcare than its EU peers but without
greater spend in recent years is Sweden. This
is in part due to its ability to provide access to
high-quality data. Sweden’s pioneering quality
health registries and digital health records
provide significant opportunities to compile
and share real-world evidence about health
outcomes. Accurate and comprehensive
health data are major elements of VBHC in
that they enable policymakers to measure
the impact of treatment, evaluate where both
care and processes can be improved, and
ultimately provide the information that can
underpin value-based pricing. Sweden has
benefited immensely from its long history
of quality registers for a variety of diseases,
including hip arthroplasty and cardiac care.13
Indeed it has been tracking treatments
and outcomes since the early 1800s when
maternity nurses were required to report key
metrics on delivery outcomes to the local
doctor. Today, the national quality registries
give a unique possibility to achieve the goal
of equal care and treatment and has meant
that value-based pricing for pharmaceuticals
and medical devices has been in operation
since 2002 in some regions of Sweden. One
early success has been in the treatment of
acute lymphoblastic leukaemia. Another was
OthroChoice, a bundled payment system for
knee and hip replacement surgery that was
then extended to spinal surgery.14
With its disease registries, electronic records
and plenty of real-world data, Sweden
has been labelled a “data gold mine”
for healthcare;15
the potential for further
development of the use of predictive analytics,
machine learning and applications for artificial
intelligence is enormous. However, despite this
early success, the Swedish healthcare system
still faces challenges around the definition
of VBHC and how to ensure integrated care
delivery becomes a key part of providing value.
Insights from Sweden have included:
•	 Getting buy-in from health providers is vital;
•	 Good data are key to effective value-based pricing; and
•	 VBHC is not always “one size fits all”.
19
RethinkingValue-BasedHealthcareScalingThroughPractice
The Netherlands
Another success story is found in The
Netherlands with the Diabeter clinic
collaboration. These are certified centres
dedicated to providing comprehensive and
individualised care for children and adults with
type 1 diabetes.
Established back in 2006 as a partnership
with Medtronic and a core adopter of VBHC
this has become the best performing diabetes
clinic in the Netherlands for children under 18.16
Core to success has been taking the long view
with 10-year collaborative contracts between
insurance companies and the clinic to manage
treatment. With a fundamentally different, low
stress user experience, higher patient to nurse
ratios and bundled payments, this has become
a benchmark with 62% less hospitalisation
rates than the country average. Superior
outcomes have led to less direct annual costs
to type 1 diabetes patients with the savings are
mainly driven by a lower patient hospitalization
rate than that of other Dutch paediatric
diabetes clinics. Initially the overall hospital
admission rate was between 20 – 30%. Now
most clinics can get to around 10 per cent
while some have rates of between 1 – 3%
giving benefits to patients and reducing costs.
In order to overcome the high levels of
variability in data found in many other countries,
Diabeter’s system has adopted dashboards
that track results for each patient and makes it
possible to compare outcomes between clinics,
doctors and therapies, driving improvements
across the network of clinics.
A key achievement here has been part of
challenging the payment structures which
may well, for example, increase the costs to
the company but reduce the length of stay.
Diabeter gets paid today for savings for what
may be an issue tomorrow. There has been a
shift from the fee for a service approach where
income for provider is based on technology,
with a promise to change outcomes, supported
by credible clinical evidence, to a fee for value
where income is driven based on delivering
improved outcomes, as a result of technology
innovation.
Key lessons from the Netherlands success includes:
•	 Outcomes must be clear and measurable to structure business models;
•	 Cohorts must be specific so actions can be easily traced to outcomes; and that
•	 Granularity in modelling the healthcare process is essential to operationalize VBHC
20
RethinkingValue-BasedHealthcareScalingThroughPractice
Transitioning to Value-Based Health
From discussions during our conference and as
evidenced by the large number of pilots undertaken to
date, it is clear that VBHC has significant potential to
transform both healthcare systems and industry and
has already delivered strong results in specific fields
such as transplants, cardiothoracic surgery and joint
surgery. However, to do this at scale is far from simple.
In Denmark both the government and regional
healthcare authorities are pushing for an ambitious
VBHC evolution. Mentioning a few inspirational
examples among initiatives in 2019 would include:
•	 The Capital Region of Denmark published a new 	
	 governance model to scale VBHC for all hospitals 	
	 in the group (serving 1.8M inhabitants).
•	 A new public-private partnership under the 		
	 Danish Ministry of Industry, Business & Financial 	
	 Affairs was established to propose a set of
	 practical tools and recommendations in order to
	 scale innovation and Value-Based Procurement.
	 Members of the partnership include the
	 healthcare regions, the municipalities, the ministry
	 itself, the largest industry organisations and the
	 ministry of health covering multiple stakeholderz
	 in the healthcare system.
•	 Danish Regions, the interest organisation for the
	 five healthcare regions in Denmark, established
	 a new council aiming to improve practical skills,
	 tools and best practice for public procurers within
	 the healthcare regions. Representatives from the
	 largest industry organisations are also present on 	
	 the board.        
Much of the current Danish development is based
upon the last three years of practical experience
from work in the Capital Region of Denmark. Already
back in 2017 the region founded a new organisation
within the group’s department of corporate
procurement. Procurement Development & Strategic
Partnerships, is dedicated to scaling Value-Based
Procurement through new outcome-based payment
models, public-private innovation and business
development of the procurement categories. The
concept of using Value-Based Procurement to
leverage Value-Based Healthcare might inspire other
healthcare systems to scale VBHC.
Although there is appetite for change, a number of
hurdles must be overcome, not least around the
need to develop a common language to describe
the value chain. Furthermore, we simply won’t get
Value-Based Healthcare until we agree what “value”
really means. Clarification of this fundamental issue
is vital to allow the multiple stakeholders - business,
healthcare providers, academics and patient
advocacy groups - to accurately describe and find
solutions for the major challenges.
First identified by research in Texas these include;
the structure of care and the supporting business
models that develop solutions (not services)
focused on the outcomes that matter most to
patients; the right number (3 to 5) and the focus
of metrics used to track outcomes; the challenge
of scale and moving beyond pilots to networks of
innovators and from value to volume; and changes
in reimbursement models to build condition
bundles, embrace a portfolio of payment models
and put more authority into the hands of the patient.17
21
RethinkingValue-BasedHealthcareScalingThroughPractice
Scaling VBHC also needs industry to understand
these challenges and to recognise payer, provider
and patient motivations so that these can be
converted into sustainable business models that
truly capture and reward value. Better training and
education for all stakeholders will play an important
role here, as will deeper wider collaboration. Both
will help build a clearer strategy and action plan that
will establish Value Based Healthcare more widely;
overcome innovation barriers and more quickly
identify growth areas and those which need
further investment.
Next Steps
In order build consensus, Rethink Value has
committed to convening a series of value focused
dialogues throughout the year. The aim is to
create an environment that builds trust across the
ecosystem, encourages innovation, helps unleash
productivity in the healthcare system and supports
mutual understanding of commercial aspects for the
healthcare industry. We would welcome all those
who are interested in this new and exciting initiative
to join us.
22
RethinkingValue-BasedHealthcareScalingThroughPractice
Future Agenda is an open source think tank and
advisory firm. It runs the world’s leading Open
Foresight programme, helping organisations to
identify emerging opportunities, and make more
informed decisions. Future Agenda also supports
leading organisations on strategy, growth and
innovation.
www.futureagenda.org
https://www.futureofpatientdata.org
https://www.linkedin.com/company/future-agenda/
@futureagenda
Rethink Value
Rethink Value is a new think tank which is all about
Value-Based Healthcare – the initiative is Danish, but
Rethink Value is born global. The ambition of Rethink
Value is to inspire thinkers who practise and apply
Value-Based Healthcare. A think tank that inspires
stakeholders throughout the value-chain of health
and care to push the evolution of true and capturable
patient value in the healthcare systems of the future.
A think tank serving as a differentiator, catalyst and
advocate of tangible strategic partnerships between
healthcare payers, providers and industry. A think
tank with the overall purpose of improving patient
value by offering international perspective and best
practice in order to inspire healthcare decisionmakers
and industry on sustainable and transparent
transaction models. Rethink Value is for people who
believe in doing, sharing and caring for sustainable
and valuable future healthcare.
www.rethinkvalue.org
https://www.linkedin.com/company/rethink-value/
Future Agenda
Lars Dahl Allerup
lars@milesahead.dk
Sam Kondo Steffensen
sakost@dtu.dk
23
RethinkingValue-BasedHealthcareScalingThroughPractice
References
1 	
https://hbr.org/2015/10/how-the-u-s-can-reduce-waste-in-health-care-spending-by-1-trillion
2 	
https://jamanetwork.com/journals/jama/article-abstract/2752664
3 	
https://www.isc.hbs.edu/health-care/value-based-health-care/Pages/publications.aspx
4 	
https://doi.org/10.1056%2FNEJMp1011024
5 	
https://www.cebm.net/2019/04/defining-value-based-healthcare-in-the-nhs/
6 	
https://www.philips.com.sg/a-w/about/news/archive/future-health-index/articles/20190304-four-steps-towards-a-value-	
	based-care-model-for-singapore.html
7 	
https://www.cebm.net/2019/04/defining-value-based-healthcare-in-the-nhs/
8 	
https://ec.europa.eu/health/expert_panel/sites/expertpanel/files/docsdir/024_defining-value-vbhc_en.pdf
9 	
http://jameslindinstitute.org
10	
https://www.bcg.com/en-gb/publications/2019/paying-value-health-care.aspx
11
	https://www.amgen.com/media/news-releases/2018/10/amgen-makes-repatha-evolocumab-available-in-the-us-at-a-	
	60-percent-reduced-list-price/
12 	
https://www.cancerresearchuk.org/sites/default/files/obp_final_report_pdf.pdf
13 	
https://www.bcg.com/documents/file64538.pdf
14 	
https://eiuperspectives.economist.com/sites/default/files/value-basedhealthcareinswedenreachingthenextlevel.pdf
15 	
Webster, P. C., “Sweden’s health data goldmine”, CMAJ, 2014 Jun 10; 186(9): E310
16 	
https://diabeter.nl/media/cms_page_media/130/Value%20Based%20Healthcare%20Diabeter%20White%20Paper.pdf
17 	
https://dellmed.utexas.edu/units/value-institute-for-health-and-care
24
RethinkingValue-BasedHealthcareScalingThroughPractice
Contact details
Rethink Value
www.rethinkvalue.org
Lars Dahl Allerup
Lars@milesahead.dk
Sam Kondo Steffensen
sakost@dtu.dk
Future Agenda
www.futureagenda.org
Tim Jones
tim.jones@futureagenda.org
Caroline Dewing
caroline.dewing@futureagenda.org
Value based healthcare 2020
Value based healthcare 2020

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Value based healthcare 2020

  • 2. Text © Future Agenda 2020 Images © istockimages.com Graphs © As referenced First published February 2020 by: Future Agenda Limited 84 Brook Street London W1K 5EH www.futureagenda.org
  • 3. 3 RethinkingValue-BasedHealthcareScalingThroughPractice Rethinking Value-Based Healthcare Scaling Through Practice Lars Dahl Allerup Sam Kondo Steffensen Tim Jones Caroline Dewing
  • 4. 4 RethinkingValue-BasedHealthcareScalingThroughPractice National healthcare providers have long had to battle with how to narrow the gap between need and demand on the one hand and available resources on the other. In some ways they are victims of their own success. The global population is growing, and people are living longer, largely because many are able to access better healthcare than ever before. However, at the same time, and in particular in Europe, SE Asia and the US, ageing populations have led to a shift from the treatment of acute illnesses towards having to manage chronic disease and deliver more complex treatment processes. This increased pressure has meant that many health and social care organisations constantly face a shortage in financial, personnel and material resources. This has come into sharp focus since the western financial collapse of 2007, as some countries have sought to scale back annual increases in funding in health services. Health systems charged with maintaining a balance between cost and quality, face a big problem. A number of different approaches have been explored including evidence-based decision making (to ensure that only interventions with strong evidence of cost effectiveness are used), quality improvement (to improve outcomes), and, of course, cost reduction. They have all delivered some success, but healthcare spend is still growing faster than inflation and, in many developed economies, higher costs have not necessarily correlated with an increase in life expectancy. Beyond this, the complexity within healthcare systems means that inefficiencies remain rife – so much so that some calculate that up to a third of current healthcare spend is wasted.1 ,2 Alternative healthcare models are being sought. One possible solution is Value- Based Healthcare (VBHC). This focuses on the outcomes that matter to patients as well as the costs of delivering them. Around the world healthcare providers are busy exploring how VBHC can both improve the efficiency and effectiveness of healthcare delivery and seed new opportunities for innovation. Context Input: Health expenditure per capita (PPP US$) Outcome: Health-adjusted life expectancy (years) Emerging economies Developed economies Health expenditure as % of GDP Ideal path Path to avoid Life Expectancy vs Spend
  • 5. 5 RethinkingValue-BasedHealthcareScalingThroughPractice Global organisations such as the OECD and WHO, G20 and World Economic Forum (WEF) are beginning to recognise the benefits of VBHC. Indeed, Rethink Value recently briefed the G20 on its potential to solve future healthcare issues around VBHC. To be clear, however, there are no easy answers. Indeed, many organisations are still struggling with the question of where to start, how to scale and how to make the value of healthcare more transparent. To review key lessons from the practice frontline, explore what obstacles and highlight which approaches may have greatest future impact, Rethink Value convened an expert conference at Danish Technical University in Copenhagen in late November 2019.Facilitated by Future Agenda, this event integrated views from philosophers, patient representatives, physicians, medical device manufacturers, pharma companies, payers and hospital managers with debate and discussion between participants drawn from across the healthcare system. This article is a summary of the pivotal insights that were shared and debated with some key quotes from the event highlighted in blue text. It explores some of the associated implications for healthcare systems worldwide.
  • 6. 6 RethinkingValue-BasedHealthcareScalingThroughPractice Rethink Value: Towards value-based transactions At Danish Technical University Agenda: Speakers and subject matter Pondering on the concept of value in a transactional perspective • Mickey Gjerris, Bioethicist, PhD Value in healthcare research - from the patient perspective • Henrik Vincentz, Founder of the James Lind Institute Value-Based Healthcare - from catchphrase to projects • Niels Lund, Vice President, Novo Nordisk New Patient Pathway for Renal Cancer - Roche Pharma and Herlev University Hospital The strategic Value-Based Healthcare perspective of a large MedTech company • Maarten Akkerman, VP Medical Affairs & Value-Based Healthcare EMEA, Medtronic Panel discussion about understanding and assessing patient value – the clinicians’ perspective on today’s agenda • Jens Hillingsø, Head of Department (Surgery and Transplantation), Rigshospitalet • Henrik Røgind, Head of Department (Rheumatology), Rigshospitalet. • Steen Mejdahl, Head of Department (Joint and Bone Surgery), Hospital of Herlev and Gentofte. Implementing the Strategy of Value-Based Health Care • Scott Wallace, Co- Founder and Managing Director, Value Institute for Health and Care, University of Texas at Austin
  • 8. 8 RethinkingValue-BasedHealthcareScalingThroughPractice In 2004 Elizabeth Teisberg and Michael Porter published an article, “Value-Based Healthcare” which set in motion the transition to a value-based delivery model.3 This proposed that “patient value is defined as patient-relevant outcomes, divided by the costs per patient across the full cycle of care in order to achieve these outcomes. Value-Based Healthcare focuses on maximising the value of care for patients and reducing the cost of healthcare.” They introduced a two-fold strategy: • First, health care should be reorganised into value- based care pathways around patient groups. These pathways should no longer be merely focused on increasing production, while shifting costs to other providers, but they should strive for the highest value for patients, i.e. the best possible outcomes for acceptable costs. • Second, these pathways should compete for the favour of patients and health care purchasers. Patients should – in turn – behave more as critical health care consumers, while purchasers ‘buy’ the best possible health care for the lowest possible costs.4 Most health systems agree that, in principle, Value-Based Healthcare could deliver access to better care that provides more benefit to patients but at a lower-cost to the system. However, in practice, as yet there is no single agreed definition of what it is or even of what value means (and for whom) in the health context. Different organisations have grappled with finding a definition that suits their needs. For example, in the UK, one perspective is that “Value-based healthcare is the equitable, sustainable and transparent use of the available resources to achieve better outcomes and experiences for every person.”5 In contrast, in Singapore, which is often rated as having one of the best healthcare systems in terms of efficiency and satisfaction, the view is that value-based care is a care delivery model where providers are paid based on patient health outcomes rather than the amount of healthcare services that they provide.6 When we talk about outcomes that deliver value there is a fundamental question of who decides the right outcomes. A treatment may not be worth it for the patient – as the way we run healthcare today not all patients understand the choices that they are making. We need to progressively focus on a pyramid of value encompassing societal value, patient value and clinical value. Moreover, the criteria will change. For instance, as patients age, physicians are often called upon to shift their priorities as end-of-life support can differ significantly from healthcare in earlier years. The challenge of gaining consensus around value and value-based healthcare is a priority. “The absence of an agreed definition of ‘value-based healthcare’ in the NHS, the lack of skills required to deliver value-based healthcare and a clear understanding of the barriers to effective development and implementation inhibits the health system in addressing problems such as overdiagnosis, too much medicine, poor allocation of resources and the introduction of inadequately evidenced technologies.”7 To help enable better understanding, in 2019, an EC expert panel proposed to define VBHC more clearly as a comprehensive concept built on four value-pillars: 1. Appropriate care to achieve patients’ personal goals (personal value), The Evolution of Value-Based Healthcare Apple 18,3% Amazon 15,0% Facebook 13,1% Organise into integrated practice units (IPUs) 1 Measure outcomes and costs for every patient 2 Expand excellent services across geography 5 Integrate care delivery across separate facilities 4 Move to bundled payments for care cycles 3 Build an enabling information technology platform6 The Six Components of VBHC
  • 9. 9 RethinkingValue-BasedHealthcareScalingThroughPractice 2. Achievement of best possible outcomes with available resources (technical value), 3. Equitable resource distribution across all patient groups (allocative value) and 4. Contribution of healthcare to social participation and connectedness (societal value).8 The WEF has also been working on an appropriate definition and suggests Value-Based Healthcare to be a holistic approach to delivering health results that matter to patients at a lower cost by; • Measuring health outcomes that truly matter to specified patient groups; • Comparing results achieved by different health systems; • Shifting payment away from volume (e.g. fee-for- service) to models that encourage prevention, integration of caregivers and high quality such as bundled payment or capitation; and • Reconfigure care delivery to improve coordination across the health system. What is agreed is that the principle of VBHC begins by measuring outcomes that matter to a particular patient. These are consolidated on a population segment level, and then the insights that are revealed are used to tailor and improve interventions all along the care pathway for those with similar conditions. It sounds simple but gathering valid and actionable health data is a challenge. There are remarkable differences in clinical practises even in the most advanced healthcare markets. Often when they do exist, health data are frequently uncoordinated, and stuck in legacy non-interoperable systems. Furthermore, the medical profession is by nature conservative and change averse, not to mention sometimes under-resourced and time-pressured, so the additional administrative burden of data collection may simply be too overwhelming for many clinicians. All of this explains why as yet very few have a rigorous approach to either measuring patient- centred outcomes or the cost of care. This is true even in countries such as Denmark and Sweden where the healthcare systems are underpinned by social democratic traditions; equal rights are explicitly protected in healthcare legislation; and measuring performance and benchmarking is very much part of the health tradition. The International Consortium of for Health Outcomes Measurement (ICOHM), and others are working to address this and to identify on what are the best measures for VBHC including definitions around value. In many countries there is not only a shift to ranking different hospitals, providers and health insurers but also compiling and sharing tables of how individual physicians perform. Some consider that this is going too far, others see that it is inevitable and far better to occur in a transparent, trusted manner rather than informally via social networks and some sort of medical trip advisor ratings. This suggests that there is some way to go before there is consensus on a shared universal definition. What is also clear is that in order for VBHC to be a success there needs to be a cultural adjustment in the public understanding of healthcare delivery and so consensus around what this should mean is a priority. VBHC requires a strong system of governance and orientation towards more relational and explorative contracts to support a new paradigm that shifts resources from (intrinsically assumed) low to (demonstrated) high value. It needs to steer public research; stimulate appropriate regulation to ensure there is appropriate accountability; support targeted actions by member states; and work with industry to deliver appropriate pricing models. Given its significance it is useful to look at how VBHC is being viewed through four pivotal lenses – patients, physicians, providers and payers.  
  • 10. 10 RethinkingValue-BasedHealthcareScalingThroughPractice Despite the lack of precise definitions, there was consensus in Copenhagen that VBHC is “all about being relevant to the patient.” The focus is on delivering a truly holistic form of care which goes beyond the traditional clinical environment and provides care and wellness services that extend into our daily lives, homes, and communities. It reminds us that, above all, patients are individual human beings with varying needs and, rather than consider health as a process commodity, the best way to achieve high-quality, cost-effective care is to consult with them - because most patients are best placed to determine what really matters with regard to their own health. Alongside this, better consumer engagement is key to obtaining a long-term view. Consumer data is becoming the foundation for predicting health risks and making social interventions into day to day life. Furthermore, regulatory pressures, highly competitive markets and advances in technology and healthcare delivery models increasingly support this approach. Value-based health goes beyond traditional clinical care in hospitals and doctors’ surgeries - it also entails prevention. While primary care has often been the first point of contact for patients, technology has now opened the door to more touchpoints beyond the physical facility. Online and app-based interaction are quite suitable for engaging patients in conversation around their health needs, conditions, values and preferences. Patients can now participate in multiple ways that facilitate communication, inform, monitor / deliver treatment at home and, importantly, build trust. As the spotlight turns away from quantity and onto value, different aspects of care gain more significance. Access to more health information gives patients the power to focus on the type of outcomes that matters to them. This typically includes pain-free diagnosis and treatment, fast recovery, a low chance of side effects and, ultimately, a better quality of life. It also enables patients to make informed decisions about the medications and care they want to receive and the doctors and care centres through which health services are delivered. Patients increasingly also expect diagnostic procedures and treatment paths to be personalised to incorporate their preferences, ideally in the comfort of their own home. Sensors, smartphone apps and data analytics allows more primary care to be delivered online. Even those who are suffering from chronic illnesses are able to accept treatments at home, reducing healthcare costs while at the same time increasing quality of life for patients. For patients the shifts towards wellness helps reduce the instance of unnecessary diagnostic and therapeutic treatments they might have to undergo. This can increase both the cost of care and risk of exposing patients to unnecessary risk. Patients also expect continued and reliable access to caregivers for advice and support while also wanting control over the availability of their personal health information to others. To move practice forward, in Singapore and elsewhere, VBHC analysis has been combined with design thinking to identify how and where healthcare support can best be provided in ways that better suit the patients’ life and needs as well as manages costs. The Patient View
  • 11. 11 RethinkingValue-BasedHealthcareScalingThroughPractice VBHC and Clinical Trials Looking ahead some also see that combining the thinking from VBHC with upcoming technologies for virtual clinical trials technologies could both reduce the time and cost of Phase 1 trials and improve the matching of patients for Phase 2 and 3. This could, it is argued, improve ratios of patients participating in new medicine development and accelerate the time to impact. Patients on early stage trials often become advocates of the new approaches. Organisations, such as the James Lind Institute, which works with patient communities on clinical trials, see that those who take part gain greater insight into the progress of their own disease but without significant inconvenience and minimal intervention; they also have the opportunity to become more informed about potential treatments through contact with expert medical staff which in turn may incentivise them to make improvements in their lifestyles. For terminal patients, or those with chronic conditions, this involvement can also affect their mental health, allowing them a sense of purpose and control.9 However, while an increased focus on the patient is important, some caution that, in terms of overall value, maximising satisfaction in the ‘customer experience’ should be balanced with the needs and interests of the other parties involved.
  • 12. 12 RethinkingValue-BasedHealthcareScalingThroughPractice Doctors are at the frontline of the healthcare value debate and face challenges from all sides. In many countries, most are nonetheless still paid according to the traditional fee-for-service model. The problem is not only that activity-based payment models lack incentives for improving healthcare value, sometimes doctors are also disincentivised to deliver care. For example, in 2019 research by the BCG suggested that privately insured surgical patients with one or more health complications provided a US hospital with a 330% higher profit margin (an additional $39,000 per patient, on average) than the margin from similarly insured patients who had no complications. This meant that there was little financial incentive for physicians to improve health care value by minimizing complications.10 Doctors are also challenged by having to deal with outdated regulation. Sometimes outdated national guidelines are holding back meaningful progress towards VBHC due to their generalized and retrospective character. One doctor said; “if I were a journalist my headline would be uproar against national guidelines”. Some are too stringent and have not kept pace with technological change. This means that doctors are obliged to make patients undergo unnecessary treatments and which they may not want or need simply to satisfy the regulators. Consider for example the number of blood tests required for terminal cancer patients. Often these are precautionary, however time is wasted discussing the result for both patient and doctor when the better provision of care may well be a conversation about how to improve quality of life. We heard a suggestion that “with a cancer patient we should spend less time discussing the results of a blood test and instead focus on how to improve their present and future quality of life.” Many agree that new technologies can help patients take more The Physician’s Perspective
  • 13. 13 RethinkingValue-BasedHealthcareScalingThroughPractice responsibility for their own health, cut waste in the system and better track the cost-effectiveness of personalised treatments over time. They also concur that improvements in health outcomes are greatest when clinicians themselves are responsible both for collecting and interpreting data and for leading efforts aimed at clinical improvement. However, as a group, healthcare professionals are naturally conservative, so some find it hard to adjust their consultancy practices to new methods of treatment. For example, although acknowledging video consultations are convenient, economic and can improve quality of life, one physician admitted that “sometimes it’s difficult for us to realise that a patient can take care of their own conditions.” Aligning a health system with a VBHC model represents a tremendous shift in culture for all stakeholders, doctors in particular. However, there is a general recognition that there is a need to transition away from what has become siloed and wasteful care delivery to a more patient-centric and especially productive healthcare. At the forefront of this is the desire to impact patient well- being, through supporting health education and encouraging healthier behaviours. Fundamental to this is the collection of good metrics. Identifying and improving access to relevant data allows healthcare providers of all kinds to better understand the most important aspects of the patient journey and then consider ways in which this could be improved. We heard that “we have a lot of data which is measured a lot - but we don’t measure the data that matters a lot.” It is certainly true that until recently the medical profession has measured its effectiveness largely by one metric: clinical outcomes. Process measures are often used in health care quality assessment, yet these, while often easy to measure, do not always correlate with clinical outcomes. Similarly, structural measures, patient experience, and other indicators are often substituted for outcomes. Going forward there will be increased emphasis on tracking and improving not just patient outcomes but the entire human experience of being a patient. Once metrics around value have been established there can be greater clarity on what appropriate targets should be and adjustments made. For example, although doctors might in principle support VBHC and agree that limiting the number of out-patient visits and instead using video consultation would both reduce system costs and benefit patients they may be unwilling to support change in that direction if their salary is based on the number of out-patients they actually see. It provides no advantage to them and, in their view, the lack of a real consultation may possibly increase risk for the patient. Although most doctors agree that standardised clinical guidelines and treatment plans are important, the challenge of building and maintaining a suitably flexible and accurate database is almost too much. However, in Denmark some questioned whether a one-size fits all strategy is practical. In addition, despite the appetite to use technology to improve patient care and reduce costs, the siloed nature of health records made some at our conference question the practicality of creating a national health database - not least because of the heavy administrative burden it places on already stretched physicians. Alongside being responsible for the communication with the patient and helping them through their course of treatment doctors are obliged to update medical records, code the activities and order treatments and tests directly in the system.  
  • 14. 14 RethinkingValue-BasedHealthcareScalingThroughPractice The Provider Point of View VBHC is dependent on all those involved in the delivery of healthcare collaborating around the common objective of putting the patient at the centre of all decision making. There are multiple options for how this can be achieved - for example by incorporating patient reported outcomes in clinical trials and real-world data studies to give a holistic view of the benefits of a particular medicine. This process is already well established in oncology, rare diseases and allergies, and is growing in the autoimmune and gastrointestinal areas. But equally there are any number of ways in which design and implementation of VBHC initiatives can be challenging -particularly when trust is at a low ebb. “Mistrust between pharma and government is at an all-time high. It’s difficult to have transformation systems on the basis of mistrust.” Participation in the VBHC model requires hospitals and other care facilities to create and follow comprehensive benchmarking plans. This, for instance, allows facility leaders to find weak points in financial, clinical, or quality performance and set measurable goals for improvement. However, it needs a range of organisations to collaborate. In spite of a growing pool of pilots and visible pockets of excellence, many are proceeding with caution, and it has not always been a positive experience; “some people join initiatives to make sure they don’t go anywhere.” Electronic health records companies have sometimes deliberately designed systems to prevent easy data-sharing, locking users into their services while several private healthcare providers have been known to hoard proprietary data because of its commercial value. Despite this, during our conference, we heard strong support for the VBHC approach. “The lack of progress is not for lack of engagement or willpower.” For the pharmaceutical industry adapting to VBHC essentially means a move from a “payment per pill to payment per outcome” model. This is a fundamental step change. Historically most innovation in pharma has taken place at the beginning of the value chain in drug discovery. In the future, several see that innovation will have to have to be far more holistic and occur across the value chain. Introducing true value-based metrics into R&D processes would help to do this, as would enhancing existing medicines in order to improve the patient experience. Decreasing the number of instances when a patient needs to take a certain medication, reducing its side effects and improving the way a drug is administered - such as moving from an injectable to an oral administration - are all ways to improve outcomes, increase adherence and reduce unnecessary spend. Further research
  • 15. 15 RethinkingValue-BasedHealthcareScalingThroughPractice around personalisation may also enhance patient segmentation and increase the odds of positive health outcomes. Roche is one company already making big bets in this area - around half of its late-stage pipeline have companion diagnostics to determine whether specific patients are genetically disposed to respond to therapies. More pharmaceutical firms are now also supporting patients with better health education about the treatment and the ongoing management of their conditions. As health systems increasingly focus on a comprehensive range of factors that affect health outcomes – drugs, technology, health information, care management and delivery, there is a huge co-ordination role to play. Also, the information associated with the development, use and impact of medication is fast becoming a very valuable asset so the organizations that can capitalise on this and use it to deliver new insights and value adding services are likely to reap rewards. This is a new opportunity for some of the established providers. However, it is also possible that several of the growing number of new players - health information companies, IT vendors and tech firms - will step up to the mark.
  • 16. 16 RethinkingValue-BasedHealthcareScalingThroughPractice One of the main challenges for healthcare providers and managers is how to maintain the delicate balance between costs and quality. Around the world, many collaborative efforts are underway to explore how VBHC can have greater impact on this by shifting the business model to become more patient-centric: “we need to buy solutions not services and devices”. As procurement in healthcare moves away from traditional lowest-price strategies towards quality, service and solutions, the possibility for stakeholders to align views increases. In addition, value-based purchasing links specific objectives to reimbursement incentives and can consequently reduce the incidence of medical errors by rewarding the best performing care provider organisations. Key to success is to establish principles around the measurement of outcomes so that payers can be comfortable about what it is they have contracted, and providers can agree what it is they should deliver. Several at our conference agreed that “there is no silver bullet in healthcare, but survival alone is not a good metric.” However, the capture and reporting of data between systems processes and stakeholders is difficult to achieve, certainly without considerable administrative effort. It requires trust, collaboration and a full-ecosystem approach. Suppliers contribute analytics, providers are best placed to measure outcomes and payers are pivotal in identifying the outcomes that matter most. The WEF is working hard to bring relevant stakeholders together to establish global metrics but it is a long journey. “There needs to be more organisational backbone about this.” In the meantime, a number of specific pilots are now generating good results. For example, in the Netherlands there is an initiative around end- stage renal cancer and another in Atlanta around the measurement of diabetes outcomes which has brought together 30 local partners across government, health systems, pharma and suppliers. The Payer Perspective
  • 17. 17 RethinkingValue-BasedHealthcareScalingThroughPractice Elsewhere different payment approaches being trialled. These are, for example, commercial arrangements where a medicine’s price is linked to the outcomes achieved for patients receiving the medicine in real-world clinical practice. Medicines that perform as expected and deliver pre-agreed outcomes are reimbursed at the pre- agreed price, while medicines that do not deliver the outcomes are reimbursed at a lower price or not at all. An early adopter of this in the US was Amgen for its cholesterol drug Repatha, where many patients were treated for six months before full reimbursement was made available: It was initially provided with a 60% discount.11 Risk-sharing schemes are also gaining popularity, even in the private sector. As outcomes are also dependent on patient behaviour, patient compliance and adherence are often taken into account here. In the UK, different types of cost sharing agreements around cancer care are being explored. These include treatments that are initially discounted until it is clear whether a patient is responding to a medicine; payment by results - where payers are reimbursed by manufacturers if a patient does not respond to treatment; and pay for performance - where refunds and rebates are provided if a medicine fails to meet pre-agreed outcome targets for individual patients.12 From a cost-saving perspective, it is apparent that the motivation has to be right – it cannot be just about spending less and reducing healthcare budgets without an upside. In Finland, for example, when a company within the public system delivers improvements, they keep 40% of the savings but the other 60% are put back into the healthcare system for others to use and benefit from. Equally, some ask “should the indirect cost-savings for the patient, their employers or insurers from, for instance, remote consultation rather than face-to- face be considered? Can a share of these savings be handed back to the hospital?” As with other industries, such as the automotive sector, more holistic models of cost and value are also emerging covering the ‘total cost of care’. Several therefore expect that Medtech players will increasingly need to deliver ‘beyond the product’ solutions that integrate education, service, consultation, and finance with the products themselves to deliver greater value for payers. Support for this approach is in part due to a response for stricter quality and safety requirements but for providers it also reduces compatibility risks as devices and their related services can be sourced from the same supplier which then become responsible for follow-up and compliance. On occasion payers (and care providers) can be distracted from considering what could be the best way to treat a patient because of the pressure to focus on the management of costs. “There is such a rush to the bottom all the time.” Initiatives such as the MedTech Europe Code of Ethical Business Practice (2017) lays out guidelines on cost transparency aims to address this. At the same time, low-cost players are challenging traditional pricing approaches; together with an increasing uptake of online tools and social media, this is leading to procurers becoming more price conscious.
  • 18. 18 RethinkingValue-BasedHealthcareScalingThroughPractice Exemplar Approaches Historically two Europeans in particular have been seen as leading examples of VBHC progress: Sweden and the Netherlands. However within recent years individual regional healthcare systems such as Catalonia, Wales and the Capital Region of Denmark have also come on board; particularly when using public procurement as leverage. Many believe that it is this which is the key to ensuring VBHC at scale. Sweden One country that has achieved higher quality healthcare than its EU peers but without greater spend in recent years is Sweden. This is in part due to its ability to provide access to high-quality data. Sweden’s pioneering quality health registries and digital health records provide significant opportunities to compile and share real-world evidence about health outcomes. Accurate and comprehensive health data are major elements of VBHC in that they enable policymakers to measure the impact of treatment, evaluate where both care and processes can be improved, and ultimately provide the information that can underpin value-based pricing. Sweden has benefited immensely from its long history of quality registers for a variety of diseases, including hip arthroplasty and cardiac care.13 Indeed it has been tracking treatments and outcomes since the early 1800s when maternity nurses were required to report key metrics on delivery outcomes to the local doctor. Today, the national quality registries give a unique possibility to achieve the goal of equal care and treatment and has meant that value-based pricing for pharmaceuticals and medical devices has been in operation since 2002 in some regions of Sweden. One early success has been in the treatment of acute lymphoblastic leukaemia. Another was OthroChoice, a bundled payment system for knee and hip replacement surgery that was then extended to spinal surgery.14 With its disease registries, electronic records and plenty of real-world data, Sweden has been labelled a “data gold mine” for healthcare;15 the potential for further development of the use of predictive analytics, machine learning and applications for artificial intelligence is enormous. However, despite this early success, the Swedish healthcare system still faces challenges around the definition of VBHC and how to ensure integrated care delivery becomes a key part of providing value. Insights from Sweden have included: • Getting buy-in from health providers is vital; • Good data are key to effective value-based pricing; and • VBHC is not always “one size fits all”.
  • 19. 19 RethinkingValue-BasedHealthcareScalingThroughPractice The Netherlands Another success story is found in The Netherlands with the Diabeter clinic collaboration. These are certified centres dedicated to providing comprehensive and individualised care for children and adults with type 1 diabetes. Established back in 2006 as a partnership with Medtronic and a core adopter of VBHC this has become the best performing diabetes clinic in the Netherlands for children under 18.16 Core to success has been taking the long view with 10-year collaborative contracts between insurance companies and the clinic to manage treatment. With a fundamentally different, low stress user experience, higher patient to nurse ratios and bundled payments, this has become a benchmark with 62% less hospitalisation rates than the country average. Superior outcomes have led to less direct annual costs to type 1 diabetes patients with the savings are mainly driven by a lower patient hospitalization rate than that of other Dutch paediatric diabetes clinics. Initially the overall hospital admission rate was between 20 – 30%. Now most clinics can get to around 10 per cent while some have rates of between 1 – 3% giving benefits to patients and reducing costs. In order to overcome the high levels of variability in data found in many other countries, Diabeter’s system has adopted dashboards that track results for each patient and makes it possible to compare outcomes between clinics, doctors and therapies, driving improvements across the network of clinics. A key achievement here has been part of challenging the payment structures which may well, for example, increase the costs to the company but reduce the length of stay. Diabeter gets paid today for savings for what may be an issue tomorrow. There has been a shift from the fee for a service approach where income for provider is based on technology, with a promise to change outcomes, supported by credible clinical evidence, to a fee for value where income is driven based on delivering improved outcomes, as a result of technology innovation. Key lessons from the Netherlands success includes: • Outcomes must be clear and measurable to structure business models; • Cohorts must be specific so actions can be easily traced to outcomes; and that • Granularity in modelling the healthcare process is essential to operationalize VBHC
  • 20. 20 RethinkingValue-BasedHealthcareScalingThroughPractice Transitioning to Value-Based Health From discussions during our conference and as evidenced by the large number of pilots undertaken to date, it is clear that VBHC has significant potential to transform both healthcare systems and industry and has already delivered strong results in specific fields such as transplants, cardiothoracic surgery and joint surgery. However, to do this at scale is far from simple. In Denmark both the government and regional healthcare authorities are pushing for an ambitious VBHC evolution. Mentioning a few inspirational examples among initiatives in 2019 would include: • The Capital Region of Denmark published a new governance model to scale VBHC for all hospitals in the group (serving 1.8M inhabitants). • A new public-private partnership under the Danish Ministry of Industry, Business & Financial Affairs was established to propose a set of practical tools and recommendations in order to scale innovation and Value-Based Procurement. Members of the partnership include the healthcare regions, the municipalities, the ministry itself, the largest industry organisations and the ministry of health covering multiple stakeholderz in the healthcare system. • Danish Regions, the interest organisation for the five healthcare regions in Denmark, established a new council aiming to improve practical skills, tools and best practice for public procurers within the healthcare regions. Representatives from the largest industry organisations are also present on the board.         Much of the current Danish development is based upon the last three years of practical experience from work in the Capital Region of Denmark. Already back in 2017 the region founded a new organisation within the group’s department of corporate procurement. Procurement Development & Strategic Partnerships, is dedicated to scaling Value-Based Procurement through new outcome-based payment models, public-private innovation and business development of the procurement categories. The concept of using Value-Based Procurement to leverage Value-Based Healthcare might inspire other healthcare systems to scale VBHC. Although there is appetite for change, a number of hurdles must be overcome, not least around the need to develop a common language to describe the value chain. Furthermore, we simply won’t get Value-Based Healthcare until we agree what “value” really means. Clarification of this fundamental issue is vital to allow the multiple stakeholders - business, healthcare providers, academics and patient advocacy groups - to accurately describe and find solutions for the major challenges. First identified by research in Texas these include; the structure of care and the supporting business models that develop solutions (not services) focused on the outcomes that matter most to patients; the right number (3 to 5) and the focus of metrics used to track outcomes; the challenge of scale and moving beyond pilots to networks of innovators and from value to volume; and changes in reimbursement models to build condition bundles, embrace a portfolio of payment models and put more authority into the hands of the patient.17
  • 21. 21 RethinkingValue-BasedHealthcareScalingThroughPractice Scaling VBHC also needs industry to understand these challenges and to recognise payer, provider and patient motivations so that these can be converted into sustainable business models that truly capture and reward value. Better training and education for all stakeholders will play an important role here, as will deeper wider collaboration. Both will help build a clearer strategy and action plan that will establish Value Based Healthcare more widely; overcome innovation barriers and more quickly identify growth areas and those which need further investment. Next Steps In order build consensus, Rethink Value has committed to convening a series of value focused dialogues throughout the year. The aim is to create an environment that builds trust across the ecosystem, encourages innovation, helps unleash productivity in the healthcare system and supports mutual understanding of commercial aspects for the healthcare industry. We would welcome all those who are interested in this new and exciting initiative to join us.
  • 22. 22 RethinkingValue-BasedHealthcareScalingThroughPractice Future Agenda is an open source think tank and advisory firm. It runs the world’s leading Open Foresight programme, helping organisations to identify emerging opportunities, and make more informed decisions. Future Agenda also supports leading organisations on strategy, growth and innovation. www.futureagenda.org https://www.futureofpatientdata.org https://www.linkedin.com/company/future-agenda/ @futureagenda Rethink Value Rethink Value is a new think tank which is all about Value-Based Healthcare – the initiative is Danish, but Rethink Value is born global. The ambition of Rethink Value is to inspire thinkers who practise and apply Value-Based Healthcare. A think tank that inspires stakeholders throughout the value-chain of health and care to push the evolution of true and capturable patient value in the healthcare systems of the future. A think tank serving as a differentiator, catalyst and advocate of tangible strategic partnerships between healthcare payers, providers and industry. A think tank with the overall purpose of improving patient value by offering international perspective and best practice in order to inspire healthcare decisionmakers and industry on sustainable and transparent transaction models. Rethink Value is for people who believe in doing, sharing and caring for sustainable and valuable future healthcare. www.rethinkvalue.org https://www.linkedin.com/company/rethink-value/ Future Agenda Lars Dahl Allerup lars@milesahead.dk Sam Kondo Steffensen sakost@dtu.dk
  • 23. 23 RethinkingValue-BasedHealthcareScalingThroughPractice References 1 https://hbr.org/2015/10/how-the-u-s-can-reduce-waste-in-health-care-spending-by-1-trillion 2 https://jamanetwork.com/journals/jama/article-abstract/2752664 3 https://www.isc.hbs.edu/health-care/value-based-health-care/Pages/publications.aspx 4 https://doi.org/10.1056%2FNEJMp1011024 5 https://www.cebm.net/2019/04/defining-value-based-healthcare-in-the-nhs/ 6 https://www.philips.com.sg/a-w/about/news/archive/future-health-index/articles/20190304-four-steps-towards-a-value- based-care-model-for-singapore.html 7 https://www.cebm.net/2019/04/defining-value-based-healthcare-in-the-nhs/ 8 https://ec.europa.eu/health/expert_panel/sites/expertpanel/files/docsdir/024_defining-value-vbhc_en.pdf 9 http://jameslindinstitute.org 10 https://www.bcg.com/en-gb/publications/2019/paying-value-health-care.aspx 11 https://www.amgen.com/media/news-releases/2018/10/amgen-makes-repatha-evolocumab-available-in-the-us-at-a- 60-percent-reduced-list-price/ 12 https://www.cancerresearchuk.org/sites/default/files/obp_final_report_pdf.pdf 13 https://www.bcg.com/documents/file64538.pdf 14 https://eiuperspectives.economist.com/sites/default/files/value-basedhealthcareinswedenreachingthenextlevel.pdf 15 Webster, P. C., “Sweden’s health data goldmine”, CMAJ, 2014 Jun 10; 186(9): E310 16 https://diabeter.nl/media/cms_page_media/130/Value%20Based%20Healthcare%20Diabeter%20White%20Paper.pdf 17 https://dellmed.utexas.edu/units/value-institute-for-health-and-care
  • 24. 24 RethinkingValue-BasedHealthcareScalingThroughPractice Contact details Rethink Value www.rethinkvalue.org Lars Dahl Allerup Lars@milesahead.dk Sam Kondo Steffensen sakost@dtu.dk Future Agenda www.futureagenda.org Tim Jones tim.jones@futureagenda.org Caroline Dewing caroline.dewing@futureagenda.org