Академический Документы
Профессиональный Документы
Культура Документы
Final Documentation
Sweden has historically had a very strong reputation for it's clinical research. Its importance for the country
through contribution to a productive health care system as well as the development of both major BioPharma
and MedTech companies is uncontested.
Over the past years several investigators have documented that Sweden's position in clinical research is
deteriorating. The reasons are many and several excellent suggestions on how to address the situation have
been proposed.
In 2008 a leading Swedish industrialist Carl Bennet gathered the 50 most senior leaders from
Payers/providers, from Academia and Industry to discuss the situation and propose actions to Government.
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Aug 18 2009 the same group was invited to discuss a concrete proposal and plan for action. In preparation a
BCG team was commissioned to assess the potential importance of Sweden's quality and patient registries.
The team formulated a 10 year vision, translated this into a concrete governance model and a 10 year
implementation plan. The project was jointly sponsored by AstraZeneca and Carl Bennet AB and executed
during 10 weeks May-July, 2009
A central insight in the project is that Health care in the Western countries needs transformational change in
order to improve productivity and secure that the broader population can get access to high quality care and
innovation. This transformation will not be successful if the motivation for clinical staff is efficiency and cost
containment. In order to mobilize the base of the pyramid in the transformational efforts the focus has to be
the quality of care for the patients.
Define a 10-year vision for how Sweden could take a leading position internationally in
value based healthcare
Define Sweden's current position in an international context, key strengths and barriers
to change
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Describe key actions, timeline and stakeholder actions required to deliver on strategy
Engage key stakeholders to test support and secure well founded recommendations
Providing high quality healthcare at reasonable cost is one of the most pressing issues facing
industrialized countries today
Unsustainable growth in spend across countries, exacerbated by current downturn
Sweden with additional challenge from drop in clinical research and healthcare industry activity
Emerging health care "value paradigm" will increase industry productivity by focusing on outcomes/cost
Cost-focus needs to be coupled with focus on outcomes to secure strong engagement by practicing
clinicians in the required industry transformation
Sweden with ~5 year head-start in new paradigm due to unique quality and patient registries
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
With shared vision and a coherent national strategy, Sweden could build world-leading platform in value-
based healthcare within 10 years
Positive and strong incentives to develop effective care for patients through transparency on performance
Increasing clinical demand for innovation to improve care performance will enhance "translational" links
between basic research and clinical practice
Platform for industry to develop and test products meeting market requirements for healthcare productivity
and safety
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
discussed with all key stakeholders
>70 interviews
...but all agree coordinated efforts are lacking Proposal built on strengths of current model
"We see huge potential and we are realizing Roadmap allowing for paced implementation
some, but we lack a joint vision to work towards" Interdependencies few but important
Providers and other stakeholders can
"We have seen definite cases of 'turf wars' " contribute independently
"We're afraid all these uncoordinated efforts can
cause fatigue and make us lose momentum"
This material contains copies of slides prepared by members of The Boston Consulting
Group, Inc, for the seminar "Sweden as the international leader in outcome based
healthcare", held in Gothenburg August 18th, 2009. A list of all the participants at the seminar
can be found in Appendix.
The market and business case estimates contained in this presentation are based upon
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
standard methodologies using public data, market interviews and assumptions derived from
the insight gained during the project and data entrusted to The Boston Consulting Group
(BCG). BCG has not independently verified all of the data and assumptions used in these
analyses. Changes in the underlying data or operating assumptions will clearly impact the
analyses and conclusions
Starting position
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Way forward
Appendix
Per capita HC exp 2006 Per capita HC cost 2006 Per capita HC cost 2006
Index 2,650 Index 2,250 Index 1,850
(1992=100) (1992=100) (1992=100)
300 300 HC Cost
300
HC Exp GDP
GDP HC Cost
200 200 200
Wages1 GDP Wages1
Wages1
100 100 100
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
1992 1995 1998 2001 2004 2007 1992 1995 1998 2001 2004 2007 1992 1995 1998 2001 2004 2007
Index Per capita HC cost 2006 Index Per capita HC cost 2006 Index Per capita HC cost 2006
(1992=100) 3,150 (1992=100) 5,351 (1992=100) 3,150
~-25%
+4%
300
400 4,000
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
200
100
0 0 0
Average 95-97 Average 04-08 00 01 02 03 04 05 06 07 08 90 92 94 96 98 00 02 04 06
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Source: The Economist
Value guided healthcare_Final Documentation_Aug09.ppt 9
Value based healthcare new paradigm emerging
Administrators Efficiency
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Clinicians Value
Source: Institute of Strategy and Competitiveness, Harvard Business School; BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt 10
Value focus win-win for all stakeholders
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Best possible outcome...
... at minimal cost
Industry
69 quality registries started to date1 >20 registries with >85% patient coverage
Quality registries by start year Quality registries by patient coverage, start year
(# of registries) (# of registries)
80 20
29 69
60 15 22 registries
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Start year
10 of registry
9
40 10 4 14 05-09
13 2 00-05
2 95-00
3 1
20 5 1 3 90-95
5
3 1 3
2 4 85-90
8 2 0 2
1 80-85
2 4 2
1
2 2 75-80
0 1 1 1
0
Not 75-80 80-85 85-90 90-95 95-00 00-05 05-09 Total >95% 85-95% 75-85% 65-75% <65% Not
known known
Patient coverage
# of registries
80
69 Short-list:
Cataract
Cataract
60
28 Gallstone
Gallstone surgery
surgery
46 45 Pain rehabilitation and Hip
Hip arthoplasty
arthoplasty
rectal cancer did not pass
selection of > 10,000 Intensive
Intensive care
care
40
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
patients, but are re-added
24 due to high report quality Pain
Pain rehabilitation
rehabilitation
24 30
Rheumatoid
Rheumatoid arthritis
arthritis
35
19 Rectal
Rectal cancer
cancer
20
17 12 Stroke
Stroke
17 10
8 7 4 Swedeheart
Swedeheart
4 3 2 1 5
0 2 2 1
3
1 2 2 1 Vascular
Vascular surgery
surgery
All registries Registries >2 years Registries Registries with Registries covering Registries with
old measuring patient >70% coverage >10,000 patients advanced reports
Procedure-oriented outcome per year and feedback
Condition-oriented
Clinic-oriented
Patient-type oriented
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
2 Evidence-based discussion 5 Only collect what is needed
Mutual respect and team spirit Easy-to-use IT interface
Committed Easy-to-use
Peer pressure in joint efforts Move towards integration with
specialists Evidence-based approach IT interface EMR systems
Strong foundation in research Easy to receive feedback
Willingness to measure Fast feedback of own results
Decision-support tools
4% 17
0.3
29
25%
100
1
106
25
41%
8
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
50
36
35
25
0
Inpatient1 Outpatient2 Primary care3 Psychiatry4 Total
1. Analysis based on KPP-data 2. Assumptions: Share captured same as for inpatient with adjustment for clinic coverage; for registries covering outpatient care, clinic coverage is same for inpatient
and outpatient 3. Quality registries for diabetes, leg ulcer and heart failure cover primary care; assumptions: cost/patient and visit 2000 SEK, 4 visits/year for diabetes patients; cost/patient and visit
2000 SEK, 52 visits/year for leg ulcer patients; cost/patient and visit 4000 SEK, 4 visits/year for heart failure patients 4. Only existing quality register for psychiatry is eating disorder; assumption
cost/patient and year 200000 SEK; 1355 patient registered in RIKST 2007
Note: Not including cost of pharmaceuticals, dental care, political activities and restructuring activities
Source: KPP-database; SKL; annual reports for quality registries, grant applications to SKL; BCG analysis and estimates
Value guided healthcare_Final Documentation_Aug09.ppt 15
Today national quality registries cover 41% of specialized
inpatient cost
MDC
Share of specialized inpatient cost covered by quality registry (%) (Major Diagnostic Categories)
00 Ungroupable
100 01 Nervous system
02 Eye
03 Ear, Nose, Mouth And Throat
04 Respiratory System
05 Circulatory System
06 Digestive System
80 07 Hepatobiliary System And Pancreas
08 Musculoskeletal System And
Connective Tissue
09 Skin, Subcutaneous Tissue And
Breast
10 Endocrine, Nutritional And Metabolic
60 System
11 Kidney And Urinary Tract
12 Male Reproductive System
13 Female Reproductive System
14 Pregnancy, Childbirth And
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Puerperium
15 Newborn And Other Neonates
40 16 Blood and Blood Forming Organs and
Immunological Disorders
17 Myeloproliferative DDs (Poorly
Differentiated Neoplasms)
18 Infectious and Parasitic DDs
19 Mental Diseases and Disorders
20 21 Injuries, Poison And Toxic Effect of
Drugs
22 Burns
23 Factors Influencing Health Status
cost captured 41% 24 Multiple Significant Trauma
30 Chest problem
0 90 Post-MDC
0 31 62
05 08 01 06 04 11 07 00 15 17 03 18 23 10 21 30
14 22
13 09 12 24
Total specialized inpatient healthcare cost by MDC (BSEK) 99 02
16 19
Note: Cost data covers specialized inpatient somatic care Cost not captured
Source: KPP-database; SKL; annual reports for quality registries, grant applications to SKL; BCG analysis
Cost currently captured
Value guided healthcare_Final Documentation_Aug09.ppt 16
Unique platform from broad range of personal registries
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Genetics data
Biobanks
Epidemiology
Comparative effectiveness
Other data
Health economics
Longitudinal studies
...
Starting position
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Way forward
Appendix
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Outcomes information services provide transparent performance data for all providers in the country.
Sweden is the fastest nation in the world in making valuable new drugs available to their population. The Swedish
MPA (LV); the Dental and Pharmaceutical Benefits Agency (TLV) and clinical research competence centers work
closely together to define how to best assess the value of conditionally registered products and efficiently determine
appropriate reimbursement levels.
Sweden is the pharmaceutical and medical technology industries' country of choice for conducting post-approval
safety, efficacy, and cost-benefit studies. This has been one of the key factors that have enabled a reinvigoration of
the Swedish life-science industry.
In addition to the clinical benefits, focusing on value based healthcare has saved the Swedish taxpayer ~50 BSEK in
reduced direct medical costs. No wonder Sweden is being flocked by researchers from other countries eager to learn how
outcomes and cost measurements can lead to world class research and clinical care.
Payers &
Academia
August 18, 2019
Providers
Swedish healthcare system envy of world
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
sources in the world. Many important clinical breakthroughs
have been made over the last years by teams integrating
comprehensive clinical outcomes data with high quality data
from national population and cost registries.
Swedish patients and their relatives are empowered to make
Patient
informed care choices based on the quality of care. Outcomes
information services provide transparent performance data for
all providers in the country.
Best possible
Sweden is the fastest nation in the world in making valuable new
drugs available to their population. The Swedish MPA (LV); the
Dental and Pharmaceutical Benefits Agency (TLV) and clinical
research competence centers work closely together to define
outcome...
how to best assess the value of conditionally registered products
and efficiently determine appropriate reimbursement levels.
Sweden is the pharmaceutical and medical technology
industries' country of choice for conducting post-approval safety,
efficacy, and cost-benefit studies. This has been one of the key
factors that have enabled a reinvigoration of the Swedish life-
science industry.
In addition to the clinical benefits, focusing on value based
... at minimal cost
healthcare has saved the Swedish taxpayer ~50 BSEK in reduced
direct medical costs. No wonder Sweden is being flocked by
researchers from other countries eager to learn how outcomes and
cost measurements can lead to world class research and clinical
care.
Industry
Norrbotten Gotland
Vsternorrland
20,000
rebro
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Gvleborg Stockholm Vsterbotten
Jmtland Dalarna Kalmar
Vrmland
Vstmanland
Skne Vstragtaland Kronoberg
Jnkping Srmland
18,000 Uppsala Halland
stergtland
16,000
40 45 50 55 60
Note: Cost including; primary care, specialized somatic care, specialized psychiatry care, other medical care, political health- and medical care activities, other subsidies (e.g. drugs)
Source: pnna jmfrelser, Socialstyrelsen 2008;Sjukvrdsdata i fokus 2008; BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt 21
Payers &
Reduced amputation
frequency from
systematic selection of Surgery Prevention 1.0% Swedvasc
patients for distal bypass
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
surgery
Reduction in stroke
readmission from Acute Prevention 1.5 2.0% Patientregistret /
secondary-preventive Socialstyrelsen
activities
Reduction of chronic
disease prevalence and Pitney Bowes /
complications from early Chronic conditions Prevention 3.0% Harvard Business
identification of risk School
factors
1. CAGR 2. EMRs and patient-data analysis tools Source: Hip-protesis annual report 2007; Swedvasc annual report 2007; Harvard Business School case study; The Economist April, 2009;
ppna jmfrelser 2008; BMC Health Serv Res. 2007 7:209. Bjrkdahl et al.; Riks stroke annual report 2008
Value guided healthcare_Final Documentation_Aug09.ppt 22
Payers &
Providers
Transparency drives best practice sharing (I)
Example: Cardiovascular disease
Karlstad central hospital
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Ranked #22
Ryhov hospital ranked #31 Staff trained on procedures National ranking dramatically
of 47 hospitals in 2003 improved:
Cooperation between physicians
and midwifes improved 3 2 2
11
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
31
40
3 300
18 21
30 2
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
2 200
44 360
20 212
36
30 248
2 25 100
10
13
3
36
0 0
2003 2004 2005 2006 2007 Short-listed Including all Potential / Potential /
Short-listed registries registries1 current quality year year
Cataract Gallstone surgery registries2 (current (adding new
Hip arthroplasty Intensive care registries) registries)3
Rheumatoid arthritis Pain rehabilitation
Rectal cancer Stroke
Coronary artery disease Vascular surgery
1. # of publications for 10 short listed quality registries in 2007 2. Average number of publications per short-listed registry 2007 multiplied by number of registries (59)
3. Adding 31 new quality registries to capture a larger share of total HC-cost
Note: Total number of publications in clinical medicine: 4,000 / year; Total number of dissertations in medicine: 900 / year
Source: Hgskoleverket & SCB 2008, KLiniks forskning ett lyft fr sjukvrden 2009; registry annual reports, registry grant applications to SKL; BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt 25
Industry
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
and best practice sharing
Industry
facilitates testing of new therapies
36
1 27
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
18
0,5
9
0 0
a
mr
a
mj
a
mr
a
mj
a
mr
a
mj
a
mr
a
mj
a
mr
a
mj
a
mr
a
mj
a
mr
a
mj
a
mr
a
mj
2000 2001 2002 2003 2004 2005 2006 2007
07
98
99
00
01
02
05
06
03
04
95
96
97
20
19
19
19
19
19
20
20
20
20
20
20
20
1. Dipotre = measured as average change of dioptre per clinic based on individual patient data 2. CRP-C = reactive protein level in blood indicating level of inflammation. Lower level of CRP indicate
lower level of inflammation short-term as well as lower risk for inflammation long-term 3. National coverage 56% while Falun coverage is 100% for all types of RA-patients. Since 1997 Falun has
measured and followed-up all its RA-patients on a monthly basis. Data has been used for regional quality work.
Source: Cataract Annual Report 2007; RA Annual Report 2008-09
Value guided healthcare_Final Documentation_Aug09.ppt 27
Payers &
Academia
Providers
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Genetic sequencing done abroad
Academia Attracting 3rd party financing:
30 applied ~40x public financing
Other research done abroad research
funding Opening up new research areas
20 Large-scale longitudinal
Translational research project
epidemiological studies
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
5-7 years
community care "
10
"Through peer-review processes we
have decreased mortality for several
Health-information Patient-data analysis of our clinics"
exchanges supporting medical
practice and drug
5
research
Source: "National Healthcare Quality Registries in Sweden 2007", CSC Healthcare; The Economist, BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt 29
Agenda
Starting position
Way forward
Governance model
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Business case
Roadmap and milestones
Appendix
1 All registries patient and disease focused capturing outcomes over care-cycle across provider
organizations
3 All registries used to identify quality of care best practice and drive continuous improvements
of care. Data use for academic and industrial studies is at the discretion of registry leaders
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
5 Registry base funding is secured long-term
6 Better data usage and registry support through shared resources with expertise and tools
7 Registry industry regulator (LV and TLV) interfaces are formalized to ensure transparent
and efficient relationships
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Industry
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Data use
Data analysis services
Data analysis Facilitate best
Licensing interface and
services practice sharing Cooperation with other registries
(LV) services
Facilitate best practice sharing
Reimbursement
(TLV) Information technology (IT) IT infrastructure and support
Coherence in data, metrics
Industry
Quality Registries
1.University Medical Center
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt 33
Proposed funding mechanism balances base funding and
rewards to attractive registries
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
50% of surplus1 allocated by
CoCe to other registries that
can show need for additional
financing
Starting position
Way forward
Governance model
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Business case
Roadmap and milestones
Appendix
280
Total required investment of ~5 BSEK
260 14 -5% over same period
12 Registry funding, building competence,
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
240 9 IT, etc.
4.75%
7
220 5
4 4.10% 254
244
200 2 235
226
1 218
1
209 10.8x multiple of money
201
180 185 193 coming 10 years
0
176
0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
400
60 60
100
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
300
40 40
200
50
20 20
100
0 0 0 0
09 10 11 12 13 14 15- 09 10 11 12 13-18 09 10 11 12 13 14- 09 10 11 12 13 14 15 16-
18 18 18
Annual basic funding per Initial cost related to resources Executive body / PMO Quality IT investments
registry 4 MSEK within competence centre 2009-2013: 30 MSEK complementary to national IT
2010: 3 Centers (excl 2014-18: 20 MSEK strategy initiative
Uppsala) Audit function Total required investment across
2011-2012: 5 Centers 2010: 5 MSEK time period: ~600 MSEK
Note: All figures in real numbers
Source: BCG analysis 2011-2018: 10 MSEK
Value guided healthcare_Final Documentation_Aug09.ppt 37
Agenda
Starting position
Way forward
Governance model
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Business case
Roadmap and milestones
Appendix
Negotiate governance,
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Functional
Establish shared
initiatives
financing
capabilities, resources Reach full data use
Establish PMO1 August 18, 2019
Define IT infrastructure infrastructure Swedish healthcare system envy of world
Set targets, deadlines In the past 10 years Sweden has emerged as the leading nation in
value based healthcare and personalized medicine. Today, Swedish
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
and milestones Run IT framework project
Initiate legal change (primary care reporting)
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Cumbersome and fault-prone for professionals National format specifications defined for select
Blocking primary care from full registry quality metrics in EMR interface
participation Full patient data sent to EMR, select metrics
sent simultaneously to quality registry
Tax-funded
healthcare costs All key chronic illness
(%) visits covered in
primary care 18%
82%
Full coverage in existing
registries 57 % coverage 77% 43%
Additional 6% coverage
23%
from adding key diagnoses
37% All key psychiatric
conditions covered
63%
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
37%
57%
63%
1. Analysis based on KPP-data 2. Assumptions: Share captured cost same as for inpatient
Note: Not including cost of pharmaceuticals, dental care, political activities and restructuring activities
Source: KPP-database; SKL; annual reports for quality registries, grant applications to SKL; Lkartidningen; peer-review journals; BCG analysis and estimates
Value guided healthcare_Final Documentation_Aug09.ppt 42
Key milestones to make 10 year shared vision reality
Strengthening
Expansion Full value capture
Foundation & Ramp-up
2009 2012 2015 2019
Ramp-up phase completed Well into expansion phase Realizing full value capture
~40% of healthcare cost ~55% of healthcare cost ~60% of healthcare costs
covered by registries covered by registries covered by registries
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
All governance, capabilities All governance, capabilities Full data use ensured through
components initiated components fully resourced active Competence Centers
IT framework established EMR interface integration near Full EMR interface integration
completion for quality reporting
All new registries in start-up Target registry coverage Target registry coverage all care
phase somatic care cycles
Starting position
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Way forward
Appendix
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Value guided healthcare_Final Documentation_Aug09.ppt 45
Steering and reference group members
Name Role
Carl Bennet Ordfrande i Getinge, Gteborgs Universitet
Steering group
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Gunnar Alvan Tidigare GD Lkemedelsverket
Gran Sandberg Rektor Ume Universitet
Kjell Asplund Tidigare GD Socialstyrelsen
Reference Group
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Ulf Wahlberg Vice President Ericsson Industry research relations Jun 11
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Mats Lundstrm Registry Manager Kataraktregistret, EyeNet May 28
Joakim Dillner Prof. of Virology Molecular Epid. Lunds U. Dep.of Medical Microbiology May 28
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Pr Sundstrm IT manager Sjukvrdsrdgivningen May 06
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Mona Heurgren Director Socialstyrelsen May 18
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Alide Chase SVP Quality and Service Kaiser Permanente Jun 12
Jennifer Baron Research public health Harvard Business School Apr 24
Philipp Ostwas CFO Klinikum Rechts der Isar May 4
Gunnar Nemeth CEO Capio May 18
Dr. Mansky Medical doctor Helios May 15
Gene Nelson Director for quality administration Dartmouth-Hitchcock May 21
Dr. David Dreis Medical director of quality outcome Virginia Mason May 11
Site visits
Schn Kliniken2 May 7
Cleveland Clinic3 May 14
1. Former head of the department and advisor; 2. One day site visit, incl. discussions with 3 physicians; 3. One day site visit, incl. discussions with quality personnel and 2 physicians
Value guided healthcare_Final Documentation_Aug09.ppt 51
Gothenburg 18 Aug Meeting participants (I)
Regeringen Regioner - landsting
Karin Johansson, statssekreterare Socialdepartementet Sren Olofsson, regiondirektr region Skne
Anders Thulin, medicinsk direktr region Skne
Akademi Hannie Lundgren, forskningschef region Skne
Professor Karin Markides, rektor Chalmers Thorbjrn Ekstrm, FoUU-direktr
VMD. Johan Carlsten, vicerektor Chalmers Stockholms lns landsting
Professor Pam Fredman, rektor Gteborgs universitet Marie Beckman-Suurkla, sjukhusdirektr Akademiska
Professor Olle Lark, dekanus vid Sahlgrenska akademin sjukhuset Uppsala (referensgrupp)
Professor Harriet Wallberg-Henriksson, Jack Lysholm, chef fr FoUU-staben
rektor Karolinska Institutet Vsterbottens lns landsting
Professor Karl Tryggvason, dekanus fr forskning p KI Peter Lnnroth, bitrdande hlso- och sjukvrdsdirektr
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Professor Peter Gudmunson, rektor KTH Vstra Gtaland
Professor Mathias Uhln, KTH Martin Magnusson, utvecklingsdirektr
Professor Mille Millnert, rektor Linkpings universitet stergtlands lns landsting
Professor Bjrn Gerdle, prodekan Hlsouniversitetet Anders Heijl, FoU-samordnare stergtlands lans landsting
Professor Bo Ahren, dekanus medicinska fakulteten
Lunds universitet Referensgrupp
Professor Gran Sandberg, rektor Ume universitet Professor Gunnar Alvan
(referensgrupp) Professor Kjell Asplund
Professor Anders Hallberg, rektor Uppsala universitet Professor Joakim Dillner
Anna Hedborg, tidigare statsrd
Utlndska talare
Professor Michael E. Porter, Harvard Business School
Jens Deerberg Wittram, Chief Operating Officer Schn
Kliniken
Value guided healthcare_Final Documentation_Aug09.ppt 52
Gothenburg 18 Aug Meeting participants (II)
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Peter von Ehrenheim, VD GE Healthcare AB
Docent Bertil Lindahl, ansvarig fr kompetenscentrum Per Btelson, VD och koncernchef Global Health Partner
(UCR) i Uppsala Magnus hman, VD St Jude Medical AB
Professor Nina Rehnqvist, ordfrande i SBU, Statens Johan Malmquist, VD och koncernchef Getinge
beredning fr medicinsk utvrdering samt ordfrande i Carl Bennet, styrelseordfrande och huvudgare Getinge
delegationen fr samverkan inom klinisk forskning
(referensgrupp)
Boston Consulting Group (BCG)
Professor Olle Stendahl, Linkpings universitet
Stefan Larsson, Partner and Managing Director
Christina Rngemark kerman, GD Lkemedelsverket
Johan berg, Partner and Managing Director
Claes nstrand, tidigare statssekreterare Utbildnings-
Rasmus Molander, Project Leader
och kulturdepartementet
Peter Svensson Project Leader
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
GallRiks Swedish quality registry on gallstone surgery
Registry example
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
8 999 cholecystectomy and 5 128 ERCP1 registered in 2007
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
10 166 operations registered in Swedvasc 2007
Process metrics
Development from small local registry to Metrics Reason for intervention, type of surgery and graft, manufacturer
nationwide, high coverage registry Health metrics
Complications, function, infection, stroke, mortality
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
24 130 admissions registered in 2007
Process metrics
Registry for quality development in Swedish Metrics Care on stoke unit, treatment with pharmaceuticals
stroke treatment Health metrics
ADL functions before and after stroke, complications, survival
Source: Interview; National Healthcare Quality Registries in Sweden 2007; SKL; annual report; grant application
Value guided healthcare_Final Documentation_Aug09.ppt 57
Swedish National Hip Arthroplasty Register
Registry example
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
20 676 registrations in 2007
Process metrics
Metrics Implant type, surgical method, operation environment
Second oldest registry, went web-based early Health metrics
Pain, life quality, re-operation, survival after 2, 5 and 10 years
Key Start of registry center in the Vstra Gtaland region, will share
initiatives IT-resources, statisticians and office space with NDR and
Onkologiskt centrum
Source: National Healthcare Quality Registries in Sweden 2007; SKL; annual report; grant application
Value guided healthcare_Final Documentation_Aug09.ppt 58
Swedeheart Coronary heart conditions
Registry example
Grant from SKL 4.3 MSEK for 2009, of which majority for
Financing competence center tied to registry
Additional financing via grants channeled through UCR on ad
hoc basis
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
62 561 registrations in 2007
Process metrics
Metrics Delay times, diagnostics, acute reperfusion, coronary artery x-
ray, PCI use
Outcome metrics
Created by consolidating four registries in 08/09 Survival rate, symptoms, complications, lifestyle changes,
medication, indicators of following national guidelines
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Value guided healthcare_Final Documentation_Aug09.ppt 60
Business case focuses on medical cost savings only
Three areas of value from outcomes work Focus for business case
1 Societal value Business case focuses on financial
Medical cost savings implications of implementing
Reduced compensation for sick-leave recommendations:
Reduced other compensations Direct medical cost savings
Improved absenteeism Required investments
Improved presenteeism Required operating expenses
Improved quality of life
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
2 Platform for life-science industry
Sweden as country of choice for value assessment of
new products eg post-marketing studies and early
launches Business case shows that medical cost
Increased innovativeness in medical system savings alone unambiguously justify
New companies & products from translational medicine investment in value guided healthcare
New healthcare information services and decision
support tools industries
x Medical
saving Multiple of money2 : 10.8x
Net cash flow ~50 BSEK
Increased cost coverage
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
by registries NPV3 09-18 ~34 BSEK
Incremental Total NPV ~250 BSEK
reduction in
healthcare Investment required 0.24% of
Registry base funding cost annual healthcare spend
+ Accumulated spend 3.0% of
Establishing of CoCe1 2008 healthcare spend
Investment
+
Executive body, PMO, needs
audit function
+
IT investment for
complete EMR
1. Competence Centers 2. Multiple of money = Accumulated savings/Accumulated costs 3. Discount rate of 6% assumed
Value guided healthcare_Final Documentation_Aug09.ppt 62
Baseline healthcare cost inflation rate estimated at 4.75%
6.23%
140 140 4.75%
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
200
3.50%
120 120
4.78%
150
80 80
1995 2000 2005 2006 2008 2010 2012 2014 2016 2018 2008 2010 2012 2014 2016 2018
1. SKL estimate assumes efficiency improvements from better use of IT-systems, org changes and unidentified other systematic improvements (no reference to specific initiatives/actions is made)
Source: OECD Health data 2008; SKL publication "Kommer vi att ha rd med sjukvrden?" 2005
Value guided healthcare_Final Documentation_Aug09.ppt 63
Outcomes work holds potential to reduce HC cost growth rate
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
2,0 4.5
1,5 proposed plan
1,0
0,5
0,0 4.0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
with
initiative
0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Source: OECD Healthcare Cost 2008, BCG estimates
Value guided healthcare_Final Documentation_Aug09.ppt 64
Backup
BSEK
Savings to society from better health /
80 reduced sickness well above medical costs
5x Compensation for sick-leave1
Other compensations
60
29 Absenteeism
Presenteeism
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
24
3x
40
19 Studies estimating total societal costs put
14 29 value at 35 x medical costs:
24
20 10 19
Obesity 4.4x
7 14 Depression 5.0X
0 1 2 4 10
7
9 12 14 Overall (stergtland) 3.0X
0 1 2 1 4 2 5 7
0 0 1 4 Overall (Healthways in US) 3.7x
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Other2
Registry management
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Metrics definition and
data capture
Personnel cost 1,800-2,000 TSEK
Provide data analysis services
Coordinate outcome
improvements across clinics
2-4 Meetings/year
Other costs Book 400-450 TSEK
Other
1. Including cost for FTEs 2. Follow-up, mobile internet Required base funding per registry ~4,000 TSEK
Note: All figures in real numbers
Source: SIR registry funding application, lnestatistik.se, BCG analysis and estimates
Value guided healthcare_Final Documentation_Aug09.ppt 66
Backup
Logic for estimated cost for establishing and strengthening
competence centers
Statistician
Study development
Marketing
Sales support
2010: ~6,000 TSEK
Personnel cost Coop. with industry 2011: ~13,000 TSEK
Coop. with health economics 2012: ~13,000 TSEK
Legal expertise
Financial expertise
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
OH
Rent
2010: ~1,200 TSEK
Office IT 2011: ~1,300 TSEK
Other 2012: ~1,300 TSEK
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Value guided healthcare_Final Documentation_Aug09.ppt 68
Full patient coverage in existing registries gives 57%
specialized inpatient cost coverage
Share of specialized inpatient cost captured by quality registry (%) Steering Committee communicates
100 importance of quality registries
Identify current obstacles and
monitor progress
80
Make basic funding contingent
upon joining competence center
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
60
Underline benefits to registries
from having high patient coverage
40 E.g. communicate private-funding
cost captured 57% logic
20
0
0 31 62
Total specialized inpatient healthcare cost by MDC (BSEK) Cost not captured
Cost captured if current registries reach full coverage
Cost currently captured
Note: Cost data covers specialized inpatient somatic care
Source: KPP-database; SKL; annual reports for quality registries, grant applications to SKL; BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt 69
Setting up new registries increases potential
cost coverage to 63% in specialized inpatient care
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
60
Define valid & reliable outcomes
metrics
Capture full care-chain
40 Ensure metrics are anchored in
Osteoarthritis
Other rheumatic disorders
profession
Chronic pain (palliative care)
20
Osteoporosis Ensure competence center support
Skeletal cancer
cost captured 63% during establishment of registry
0
Cost not captured
0 Parkinson 31 Kidney cancer 62
Bladder cancer Burns Cost captured with new registries
Epilepsy
Urinary tract infection
Cost captured if current registries reach full coverage
Total specialized inpatient healthcare cost by MDC (BSEK)
Cost currently captured
Note: Suggested diseases and disorders can constitute new quality registries, or merge with already existing registries
Source: Interviews; BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt 70
Addition of primary care in quality registries drives full care
cycle coverage
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Limited quality improvement potential for routine diagnoses COPD
e.g., sinus infections, tonsillitis, urinary infections Dementia Coronary artery disease
Child obesity
Pilot initiative for 4-5 chronic diagnoses first step towards Multiple sclerosis
including primary care in existing quality registries
When pilot is up and running, expand to remaining chronic
disorders Quality of registry2
Primary care included in registry, high coverage
Primary care included in registry but currently low coverage
1. Based on estimates of primary care cost 2. Based on patient coverage of registry Primary care not included in registry
Source: Interviews, annual reports for quality registries, grant applications to SKL, BCG analysis and estimates
Value guided healthcare_Final Documentation_Aug09.ppt 71
Psychiatry registry development to build on ongoing initiative
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Initiate effort to increase patient coverage in existing
registries
Define action plan
Identify competences and resources needed to
execute on plan
Communicate importance and benefits of registries
Monitor reporting compliance and act if insufficient
1. Specifications on portal: capacity to handle all national quality registries in psychiatry, existing as well as new registries; one single module for patient base information for all users, diagnosis
specific quality registries connected to portal as separate modules
Note :RIKST Eating disorders, BipolR - bipolar affective disorder, RUSA - severe adhd, PsykosR psychosis, SBR Svenskt Beroende Register, SK - Nationellt kvalitetsregister fr barn och
ungdomar som konstaterats/misstnks ha blivit utsatta fr sexuella vergrepp, RttspsyK Rttspsykiatriskt kvalitetsregister
Source: SKL; Socialstyrelsen; BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt 72
Detailed way forward Roadmaps
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Value guided healthcare_Final Documentation_Aug09.ppt 73
Actions to get momentum coming 2-3 years and beyond
Program Establish Oversee key implementation projects Executive body handling permanent
Management PMO Prepare decision material for steering comm. tasks
Office (PMO) / Follow up and provide guidance in key projects Assessment, follow-up
Decision-support for SC
Exec. body
Set up steering Initiate legal changes
committee primary care, patient data law
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Secure full registry
Functional funding
initiatives Push for wider Identify new CoCe to start and extend
CoCE mandate activities of existing CoCes
1
Socialdepartementet Financing
Counties
2
Socialstyrelsen Steering Committee
SKL LV Provider rep Academia rep
SoS TLV Patient rep Industry rep
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Program
1 Financing mechanism & level Management
Office
2 Steering Committee setup
3 PMO2 mandate & organization
4 Initial roadmap 4
Estab. PMO1 PMO monitoring implementation process Exec. body permanent SC support tasks
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Map competence and registry gap
competence
Appoint new reg. team, strengthen exist
development
Gradual training / recruiting
Def. framework
Information
Adapt providers to integrated solution according to timeplan for compliance
technology
(IT) Develop decision-support tools for integrated solutions
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
define plan / vision
Set up framework
Ensure full and for conditional
stable basic licensing &
registry funding reimbursement
Governance Test framework
w. pilot
Strengthening of existing CoCe
Create coherent vision
Set up objectives, time plans and resource needs
Determine process for
making outcome data public
to patients
Integrate regional cancer registries
into new national CoCe-model
Determine BP sharing
1.Program Management Office process
Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt 77
Functional initiatives
New CoCe /
Key All required governance model
milestones registries started fully in place
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
ensure competence and resource
distribution
For existing registries; evaluate
Resource/ and strengthen resources and
competence competence needed
develop- Mapping of
competence
ment need vs.
availability
Define approach
for adjusting
resource pool
Information
Technology Adapt providers to integrated solution according to paced timeplan for
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
compliance
(IT)
Legal
Revise Law on patient data to enable e.g. individual
feedback from quality registries and cross-referencing
Launch initiative
Increase
coverage in Define action plan Monitor progress
current
registries Arrange BP-sharing meetings
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Add new App. owner Build registry Monitor progress
registries Support process
Integrate cancer registries
Develop action plan Expand registry Ensure full coverage
Develop evaluation
Primary Assign pilot process
Evaluation of pilot and give feedback
care "owner"
Develop IT interface solution Expand pilot to all relevant areas in PC
Organize best practice sharing for registries
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Ensure full coverage for inpatient
Increase Communicate importance and
benefits of registries
coverage in Ensure compliance from clinics
current
registries Specific initiative to ensure full
outpatient coverage
Identify white-space
Communicate importance of
participation
Ensure compliance from
clinics
Organize best-practice sharing meetings
Develop individual
action plan for new
registry
Build registry according to identified
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Identify
resources and best-practice model
competence Ensure full coverage
needed
Identify metrics
New quality Decide on
registries CoCe-
membership
Organize BP sharing
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
Evaluate pilot and give feedback
Develop process for
To pilot registries
evaluation of pilot
To expansion registries
Identification
of expansion
Expand pilot to all relevant chronic disorder in
registries,
primary care
appoint
owner
Copyright 2009 by The Boston Consulting Group, AB. All rights reserved.
needed
Identification
of expansion Ensure full cov. for existing registries
registries, Communicate importance and benefits
appoint of registries
Psychiatry owner Ensure compliance from clinics
1. Kvalitet i Psykiatrisk Vrd Recently established CoCe for psychiatry. Source: BCG analysis
Value guided healthcare_Final Documentation_Aug09.ppt 84