It may sound like a tired truism that healthcare leaders from different countries around the world can learn from each other, and collaboratively accelerate healthcare system change globally, but at an educational session at HIMSS18 Thursday morning, the truth of that idea sprang to life, as international healthcare leaders shared valuable insights and perspectives with one another.
“Creating Healthy Incentives to Improve Integrated Care: Lessons Learned from Around the World,” brought together leaders from Canada, the United Kingdom, Australia, and the United States, to discuss some of the common challenges and opportunities facing the healthcare systems of all the advanced industrialized nations, with insights from extensive international experience shared all around.
Anne Snowdon, Ph.D., a professor of strategy and entrepreneurship at the Odette School of Business at the University of Windsor in Ontario, Canada, and the chair of the World Health Innovation Network, a consortium of healthcare leaders from several nations, introduced a series of brief presentations, and then led a panel discussion among all the presenters.
Dr. Charles Alessi, a senior advisor to Public Health England, a government agency in the UK that “exist[s] to protect and improve the nation's health and wellbeing, and reduce health inequalities,” spoke first. “I don’t think many of us really appreciate how similar our health systems really are,” Dr. Alessi said. “There are different payers; we have the NHS [National Health Service] and a single-payer system. You have a mixed system,” he said, addressing the American healthcare leaders in the audience. “The Germans do, too. But ultimately, they’re all the same time. There are some differences in who pays, and how they’re administered. But in essence, we’re all on a common journey, with some common pain points. And we can learn from each other by not making the mistakes again and again and again, so that we can learn from each other in what not to do.” In sum, he said, “There’s much, much more convergence than we appreciate.”
Indeed, Alessi continued, “The struggles are very similar. Two weeks ago, I was in Japan,” he noted. “They’re going through a demographic time bomb, with 33 percent of their population over 60, with dementia increasing dramatically. And a lot of European countries are following them very, very quickly; and a lot of Asian countries are starting to follow them, too, demographically; Singapore is one example.”
Among the common challenges he cited: “struggling demographics and financial challenges”; “a problem with marrying ‘medicine by body part’ with the person”; “struggles with medical errors”; “struggling with workforce issues,” particularly shortages of key types of clinicians; “struggles with the consumerization of healthcare”; and, struggles with “how we’ll work with digital, and create ‘digital practice and extenders,’” to meet new staffing and care delivery needs.
At the same time, Alessi said, all the countries he’s aware of are also inevitably moving in the same broad direction around certain general goals. “Inevitably,” he said, “everyone is moving towards person-centered systems. We call them integrated care systems, you call them ACOs [accountable care organizations] here.” Also, “There’s a shared understand that the non-health determinants of health are at least as relevant” as strictly medical factors, in overall health. “Do people have a home, a job, purposefulness?” And, of course, the digitization and automation of society, and the continuous advancement of technology, are going to be major factors in moving all healthcare systems forward.
In addition, Alessi said, the shift from volume to value is not only evolving forward in the United States, but in all the healthcare systems of the advanced, industrialized nations. In all this, he said, “There are significant implications here; there’s much more that binds us than is different.” Even in some of the particulars, there’s more similarity than difference, he noted: “We all face similar challenges around data integration and data governance laws, and everyone is adopting data-driven solutions to drive better outcomes.” And, he added, “The emphasis on common standards in data systems is increasing and likely to increase even further.”
Alessi was followed by Dorothy Keefe, M.D., professor of cancer medicine and clinical ambassador for the Transforming Health initiative, at the University of Adelaide, in Australia. As Keefe put it, “The good news is that Australia has some of the best healthcare outcomes in the world, which is lovely. And we live a long time.”
Meanwhile, Keefe said, “We have a mixture of public and private funding, which is actually quite complicated. We have a universal system we call Medicare, which is federal, and which covers everyone. We also have very blurred lines between federal and state systems, and very complicated funding and regulatory models.”
The good news? “We spend 9.5 percent of our GDP on healthcare, and about $6,000 per patient per year, about half the cost per patient per year in the United States. The bad news? We have a rate of overweight and obesity that is among the highest in the world, perhaps higher than in the U.S. We also have low rates of mammographic screening, and our post-operative infections are the second highest among OECD countries. We also have terrible outcomes for indigenous Australians; and our cancer outcomes are actually getting worse. We also still have a volume incentive.”
In that context, Keefe said, the Transforming Health Program that she’s helping to lead is working to build evidence-based, statewide models of care that she and her colleagues hope will lead to improved productivity and cost-effectiveness; and their work is also aimed at “leadership training for reform.”
The final presenter in this series of presentations was vice-admiral Raquel Bono, M.D., a director in the Defense Health Agency at the U.S. Department of Defense. “As a military healthcare system,” vice-admiral Bono said, “we’re not only a microcosm of what the other presenters shared, we are an example of an environment for innovation in the U.S.” One example she cited was the cooperation that has already taken place between nurses and other clinicians in patient care settings in Germany, where German clinicians have been “working better together with Americans in uniform” serving in that country.
What’s more, because of field medical operations managed by alliance forces in Afghanistan and Iraq, U.S. military clinicians have interacted very collaboratively with their European and other international colleagues from NATO and other countries, in battlefield care delivery. “On the battlefield, while working with our coalition partners—who could be British, Australians, Belgians, etc.—we will take soldiers into very cramped quarters, and fly them out with helicopters,” Bono noted. “We’ve done things like setting up an ICU in the back of the airplane.” Those forms of cooperation have helped to create international standards of practice for battlefield and other types of care delivery, with military clinicians from many countries learning from each other, she noted.
Finding points of commonality to help facilitate international exchange
Following the three brief presentations, all the panelists engaged in a fruitful discussion about the opportunities for the leaders of healthcare systems around the world to work on common problems and issues. “If we think in terms of the person being at the center, that changes everything,” Alessi said.
Keefe followed up that comment by reinforcing it, saying that “Success looks like when the patient feels good. And in terms of perverse incentives, it’s really difficult to switch the mindsets of clinicians. So the veneer of patient-centered is very, very thin. And until we get to paying for outcomes, we’ll never get there.”
“So where do you start?” Snowdon asked. “There isn’t a health system in the world that doesn’t want to get to better outcomes. The tough question might be, where do you start?”
“I think we can start somewhere,” Alessi said. “And the way you’re changing your Medicare program to value, that’s showing the way.”
“We can move the conversation away from what’s good for providers to what’s good for patients,” Bono said. “There’s the need for the clinical leadership to take on this challenge and disrupt the status quo.”
“I absolutely agree,” Keefe said. “We all know that we can do it. It’s a cultural issue. Our culture of clinical practice is that the medical profession does not feel that it’s part of a public service.”
“How do systems learn from each other?” Snowdon asked the panel. “If each system has to learn how to rework things, we’re going to be taking a very long time to creating change on a global level. We have a bad record in healthcare constantly reinventing things. Each country has a unique context, no question, but how do we start to learn from each other, so that at least we could speed this up?”
“Even within the U.S. military healthcare system, we’ve got Army, Navy, and Air Force medicine, with different cultures,” Bono noted. “But working with other NATO countries—we have to create certain standards, and that’s helpful. And what you’re proposing is, I think, extremely important. And would be a helpful start.”
“As we all know, it takes 10 to 20 years to implement something that’s been proven to be right, across medicine, so that’s not going to help us,” Keefe said. “But I think the exciting thing is that I actually think that consumer-led digital innovation outside the healthcare system will help to lead the way.”
“I completely agree, Dr. Keefe,” Alessi said. “In many respects, the digital revolution is going to set some terms for us. It will force comparisons.”
“And consumers will hold us accountable to much greater degrees than we’ve ever seen before,” Snowdon said. “So it’s no longer the provider-centric system that our parents and grandparents are used to. The millennials are going to change things. So you’re right, consumers will change things for us.”
“How do we actually define value?” Snowdon asked. “That’s a wonderful question,” Alessi said. “We did some research in England, we showed that most physicians wouldn’t want the care they give their patients. We’ve learned a lot around wellness from you, in the U.S. And certainly, what we’re trying to do within public health in England is to measure outcomes, not by things like number of diseases, but in a different way.”
“We really do need to change medical education; but it’s very difficult,” Keefe said. “I remember, thinking back to my time in medical school, that the ‘fluffy bits’ were not very interesting to me,” she said, referring to topics like nutrition and others. “But I realize now that I should have been paying attention. Because if medical students and new doctors think that wellness is the absence of disease, we won’t make progress. Essentially, you have to look at everything. It’s about everything—sanitation, nutrition, housing, etc. And unless we fix that, we’re not creating value.”