We know what the ideal healthcare system should look like
Imagine a healthcare system in which the patient is the most empowered member of the care team.
Healthcare delivery is seamless, efficient and user-friendly for both patients and clinicians, and every component of the system contributes directly to a single goal: the outcomes that matter most to the patient. Medical practice is data-driven and technologically sophisticated, enabling a continuous self-sustaining flow of evidence-based, translational innovation and improvement; the system is dynamic and continuously able to learn from itself.
All stakeholders, regardless of functional area or geography, use the same global currency and target the same bottom line: the outcomes that matter most to the patient. Stakeholder relationships are transparent, there is no information asymmetry, and there is supreme confidence because all incentives are aligned. Payers know that every penny spent can be linked to a positive outcome for the patient.
Products and services are, similarly, built and procured based on how well they target the outcomes that matter most to patients: this targeting of patient outcomes is the very impetus for innovation. Local, regional and global outcomes variation is minimal, and patients all over the world receive roughly the same positive outcomes no matter where they seek care.
And finally – whether viewed as a human right or a product – “healthcare” that delivers excellent outcomes is accessible to all.
The ideal healthcare system focuses on a single bottom line
When we think of the ideal healthcare system, these two words come up repeatedly. Whether you are a patient, provider, payer, government, professional medical society, or life sciences company, your goal is to produce the best possible outcomes for patients. It is the single bottom line for all stakeholders across the industry.
Many of today’s healthcare systems are set up to fail because they don’t focus on this bottom line
Many would argue, therefore, that healthcare should be simple. The reality is that – broadly speaking – healthcare lags far behind other industries. It is fragmented, inefficient, heterogeneous, and highly political, with a notable disconnect between design, delivery and result.
Why? Because “patient” and “outcome” are not the engines that drive the healthcare systems of today. Neither patients nor caregivers are empowered with standardised outcomes data. Instead, we tend to focus on process and proxy data. Where outcomes are measured, data definitions are heterogeneous or our targets are too superficial – e.g. mortality rates or length of stay in hospital, but not quality of life or functional outcomes – making it difficult to use data to learn from each other or to go further for our patients.
Healthcare systems are not designed around end users; most find them very difficult to navigate. Healthcare stakeholders have different goals that may or may not eventually contribute to better patient outcomes – for example, the key performance indicators for a hospital and a payer tend to be wildly different, leading to misaligned incentives in payer-provider relations.
Neither products nor services are procured generally based on the outcomes to which contribute; price points historically have been arbitrary and based on willingness to pay, rather than long-term value.
Finally, outcomes variation is significant – not just globally but also within localities – often a reflection of variations in practice. For example, Aravind Eye Hospital in Tamil Nadu, South India, achieves some of the best outcomes in the world for cataract surgery – better than those in some of the most advanced healthcare systems in Western Europe and the USA. However, most other local hospitals in South India do not. Another example is the Martini Klinik in Germany, which achieves world-leading patient-centred outcomes – e.g. low rates of urinary incontinence – following radical prostatectomy, through focusing on outcomes – in fact, significantly better than the German national average. Whilst this is great news for the Martini Klinik, it again also reflects the fact that excellent outcomes organically do not become the norm in an environment that fails to facilitate them.
This will have broader consequences for society
A quick glance at the economics of healthcare tells us that whilst costs are rising, outcomes are failing to keep up. Advanced economies are struggling to cope with the rise in chronic diseases and ageing populations, but only account for around 20% of the world’s population. How then, will the other 80% of the world – in low and middle-income countries – cope as they follow the same epidemiological curve? How will this affect us more broadly as a civilisation? The status quo is unsustainable and the impending societal spillovers concerning. Indeed, as more and more ‘people’ are getting on (and staying on) the healthcare conveyer belt and becoming ‘patients’, healthcare systems are struggling to stay afloat – from both an outcome- and cost perspective.
We are starting to see a healthcare revolution that will tackle this head-on
By focusing all aspects of healthcare design and delivery on our desired result – patient-centred outcomes – we can achieve conceivably the ideal healthcare system described above and also offset the ever-expanding chasm between outcome and cost. Stakeholders from across the industry have already begun taking active steps towards this ambitious goal, with a view to revolutionising healthcare around outcomes and value.
The first step is to define the outcomes that matter most to patients for all medical conditions. These ‘definitions’ need to be standardised globally so that every healthcare system in the world can measure the same outcomes in the same way, generating homogenous and comparable data on performance towards a common end goal – the outcomes that matter most to the patient. Since 2012, the International Consortium for Health Outcomes Measurement (ICHOM) has been championing the development of globally-standardised, patient-centred outcome sets around different medical conditions for all global healthcare systems to measure and begin generating data.
This real-world data on outcomes will be used to innovate, improve and reshape the entire spectrum of healthcare – from clinical practice and service redesign to drug development and the procurement of medical technology. Where positive outcomes exist, we can investigate the processes leading to those outcomes and make these our gold standard practices. Where outcomes are poor, we can discontinue or modify practices. On a broader scale, we can reinforce the components of a healthcare system that deliver positive outcomes and remove any wasteful components that do not. We will use outcomes data to produce global benchmarks, to learn from the best, and to raise the overall standard of care, reducing outcomes variation and shifting trends towards the best performers. In other words, we can begin to sculpt an inefficient, combative and chaotic healthcare ecosystem into one that exudes focus, value and harmony. Outcomes data will also provide the platform for greater precision medicine of previously unparalleled phenotypic resolution.
Naturally, as different stakeholders all begin to focus on the same common goal – patient-centred outcomes – intra and inter-sector collaborations will increase in both quantity and quality. In the state of Michigan in the USA, Blue Cross Blue Shield’s Collaborative Quality Initiatives (CQIs) have brought together state-wide communities of providers around different medical conditions. These providers share openly their outcomes data with each other at consortium-wide meetings to facilitate learning, best practice identification, and practice improvement across the provider network. The CQIs are funded by a single payer – Blue Cross Blue Shield – and championed by the University of Michigan – bringing providers, payers and academia together around this single common goal.
In Europe, the Innovative Medicines Initiative (IMI), EFPIA, and European Union are championing the development of pan-European translational platforms for patient-centred outcomes data by bringing together institutions from life sciences and academia.
These two stakeholders – frequently at odds with each other – are beginning to develop more constructive collaborations based on this single common goal. As the targeting of this shared goal becomes the norm across the industry, different players will become more transparent about what they are able to achieve, reducing information asymmetry for all.
Outcomes-based healthcare is an adaptable concept: from Stanford Health Care in the Bay Area of California, to Aneurin Bevan Health System in Wales, to the Victorian Cardiovascular Outcomes Registry (VCOR) in Australia, providers and registries all over the world are beginning to measure outcomes routinely.
Payers such as Stockholm County Council in Sweden have introduced bundled payment models that reward positive outcomes across care cycles. CMS reforms in the USA – specifically Alternative Payment Models (APMs) and Merit-Based Incentive Payment System (MIPS) under the Medicare Access and CHIP Reauthorisation Act (MACRA) 2015 – are shifting payer-provider relations from volume to value. Professional medical societies – in collaboration with payers – have built national outcomes registries in the Netherlands via the Dutch Institute for Clinical Auditing (DICA) that have planted the seeds for improvements in outcomes and cost reductions.
Pharmaceutical companies have begun to build outcomes-based contracts with payers – just a few examples from 2016 include the drugs Entresto (Novartis), Repatha (Amgen) and Praluent (Sanofi and Regeneron). MedTech companies, such as Medtronic, have evolved their global strategies to focus on value and outcomes – both through product development and the offering of integrated health solutions.
Where procurement is concerned, the passing of the Directive 2014/24/EU by the European Parliament in 2014, means that public authorities are now encouraged to evaluate tenders using a value-based framework – that is, the consideration of both outcomes and costs over the long term.
As the industry focuses more on outcomes, costs will reduce naturally – that is, wasteful components (e.g. inappropriate interventions and complications) that do not contribute to positive patient outcomes will be whittled away. True best practices will become more widespread and the high cost of managing poor outcomes will reduce. Resources saved can be used to reach more people and expand access to healthcare. Through standardisation, we can, incredibly, deliver more personalised care through the redistribution of saved resources.
The entire healthcare industry must walk this path to a Healthier Future together
Patient-centred outcomes are a new form of ‘truth’ in the healthcare industry. In focusing our efforts on this single bottom line, we will begin to deliver high-value healthcare for all involved – the best possible outcomes at the lowest possible cost. We have mapped the path to the ‘ideal’ healthcare system, but this revolution won’t happen overnight. The entire industry must walk this path to a Healthier Future together, from defining what success in healthcare is for all stakeholders, to determining how to pay for it. Weaving the thread of patient-centred outcomes through the design and delivery of healthcare will give us the results we are all seeking to achieve – sustainable, accessible, and high-quality healthcare for all. And underlying all of this will be the ever-growing and increasingly powerful engine of patient-centred outcomes data.11