Bending the Cost Curve Global Best Practices Berlin, Germany

Bending the
Cost Curve
Global Best Practices
22 – 23 January, 2013
Proceedings Report
Berlin, Germany
The views and opinions expressed in this document
are those of the roundtable participants and not
necessarily of the speakers. All comments were made
off-the-record.
Introduction
Healthcare expenditure is not immune to the new era
of austerity, with global levels set to grow by just 4% per
capita in 2013 – half the average in the decade up to
2007. The European Union has been particularly hard hit,
with health spending per capita actually falling in 2010
for the first time since 19751.
As governments around the world seek to bend the cost
curve, our past symposia have examined the changing
relationship between the public and private sectors, with
private providers constructing, maintaining and in some
cases operating clinics and hospitals. However, in the face
of budget cuts and rising demand, many nations may also
need to re-think their system-wide funding models, and
the traditional balance between social and private insurance.
Such ideas challenge the notion of the respective roles of
private and public sectors, and may prove to be controversial
in societies where the state has traditionally been seen
as the main provider.
1
Health at Glance: Europe 2012 (based on OECD Health Data 2012; Eurostat Statistics Database;
WHO Global Health Expenditure Database).
2
Bending the cost curve
Governments cannot afford to shy away from this debate;
and neither can they resist the new health ‘consumerism’,
where access to data and changing perceptions about value
are giving patients more control and influence over their
care. People are demanding a greater say in the delivery of
healthcare, so those running the systems need to find formal
and informal ways to engage and involve their citizens, or,
to put it more correctly, their customers.
The same technologies that are driving these changes
are also opening up opportunities for providers to enhance
care quality, by sharing and analysing patient data and
trends, and benchmarking performance. Sometimes the
solution can be staggeringly simple; asking patients about
their perceptions of the care they receive can lead to
important breakthroughs in delivery, as providers identify
correlations between different inputs.
This approach highlights the power of asking the right
questions, but in some cases there is no need for a question
at all. Simply publishing data – or ‘setting it free’ – can
encourage clinicians to compete for higher rankings and
stimulate new ideas.
Of course, none of this can be achieved without leadership
and vision, to reimagine entire health systems and challenge
traditional thinking on the roles of institutions. Health
ecosystems can involve a wider range of facilities, from schools
to gyms, through to preventative public healthcare such
as nutrition, water fluoridisation, fitness and anti-smoking.
These are just some of the innovations that are expanding
the horizons for healthcare and helping to bend the cost curve
in a sustainable way.
3
The story so far
In 2011, PwC launched Bending the Cost Curve:
Global Best Practices, a series of international
symposia designed to give healthcare leaders
a forum to exchange ideas, and find transferable
solutions in an industry that is under enormous
pressure to change.
•November 2011 in Singapore – keynote
address by Gan Kim Yong, Minister for
Health, Singapore.
•March 2012 in Stellenbosch, South Africa –
keynote by Sir Richard Feachem, Professor
of Global Health, University of California
San Francisco and University of California
Berkeley; Director, UCSF Global Health
Group California, United States.
Each Bending the Cost Curve event brings together
around 30 leaders from both the public and private
sectors, ranging from government ministers to CEOs
of major healthcare organisations. Five roundtable
discussions have been held to date – in Washington, •January 2013, Berlin, Germany – keynote
speech by Daniel Bahr, Minister of Health,
DC, Amsterdam, Singapore, South Africa and Berlin –
Federal Republic of Germany.
featuring innovative projects from around the world.
They are off-the-record, private symposia where
Over the course of the five events the attendees
we debate and discuss five case studies that prove it
have enjoyed compelling discussions on a broad
is possible to deliver quality healthcare in a more
and challenging series of case studies from
cost-effective manner.
Lesotho, Singapore, the United States, Hong Kong,
Spain, India, Australia, the Netherlands, Abu
In addition to a distinguished community of leaders
Dhabi, Kenya, Canada and the UK.
that participate in the roundtable discussions,
prominent keynote speakers helped set the stage
Across the first four symposia a number
at the opening of each meeting, including the
of important themes emerged from the case
following:
studies and subsequent discussions:
•February 2011 in Washington, DC – keynote
Leadership and culture
speech by the Kathleen Sebelius, Secretary
to embrace change as the ‘new normal’
of the US Department of Health and Human
in healthcare will require agile and decisive
Services.
leadership.
•June 2011 in Amsterdam, Netherlands – keynote
Integrated care
speech by Alan Milburn, former Secretary
integrated care should align incentives between
of State for Health with the British Labour Party.
payers and providers to encourage efficient,
outcome-based healthcare.
4
Bending the cost curve
Public-private partnerships (PPPs)
to have a radical impact on access and quality,
PPPs should now move ‘beyond the build’
to include clinical service delivery.
Process improvement in hospitals
hospitals can adapt classical industry-based
techniques to a clinical environment.
Geriatric care innovations
traditionally high-cost delivery centres can radically
improve their care and business models and reduce
costs for geriatric populations.
Data analytics and measurement
healthcare lags behind other sectors in going
digital. It should encourage standardisation,
portability and privacy.
‘Care anywhere’ – the enabling power
of technology
low cost, ubiquitous mobile technology is
changing healthcare business models to bring
high-value, low-cost chronic care to even
the poorest of populations.
recision medicine
P
although empiric, population-based studies will
remain important, the ability to measure and
predict on an individual level will help the sector
‘industrialise’, reducing waste and raising quality.
Clusters – creating sustainable
health economies
by promoting innovation and creating thousands
of new jobs, bioclusters show how healthcare
is not just a cost but a vehicle for generating value
and wealth.
This report describes the case studies and
discussions held at the fifth symposium in Berlin,
22 – 23 January, which generated further themes
that will be of vital importance in health systems’
efforts to bend the cost curve. The case studies
described in the following pages were chosen as
leading practices with the potential for application
in other markets and geographies. Each summary
gives some useful background, details about
the case itself and issues that arose during the
roundtable debate.
5
Session 1
A symbiotic relationship between
public and private sectors
Case study
Hong Kong’s Health Protection Scheme
Case introduction
The Right Honourable Alan Milburn, former UK
Secretary of State for Health (1999 – 2003);
current Chair, Social Mobility and Child Poverty
Commission, UK Parliament
Speaker
Dr. York Chow, former Secretary for Health,
Welfare and Food, Hong Kong
Background
Like many markets, Hong Kong has been
considering the balance between public and
private health provision, as it seeks to fund
healthcare and create additional capacity.
The respective roles of the public and private
healthcare sectors have undergone considerable
change in the past two decades, with an increasing
number of partnerships of different levels, from
‘design-build-maintain’ agreements through to more
sophisticated, integrated models where private
providers have full operational responsibility for
clinical outcomes.
Pressures on public finances, combined with
overwhelming demographic change, have
caused this relationship to constantly evolve
as governments seek to bend the healthcare
cost curve. Citizens’ perceptions of these changes
differ markedly; in countries with a history of
public health provision, private sector involvement
is viewed with scepticism and often opposed
strongly. One big concern over the rise in private
health is the potential of shrinking the public
safety net, and a shift to more restrictive terms
of private insurance.
Conversely, where there is more of a tradition
of private health, taxpayers may resent any
expansion of state healthcare, fearing they are
handing control to the bureaucracies of government.
6
Bending the cost curve
Compared to many European countries, Hong Kong
has an efficient, low-cost healthcare system. It
spends considerably less on health (as a proportion
of GDP) than most other OECD countries, yet life
expectancy of citizens is among the longest in the
world.2 3 However, like other nations, Hong Kong’s
healthcare system is coming under huge strain from
demographic change, with public health expenditure
set to more than triple to HK$127 billion by 2025.4
Expenditure on healthcare is split roughly 50-50
between private and public, with a clear division
of responsibility: the public sector provides the vast
majority of inpatient care, while almost threequarters of outpatient care is paid for privately via
insurance or out-of-pocket expenses.
Hong Kong’s state health sector also suffers from
a shortage of doctors. Public hospitals account for
70% of the nursing staff, but only 35% of Hong
Kong’s doctors. The 65% of physicians in private
practice, therefore, represent a relatively strong
constituency when it comes to health reform and
benefit by the shortage of physicians. The region’s
government has chosen to put the matter of reform
to its people by way of a public consultation.
Case study
By proposing a new regulated voluntary health
insurance scheme and building more private
hospitals, the Hong Kong government aims to
ease the burden on its public health system,
by shifting more patients to private providers.
This radical new scheme hopes to alleviate fears
by heavily regulating private provision, offering
a number of assurances including guaranteed
renewal, coverage for pre-existing conditions,
portability of policies, up-front certainty of
protection and charges and, last but not least,
a reliable procedure for making claims.
Coverage extends to high-risk people, with potential
government subsidies and tax exemptions to make
policies more affordable. Benefits such as no-claims
discounts have been factored in, to maximise
participation, while doctors and private hospitals
have also been offered various incentives to
participate in the electronic record system. A new
authority has been established to negotiate with
providers and insurance companies, to agree on
suitable premiums. A draft ‘charter’ also sets out
a number of important goals such as professional
standards, accreditation, codes of conduct and
monitoring, and guarantees of care for the poor
and needy.
Some commentators have criticised the new
proposals, claiming they will erode the public health
sector, raise insurance costs and increase the
number of disputes over claims. Insurance companies
are not completely convinced either, as they are
understandably nervous about the heavy regulation
that forces them to take on policyholders with
pre-existing conditions at no extra charge.
Hong Kong’s Domestic Health Accounts,
1989/90 – 2008/09.
3
Hong Kong Census and Statistics Department, 2011.
4
Your Health Your Life; Hong Kong People Among the
Healthiest in the World, Fact sheet on Healthcare
Reform, Food and Health Bureau, Hong Kong Special
Administrative Region Government, March 2008.
2
Since 2008 the Hong Kong government’s regular
consultations on healthcare reform have indicated
a strong opposition to any mandatory social
tax, with people preferring the option of voluntary
private health insurance. The government has
responded to these findings by proposing a voluntary
Health Protection Scheme (HPS), due for launch
in 2015, aimed at giving patients greater choice and
generating more competition among private health
insurers and providers.
7
Figure 1
Hong Kong’s health protection scheme
Health protection scheme
Sustainable and reliable protection
Health insurance
Private healthcare
Public healthcare
Accessible to all
Increase capacity
Safety net for all
Guaranteed renewal
Quality insurance
Queue relief
Fully portable
Healthy competition
Needy groups
Transparent medium
Transparent pricing
Acute & emergency care
Consumer protection
Consumer confidence
Catastrophic care
Healthcare system
More choices, better protection and more sustainable development
However, the Hong Kong government is confident
that this new scheme will complement rather than
replace the public system, and more importantly
will increase the total capacity of both the public and
the private sectors. A large scale insurance scheme
reduces the risks for private hospitals and clinics, as
they have greater assurance of customers, making
them less susceptible to economic downturns (in past
recessions, some had to close down). And those
already paying for private health will benefit from
regulated prices for doctors.
Four pieces of land have been set aside to develop
private hospitals, and preparatory works for
the new scheme are expected to be rolled out in
the 2013, followed by legislation ahead of
full implementation.
8
Bending the cost curve
Discussion: how to implement this model
on a wider basis
Set a vision for the future structure of the
health system
By laying out a blueprint clarifying the roles of
private and public providers, governments can
address issues such as capacity – and alleviate fears
over a deterioration of public healthcare. These
roles will vary according to pre-existing health
system structure; Hong Kong has chosen to make
the public healthcare system as the bedrock for
the poor and the needy, as well as the main provider
of high-risk services such as intensive care, which
is not well suited to private provision due to its
excessive costs. Expansion of private sector capacity
should be another goal, to relieve the pressure on
the existing public services. Ultimately, rather than
an end in itself, the public/private debate must be
part of wider plans for reform, which should include
advances such as integrated care, e-health improved
operational efficiency and innovative approaches
to long term care. A participant summed this up
when commenting: “Health insurance is not a silver
bullet but part of an arsenal of change to grow the
overall capacity of the system.”
Establish a contract with the private sector
Collaboration presents an ideal opportunity to
achieve greater consistency of care. The expectation
of private providers must be laid out clearly, with
strong regulation and monitoring, accountability,
an agreed approach to premiums and pre-existing
conditions, and vehicles for arbitration and disputes
over claims. Common standards should apply to
all providers, regardless of which sector they come
from. Service levels must be agreed and enforced,
with results published and poor performance
punished. Equally, private healthcare operators
need sufficient opportunities to thrive, and
should be given some leeway to offer services such
as private wards. Ultimately the scenario should
be win-win, according to one attendee: “The
private insurers are willing to comply as they know
that such a scheme gives a huge opportunity to
increase their market penetration in both direct or
employer-funded schemes.”
Carry the people with you
Healthcare is an incredibly emotive topic that can
produce huge personal and political divisions
in society. Several participants noted that a similar
proposal in a European context would be politically
toxic: “public-private collaboration is being used
by the opposition political party basically as a whip
to give bad publicity … we really haven’t found
a political consensus within all parties to go into this
big challenge”. The answer for Hong Kong was
public consensus “as a critical factor”, ensuring the
private sector would be monitored, and not
positioning privatisation in opposition to the public
sector, but as a complement. By engaging with
its citizens, the Hong Kong government has arrived
at a consensus and shown it is really listening
and acting upon the views of the people. Similar
conversations need to take place around the
world, with formal accountability for making
things happen.
Retain a strong focus on prevention
Private insurance need not be limited to treatment
and should also offer a range of preventive
services that will ultimately save money for the
overall system and reduce costs for private
providers. Regular health checks and support for
healthier lifestyles, anti-smoking and obesity
benefit society as a whole and cut the costs of care.
Maintain a public service ethos
One concern about an expansion of private provision
is that values will erode, as clinicians and nurses
leave the state sector in search of higher salaries,
with an emphasis upon money over public duty.
One way to challenge this trend is to ensure that all
health professionals spend some time in public
hospitals, as a participant commented: “In this
environment you develop a set of moral, ethical and
professional standards and build a sense of duty
to all patients, rich or poor. These are values that
they can carry with them if they go into private
practice, and help ensure that making money is not
their primary aim.”
9
Session 2
Sustainable system-wide reform
on an unprecedented scale
Case Study
The New York State Department of Health, US
Case Introduction
Dr. Nirav Shah, New York State Commissioner
of Health
Speaker
Dr. David Levy, Global Leader, Health Industries, PwC
Background
In the face of demographic change and budget
restrictions, the current growth rate of public
health expenditure is unsustainable. New York
State is seeking to address the challenge
through radical reforms.
In most developed countries, healthcare represents
a huge proportion of the public purse, with regional
and national budgets amounting to tens of billions
of dollars. Many attempts to trim health spending
around the world concentrate on immediate savings
but there is often a lack of a broader vision.
New York’s Medicaid program – which assists those
who are unable to afford healthcare and is funded
through state, county and federal taxes – serves
more than five million enrolees, costs over US$50
billion a year and experienced double digit growth
in 2009 and 2010. It accounts for around 40% of
the total state healthcare budget and in a majority
of the state’s counties, eats up more than half of
the entire tax revenue.
Despite an annual spend per enrolee of US$10,000
(almost twice the national average) New York State
only ranks 18th out of all states for health system
quality and a poor 50th in terms of avoidable hospital
use and costs.5 6 The New York State Department
of Health (DOH) not only administers the Medicaid
program but also regulates the hospitals and
other healthcare facilities, including laboratories
and public health programs.
10
Bending the cost curve
In a further example of collaboration and
consultation, in 2011 Governor Andrew Cuomo
brought together citizens, stakeholders and
experts from around the state to form a Medicaid
Redesign Team (MRT). Utilising meetings,
public forums, webinars and focus groups, the
team generated over 4,000 ideas that led to
78 comprehensive proposals. Stephen J. Acquario,
Executive Director, New York State Association
of Counties commented that: “The process used
to produce this report was extraordinary …
engaging health care experts and the public.”7
Case study
Wide ranging reforms are set to save the New
York State Department of Health a staggering
US$34.3 billion over the next five years, at the
same time significantly raising standards of
healthcare and adding 150,000 new patients
to Medicaid.
In the most comprehensive reform programme
in state history, costs are being slashed across the
spectrum and the healthcare delivery system is
being completely restructured, to focus on evidencebased care. The state has pledged to end the feefor-service system, invest in primary care and
integrated care, and align spending growth to the
medical consumer price index at 4%.
A range of ‘quick wins’ have wiped hundreds of
millions of dollars off the Medicaid bill by focusing
on practical ways to improve value (rather than
volume), including an increased rate of generic drug
substitutions, and refusing to pay for growth
hormone injections given to youngsters with short
parents, putting a stop to elective caesarean
sections, and simply replacing unnecessary
ambulances rides by encouraging use of another
mode of transportation. In another move, the
Department decided to simply issue a letter
to several thousand Medicaid patients who often
called an ambulance to go to the hospital for
minor diagnoses. The letter, encouraging them
to take an alternate form of transportation,
saved US$5 million in the first year alone.
As part of a move to primary care, a million New
Yorkers are getting access to ‘patient-centred
medical homes’ that use the latest electronic health
records and communications to manage chronic
conditions outside of hospitals. And within three
years, almost the entire Medicaid population will
be taken out of the fee-for-service system and
enrolled in managed care, which will cut costs and
improve outcomes.
Hospital readmissions are another huge expense
and the reforms aim to prevent such incidences
by coordinating patients’ care when they leave
the hospital. The State also intends to invest
in public health and prevention and continue to
explore the potential of innovative new publicprivate partnerships.
As part of a drive to improve clinical performance,
the New York State Department of Health publishes
a range of results from its hospitals, including cardiac
surgery recovery rates and number of deaths from
sepsis. Anyone can access this information, and as
such transparency acts as a benchmark to encourage
clinicians and nurses to be more accountable. In the
case of cardiac surgery, the number of inappropriate
procedures has gone down by almost 50% in the
last six months, well below the national average, by
simply publishing the reports.
This ground-breaking partnership between the
state and its healthcare system is projected to save
the state and federal governments US$34.3 billion
over the next five years. Before these reforms were
planned, state and federal spending on the New
York Medicaid program was forecast to grow by over
US$4 billion in 2011 – 2012 alone. Over US$10 billion
of the federal savings will be reinvested in the
state’s healthcare system, with any future spending
growth remaining within sustainable levels.
New York State, Department of Health, New York
State Medicaid Redesign Team (MRT) Waiver
Amendment, Albany, 2012, p. 16.
6
Medicaid enrolment rises in New York; More than 5.1
million New Yorkers registered in program, Rochester
Democrat and Chronicle, 9 December, 2012.
7
“Governor Cuomo Accepts Recommendations from
the Medicaid Redesign Team”, Governor Andrew M.
Cuomo press release, 24 February, 2011,
www.governor.ny.gov/press/022411cuomoaccepts_
medicaidredesignteam.
5
11
Governor Andrew M. Cuomo said: “The reforms
put in place by the Medicaid Redesign Team have
already resulted in major savings for taxpayers
and better quality of care for New Yorkers. This will
allow New York State to fully implement the
ground-breaking MRT action plan to permanently
restructure our health care system and continue
to make New York a national model.”8
8
“Governor Cuomo Announces that New York Submits
Federal Waiver to Invest $10 Billion in Medicaid
Redesign Team Savings to Transform the State’s
Health Care System”, Governor Andrew M. Cuomo
press release, 6 August, 2012. www.governor.ny.gov/
press/08062012-federal-waiver-health-care
Discussion: how to implement this model
on a wider basis
Plan the transition to outcome-based care
If health systems are to move away from a fee-forservice model, they have to establish a common
way to measure and compare performance by
individuals and institutions. Some data – such as
the number of readmissions – is relatively simple
to acquire, while other information – such as deaths
from sepsis – is harder to define. Over time, all
practitioners, clinics and hospitals will have to agree
on a suitable measure for outcomes, report on their
performance, and be paid on results. The starting
point is to achieve regular publication of data,
possibly using rough proxies, and the approach will
evolve and become more sophisticated and accurate
over time. Payments can also be linked to patientreported outcomes.
Figure 2
Before 2009, New York State Medicaid costs rose unsustainably
Total Medicaid cost
(in billions US$)
50
4%
Cost per beneficiary
(in thousands US$)
8%
6%
2%
8.0
30
6.0
20
4.0
10
2.0
2008/09
11.1
11.1
11.0
10.8
2007/08
2008/09
2009/10
2010/11
2011/12
10.0
40
2007/08
10.8
2009/10
2010/11
2011/12
Sources http://www.health.ny.gov/health_care/medicaid/redesign/docs/mrtfinalreport.pdf
http://www.health.ny.gov/statistics/health_care/medicaid/quarterly/ssd/
http://www.statehealthfacts.org/comparemaptable.jsp?ind=636&cat=4
12
Bending the cost curve
Figure 3
Expected savings as a result of the Medicaid Redesign Team
Medicaid expenditure
(in billions US$)
Estimated value of growth trajectory
without Medicaid Redesign Team (MRT)
65
60
} $4 billion
55
50
$34 billion
projected savings
over the next
5 years
45
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
Sources http://www.health.ny.gov/health_care/medicaid/redesign/docs/mrtfinalreport.pdf
http://publications.budget.ny.gov/eBudget1213/fy1213littlebook/HealthCare.pdf
Take advantage of ‘burning platforms’
Many healthcare systems are facing financial
and demographic crises, which actually provide
a great foundation for introducing radical ideas.
However, under the pressure of a crisis, leaders
might be looking for quick fixes. Rather than an
instant response, leadership should build and
then implement a vision that makes the overall
care system more robust and able to cope with
similar events in the future.
But how do you enact change when a burning
platform does not exist? It is possible to create one
by asking the right questions, for example as
one participant noted: “If you had the business
intelligence, you could show a huge problem – ‘Why
is the rate of C-sections 60% versus 15%? Why
are people dying twice as much from sepsis in this
hospital compared to that hospital?’ – and then
use that burning platform to focus on quality and
safety, which everyone agrees is important.”
Data is at the heart of healthcare – and belongs
to everybody
The New York State Department of Health’s successes
could not have been achieved without excellent
data, so health systems must make reporting
mandatory and ensure that all stakeholders are
interconnected. Sometimes it may be enough
to simply publish information such as cardiac surgery
success rates on accessible websites, and citizens
may choose to process the data and start to identify
and publish useful trends and rankings. Setting data
free in this way can lead to surprising innovations.
Clinicians will also benefit from such transparency
and strive to improve their results. As a participant
observed: “The information is simply put out
there. We don’t tell doctors what to do; we tell them
what they’re doing.”
13
Use education to change culture
Traditional medical training is oriented towards
diagnosis and treatment, and clinicians need to learn
how to take a more holistic view, to consider
quality of outcome for the patient over a longer
term, rather than simply prescribing drugs
or carrying out operations. Doctors, nurses and
other health professionals should be educated
together in the classroom and on the ward
as a team, learning together and building trust,
which should lead to a fundamental change in
attitude and understanding, with training oriented
around the patient and his or her needs.
Re-imagine hospitals – and those who work
within them
An over-emphasis upon in-patient care has led
to a surplus of hospitals in many countries,
which is pushing up the cost of care. The hospital
of the future should be more of a 24-hour
urgent care centre consisting of operating theatres
and intensive care, with remote telemedicine
to handle some acute cases. One participant said
that: “Some smaller hospitals get the majority
of their profits from primary care and outpatient
care. The smart ones have effectively moved
into other businesses.”
Nevertheless, closing or downscaling a hospital
means significant job losses at what is typically
the largest local employer, so it is important
to commit funds towards workforce re-training,
to divert staff into community homes or primary
care. There will inevitably be massive resistance
to such change, involving trades unions. In
response, leaders need to hold public hearings and
present the strategy and, importantly, the data
that argues the case for less tertiary care. And by
offering re-education, a proportion of displaced
staff may gain alternative roles in the new system,
which could include becoming school nurses,
to reduce chronic incidences such as asthma, thus
relieving the pressure on hospitals.
14
Bending the cost curve
Maintain a consistent vision
Leaders should not just be able to come up with
and implement good ideas that bend the cost curve;
they need to have an enduring vision of public
healthcare, and of “what success looks like”, which
sets the direction for the entire system. The natural
consequence of such a vision is a health ecosystem
involving a wide range of institutions and individuals,
all aimed at producing better outcomes for citizens.
An attendee summed this up by saying: “You need
a very pure and clear idea about what public health
is about, what community health is about, and
what the system ought to be doing. That consistent
compass reassures all stakeholders that we’re all
moving in the same direction.”
Session 3
A new level of public engagement
Case study
The Citizens’ Reference Panel on Ontario Health
Services, Canada
Case introduction
Ms. Ceci Connolly, Managing Director,
Health Research Institute, PwC US
Speaker
Mr. Peter MacLeod, Principal, MASS LBP
Background
Debates about healthcare policy need to involve
and engage citizens, in order to build a credible
consensus for change.
Healthcare is an intensely personal issue that
generates strong emotions, with any changes likely
to be strongly contested. Nowhere is this truer
than in countries with cherished national health
systems, such as Canada and many European
states. In building an argument for change, however,
governments often fail to recognise the potential
role of citizens to inform and shape policy. One of the
biggest fears about public debates is that people will
simply ask for more spending at a time when every
economy is desperately trying to reduce its budget.
Yet such concerns underestimate the common
sense and intelligence of the public, who should be
seen as a resource and not a risk. By consulting
the people, politicians gain greater legitimacy over
tough decisions, restore mutual trust and confidence,
and make better choices – as demonstrated in the
Hong Kong and New York State cases. In the words
of André Picard, a well-known Canadian health
commentator: “The adult conversation we need to
have about healthcare has not occurred, in large
part, because politicians, policy-makers, experts and
pundits have largely cast aside the public.”9
9
André Picard, “Finally, a health-care paper that makes
sense”, The Globe and Mail, 22 June 2011.
15
Most public consultations tend to lack substance
and fail to come up with radical new ideas. All too
often, they are brief surveys and polls that do not
approach a subject with sufficient depth. Therefore,
in a bid to improve levels of engagement and
come up with useful and practical ideas, MASS LBP,
a respected Toronto-based firm specialising in
public engagement, conceived the 2011 Citizens’
Reference Panel on Ontario Health Services.
The ensuing recommendations confounded the
sceptics, with the panelists showing an acute
awareness of financial limitations and a need for
practical responses. And while the panelists
affirmed their confidence in the public health system,
they also expressed frustration over its inefficiencies.
Rather than asking for more money, they argued
for a system-wide transformation in care delivery,
along with greater prevention to reduce demand.
Invitations were mailed to a random group
of households reflecting the province’s gender,
age and geographic mix, and achieved an
incredible response rate despite asking for a high
level of commitment from panel participants,
with no financial incentives save for travel and
accommodation. Health professionals and
administrators and elected politicians were
excluded and the final list of 28 members
was chosen via a blind draw, after which the
selected group proceeded to gather for three
separate weekends, along with a number
of health experts, whose role was to inform
and facilitate.
Interestingly, the group acknowledged the need for
a mix of private and public finance, and also called
for a replacement of fee-for-service with outcomebased funding, along with family health teams, as
well as greater integration between care sectors and
institutions. Measurement was high on the agenda,
as was community care to keep people active and
out of hospitals. And finally, e-health was seen as the
vital glue that would join up disconnected parts of
the health system and improve information-sharing.
Case study
The discussions generated highly practical
recommendations that were subsequently
presented to senior government members in
Ontario, and have informed the province’s
latest health policy.
Panelists were assisted and directed by a volunteer
Advisory Board composed of respected doctors,
researchers and health executives from Ontario,
along with 15 of the province’s most respected
health leaders.
The debates focused on ways to achieve sustainable,
high-quality public healthcare that met the needs
of a complex and diverse community, with an
emphasis upon practical solutions. Topics covered
included primary care, accountability, incentives,
information sharing, e-health, privacy and the future
of community care.
16
Bending the cost curve
A wide ranging influence
The impact of the report was so positive that within
a week of publication the panel was asked to present
its findings to senior members of the Ontario’s
Provincial Parliament, including deputy ministers.
Ultimately the recommendations have been put in
front of more than 800 public health officials within
Ontario and also across other provinces in Canada.
And the panelists’ suggestions appear to have
informed provincial health strategy, as the key
themes of prevention, family health and care
closer to home are very much in line with Ontario’s
2012 government health strategy Ontario’s Action
Plan For Health Care.
As a valuable exercise in public participation,
the Citizens’ Reference Panel has shown that
well-informed citizens can get to grips with the
complexities of modern healthcare and produce
a mature, practical strategy. Such dialogue
should also help to restore trust and confidence
in political bodies.
Discussion: how to implement this model
on a wider basis
Focus on a specific challenge
Consultations should have a finite task to be
completed in a set time, which ensures that
everyone concentrates on addressing the problem
and does not get distracted by other issues. The
danger of many debates is that people simply turn
up to offer opinions, which does not necessarily
generate valid outcomes. Equally, a permanent panel
or group that meets on a regular basis may run out
of challenges and become a burden. The facilitators
and the citizens should always be aware that they are
there for a specific purpose, and keep all discussions
within the agreed parameters, with a target to
produce recommendations by a fixed deadline. One
attendee summed this up by saying: “We’re not
asking people what they think; we’re asking them
to solve a problem. This was a conversation about
ensuring high quality, publicly funded healthcare.
Although some panelists wanted to expand the
agenda, this wasn’t allowed – and they respected
that decision.”
Position the task as a public service
In every society, hundreds of thousands or even
millions of individuals are willing to volunteer to
help with schools, hospitals, nursing homes
and other institutions. A consultation should be
a natural extension of such public spiritedness,
where citizens view the process as a way to improve
quality of life for others, while acknowledging
that ultimately it will be professionals that make
it happen. By asking the participants to “put
themselves in the shoes of those they’re trying to
help (i.e., the patients),” the facilitators can
remind them that it is a privilege to serve. One
of the symposium attendees commented that:
“Being a citizen is about more than just voting and
paying your taxes.” This Ontario forum was not
just a chance to voice opinions, but was positioned
as a public service to improve a cherished
health system.
Manage expectations of citizens and
policy makers
The citizens taking part in the debate should be
aware that, although their proposals will be viewed
by senior officials, they are not a mandate for
specific action. And the audience – politicians, civil
servants and other professionals – must also
pledge to consider the recommendations seriously,
and explain why they have or have not responded
to each point and the subsequent action taken. This
amounts to what one participant described as a
“Dual contract, where the client agrees to a degree
of action. Although not going as far as acting on
the letter of the report, they commit to very publicly
acknowledge the process and make a good-will
effort to act on a number of the recommendations.”
Ensure that the debate is about choices
Part of the facilitators’ role is to emphasise the
need for pragmatic decision making, which
involves making tough choices that will not please
everybody. However, this need not be a strait
jacket but an opportunity for innovation, to change
the healthcare model to respond to evolving
financial and demographic pressures.
Inform citizens objectively
Any expert support and advice should be as
independent as possible, whether written or verbal.
The experts supporting the process can never
be entirely neutral, but they should be carefully
screened to ensure that they do not try to influence
the participating citizens, with a clear brief on
their role as educators and facilitators. In the words
of one participant: “When we talk about public
consultation, we should be talking every bit as
much about public learning, and how public system
administrators can do a better job sharing what
they know, and framing their choices in a way that
the public can interact with.”
17
Aim for quality over quantity
Surveys and polls strive for statistical validity by
aiming for an appropriate sample size. However,
consultations are not designed to produce a
definitive response, but to come up with workable
recommendations from informed participants.
Legitimacy does not depend upon the size of the
participatory group; so long as the members
are roughly representative of the surrounding
population, and are given sufficient background
information, they will have sufficient credibility.
Choosing the right approach
Ultimately, the level and type of engagement should
be based on public expectations of the intended
outcome. To offset any criticism the government may
encounter when proposing a policy change it is
wise to take into consideration the views of the
people, making the crowd-sourcing approach used
by the Hong Kong and New York State appropriate.
However, unlike the Hong Kong and New York State
examples, the Citizens’ Reference Panel was
instigated by a third-party. It also explored issues
that were cerebral and complex in scope, better
addressed through intense dialogue. But this does
not mean that decision-makers must use one
approach over the other. Depending on the goal,
it may be useful combining general consultations
and meetings with targeted discussions.
18
Bending the cost curve
Session 4
The power of sharing
Case study
Kaiser Permanente and Health Information
Exchange, US
Case introduction
Mr. Peteris Zilgalvis, Head of Unit, Health and
Well Being, DG Communications Networks,
Content and Technology, European Commission
Speaker
Mr. Hal Wolf, Senior Vice President,
Chief Operating Officer, The Permanente Federation,
Kaiser Permanente
Background
A pioneering US health system is attempting
to utilise the power of technology to create
seamless patient record sharing.
Interoperability has enormous potential for
reducing costs and improving quality when patients
are seen outside of their immediate health system.
Instant access to patient records cuts out duplication,
unnecessary tests and procedures, and equips
clinicians to make better decisions thanks to
knowledge of pre-existing conditions, allergies
and medication. One leading US healthcare
organisation claims that the cost of repeat CT Scans
alone in a non-integrated system can be as high
as 50% (compared to 20% in integrated systems).10
Healthcare systems around the world are seeking
to become more interconnected, but they face several
big hurdles to establish a framework, common
architecture and standards, open source software
(to ensure the flow of emails and provide access
to files) and strong, multi-level governance. To make
matters more complicated, many systems are not
fully digital, and even those that have transitioned
to electronic records often suffer from uncoordinated
systems that don’t talk to each other.
Charles Sorenson, MD, “The Care Connectivity
Consortium: Taking Health Information Exchange
to New Heights”, HIMSS12: Annual Conference &
Exhibition, 2012, 69.59.162.218/HIMSS2012/
Venetian%20Sands%20Expo%20Center/2.22.12_
Wed/Venetian%20Showroom/Wed_1300/97_George_
Halvorson_Venetian%20Showroom/2.%20CCC%20
View%20from%20the%20Top_Halvorson_FINAL.pdf
10
19
Managing and storing data creates a further
challenge, with the option of centralising data
warehouses or single transfers when needed.
And while data availability is the goal, too much
data can be overwhelming, so it is important
to choose which information will be of most use
to clinicians and set parameters. Data security
remains a further issue, with questions about who
actually owns the data.
At a macro level, countries, regions and ultimately
the whole world needs established standards
to ensure that data from one system is compatible
with another. The pan-European pilot Connecting
Europe Facility is probably the largest and most
ambitious current project, and will eventually
span 47 partner organisations in 23 member states
across the European Commission. Most of the
participants are regional ministries of health.
In the US the government is encouraging physicians
to adopt electronic health records, while health
information exchanges (HIEs) are emerging to share
data among medical groups. Kaiser Permanente,
a healthcare provider and non-profit health plan
in the US, has pioneered clinical HIEs, participating
in a five-organisation health data exchange
demonstration through the California eHealth
Collaborative in 2009 and partnering with the
Department of Veterans Affairs (VA) to provide
clinicians with a more comprehensive view of
their patients’ health status and improve care for US
veterans. This latter initiative managed to achieve
legal agreements on how data would be exchanged,
as addressing issues of security and privacy and
giving patients the option to opt out.
Case study
Five leading US healthcare systems have joined
together in a secure electronic data exchange
involving millions of patients across the country.
Launched in 2011, the Care Connectivity Consortium
involves Kaiser Permanente and four other US
health systems which have established a private
network that electronically connects all the
participating doctors, giving them comprehensive
patient records. This unprecedented collaboration
has been helped by the advanced e-connectivity
of the five participating providers, all of whom
had already embraced digitised medical records,
e-visits, e-scheduling, e-consults and computer
reported lab results.
The consortium does not use a central data
repository, and instead has opted for a free-flow
of information between organisations. Costs
have also been kept under control, with maximum
use of existing infrastructure, protocols and
tools. And all the information exchange conforms
fully with national US health information
technology (IT) standards to ensure patient privacy
and security, with patients given the choice to
be part of the programme.
Early results have been impressive, with exchanges
of patient data enhancing hundreds of thousands
of cases. When a member of one system requires care
from a clinician in another system, the medical
professionals have the full records at their fingertips,
enabling them to offer the most effective treatment,
avoiding unnecessary tests and unintended
consequences such as adverse reactions.
Patients with chronic conditions such as heart
disease, diabetes and asthma, as well as those
in emergency care, have gained much from
the consortium. Increased connectivity is also
stimulating greater sharing of results and
leading practices, which should ultimately lead
to higher standards of care and lower costs
for all the five healthcare systems.
20
Bending the cost curve
It is unlikely that the consortium will stop at five
members, and some of the five are also part
of regional HIEs. Electronic health information
interoperability and connectivity is a critical
next step, and the Care Connectivity Consortium
has demonstrated the potential for effective, timely
and secure health information exchange among
geographically disparate health care providers.
Discussion: how to implement this model
on a wider basis
Empower patients to create better healthcare
Today’s patients have access to vast amounts
of general medical information and often research
their conditions prior to visiting their doctor or
nurse. Interoperability will help them become even
better informed and therefore more engaged
with their health by giving them access to lab results
and other reports. Seventy percent of Kaiser
Permanente’s patients have chosen to be connected,
a quarter of interactions are now electronic, and
most will see test results before the doctor. Health
providers can build on this new level of patient
engagement by communicating advice on diet and
lifestyle and enabling patients to set their own
appointments and have group discussions online,
linking into social media. According to a
symposium attendee: “We all are working to put
prevention online, and this is a huge area of
exploration. If we don’t have the patients engaged
in utilising all of these social aspects, we’d be
missing a huge opportunity.”
Build on a common vision
Interoperability may be easier when participating
health systems share values, which should ease the
path to standardisation and information exchange.
This point was emphasised by one participant: “It’s
about much more than commonality in technology,
but rather a commonality around the practice
of medicine, the way physicians are remunerated,
and a common vision around patient-centric care.”
In the case of pan-European connectivity, the
existence of common systems of capitated payment
could mean that each national system has a similar
motivation to reduce costs and improve patient care.
Engage clinicians in the change process,
“early and often”
Doctors can be resistant to change, and many
have opposed the introduction of electronic records
as they are concerned about data security and
potential for errors. Some systems have invested in
inappropriate IT, which has compounded such
fears. In articulating the case for change, clinicians
must be educated on the universal benefits of
interoperability, such as the ability to spot trends,
carry out large scale studies, improve care pathways,
and utilise resources more efficiently. This means,
as a participant acknowledged: “Spending an
exorbitant amount of time and money bringing
doctors together in large groups, to carefully
determine how the information exchange should be
designed and utilized.” Systems such as Kaiser
Permanente measure speed of response to patient
queries, which is a key performance indicator, so
doctors should be motivated to embrace the power
of new technology to achieve such goals. Another
attendee felt that providers needed enthusing: “Yes,
it’s expensive, but you need to state the key benefits,
and if you articulate that vision you can start
moving toward electronic health records.” Leaders
also need to build in a transition period where
productivity may actually go down as new users get
used to the new IT system.
Invest in interoperability
Connectivity can be costly and requires considerable
financial support. The business case is built
around efficiency, care quality and safety, but also
cost savings from reduced duplication. In the
case of national and pan-national collaboration,
this business case can be used to garner support
from governments and other governing bodies
in order to speed up the transformation. Once the
government has been convinced of the benefits,
it also needs to offer incentives to potential
participating health systems to encourage them
to adopt common standards. However, one
participant added that “the great benefit to this
is not a financial return, not just from an HIE
aspect. It is a patient safety return. There is some
financial gain to be made, but it’s a quality and
a service relationship.”
21
Do not view privacy as a barrier
Those health providers that have gone fully digital
find that very few patients opt out. Each health
system has its own legal relationships with patients
or members, so interoperability agreements must
respect these standards. Kaiser Permanente, for
example, uses data from its own and other systems’
patients to perform trend analysis and benchmark
against national standards. However, any data
on individuals should only be used on an aggregate
basis when sharing with the outside world. One
participant felt that data privacy was a generational
issue: “Many younger people are happy to share
all their personal information on the web, so security
may become less of an issue in future.” Another
participant added that a success factor may lie in
allowing personal choice: “People seem to be assured
by the fact that they have the choice to share or not.”
Choose the right IT
Given the likely participation in HIEs, any IT
purchase decisions should take account of existing
and emerging standards for software to minimise
the need for further spending in the future. Health
systems and governments are spending a lot of
resources and going through the growing pains of
creating a more connected health ecosystem. It
may require a disruptive technology innovation
to truly remove the barriers between systems and
scale-up across jurisdictions.
22
Bending the cost curve
Session 5
Measuring what really matters
Case study
ActiZ: the Dutch association for residential and
home care organisations and infant and child
health clinics, Netherlands
Case introduction
Mr. Theo Langejan, Chairman, Dutch Healthcare
Authority (NZa)
Speaker
Mr. Aad Koster, CEO, ActiZ
Background
Over a period of 15 years, this members’
association has been attempting to crack
the code to effective, multidimensional
benchmarking.
In the information age, healthcare providers
receive vast amounts of data, yet this does not
always lead to better decision making. Many
benchmarking studies fall short and don’t produce
complete, meaningful comparisons because
they are not applied universally with a common
methodology over a sufficient period of time.
Lack of consistency also makes it hard to correlate
different data sets to achieve a reliable causeand-effect analysis.
One of the hardest tasks is to ask the right questions
in the first place. A common failing is that health
providers measure what they believe to be important
rather than what the patient values.
At a system-wide level, comparative studies are often
dismissed, with each organisation claiming that its
results are not comparable to those of its competitors
or peers.
The ultimate goal is to have a single, simple
benchmarking instrument that is used consistently
over the years by every healthcare provider,
with each organisation openly accountable for its
performance. Over time the accumulation of
data would result in a valuable body of evidence.
23
Long-term care is an under-researched area of
healthcare, yet demographic trends in ageing suggest
that the costs of caring for the elderly could devour
every nation’s health budget over the coming
decades. One of the biggest debates in long-term
care centres on quality of life, with a concern
that care homes are focused purely on medical
treatment rather than on wellbeing.
As a trade association, ActiZ tries to influence Dutch
national health policy development, and negotiate
financing with national and local agencies and
insurance companies. Its members provide care for
more than one million public and private patients,
with around 430,000 employees. Over 15 years ago,
ActiZ set out to create a valuable multidimensional
benchmarking process for all its members, with the
aim of raising quality, cutting costs, and enhancing
transparency for all stakeholders.
Case study
ActiZ’s multidimensional benchmarking system
opens a window into the performance of
home care providers and nursing homes in the
Netherlands, enabling providers to improve
care quality and efficiency.
Realising the importance of a critical mass of
contributors, ActiZ gained agreement from the
vast majority of its members to participate in
the benchmarking system. It also acknowledged
the need for a sophisticated system that would
produce valuable comparisons within and between
organisations, and over time has designed and
refined a series of regular reports that consider
provider performance across three dimensions:
1.Patients’ view of care: including reliability of
care, quality of treatment, safety, concern for
mental well-being, professionalism of staff and
communication.
2.Employees’ views of employer quality:
including corporate vision and ambition,
leadership, job content, pressure of work,
atmosphere and fun, and concern for patients.
24
Bending the cost curve
3.Operational and financial performance:
number of clients served, costs per client
group, covering margins, capital expenditure
ratio, information technology costs and
human resource costs per employee.
Not only do the results give insight into performance,
they also show interesting and often surprising
links between variables. For example, there appears
to be little correlation between hours of caregiving
and quality of care received, suggesting that it is
more important to improve the nature of care than
the volume. These and other findings are raising
the average standards of perceived quality of care,
employee engagement and financial performance
across all members. A provider can also use the
benchmarking data to compare units, wards and
locations within a single organisation and pinpoint
high and low performers.
Approximately 10% of the members receive the top
‘AAA’ score each year – meaning they have excelled
in each of the three dimensions: client experience,
employee engagement and financial performance
(A=top-tier, B=mid-range and C=low-range). Trends
and characteristics of leading practice organisations
can be shared amongst members to raise overall
standards, with a further option of an in-depth
consultation with benchmark researchers and ActiZ
to discuss one’s scores.
The system is now almost fully automated, with
data transmitted via hand-held devices to a stateof-the-art data warehouse. And with more than
50,000 patients and 50,000 employees completing
questionnaires annually, ActiZ is building up
a substantial body of data, enabling it to identify
notable trends. It has also saved considerable
work for members, as the data can also be used
for statutory reports to government and
insurance companies.
Figure 4
ActiZ data shows actual staffing has no direct correlation to perceived availability
of staff by clients and perceived workload by employees.
Perceived availability staff
(Volume of staff as % of standard)
Workload
(Volume of staff as % of standard)
115%
115%
110%
110%
105%
105%
100%
100%
95%
95%
90%
90%
85%
85%
5
6
7
8
9
5 high 5.5
6
6.5
7
7.5 low 8
Source ActiZ Benchmark in de Zong, 2012
Naturally, the system is dynamic, and as new
approaches to healthcare emerge, criteria and
rankings change accordingly, meaning that
the benchmarking is adapting to changes such as
demand-driven care and an increasing emphasis
upon outcomes over volume.
The ActiZ benchmarking system demonstrates the
value of asking the right question to the right
person, and has made a big difference to the quality
of care for the elderly in the Netherlands, helping
government make savings and giving patients and
their families better-informed choices over
homecare providers.
Discussion: how to implement this model
on a wider basis
Ask the right questions
Whether surveying clients on the quality of their
food, or quizzing staff on whether they would
recommend their care home to relatives or friends,
the power of the right question is immense. One
attendee was particularly impressed with the ActiZ
results: “The idea that there’s absolutely no
connection whatsoever between hours worked by
staff and clients’ perceived quality just blew
me away. Armed with this kind of knowledge, you
change your paradigm of thinking.” Survey content
should be continually reassessed to determine the
relevance of responses, and organisational priorities
should also be reconsidered in the light of responses
to new, enlightening questions.
25
Figure 5
Solving the perceived quality gap
between clients and staff is an industry challenge
Clients
Employees and clinicians
Best Practice Organisation’s Clients
Best Practice Organisation’s Staff
ActiZ ambition loyal clients
80
80%
70
70%
60%
75
82
79
72
56
50%
48
40%
“The client can
influence how
and when care
is delivered”
“The organisation
is open for client
needs and wishes”
Leading practices have a better aligned organisation
(Values are based on self-evaluation scores on a scale of 1 – 10)
administrative
middle management
top management
8.0
8.0
7.7
7.5
7.0
7.2
7.5
7.3
7.0
6.5
6.0
5.5
Shared vision
and ambition
Communication
about changes
Source ActiZ Benchmark in de Zong, 2012
26
Bending the cost curve
Use measurements to influence behaviour
As healthcare becomes more outcome-oriented,
issues such as happiness, personal freedom,
respect and dignity take on greater significance.
By measuring and benchmarking these variables
from the clients’ perspective, providers can
act on the findings and hasten a change in culture,
linking scores to rewards to place clients at the
centre of their operations. According to a participant:
“What we measure and what we reward is a live
issue, and science of what we reward is evolving,
so a body of evidence can take us further down
this path.”
Publish data
Many healthcare systems are considering giving
patients more control over how their budgets
are spent, and in future a greater proportion of
charges will be paid for out of personal savings,
so patients and their families will have more
choice over which provider to use. By publishing
the results, individual citizens are empowered
to make their own decisions on which providers
to use, which should increase competition and
raise levels of care. Publicly available data also
appeals to the competitive nature of clinicians,
stimulating them to improve their performance
and climb the league tables, as one participant
remarked: “The comparative position of being in
the bottom quartile rather than in the top is
a very powerful driver for clinicians and carers.”
Ensure that benchmarking is independent,
standardised and continuous
Information compiled purely by a provider is less
likely to be trusted, so it is preferable for an
independent, objective party to collect, manage
and analyse the findings. Standardisation
of measurements on an ongoing basis will give
meaningful comparisons and help identify
important trends.
Benchmark internal performance regularly
A participant noted that: “The variance within
organisations is much bigger than the variance
between organisations,” a comment that is consistent
with the ActiZ figures, which show that, for a single
provider, variances between different internal units,
teams and wards are often significant. By carrying
out certain measurements continually – possibly
even every day – it is possible to track performance
accurately and make appropriate adjustments.
Align objectives at all levels within
an organisation
The top healthcare providers score highly across
the three variables of patient satisfaction, employee
engagement and financial performance. In these
organisations, senior management is typically
in close touch with what’s going on in the wards,
and uses this knowledge to set realistic targets
aimed at improving quality and efficiency. This
creates a virtuous cycle of continuous learning
and improvement and employee satisfaction,
as staff feel that leaders are listening to their needs.
In a people business, like long-term care, this
approach drives the client experience, which drives
financial performance as a result.
27
Conclusion
Over the course of two years, the five Bending the Cost Curve
symposia have produced 25 innovative case study presentations,
highlighting a number of pioneering ways to bend the cost
curve and, moreover, cross-pollinate these new, ground breaking
ideas across different geographies. The discussions in Berlin
built on some of the themes we encountered in previous events
– as described in the opening of this report – adding further
insights and recommendations for practical application of emerging
practices. For example:
•Leadership and culture
As change becomes the ‘new normal,’ strong, agile and decisive
leadership will be needed to guide health systems through
periods of major transition. Hong Kong’s government tested the
water through careful public consultation, helping it to refine
its ideas for a voluntary private insurance plan and reassure
citizens that the public sector would not disappear. In New York,
the refusal of Governor Cuomo and his expert team to veer from
their vision has enabled sacred institutions and practices to be
challenged and improved. The Ontario Citizens Reference Panel
has positioned the public as a vital part of the decision-making
process, to bring engagement to a new level, making consensus
a bridge rather than a barrier to progress.
28
Bending the cost curve
•Integrated care
Integrated delivery systems should align incentives between
payers and providers to encourage efficient, outcomebased healthcare. Information can hasten this practice,
as demonstrated by the Kaiser Permanente and New York
State Department of Health case studies. Providers, like
in the Kaiser system, use technology and data to improve
and manage care pathways. And by making data freely
available, users are empowered to make better choices over
providers and treatment types, which should stimulate
competition to offer the best outcomes. New York has shown
how a fully integrated healthcare ecosystem does not just
rethink the boundaries of primary and tertiary care, but
extends the concept of ‘healthcare’ to include schools and
gymnasiums, as well as preventative public health measures
such as water chlorination and health education.
•Changing roles of the public and private sectors
Public-private partnerships (PPPs) have started to move ‘beyond
the build’ to include clinical service delivery. Hong Kong has
added a further dimension, by using the private sector to finance
expansion and expand access and capacity, as well as encouraging
better public health through programmes to combat obesity
and smoking through healthier lifestyles. This shifts the
argument from “either or” towards a more sustainable system
that makes the most of the strengths of both sectors.
•Geriatric care innovations in hospitals and
the wider community
Care for the elderly is typically high-cost and resource intensive,
yet, as ActiZ has shown, less can sometimes mean more, with
a stronger emphasis upon care that seeks to improve quality
of life and gives individuals greater independence and dignity.
Benchmarking the providers on quality-of-life indicators can
help to improve care and reduce costs, freeing up institutions to
become more productive in other service lines.
29
•Data analytics and measurement
The combination of electronic medical records and personal
mobile healthcare technologies offers incredible opportunities,
giving patients and providers information on patient
preferences, service delivery and clinical outcomes. As one
participant noted: “If you can’t measure it, you can’t change
it.” Strong business intelligence gave the New York Medicaid
Redesign Team and Kaiser Permanente the tools to identify
clinical trends and operational inefficiencies, helping them to
make appropriate interventions and cut costs and, in the
case of Kaiser, encourage standardisation and interoperability.
However, as the ActiZ example demonstrated, data use and
measurement must go hand in hand with creative thinking; only
by asking the right questions can providers generate the right
data to stimulate innovation and improvements.
The Berlin meeting added a new dimension to these recurring
themes, from leadership to integrated care to measurement.
However, at every symposium since the inaugural 2011 meeting
in Washington DC, new ideas emerge in discussion that take
our discourse further. In Berlin this was perhaps captured in a new
finding for our series, the power of human-centred design.
Although systems are important, healthcare is essentially about
individuals and should be designed around the patient. The ActiZ
case study was a great example of orienting care towards what
clients have actually said they want, as opposed to what providers
think they want. The Ontario Citizen’s Reference Panel elevated
the healthcare debate by recognising the legitimacy of informed
public views.
30
Bending the cost curve
Most systems innovations start with a technological breakthrough,
followed by a new business model which is marketed to people.
However, human-centred design starts with people, followed
by business solutions and technology to deliver new choices
and customisation.
Technology is already driving a more personalised approach in
other fields; banking and travel are just two industries that
have had to accommodate clients demanding more information,
options and autonomy. Healthcare must catch up, treating
patients as customers who know what they want. Increasingly,
thanks to personal technologies, the healthcare consumer is
empowered to make more decisions and “hire” the right product
that will lead to a desired outcome.
Human-centred design can be a starting point to build health
systems that are more active, adaptive, participatory and
emotionally satisfying. Applying a design thinking discipline
to healthcare services is not new. Healthcare organisations
are starting to use design thinking to re-examine aspects of care
delivery to make the patient experience better. But the next
level of health system redesign will require adding choice and
influence to the patient experience. In other words, going
beyond patient-centricity and allowing patients to be active in
co-designing their care.
Patients now want more self-management of chronic illness, more
care-anywhere solutions and more sophisticated and personal
services. This irreversible change is disrupting the traditional
doctor-patient concept. As more and more information becomes
freely available, health providers will continue to learn more
about what patients are looking for. A more informed provider,
coupled with a more empowered and knowledgeable customer,
will create efficiencies in a system and a big leap toward bending
the cost curve.
31
Agenda
22 – 23 January, 2013
22 January, 2013
Dinner Keynote Speaker
Daniel Bahr, Minister of Health of the Federal Republic of Germany
23 January, 2013
7:30 – 8:30
Registration and continental breakfast
8:30 – 8:45
Opening remarks by Dr. David Levy, Global Leader, Health Industries, PwC
8:45 – 10:00
Session 1
Reforming healthcare delivery through public-private collaboration
Introduction
Rt. Hon. Alan Milburn, former UK Secretary of State for Health;
current Chair, Social Mobility and Child Poverty Commission, UK Parliament
Case Study
Hong Kong’s Health Protection Scheme
Presented by
Dr. York Chow, former Secretary for Health, Welfare and Food, Hong Kong
10:00 – 11:15
Session 2
Controlling costs while reinvesting in healthcare
Introduction
Dr. David Levy, Global Leader, Health Industries, PwC
Case Study
The New York State Department of Health, US
Presented by
Dr. Nirav Shah, New York Commissioner of Health, US
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Bending the cost curve
11:15 – 11:30
Coffee break
11:30 – 12:45
Session 3
Consumer-led health reform
Introduction
Ms. Ceci Connolly, Managing Director, Health Research Institute, PwC US
Case Study
The Ontario Citizens’ Reference Panel, Canada
Presented by
Mr. Peter MacLeod, Principal, MASS LBP, Canada
12:45 – 13:45
Lunch
13:45 – 15:00
Session 4
Health IT integration on a regional level
Introduction
Mr. Pēteris Zilgalvis, Head of Unit, Health and Well Being,
DG Communications Networks, Content and Technology, European Commission
Case Study
Kaiser Permanente and Health Information Exchange, US
Presented by
Mr. Hal Wolf, Senior Vice President, Chief Operating Officer,
The Permanente Federation, Kaiser Permanente, US
15:00 – 16:15
Session 5
Achieving sustainability in long-term care with an ageing demographic
Introduction
Mr. Theo Langejan, Chairman, Dutch Healthcare Authority (NZa), Netherlands
Case Study
ActiZ, Netherlands
Presented by
Mr. Aad Koster, CEO, ActiZ, Netherlands
16:15 – 17:15
Closing remarks and reception
33
Roster of
participants
Mr. Hervé Barge
General Manager, National eHealth Agency,
Luxembourg
Dr. David W. Bennett
Chair and Chief Executive, Monitor, UK
Dr. Paolo Bordon
CEO of the Public Health Agency Bassa Friulana,
Friuli Venezia Giulia, Italy
Mr. Michael Burkhart
Leader, Healthcare, PwC Germany
Mr. Javier Ellena
General Manager, Lilly, Spain, Portugal and Greece
Mr. Håkon Grimstad
CEO, Norwegian Healthnet, Norway
Dr. Heinz-Walter Große
CEO, B. Braun Melsungen AG, Germany
Mr. Karthic Jayaraman
Director, The Carlyle Group, UK
Mr. Aad Koster
CEO, ActiZ, Netherlands
Mr. Luis C. Campo
Director General, GE Healthcare, Spain and
Portugal
Ms. Annette Kumlien
CFO and Board Member, Diaverum, Germany
Dr. York Chow
former Secretary for Health, Welfare and Food,
Hong Kong
Mr. Theo Langejan
Chairman, Dutch Healthcare Authority,
Netherlands
Ms. Ceci Connolly
Managing Director, Health Research Institute,
PwC US
Dr. David Levy
Global Leader, Health Industries, PwC
Dr. Carlo Conti
Vice President of the Government of the State
of Basel; Minister of Public Health, Canton Basel,
Switzerland
34
Bending the cost curve
Mr. Rasmus Lønborg
Head of Health Economics & Finance,
Ministry of Health, Denmark
Mr. Peter MacLeod
Principal, MASS LBP, Canada
Dr. Andrew G. McCormick
Permanent Secretary, Northern Ireland Department
of Health, Social Services and Public Safety, UK
Mr. Marco Meerdink
CEO, Espria, Netherlands
Rt. Hon. Alan Milburn
former UK Secretary of State for Health; current
Chair, Social Mobility and Child Poverty
Commission, Parliament, UK
Mr. Christian Molt
Member of the Board, Allianz, Germany
Mr. Yalçin Nak
COO, Acibadem Healthcare Group, Turkey
Dr. Axel Paeger
CEO, AMEOS Hospital Group, Switzerland
Mr. Stefano Santinelli
Head of Business Development, Swisscom,
Switzerland
Dr. Nirav Shah
Commissioner of Health, State of New York, US
Mr. Jan Sturesson
Global Leader, Government and Public Services,
PwC
Mr. Søren Frejo Varder
Senior Adviser, Ministry of Finance, Denmark
Mr. Hal Wolf
Senior Vice President, Chief Operating Officer,
The Permanente Federation, Kaiser Permanente, US
Mr. Pēteris Zilgalvis
Head of Unit, Health and Well Being, DG
Communications Networks, Content and
Technology, European Commission, Belgium
Prof. Jonas Rastad
Executive Director, Region Skåne, Sweden
Dr. Andrzej Rys
Health Systems and Products Director, European
Commission, Belgium
35
Contacts
David L. Levy, MD
Global Leader, Health Industries, PwC
+1 646 471 1070
[email protected]
Italy
Lino Mastromarino
[email protected]
+39 02 66720554
Christine Walters
Global Marketing Director, Healthcare, PwC
+1 646 471 3359
[email protected]
Luxembourg
Guy Brandenbourger
[email protected]
+352 494848 2386
Silvia Fracchia
Global Marketing Senior Manager, Healthcare, PwC
+1 646 471 3024
[email protected]
Netherlands
Robbert-Jan Poerstamper
[email protected]
+31 (0) 887926314
European healthcare
industry leaders:
Norway
Dagfinn Hallseth
[email protected]
+47 95 26 12 48
Central & Eastern Europe
Mariusz Ignatowicz
[email protected]
+48 22 523 4795
Spain
Ignacio Riesgo Gonzalez, MD
[email protected]
+34 915 685 747
Denmark
Christian Klibo
[email protected]
+45 8932 5514
Sweden
Roine Gillingsjo
[email protected]
+46 0 10 2124883
France
Elisabeth Hachmanian
[email protected]
+33 156575876
Switzerland
Rodolfo Gerber
[email protected]
+41 0 58 792 5536
Germany
Michael Burkhart
[email protected]
+49 69 9585 1268
Turkey
Serkan Tarmur
[email protected]
+90 212 376 53 12
Ireland
Aidan Walsh
[email protected]
+353 0 1 7926255
UK
Dean Arnold
[email protected]
+44 020 721 38270
36
Bending the cost curve
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