Collaboration of the 5P Leaders for Effective Healthcare Delivery. What does it take in Switzerland?
Part three of five in a series of ‘Growing the Collective 5P Value Pie in Health Care’ articles
This article is based on the narrative of my keynote lecture given upon invitation to the Swiss Healthcare Startups (SHS) Public Event on August 26th 2020 at the biopôle in Lausanne.
There is no better time to talk about health care than now — during a global pandemic.
Health care is very personal; it touches all of us. At the same time, it is also incredibly complex and globally interconnected. This year alone, health care spending is projected to be close to $4 trillion in the US; in Switzerland, the health care budget is surpassing CHF80 billion; and, globally in a 1000 people, 100 work in the health care sector. Many of whom have actually lost their jobs during the pandemic. This global health crisis painfully reminds us how deeply ingrained health care is into the fabrics of our economies & societies. If you think about it: a single virus propelled the world into the deepest recession of modern times.
Personally, after having worked many years both in the public & private health care sectors, I came to conclude that only if the top 5 decision makers in health care, patients — providers — pharma — payers — policymakers, rally behind a common purpose, realign interests & work together, will we be able to fundamentally transform & renew our complex health care systems.
A complexity that I have recently described as a Tango for Five. Or in other words, imagining an orchestra with 5 first violinists playing without a conductor. In health care, the 5Ps are independent decision makers on a daily basis, yet are rarely aware of their highly entwined interdependency. There are mostly bilateral relationships, occurring between patients & their doctor; physicians & pharma working on drug development; pharma & payers; and policymakers with payers & pharma, for example.
Over the years, a mostly transactional way of working in a so-called fee-for-service (FFS) system has led to an accumulation of bargaining power, silo-mentality in a 0-sum game, where actors are shifting costs to one another. But in addition to cost — even more so — we do have an issue of quality. Too much care, too little care, and the wrong care, which do not add anything to consistently create value for patients. A FFS instead that erodes quality, fosters inefficiencies and creates excess capacity.
The headlines are plentiful to single out villains. However, neither the problem nor the solution can be found in a single aspect nor in a single actor.
All share responsibility.
What we need is a holistic approach. And, we need 5P leaders to act as integrators and build bridges among each other.
So, the question is:
How can we maintain the virtuous circle of innovation with repetitive investments, scientific discoveries and therapeutic advances on the one hand? An innovation that has led to a tangible decrease of mortality in oncology for example and saved millions of lives since the start of the millennium. On the other hand, how can we cut through the vicious circle of increasing cost spiral, wasteful care delivery and skyrocketing bureaucracy driving inefficiencies? This is the unique quandary of the health care industry where a sheer amount of infinite scientific solutions needs to fit into a framework of finite resources.
I am saying: We do not have an issue of shortage of resource, but an issue of resources in the wrong place. What if we turned waste into a resource?
We cannot fix the problem with the tools, measures & behaviors that created it. Indeed, today’s resource-constrained environment is driving value-based principles, patient centricity & care coordination over the whole health spectrum. Value in the context of health care being defined as outcomes & results that matter to patients per dollar or franc spent. There are plenty of pilot projects progressing around the world, demonstrating that adhering to these principles is not only the right thing to do for patients, but actually is able to generate value for all 5Ps. In brief, for a system or a country to successfully transition to a VALUE-BASED HEALTH CARE (VBHC) model, 3 actions need to be prepared:
- DEFINING HOMOGENEOUS POPULATIONS: patients who are sharing similar needs because of comparable disease characteristics (ie, diabetes type I; diabetes patients with renal insufficiency; advanced colon cancer patients; hypertension with or without kidney failure etc) —
- DETERMINING OUTCOME MEASURES: meaning to define tangible metrics in terms of quality outcomes, survival, or response rates (ie, increase heart failure related survival by x%; decrease diabetes related complications such as wound infections by y%; number of patients who regain full mobility at 90 days after a hip replacement etc) —
- IDENTIFYING A TIMEFRAME: none of the two above measures would be really meaningful if there wasn’t a time limit bound to it; for example, the Atlanta Heart Failure Project set a target to improve heart failure related survival by 2022, and the Ontario Diabetes Pilot to reduce disease progression and to limit well described complications by 2021.
The principles of this value approach are of global validity. The implementation though will always depend on local 5P leaders — in light of political differences, cultural choices & historical health systems growth.
Now that we have seen WHAT needs to happen (VBHC) & WHO needs to drive change (5Ps), let’s shift gears to explore HOW the 5Ps can possibly make it happen.
In other words:
shifting a Tango for Two towards a Tango for Five, and moving a 0-sum game into growing the value pie in terms of 1+1=3.
How does it work?
After reviews of meters of bookshelves & spending hours of discussions with experts in the field, I am proposing three main levers that can be explored to gain momentum with this move:
- In absence of a conductor, the 5P independent constituents require a common PLAYBOOK that orchestrates their decision-making;
- In a growing value-based world with emphasis on healthy living & lifestyle choices, the power of the PATIENT & the health CONTINUUM — from prevention, to treatment, to long term follow-up — is coming into focus;
- Lastly, we need to find ways to accelerate the use of DIGITIZATION, artificial intelligence (AI) & machine learning (ML) to master the complexity, enhance efficiencies, and implement outcome measures.
First, one doesn’t have to search far to find a successful playbook for multiparty negotiations. Almost 50 years ago, Roger Fisher at Harvard Law School pioneered a master plan based on 7 principles for mutual value creation: Communication, Options, Legitimacy, Commitment & Alternatives, as well as Interests & Relationships. Investing time to build long-lasting relationships that will perpetuate beyond the actual transaction at hand, and investing efforts to understand each other’s interests & needs more deeply rather than assuming a positional opinion, are two of the key elements to success. This framework has proven its worth in prominent examples such as the breakdown of the apartheid in South Africa, as witnessed in this picture where you can recognize Roger Fisher standing next to Nelson Mandela. Subsequently, it has become very popular in many areas of business & politics alike. No reason that this concept wouldn’t work in the realm of health care. Together with many talented colleagues, I have personally been fortunate enough to witness the power of this interest-based framework in various cultural environments, and seen it opening doors at the 5P leaders’ table that were previously thought to be sealed & locked for good.
Second, there is much that health care can learn from other industries as it relates to the power of the customer & the importance of the customer experience. Be it the hospitality, airline or electronic device industry, they all have successfully reinvented their business models putting the consumer experience at the center. In a value-based health care model and in light of 2 mega-trends of the future — such as an ageing population & increasing number of chronic illnesses — the focus on prevention of disease as well as long-term follow-up & survivorship are critical elements to enhance value. Better Health is less Expensive than Illness, they say. Or, as L.S. Dafny & T.H. Lee elegantly summarized in a relevant HBR article: Put the patient at the center of care; create choice; stop rewarding volume; standardize value-based methods of payment; and make data on outcomes transparent.
Lastly, if we’d move the needle on health care, we finally ought to find ways to pick up speed with the advent of what the 4th industrial revolution toolbox holds. Health care has been late to show of digitization. What we need to do is use AI, ML & the digital armamentarium as an enabler to navigate the sheer complexity of health care; identify common patient populations; and help to measure health outcomes in a consistent & transparent way. We will hear shortly by some of the Swiss Health Care Start-Ups such as Collabree & Imito on what their contributions are to this digital journey in Switzerland.
Only two months ago, Dr Ezekiel Emanuel published an astonishing as much as intriguing overview of the top 11 health care systems in the world — worth a read for all interested health care experts who are passionate about improving health care solutions by learning from other countries and regions.
Looking at this International benchmarking, the Swiss system holds up very well. Yes. It is world-renown for its quality, wide patient coverage & provider choice, as well as for its innovative power. However, its unique challenges revolve around the fragmentation of the 26 cantons, which constitutionally own health care coverage. This represents one of the main sources of skyrocketing costs in a country that spends 12% of its GDP on health care. That number on its own though is of little meaning. What is of eye-opening meaningfulness is the weight this poses on a patient’s pocket. Out-of-pocket expenses for Swiss citizens have reached an average of 28% and as such rank 2nd highest after the US, as Zeke Emanuel reminds us. In line, Swiss residents are paying exorbitant premiums as employers mostly do not contribute to coverage. Albeit, Switzerland as a whole being considered a wealthy country, this translate into 22% of the Swiss population effectively not getting the required care when needed, and a number of low to mid-income families spending as much of their household budget on health than on rent.
The cantons have to pay more & more. The system will crack, because nobody will be able to pay the premiums & cost any more. Everyone agrees it is too expensive, but no key player –insurers, physicians, patients — seems willing to give up their advantage; writes Dr Emanuel as he looks across the top performing health systems in the world.
Practically speaking: when a patient is circulating from one canton to another (sometimes this is a matter of a few kilometers only), their treating physicians won’t be able to transparently share patient’s data because of mostly hard-copy chart-keeping and 26 different ways of capturing the data. In short, the lack of electronic data recording, insufficient data transparency and inconsistent outcome measures are fueling a culture of overtesting, overtreating & duplication of efforts.
However, in all of this, there is some good news arising on the horizon. Just before the pandemic lock-down earlier this year, the Swiss government launched a new strategic vision and practical roadmap, referred to as ‘Santé 2030.’
It outlines measures to address some of the key aspects I have also referred to herein:
redefining a new balance between federal coordination & cantonal ownership to increase the harmonization of data transparency & data sharing while leveraging digital enablers; emphasizing care coordination and patient-centric quality levers; and, focusing on the two mega-trends that come with the ongoing socio-demographic changes: an ageing population & the rising prevalence of chronic illnesses.
In summary — certainly — none of this is easy.
It is incumbent on us. It is incumbent on us as leaders to cut through the noise and accept uncertainty. Giving up some aspects of our rewards that were part of a historical system that created the unsustainable framework in the first place. Now, seeing so many talented & passionate 5P leaders around me, who are being persistent & resilient despite the debilitating incentives & frustrations triggered by failed attempts to fix the system previously, I remain confident that change is possible.
In addition to strong leaders, what we need is a strong vision and a practical roadmap. A plan that attempts to redress competing interests in a patient-centric, value-based model and that aligns leaders behind a common purpose. It requires to adopt digital enablers that help organize the complexity, using performance data, and to learn collaborative approaches. Coupled with political and societal will, we can do it. Collaboratively.
Be reminded what is at stake: we really do not have any good alternative.
Be the Change You Wish to See in the World, as Mahatma Gandhi said.
In the following panel discussion, it was my honor & utmost pleasure to welcome my distinguished fellow 5P panelists: Ms Hanna Boëthius, Dr Oscar Matzinger, Mme la conseillère Florence Bettschart-Narbel, as well as the three start-up founders of Collabree, Imito & Pharmabiome. The conversation revolved around three aspects: first, what are relevant value-drivers in Switzerland; second, how can we optimize digital enablers; and third, what are examples of 5P collaborations that could be adopted here.
During a 40minute lively debate including excellent comments & questions from the audience, this open conversation touched on five practical areas of possible action:
- Rebuilding Trust. We are facing a situation of mistrust between various parties: among 5Ps in general and between the public & private sector in particular. There was unanimous applauding to having both a patient and a policymaker view in the debate. Both actors not only being essential to any transformative work and any patient-centric system in health care, but them also providing substantial value-driving insights in the co-creation of required actions with providers, pharma & payers.
- Preparing regulations for digital enablers. Pro-actively involve policymakers in defining required regulation changes to enable digital tools & solutions such as treatment & adherence applications. For example, a novel tech device that helps with patient self-management, education & treatment adherence may require a revised regulatory framework since it has never existed before and certainly is not considered a therapeutic nor a medical device.
- Overcoming dogmatism and embrace opportunities for solutions that come from the private sector for application into public health care, or vice versa. Why do we need to reinvent the wheel when it comes to digitization? Can’t we learn from other countries? (ie, e-Estonia) Can’t we adopt solutions from the private sector even if the need is in the public sector? Linked to *1 above, what we need to do is identify concrete projects where 5P leaders from both the public & private sectors can co-create options that address needs from each of the 5P sectors.
- Considering an overarching committee which regroups members of the 5Ps such as a comité citoyen involving health care professionals with subject matter expertise. This group would be able to infuse a ‘3rd party’ look, act as both a neutral observer, and look above positional opinions. Coupled with subject matter expertise, it co-creates options for solutions that require rapid action, such as data transparency, data capture and harmonized outcome measures, to only name a few examples.
- Consider a ‘6th P’ acting as a peacemaker & honest broker. In highly confrontational scenarios where positional opinions are strong, this has proven to be effective, as showcased by the prominent example of Roger Fisher mediating in South Africa. Today — in health care, in Switzerland — I am sure that many of us can hold up examples where the perception of insurmountable barriers, lack of visible solutions and feelings of frustrations are reaching deep. Yet, we cannot possibly leave the situation as is, ever since we have understood what is at stake.
To conclude, my gratitude goes to Olivia Zollinger, CEO of SHS, who had the foresight to pull together this productive panel & audience. Together with the team at SHS, she is sharing the passion for interconnectivity, collaborative engagement and solution finding in health care.
Please contact anyone of us listed here above with any feedback, thoughts & ideas so that we can further evolve the dialogue, and, enlarge our community of practice towards a more connected 5P health care system in Switzerland.
