Player is loading...

Embed

Embed code

Transcriptions

Note: this content has been automatically generated.
00:00:00
you're a much um is the president isn't gentleman uh your colleagues it's it's a great pleasure being here
00:00:07
in switzerland i'm getting the opportunity to talk about value based house k. r. oscar quality
00:00:13
german you should be humble bringing up those topics but um i think there is there
00:00:19
is a lot of of of you know interesting developments we should discuss today
00:00:24
and i'm i'm i'm happy you were supposed to listen to me i brought a lemon
00:00:32
and full disclosure i have i've taken that from the industry
00:00:34
exhibition i will bring it back afterwards it's it's organic
00:00:40
and uh when i read this lemon actually i was thinking about what can you do with a lemon
00:00:45
can squeeze it into can drink can bring the stuff in it you can clearly to commute it
00:00:51
can you know make fancy drinks out of that but i remember when i was young
00:00:56
we were using the lemon juice as an as an invisible ink i don't know if
00:01:02
if if you have them that you know you you just use the lemon
00:01:06
juice you write something on a piece of paper it will disappear
00:01:10
but once you hit not to let paper you will read it so it
00:01:14
was a great thing that that we did um liked generations of children
00:01:23
in nineteen ninety five this gentleman here recorded on a
00:01:28
surveillance camera and his name was mike after willow
00:01:32
was rubbing two bands the same day in pittsburgh one in the morning one in the afternoon
00:01:40
of course he was he was caught by the survey and cameras and it just took half a day to get him the rest it
00:01:47
when he was arrested he said but i work the juice into didn't understand
00:01:52
it so what he did was actually he was squeezing lemon juice
00:01:57
was covering his face with a lemon juice and hoped to be invisible
00:02:03
to double check if you was truly invisible he was taking a polaroid picture and
00:02:08
somehow you know the polaroid camera was broken so it he he got a
00:02:12
blank blank you know paper out of that it's okay it's working
00:02:19
this is a kind of funny story but it's true it happened
00:02:24
and um the newspapers were writing about it in nineteen ninety six
00:02:31
by that time two gentlemen to social psychologist
00:02:35
from cornell university in new york city
00:02:38
we're reading about that they found that interesting the name of the two gentlemen was downing and kruger and dunning improve
00:02:45
there were thinking oh is there a pattern is there a pattern that people are doing something like that
00:02:53
and they started to do very systematic research on the question
00:02:58
is there a relationship between ignorance
00:03:03
and what people are doing and after a few yes um they were publishing a a breakthrough paper
00:03:12
where they introduce the so called dunning to that effect
00:03:17
but don't include the effects simply means incompetent but confident so uh what they
00:03:23
were actually finding out is that there is a pattern that people
00:03:27
who at are the least skilled and the least knowledgeable
00:03:33
i have a tendency to have the highest confidence
00:03:39
they describe it as mount stupid
00:03:44
and the mechanism behind that is that people who
00:03:48
are the least experienced the least skilled
00:03:54
have a tendency to underestimate the risks in what they are doing
00:03:59
and the same time they have a tendency to overestimate their own capabilities and as the third aspect
00:04:07
they typically don't asked the ones who are knowledgeable to help them
00:04:13
what happens over time a is the more you are getting experience the more you know
00:04:20
the more this confidences disappearing this is not simply in effect of humility
00:04:26
it's in effect of data understanding the environmental working in
00:04:31
data understanding the complexity of your daily tossed
00:04:34
and it takes a while to go through this valet before you
00:04:38
become a true expert you are skilled you are knowledgeable
00:04:44
you you know you you you feel good asking others for their help in case that we are struggling
00:04:51
and you get this let's say healthy self confidence that you need
00:04:58
here's a test if you want to find out if dunning who got effect
00:05:05
is at all meaningful for you in your life you can simply ask yourself the question
00:05:13
have i ever been in a situation where i was you know
00:05:18
insecure or regarding the risks of what i was doing
00:05:23
did i i have a had the feeling that i was over estimating that one capabilities
00:05:30
and did i have ah asked someone to help me because i was actually
00:05:34
appreciating his or her knowledge if this is true you are good
00:05:40
if you say this is bullshit
00:05:43
i never have seen something like that you are in danger you are probably yeah
00:05:53
a good example of the dining to that effect
00:05:58
here in switzerland particularly it can be seen a lot opponent
00:06:03
lot opponent is the dorado off of base jumping
00:06:08
and i'm pretty sure that most of you have heard about base jumping you know you wear these fancy wins youths and you
00:06:14
you know jump down from a rock or building or whatever and you hope to land safely
00:06:22
it turned out that this is the most deadly sports you
00:06:25
can do i think apart from climbing mount everest
00:06:31
so the mortality rate in in in base jumping is one in sixty pretty high
00:06:36
and since they are recording every based on that that has happened
00:06:41
since ninety eighty one also we have a very nice registry
00:06:45
and we see that this one in sixty is pretty stable is not changing
00:06:51
and you have these you know wonderful graphics illustrating how you
00:06:56
are actually dying several ways how you can do that
00:07:02
but it's very obvious that you know the true reason is the dining hall that
00:07:06
affect the ones who are the least experienced the lease skills have the tendency
00:07:14
to under estimate the risk of jumping to overestimate their own capabilities and they
00:07:19
never ask that's the reason why those are the most likely to die
00:07:26
there are these one hundred jump wondrous these guys whoever you you always
00:07:31
get it right those other once we have a very healthy risk
00:07:38
you know estimate and have a very good sense about their own abilities
00:07:44
but i don't want to talk too much about base jumping today with you let's talk about mortality
00:07:49
this is probably a topic which is much closer to your heart
00:07:56
it's not so easy to find good data on mortality in surgery
00:08:00
in switzerland but i found something and i would like to to share that with you what i found is the following
00:08:07
hank radically section of cancerous lesions tech protector me him you can protect to me what all
00:08:14
all this kind of stuff complicated surgery as far as i understand it's a molecular biologist
00:08:22
the mortality rate of the best hospital that is reporting mortality rates in switzerland is two point nine percent
00:08:30
the number ten out of those ten possible full reporting
00:08:36
as mortality rate of twelve point nine percent so this is a four point five
00:08:41
fold difference in mortality out of the ten hospitals who are reporting mortality
00:08:48
unfortunately this is not telling us too much about this kind of surgery in switzerland at all because
00:08:54
there are fifty three hospitals fifties rehearsals in your country we're doing a pack practically sections
00:09:03
for two hospitals are performing less than ten surgeries yeah
00:09:10
and they are not reporting any data
00:09:14
i leave it up to you to refer that to the dining progress fact let's look at colorectal we section
00:09:21
similar pattern number one reporting all point two percent the ones
00:09:26
were reporting other once we have higher case numbers
00:09:30
number sixty four
00:09:33
as a sixty one fold mortality rate
00:09:39
but again
00:09:41
this is only the sixty four possible for reporting data to ah hundred hospitals in
00:09:46
switzerland could do incorrect re sections and seventeen outperforming less than ten cases
00:09:53
same pattern in open heart valve replacement
00:10:00
nine full difference out of five possible for reporting fortunately you have
00:10:06
like twenty hard centres and i learned this morning that there's the next one to be open soon
00:10:14
and last but not least or taken with them surgery ten hospitals performing less than ten cases
00:10:22
this is reality of space health health care today which it is
00:10:29
euro called by many people across the world as one of the best healthcare systems that exists
00:10:38
and no matter if you get the pack radically section record rectory section or
00:10:44
open heart valve replacement mortality rate is always higher than base jumping
00:10:53
for those of you will not so interested in mortality rates
00:10:57
these are data on infection rates again you see
00:11:03
a huge spread of infection rates after colon surgery between zero
00:11:08
and forty percent and again a pattern those hospital who
00:11:12
do less are the ones who have the high rates of infection which is not surprising at all isn't it
00:11:24
so i'll
00:11:28
what does it mean for switch healthcare it means something about you know well this system you're working in
00:11:37
the hospital structures
00:11:40
of course you know the political aspects it
00:11:44
how this is actually driving the quality
00:11:49
in a system where everybody tries hard to provide less care
00:11:54
to patients everybody's trying hard this is a business
00:11:58
not of says the cynicism it's a i think the business where everybody tries to achieve great outcomes
00:12:06
if you put that in a broader context comparing switzerland to other countries across the world
00:12:13
you see that's what's our land is now kind of average
00:12:20
these are data on post operative partner we embolism
00:12:25
after hip replacements
00:12:28
you see a huge spread across the o. e. c.
00:12:33
d. and it's interesting to see that switzerland has
00:12:36
you know twice the rate of l. p. e. is then for example italy sweden or israel
00:12:45
is this a matter are often money
00:12:49
is the reason that you don't have the money to pay the drugs that you don't have the personnel
00:12:55
taking care of that well you have the highest rate of nurses in the o. e. c. d.
00:12:59
per capita you have among the highest rate of doctors in the o. e. c.
00:13:03
d. and of course you're spending a lot of money on health care
00:13:08
only the americans pay more than we do i learnt at this year's historic here because in two thousand eighteen
00:13:16
every swiss that citizen is spending more than ten thousand swiss francs per year on health care
00:13:25
so it's not a matter of money it's not a matter of ambition
00:13:30
it's certainly not a matter of training there is something else going
00:13:34
on that you have those quality issues at very high costs
00:13:42
some people believe that there are political reasons for that yes a
00:13:46
huge political d. date how we should organise healthcare systems
00:13:51
but what you see here is that no matter where you are
00:13:55
the picture is always the same united states healthcare spend higher than income inch t. v. p.
00:14:04
switzerland sweden germany netherlands inland and so on and so on actually we have a kind of
00:14:11
uh the excel sheet and we can just press the country where we
00:14:15
go to we will create this picture automatically it's always the same
00:14:20
the interesting part from my point of view is that
00:14:27
you know we all estimates the political aspect of health care very much
00:14:32
you know there are a lot of people say well we have to move into a a national health system we need to have
00:14:38
a public health system because public health is the best way to fix the quality and cost issues i was not true
00:14:45
sweden has a public system in it has a topic system same problem
00:14:51
the netherlands moved from the public system to private system
00:14:55
they get that i know
00:14:58
and the united states have probably the most competitive system at all
00:15:04
and they have a huge the the the largest problems
00:15:08
so the solution to this problem is from my point of view not to ask for
00:15:15
a different political set up we have to
00:15:18
ask ourselves very honestly how do we
00:15:22
organise healthcare and how are we competing and outcome yeah in in in health care
00:15:29
what are we competing for who is winning who's losing and why
00:15:33
and i would like to introduce a concept of competition that we have
00:15:39
develop at harvard that actually explains very nicely how health care works
00:15:45
and you know for the sake of the argument i i would keep it a little bit provocative uh forgive me
00:15:51
so i'll
00:15:53
this is switzerland and here are for stakeholder groups in the swiss healthcare system in
00:16:00
if it feels that are we can say this is germany or france or england whatever
00:16:07
we have a medical device company hospital we have health insurance and
00:16:11
we have doctors in private offices so what is happening
00:16:17
on a nice and sunny monday morning the device industry is coming around the
00:16:21
corner with a new device and um i've spent a couple of minutes
00:16:26
the other for or in this whatever industry exhibition there are a
00:16:29
lot of cool devices that come up handy beautiful practical
00:16:35
smart expenses so there's a lot of stuff every day coming out of this industry
00:16:42
and you know these guys are well trained to talk to the doctors to hospitals
00:16:47
to convince them to buy this stuff and sooner or later it will happen
00:16:50
so from the point of competition was happenings actually that the cost
00:16:55
that are crude here for developing for marketing for sales are going
00:17:01
to the hospital into the doctors so the costs are shifted
00:17:05
to the next level okay so doctors possible to using this stuff over time of course they will reach out to the health
00:17:12
insurances ellison everything is getting more expensive we're now using staples instead
00:17:17
of stitching we have a new generation of of of
00:17:21
heart else we have a new generation of whatever we're using tardy so we need money for that
00:17:27
and over time they will succeed they will get a higher reimbursement we see that reimbursement is increasing in
00:17:33
many areas this is by the way one of the reasons why the healthcare costs are going up
00:17:40
so the health plans now i'll get the money from the hospitals
00:17:44
and they have somehow to get rid of this money
00:17:47
of these costs so what could they do for example they reach out to the doctors in the private tactics
00:17:55
i mean they are not related to this problem but anyway you can can always we
00:17:58
just put two these two are the least likely to defend themselves and say listen
00:18:03
uh we have to do something we have to we and reduce your reimbursement
00:18:07
i think your current discussion about time aids terrorists is exactly that
00:18:13
is simply wants to reduce tariffs for outpatient care because they have
00:18:19
a cost issue at the health plans there's no logical reason
00:18:24
but what is very clear from other countries that have done that is there's
00:18:29
only one way for a doctor in a private factories to react
00:18:34
this is to increase volume
00:18:38
right now switzerland has the lowest number of patient visits per doctor
00:18:44
private air in private factories in the o. e. c. d.
00:18:49
in germany it's about two are in five times higher
00:18:53
it's not because german doctors lofty idea to spent only four and a half minutes with the patient is because
00:18:59
we have introduced your g. system already in two thousand for it
00:19:02
all the time we have wrote reduce terrorist so much
00:19:06
that now everybody is just trying to do volume volume volume volume so it's not
00:19:11
unlikely that you are moving into this direction as many other countries before
00:19:16
more cases shorter time a patient in the money
00:19:21
is back to the help line next that that's work on the d. o. g.'s
00:19:31
we have to reduce the payment particularly for these high volume
00:19:34
things the joint replacements the p. c. i.'s standing
00:19:39
this is what happens in germany every year now we see that
00:19:42
the terrorists ideologies for these high volume procedures are going down
00:19:48
and you start to introduce boldly you concept emulate research re
00:19:54
why do you do this in your hospital you have
00:19:57
to do it in ambulatory setting and by the way we are going to bring down the prices for that
00:20:02
typical mechanisms i'm not against ambulatory surgery but the way how
00:20:06
it is introduced in switzerland is pretty bored isn't it
00:20:14
and again the only thing the hospital can do is doing more
00:20:17
cases increasing volume and asking the device industry for discounts
00:20:26
in my experience as a hostile men chase this is what we are doing basically every single day
00:20:32
increasing volume pushing for more cases trying to get discounts negotiating with
00:20:39
health plans and so on and so on and so on
00:20:41
so this is a competitive model where the stakeholder wins who is the best in
00:20:47
shifting costs if you can shave your cost other stakeholders you will win
00:20:55
and and you see that this is check changing right now in germany to
00:20:59
health plans have been the most effective in in in um shifting costs
00:21:04
they have twenty eight billion euros as a surplus on their accounts right now
00:21:11
but you know ten years ago the hospitals were pretty wealthy and you know the health plans were
00:21:18
we're i'm actually in the deficits so you can do that for
00:21:21
ever the problem is twofold one problem is this model
00:21:27
is not leading to lower costs although everybody is trying
00:21:32
to shift costs around costs are going up
00:21:35
because you're a lot of things happening what driving cost small volume shorter time more devices
00:21:41
and so on it's on it's on this is a cost making the she
00:21:46
and secondly quality doesn't matter at all
00:21:52
nobody in this system is asking the question if any patient needs additional for peace
00:21:58
nobody is asking the question for the right indication no matter as asking nobody is asking the
00:22:04
question for complications other quality issues this is a
00:22:08
system that we call zero some competition
00:22:15
few examples
00:22:18
why do you have the highest number of joint replacements in all all the
00:22:22
c. d. is not because everybody is is climbing mountains every every day
00:22:28
it's because you have this system in place that is actually paying
00:22:33
a lot of money to those were doing don't the presents
00:22:38
and there is an industry behind it was pushing that there's nobody stopping it and now you can start to argue
00:22:44
in a country that is doing you know twice the number of of john for
00:22:48
persons than average o. e. c. d. countries if you are doing too much
00:22:55
and what does it mean for your patients
00:22:59
and if you use always the latest and greatest technology
00:23:03
and all the new devices and instruments and and and so on and so on
00:23:09
and if you become the number one market in europe for bringing those
00:23:15
you start um uh into the hospitals your becoming very expensive
00:23:22
this is the reason why you'll have a very high price
00:23:26
for many of the medical procedures that you are doing and there is no logical reason
00:23:31
why a joint replacement in switzerland needs to be twice as expensive as in france
00:23:39
if you put all this together zero some competition increasing volume
00:23:45
the problem of the prices plus the quality issues
00:23:50
that are again increasing costs in the system you know that you have to do something this is not sustainable
00:24:00
so tell and as much as many other countries is suffering from
00:24:05
serious quality and cost issues in health care full stop
00:24:10
no matter what people tell you about the great switch healthcare system and full access
00:24:15
into the hospitals you have a problem like most countries in the world
00:24:22
and the question is how can we fix it
00:24:28
first of all let's think a little bit what is actually driving the quality issues the
00:24:34
outcome variation health yeah i think it helpful to to discuss that a little bit
00:24:39
because when we talk about solutions first need to agree on what is a problem
00:24:47
when we speak to people who are in hell scared asked them what is actually driving
00:24:52
i'll come variation quality differences they say well typically
00:24:57
three things first of all the patients
00:25:01
patients are different and you have everybody of us heard this you know but i have
00:25:05
the most difficult patients i'm university hospital i'm can't wanted to die i'm the
00:25:09
place where they sent all these difficult cases that's the reason why my quality numbers
00:25:15
might be different than in others and this is true this is true
00:25:20
we cannot compare one hostile to the other without proper risk adjustment no question
00:25:25
so we have to understand what is actually the patient cool what we're taking care
00:25:29
of how it's developing and how can we achieve good outcomes in those groups
00:25:36
and again remember the dining frugal effect a second aspect products particularly in a
00:25:43
country like switches like switzerland where that has a great tradition in in
00:25:47
wonderful net tech products over decades it is important that people think about
00:25:53
infrastructure to i used to write devices to get the right supplies
00:26:00
to have the right technology sweets that i need so yes products might play a role
00:26:07
when we want to achieve great outcomes and thirdly a because the question off kept factories
00:26:16
there are differences in the way how doctors and nurses are treating patients
00:26:25
and there are differences in individual skills and experience spoke about that very early
00:26:32
but there is also you know a difference in in in scientific evidence we're doing a
00:26:36
lot of things in house care where we don't have the scientific evidence today
00:26:41
that makes it difficult and of course differences in medical training and so on so this
00:26:45
is actually the drive us let's just reflect a little bit about those drivers
00:26:51
this is a slide that i got from from um
00:26:55
you about the gay from from the residue of the rake someone who's interested in in in multi mobility research
00:27:02
i find it very interesting one actually it looks at a average
00:27:08
primary care cohort in united kingdom people older than
00:27:13
sixty five and they were actually looking
00:27:16
in the data that are available in and ages in in to find out
00:27:20
to what extent have patience was diagnosed with
00:27:23
one of those medical problems have other
00:27:28
medical problems as well so the how do you have to read it
00:27:32
out of those people what diagnosis coronary artery disease fifty
00:27:36
two percent also have hypertension out of those
00:27:39
patients who have a twelve the relation twenty one uh a fourteen percent have depression depression
00:27:48
and so on and so on if you look at this you will see that
00:27:52
the average the average every patient older than
00:27:55
sixty five has around five commodities
00:28:02
and this is the challenge of health care today and tomorrow these are probably the patients you taking off and
00:28:10
let's face it we have never been trained for
00:28:16
you know how to take care of patients we have five different lighting conditions sometimes it's not even clear
00:28:22
what do you do with a lady was diagnosed with c. o. p. d. and osteoporosis
00:28:29
some people say well i get for quarter creates anyway other say i would never do it because of the osteoporosis
00:28:37
if you look into the data you will see very random decisions that are happening
00:28:42
and now add another and another and another medical condition you will learn that
00:28:47
taking care of these patients alone is a big challenge but doing that
00:28:52
in the context of surgery so putting those patients under stress
00:28:58
this is dangerous
00:29:01
again do we always
00:29:05
estimate the risk the right way we always estimate our own it capabilities in the right way
00:29:12
i think that this kind of picture is actually a asking the question for k. integration
00:29:21
i think that is the only us answer to this question is
00:29:24
how can we work much closer together as medical specialities
00:29:30
in certain medical conditions and patient quarts in order to understand what we were doing
00:29:38
and it also tells me we need to measure data we need need to systematically measure
00:29:42
outcomes in order to understand what is really happening with those patients in we'll word
00:29:49
right now we're at the beginning of that
00:29:53
cataracts i was that person experience that i had when i was um
00:30:00
responsible for for fifteen apostles in germany were doing
00:30:04
around seven thousand it any replacements for yeah
00:30:08
well i spoke to the doctors it the services and ask them about you know
00:30:13
you do don't replacement there was that well this is a very very standardised procedure we all do it the same way
00:30:20
it's not worth looking at it
00:30:23
and we had the opportunity in a in a study that we did together with harvard business
00:30:27
school on costs to do a very detailed analysis of what i learned was actually
00:30:32
did the depot willow the more we sort of the differences uh the and there was zero standardisation
00:30:39
you know one hospital was using um the sedation now there's didn't want the
00:30:44
the side hectic a static nerve block uh one was using um the
00:30:50
implant a the other one another a blind uh the whatever the more
00:30:55
you were looking the more your soul differences in kept factors
00:30:59
so we always realise that you know because it was a tech spoken there are
00:31:03
guidelines everybody's doing the same no we do not the same you doing
00:31:06
vastly different things and we typically don't know very well how these differences are
00:31:12
influencing the outcomes of operations if we don't measure we don't know
00:31:18
that's one of the reasons why we see the big differences within the
00:31:22
o. e. c. d. between countries because they are schools of thought
00:31:26
traditions that are different from one generation to the other
00:31:30
that could be dramatically different between neighbour countries
00:31:35
joint replacement in germany needs to stay for ten days in no acute care setting
00:31:41
and because people don't love to be for ten days in the acute care setting you need to him although
00:31:46
i stand so we do everything that we can in germany to him over lies our joint patients
00:31:51
in denmark just across the corner huh they do the same in three days
00:31:57
this is a cat tradition doesn't make any sense and these are the tools
00:32:02
that we're using in germany in order to in mobile ice patients
00:32:08
we put them in in it we would put cafeterias in them we put them
00:32:11
on passive motion machines all this kind of stuff this is all creating costs
00:32:17
but if you look at the impact on how cans if you look into
00:32:20
registries does it really make a difference you will find very little
00:32:27
my doctor's last to use spacesuits and the argument was always like
00:32:32
you know this is only a one hundred fifty euros
00:32:35
single use device but if i only prix went one in a hundred infections
00:32:41
that's worth the money yeah i mean this is a nice sets approach
00:32:45
but if you to comprehend any you actually burning every year the money worth and robots
00:32:56
plastic greats
00:32:58
it's wonderful tradition and the the ritual to put this past the great around
00:33:02
the like before you do the first incision but is there really data
00:33:06
to date a real world data registry data showing that there is a positive effect
00:33:12
very little that's the reason why we have some countries we're doing that and others never do it
00:33:19
and the implants story is probably the most striking one
00:33:24
this is a study um that um has been done by a group
00:33:28
of people from from the netherlands and they actually did a matter research where they looked
00:33:33
at all the studies and all the registry data record found around the five let's say large dick
00:33:41
inventions innovations in joints in the last ten yes
00:33:47
and the conclusion is very clearly we did not find convincing high quality evidence supporting the to use
00:33:54
of five substantial well known and already implemented device innovations in of the peaks
00:34:04
if we spend our money for cat traditions that
00:34:10
are not automatically related to better outcomes
00:34:14
if we spending thousands and thousands of additional costs on product that never prove
00:34:21
outcome benefit in real world we will put our system under stress
00:34:27
and what we typically do is that we have to rationalise here somewhere else
00:34:34
i know that there's now this discussion in switzerland about the global budget and we know
00:34:39
from data that people in switzerland because of the high costs are starting to
00:34:46
you know avoid taking drugs not going to the doctors sell wherever we spend our money
00:34:52
we take it away somewhere else and we typically get those in the population
00:34:59
who are the least helpful to read the most vulnerable the ones with a chronic diabetes and so on and
00:35:06
so on this is a pay it at the price that we pay so how can we solve that
00:35:13
the idea to solve that came from harvard michael porter wrote this bloke redefining healthcare twelve years ago
00:35:22
he is not a doctor and he has very little ideas about health yeah but he was looking at the
00:35:28
competition side the zero some competition that we were discussing
00:35:32
earlier and he said well we have to compete
00:35:36
not on cost shifting the whole idea of cost shifting is wrong the
00:35:41
central golden healthcare is value for patients this is something that
00:35:45
we all can agree on value is the health outcomes that matter
00:35:49
to patients so the ability of a patient to walk
00:35:54
to enjoy life to sleep to eat to participate in normal life to be pain free not to be depressed
00:36:00
and so on and so on so the high health outcomes that matter to patients it's our goal
00:36:06
yesterday my neighbour it it didn't asset to me w. was always michael this
00:36:11
is always the goal for everyone and healthcare to improve someone self yes
00:36:16
and of course we all understand that this comes at a price
00:36:21
so value is the outcomes that not adaptation that we chief
00:36:27
divided by the costs that we need to spend in order to achieve those outcomes
00:36:32
out comes over cost so if we could organise healthcare
00:36:36
and the way that we are competing on value
00:36:40
you know the institution the doctor the insurance wins who
00:36:44
has the highest value the best outcomes at the
00:36:47
most reasonable cost then we would be good this is the idea of the only based health care
00:36:55
and this is the solution i would like to discuss with you because there are a
00:36:59
lot of things going on in switzerland it up pointing to the right direction
00:37:06
yeah just starts not of the political side there is a political side
00:37:10
but let us start with our selves let's talk let's talk about care delivery because the idea
00:37:16
of philly based health care is an idea about how to we organise care delivery
00:37:22
and what michael puerto basically says is there are six things
00:37:28
that we need to do
00:37:31
very simple six aspects and equal to the subject agenda first of all these
00:37:36
as if we want to take care of patients and their medical problems
00:37:44
and we understand that these patients are facing multi mobility
00:37:49
and all these other challenges we were talking about then
00:37:52
we have to organise ourselves in integrated care units
00:37:57
so for someone with the back pain problem we don't need justin also peacock
00:38:01
too knows how to do second surgery we might need a neurologist
00:38:06
we might need it psychologist we might need to fit your therapist we might need um
00:38:12
and internal medicine doctor so we need a group of doctor that is working closely together in order to sauce
00:38:19
a group of patients suffering from a medical condition this is applicable for all
00:38:24
medical areas in some areas of health care we are starting doing that
00:38:29
we have spine centres were trying to bring those experts together
00:38:34
we have some colleges santa's will bring him psychologists
00:38:38
surgeons and oncologist so we see that there
00:38:41
is a movement into the right direction but we need to be much more radical
00:38:47
and again the goal is the outcomes that matter to patients
00:38:51
and not to chief certain random medical data point
00:38:57
secondly and from my point of view the most important one we have
00:39:01
to measure the outcomes for every patient ideally also the costs but
00:39:06
i would like to emphasise the outcomes only if we were systematically measuring
00:39:11
for every single patient the outcomes over the car is cast
00:39:15
cycle we really learn if we helped us patient
00:39:20
and what we will see is very clear we will see deviations we'll see differences i mean just by looking at these
00:39:26
few or data at the beginning we already so big variation will see the big variation but this is great
00:39:33
because variation is a enter point for us to start to improve to learn to get better
00:39:42
thirdly we have to move into w. base reimbursement models it doesn't make any
00:39:47
sense that a hospital that is doing more or less use the surgery
00:39:53
it is created a lot of complications get as much money as a hospital who is selecting the
00:39:59
right patient it's achieving great outcomes doesn't make any sense in the current system the financial success
00:40:07
and the value for the patients are pretty much disconnect it
00:40:13
we have to connect it and i would like to talk a little bit about value based reimbursement later
00:40:18
we have to integrate between separate facilities have to bring together a facilities
00:40:24
were taking care of similar patient groups that don't work together
00:40:28
and once we have a good solution in place we have to expand them
00:40:34
very systematically rather than having you know three hundred plus hospitals spread over
00:40:40
a relatively small country and hoping that they will one day
00:40:45
learn to focus into close down the once would nobody no yeah nobody needs you know you need to do
00:40:51
that very actively like in denmark right now of course today we need fold is a i. t. platform
00:41:00
this is a political side in this is work that we're doing with the with the web for the world economic forum intervals
00:41:06
believe it or not there is a work stream within what economic
00:41:09
forum on value based health care since uh two thousand fourteen
00:41:13
and they are very systematically industry leaders from hospital health
00:41:18
ministers from the industry a net take them out
00:41:21
family history they are thinking very systematically how can we
00:41:25
transform health care systems politically into this right direction
00:41:30
and i like this picture because it explains faces face one is individual organisations begin
00:41:37
measuring quality and reducing variation of patient outcomes that result from treatments products
00:41:45
that's the way out starts
00:41:48
five years ago in the united states um partners healthcare so the break ins and bastion
00:41:54
started to measure systematically prawns the beginning a lot of people were shaking their heads
00:42:00
now it's a stand out now every big healthcare system in the united states has it from program
00:42:07
cleveland clinic started already in the seventies with it
00:42:12
phase two outcome metrics a standardised and once you have standardised data you can start to
00:42:19
compare you can start to risk it just you can learn across borders across facilities
00:42:27
so that's the face of comparison something that happens for example in the netherlands right now
00:42:32
in other lands we have a standardised way how we measure outcomes in heart
00:42:36
surgery every possible is doing that these data are shared and compact
00:42:42
in germany if you want to be certified as a prostate cancer centre there
00:42:46
are one hundred thirty five prostate cancer centres you have to measure
00:42:50
systematically for every patient page report outcomes data will be transparent over the next years
00:42:56
phase three public reporting create incentives financial non financial that means
00:43:03
data become available to the public you have websites ward doing some of that
00:43:10
i would say it's a beginning it's too complicated it's not all relevant on in it but
00:43:15
if it gets traction you will see that hospitals and doctors are starting to move to do things
00:43:21
differently and of course the financial incentives are the reimbursement malls i going to talk about
00:43:26
last but not least we hope that we move one day insistence
00:43:30
that are totally focusing on value rather than costs and volume
00:43:36
just a few example is is a score card it is used for
00:43:41
joint replacement surgery in saigon sky which is the university hospital in gotham burke in sweden
00:43:47
you see that they very systematically track for every patient a number of outcomes
00:43:53
most of these outcomes are actually collected in the national registry
00:43:58
this is a well sort of swedish healthcare system they have more than a hundred
00:44:01
national registries where they share the state um make them transparent and public
00:44:06
and credible source for research but also for improving and learning
00:44:12
this is a screen shot from boston that i got this morning bustle is now the places
00:44:18
with the land that is starting to introduce systematic outcome measurement for certain patient groups
00:44:25
again this is not a peak service here we do work and breast cancer
00:44:29
they are planning to move into other um i'm colour jekyll this or this
00:44:34
and and and also in heart surgery so this is happening today
00:44:39
and we know that the records is and also i'm working on that topic
00:44:45
standardisation we believe very much that standardisation is important because
00:44:49
you can learn so much particularly cross corpus i spoke about different cat traditions
00:44:54
this is an exciting opportunity to learn from other countries from institutions who are trained in
00:44:59
a different way maybe they do things but i maybe they do things just differently
00:45:05
and in order to drive that we have or um we have started this institute i charm that much i got caught was mentioning
00:45:13
this is a nonprofit organisation that brings together leading physicians from all over the world with patients
00:45:18
without can expert and they are defining standard sets that can be used for free everyone
00:45:25
in order to enable data collection and data comparison
00:45:31
as you can see these are these sets they're
00:45:35
typically covering different aspects of outcomes here is
00:45:39
a you know a logical hierarchy uh outcome hierarchy that has been introduced by michael puerto
00:45:45
i'm worth meeting it's a thirty pages thirty pages article in during the
00:45:49
job of lettuce and written by an economist happening very rarely
00:45:54
this explains you in in detail how we have
00:45:57
to measure outcomes systematically for different medical conditions
00:46:01
and i charm is reflecting this hierarchy in their outcome standard sets
00:46:07
very pragmatic keep it simple keep it easy we have now
00:46:11
twenty three outcomes sets ready covering more than fifty percent of the global disease burden and we're working on that
00:46:19
public reporting you have something that's coming up private initiatives in in in
00:46:25
a um switzerland also some national data from your own health ministry
00:46:31
but we see that some countries are going much further
00:46:34
this is from from an entertainment entertainment is reporting
00:46:40
outcome data for every service who is taking care for example on don't of joint replacement patients
00:46:47
and you can click on these um you know um items here and then you get really detailed
00:46:54
information and what you see is the more you up publishing these data more patients are
00:47:00
taking decisions to go to the right provider and the
00:47:03
more we see hospitals are improving those issues report
00:47:09
describing how hospitals in u. k. have used the problems data from patients in
00:47:15
order to systematically improve the services for them was a great learning experience
00:47:21
last point how do we actually reimburse k. r. in the value
00:47:27
based health care world certainly not with your g. per case
00:47:33
this is a model that has been introduced already in two thousand and seven in sweden actually a model
00:47:39
where they pay a bundled price including the pretty impossible
00:47:43
and the possible possible services for joint replacements
00:47:48
and there is a complication guarantee included into that
00:47:53
and three point two percent of the payment is actually retained
00:47:58
in only paid off if you'll need certain quality issues
00:48:02
um they didn't evaluation of this program um a couple of
00:48:06
years ago and what you see is complications went down
00:48:11
cost per patient went down so i'll looking at these value equation outcomes went up cos
00:48:17
went down value goes up a last and most exciting example that i have
00:48:24
this is the reimbursement model for spine surgery in sweden in stockholm
00:48:30
it's not the future it's today it's happening so if you do
00:48:36
by surgery in stockholm maybe you do it on the neck to me you get a payment
00:48:42
which is a prospective tenant like d. r. g. you get kind of base payment
00:48:47
you get an individual adjustment for the risk
00:48:53
off the individual patients so they look at the patient profile h.
00:48:57
gender smoker nonsmoker awful on pain and on and on
00:49:01
compare those data with a national registry and depending on the wrist
00:49:05
level of the patient you might get an individual adjustment
00:49:11
in this case here you get for example five hundred forty eight euros less
00:49:16
because the patient was a less difficult case but now the interesting piece
00:49:22
six months after surgery the national registry is reaching out to the patient is asking how
00:49:29
are you doing how is your pain level how is your quality of life
00:49:35
and depending on this question the hospital will receive a performance payment
00:49:44
and in the best case you can get up to
00:49:47
thirty seven percent class on your current payment
00:49:54
and in the worst case you can lose up to twenty four percent
00:49:59
so imagine no we're out that you are doing surgery in six months later
00:50:05
depending on the patients quality of life your payment will be
00:50:11
thirty percent high or twenty percent lower than expected
00:50:16
also think about what does it mean for the manager of the hospital
00:50:22
this is the reality in sweden today and again if you look at the data what you see is
00:50:28
doctors are getting more careful in doing
00:50:33
you know the the um use the surgery they are getting
00:50:37
much more attentive in doing the post hospital care
00:50:41
yes spending much more money on um on patient addiction and also on rehabilitation
00:50:50
i would like to finish my provocative statement and
00:50:55
as they are called asked me to be provocative so blinded to hand by a quote from the other built
00:51:04
came from north germany but he was actually spending most of his professional time in switzerland
00:51:11
and he said soon there will be a time that our scholars and colleagues will not be satisfied with general
00:51:18
comments on quality instead they will call any doctor shot
00:51:22
on who's an able to quantify this medical outcomes

Share this talk: 


Conference program

Recommended talks

Medirio : améliorer le traitement du diabète
Irio Calasso, CEO de Medirio (Suisse)
6 June 2014 · 12:11 p.m.
Nutrition, metabolic health, cancer and NCDs
Elio Riboli, Imperial College London, England
28 Sept. 2017 · 2:27 p.m.