September 20th 2018
Picture taken during the symposium showing Prof. Matthias Rose explaining the timeline of patient’s questionnaires and follow-up.
Under the lead of Prof. Christoph A. Meier, the first national symposium on value-based healthcare took place at the Basel University Hospital. Gathering several speakers, it allowed us to have a deep dive into Value-based healthcare and its implementation in the hospital setting.
We know today that the healthcare system doesn’t work properly in terms of quality and prices. It needs to switch from volume to value not only from a mindset perspective but also from a payment standpoint.
Beside initiatives like Smartermedicine and Lean, Value-based healthcare is necessary today to make our healthcare system more sustainable.
Keynote – Value-based health care
Dr Jens Deerberg-Wittram
Taking the Dunning-Kruger effect showing the link between incompetence and self-confidence, he showed how we could potentially explain significant mortality rate differences between hospitals in Switzerland (and everywhere else in the world). When you are inexperienced, you tend to be self-confident. The more experience you are getting, the more you are losing confidence to get it back after some time.
Dunning-Kruger is linked to 3 elements:
– People underestimate risk and complexity
– People overestimate their ability
– People never reach out for help
It is linked to quality problems and outcome issues in the hospital setting.
The other problem is how much money we spend to achieve those poor outcomes. Healthcare costs currently grow faster than the GDP. That deviation puts the question of the sustainability of the system at the center. None of the solutions we tried seem to work: more competition (US) or public centralization (Sweden) lead both to increased costs. In a nutshell, the financial challenges in healthcare cannot be solved by a political solution.
Michael Porter, in his book Redefining healthcare shows that value has 2 components: 1/ health outcomes that matter to patients and 2/ cost to deliver the outcomes.
Outcome measurement the first step towards value-based healthcare. In order to do so, healthcare organizations should start to measure quality and reduce variation in patient outcomes. Then the standardization of the outcome metrics will enable comparisons across and within health systems. Public reporting and transparency will support the continuous improvement of the system, especially if reimbursement is closely linked to the patient outcomes.
Outcomes measurements should also be uniformly and internationally defined. ICHOM provides standard sets for outcomes measurements by therapeutics area / disease. With already 23 standard sets developed covering 50% of the global disease burden, ICHOM is also working on having adult and pediatric sets for multi-morbid patients (preventing them from receiving questionnaires for each pathology they have).
Financial incentives to improve value could be implemented through several models: bundle payment, complication guarantee, result-dependent payment.
Bundle payments are the most appropriate model to finance care. In Sweden, the money the hospital gets will depend on the pain the patient is feeling 6 months after the surgery. 40% of the revenue could be tied to patient reported outcomes. Risk-sharing agreement are also part of the landscape.
What to do to implement Value-based healthcare?
– Organize integrated practice units. Organized by disease
– Measure outcomes and costs for every patient
– Move to value-based reimbursement model
– Integrate care delivery between separate facilities
– Expand excellent services geographically
– Build enabling IT platform
The Economy of VBHC for the Payers
Prof Thomas Szucs, Helsana
It is important to be more fact-based and not anymore policy-based. Value-based healthcare is an evolutionary process.
It could start by using data that we already have. Helsana did a study to evaluate performance indicators for chronic disease in alternative insurance models. They saw differences and were willing to understand the underlying reasons of those variations? In diabetes and cardiovascular disease, they could see statistically significant difference in the reduction of hospitalization by 13 and 8%, respectively. But it was not the case for asthma.
Pharmaceuticals are an innovation that could prevent expensive hospitalization in asthma, for example. However, where does value come in? In an efficient, market price is regulated through supply and demand but healthcare is not a normal market (beneficiaries do not pay or decide; there is information asymmetry and a need to build capacity to protect from potential economic downside).
What makes a product “valuable”?
– Unmet clinical need of high priority
– Meaningful clinical difference
– Clinical and other evidence that cannot easily be ignored or discredited
– Manageable budget impact
– Acceptable cost-benefit ratio
You need clinically meaningful differences to determine the extent of innovation. But very often price does not reflect value as there are price regulations, price referencing schemes and health technology assessments.
Values are benefits over price. Values are not static over time.
Pricing situation today lacks transparence. Current margin structure creates false incentives (low generic quota, high generic prices, slow adoption of biosimilars).
In Value-based pricing, the vision is to minimize the risk of inappropriate pricing. We need real world data. For example, Entresto real world evidence data showed beneficial impact on quality of life. Appropriate does not mean neither affordable nor accurate unfortunately.
Responsible pricing in value-based assessment of cancer drugs: real-world data are an inevitable addition to select meaningful new cancer treatments, W. van Harten, eCancerMedicalScience, 2017.
The enigma of value: in search of affordable and accessible health care, T. Szucs & al., European Journal of Health Economics, 2017,
Implementation of ICHOM at the USB
Prof Marcel Jakob, Prof Walter Weber
The real case of the implementation of ICHOM at the Basel University Hospital in two areas:
The goal was really to improve the quality of life and aesthetic outcomes for breast surgery.
ICHOM was chosen because of the standards defined by the team. Using the best tools and the most appropriate questionnaires as well as KPI (oncoplastic breast conservative surgery) allows doctors to have the most useful and actionable feedback from patients. Patient reported outcomes should be measured in everyday standard clinical practice.
ICHOM allows patient reported outcomes measures (PROM) to be benchmarked among institutions. PROM are also discussed with the patient to refine further treatment and refer her to the appropriate specialist.
Implementation phase was supported by intensive collaboration between chief medical office and clinicians. It follows the clear path of Plan-Do-Check-Act in 6 steps:
– Initial discussion
– Kick off with the team
– Reviews, attend consultation hours
– Adaptations on the process
– Evaluation, key learnings and handover to the clinic
1 year later: 97% of patients are included in ICHOM. It is widely accepted by patients (close to 95%).
Orthopedic implementation of ICHOM at USB for hip replacement. The main expectation were quality-based: indication, perioperative management, surgical performance and postoperative care.
In a nutshell, the quality of life is expected to be better after the treatment. However, there were some challenges, especially the additional workload because of different types of patients.
Quality control is an effort that has to be supported by all staff members. Filling a questionnaire on the iPad could be difficult for some people sometimes because of the technology or because of the type of questions. Personnel should be available to help the patient; otherwise, there is an increased risk of drop-out. To improve the acceptance of the questionnaire, it needs to be adapted and shortened.
It is important to explain why those studies are important in order to recruit and motivate patients to follow up and be committed.
Opinion of patient could change based on to whom they speak. It is fundamental to interact with the patient to find out her/his true opinion.
Good visualization of PROM allows doctors to focus on the patient’s problems and to factually show improvement or deterioration of the health and well-being.
OECD Working group on Healthcare Quality Indicators and Outcome (HCQO).
VBHC for Depression & Anxiety
Prof Matthias Rose
Depression and anxiety are the most frequent disorders (#2 for depression and #7 for anxiety in global burden of disease)
Many scales and initiatives are country specific. Howeve, international standardization is fundamental to allow benchmarking as well as best practices implementation. ICHOM promotes an international standardization (see below).
Source: ICHOM website.
Michael E. Porter, the pioneer and founder of Value-based healthcare, sets the definition of value in one of his article as well as the methodology for outcomes measures.
Source: M. E. Porter.
In order to define the most appropriate measures, it is crucial to have the thorough understanding of the disease trajectory. Do we have a comprehensive measure of the disease focused on psychometric soundness, comprehensiveness, the number of available translations but also available royalty free.
Factors for Success and Sustainability of PROMs
Prof Jan A. Hazelzet
How to maintain the success of patient reported outcomes measures (PROM) in the future?
A lot of quality measures currently exist, but the majority is dedicated to processes even if some of them cover quality and outcomes but mainly medical outcomes and few linked to patients.
What are the benefits and the harms that the patient will get from the intervention? This is one of the first question to ask. Growing evidence, supported by the movement Smarter Medicine, goes in the direction of decreasing medical intervention when unnecessary.
Actually, we can only make healthcare better if we redefine it.
Health care quality should be focused on being:
– Patient centered
There is more than the cost, the flow is equally important as well as the patient experience; and that is value. Focusing on the individual with the disease and not on medical specialties to change the mindset and becoming patient-centric. A team-based approach, in which a team is accountable for the whole process could help set up real care path toward a fully integrated care. It means change for organization and culture.
Patient reported outcomes measures means questionnaires because biomarkers and clinical analysis do not consider how the patient really feel. Results of the questionnaires should be discussed with the patient, it will support the commitment and the follow-up of the patient. Visualization is also extremely important for both the patient and the doctor
Overall health sets make sense for multi morbid patients instead of sending the patient 3 different sets.
The patient should definitely be considered as a real partner. Patient engagement/involvement is really strong and meaningful. Value based care is patient centered care instead of clinician based. It should be integrated and continuous. A disease team (united, responsible, and accountable) could define a care proposition with data support as well as performance data set. Patients can help with focus groups
Data should be FAIR – findable, accessible, interoperable, reusable
Evidence-based medicine and values-based medicine: partners in clinical education as well as in clinical practice.
Round Table with Questions & Discussion
– How do you see the integration of GP? The most natural starting point is the identification of conditions where GPs play a crucial role. Integration between GP and hospitals is very crucial. The exchange of information between GPs and hospital is equally important to insure the close follow-up of the patient and the continuity of care. For many patients, the visit to the doctor’s office is very important. Putting iPads on the waiting room to collect some data on the patient that could help the follow up is also crucial.
– Value based care has to be linked to payment and we need to reward institutions that can provide good quality of care. In Switzerland, an experimental article will be approved soon and a pilot project should be launched right after.
– How to manage the fact that people will select always the best surgeon on the list and never go to the last on the list? The transparency will probably be more on the institution level and not specifically on the single doctor. Institutions will be specialized and will do volume in specific procedures. The main incentive should be that healthcare providers offering the same medical specialty talk to each other and share best practices.
– Value-based care should be supported by the doctors or it could not be implemented. Start with clinician champions that can talk and teach to the others.
– Value-based care adds value to the patient file and knowledge on how to better care and follow up with him.