There is absolutely question that U.S. healthcare is in a state of great ferment these days. The shift from volume-based payment systems to value-based ones is well underway, with accountable care organization (ACO) programs, both federal and private ACOs growing by the day in number and scope, and with population health management and enhanced primary care initiatives moving ahead by leaps and bounds. Meanwhile, with healthcare costs continuing to rise, and with public and employer healthcare expenditures growing by the day, hospitals, physicians, and other providers in the U.S. are inevitably facing a variety of combinations of pay cuts and an ongoing, accelerating shift towards value-based reimbursement, going forward.
What’s more, the foundational dynamics underlying these changes are only accelerating: an aging population, an explosion in chronic illnesses of all kinds, but especially those related to obesity and poor lifestyles, and exploding costs related to advances in medical technologies and pharmaceuticals. Taken together, they portend a kind of “perfect storm” facing United States society. As I’ve referenced in a number of articles and blogs this year, the Medicare actuaries estimated back in July that total U.S. healthcare expenditures had reached $3.3013 trillion in 2014 and 17.5 percent of gross domestic product, but further, will grow to $5.631 trillion and 20.1 percent of GDP in 2025. In other words, a 70 percent increase in a decade. And as everyone knows, we as a country are struggling to pay for the healthcare system we have now, let alone one costing 70 percent more (and with fewer younger taxpayers to support the increasingly expensive system over time).
All of this is concerning—even alarming—of course. And really, anyone who is awake and alert should be concerned about all of this. But the reality is that this set of challenges extends far beyond the United States. Indeed, virtually all of the western European nations, as well as such advanced, industrialized nations as South Korea, Japan, and Taiwan, and, increasingly, nations like China and India, which have growing middle classes (whose members are also eating more and more processed and fatty western foods), and which are beginning to see their populations move into the age curve as well, are facing these challenges. As some demographers and sociologists have noted, as industrialized societies advance, their fertility rates decrease, creating a growing “upside-down pyramid” problem that has policy experts in many countries worried. Interestingly, it is Italy, historically and stereotypically perceived as a society of large families, now has the lowest replacement factor of all the western European countries, at 8.4 per 1,000 people, as this Telegraph of London report notes. At that rate, people in Italy who are dying are not being replaced by newborns, meaning that Italian society is headed towards a crisis of social services, as people become older and require more healthcare and other services, and the burden for supporting that country’s social welfare system, including its healthcare system, falls on fewer younger, healthier people.
That’s why it was particularly fascinating to participate in the World of Health IT (WoHIT) Conference in Barcelona in November, sponsored by the Berlin-based HIMSS Europe, a division of the Chicago-based HIMSS (Healthcare Information and Management Systems Society). Not that anyone should derive satisfaction from the fact, but it was strangely heartening to learn that virtually all of the western European societies are struggling with the same core problems facing us in the United States.
True, the governmental systems and national healthcare systems of western Europe are different from those of the United States, in very significant ways. And the same goes for many of their societies. For example, the Nordic countries—the Scandinavian countries of Norway, Sweden, Denmark, and Iceland, plus non-Scandinavian Finland—enjoy broad social and cultural homogeneity with relatively small populations, strong overall sociopolitical consensus around the idea of a progressive and encompassing social welfare state, and single-payer healthcare systems. At the same time, all of those countries are experiencing the aging problem that Italy has; and all have significant levels of chronic illness, as well (though none have the rates of chronic illness that the United States has, and none have levels of adult or child obesity comparable to those in the U.S.).
So the need to figure out how to reaching population health solutions is great in the Nordic sphere, as it is in the U.S. And thus, it was excellent to be able to sit down with Jaana Sinipuro, whose title is leading specialist in the Digital Health Hub at SITRA, the Finnish Innovation Fund, a Finnish public organization sponsored by the Finnish parliament that sponsors innovative work in social welfare services, education, and technological development. Sinipuro is helping to lead the architecting of what is known as “Isaacus—the Digital Health Hub.” The Isaacus initiative is preparing to collect health status and health data from across all relevant databases in Finland—not only those from the provider sector of Finnish healthcare, but also from social welfare agencies and other sources—in order to improve the capabilities of researchers to uncover social welfare and health status patterns across Finnish society, and therefore support the development of new policies and programs to address issues such as chronic disease and the social determinants of health in that country. As Sinipuri told me on Nov. 26, the Isaacus initiative is creating a national data protocol (another version of this already exists in neighboring Estonia), which will collect data of all types, from all sources, on the Finnish population, in order to proactive engage in analytics that can help improve the healthcare—and health—of all Finns.
“Why Finland, and why now? We believe that there are several elements that are positioning Finland optimally for this work right now,” Sinipuri told me at WoHIT. “First, we have a relatively small population, of a little over 5 million people nationwide, and it is a population with an isolated gene pool. Second, we already have a biobank law that was passed in Finland in 2012 and went into effect in 2013 [read about that law, the Suomen Biopankit, here]. Third, all Finns already have a national personal ID, which makes data collection easier. And fourth, we already have exceptionally extensive, high-quality data, being collected, and available to researchers, across numerous fields of endeavor, now, in Finland.”
So, for American healthcare leaders who struggle a bit to frame all this for themselves conceptually, it is worth remembering that Finland’s population of a little over 5 million is closer to that one of the larger cities—or smaller states—in the United States. And that makes it easier to understand a national database in Finland, as there are U.S. states that are beginning to approach aspects of what is happening in Finland. So really, given an adequate level of social and political consensus—something all the Nordic societies have in abundance—it would be possible to imagine the Isaacus initiative being replicated in the U.S. And that is heartening.
Meanwhile, it was equally excellent to sit down with Vincent Moncho Mas, the next day, at the Centre des Convencions Internacional in Barcelona, during WoHIT, and to hear about the groundbreaking things he and his colleagues are doing in Valencia, Spain. As Moncho Mas, the CIO the Hospital de Dénia/Marina Salud S.A., in the suburb of Valencia called Dénia, told me on Nov. 27, he and his colleagues are providing care to a defined population in the Valencia region for an annual capitation rate of €720 per person per year, or $763.20 PPPY at the euro-dollar exchange rate on the date I interviewed him—in other words, in U.S. managed care terms, a per-member, per-month (PMPM) cap of $63.60. What’s more, as he shared with me, Hospital de Dénia/Marina Salud’s population includes a fair number of seniors, including “snowbird” British, German, and Dutch citizens who winter in the Valencia area and who, as European Union citizens, have the right to access healthcare anywhere in the EU—with a significant percentage of those northern European part-time residents having the same chronic illnesses that American seniors have, most particularly diabetes.
So Moncho Mas and his colleagues are engaging their covered-population members using some of the same patient engagement strategies as are their U.S. counterparts, including via a patient portal, secure direct messaging, and the Spanish equivalent of OpenNotes. Speaking of the organization’s patient portal, Moncho Mas told me that “The patient portal is the highway; it is the door that we open to our patients for channeling their clinical information. And it’s quite important to have this portal, with some standard functionality, such as access to clinical notes, to records, lab results, radiology, etc.,” he told his audience. “It’s quite important to share this with the patient. Of course, we also need to support mobile apps. We need to give all the information not only on a web platform but also through a mobile platform, because patients always have phones with them, but not laptops.”
It was also my honor to moderate a discussion of the Nordic Community Workshop on the Sunday of the conference—in which health information exchange was a major topic; and to moderate an international discussion of healthcare data and IT security on Monday, which absolutely reminded me of how global that set of challenges is right now.
Does any of this sound familiar? It really should. The reality is that, in spite of differences in their governments and the national healthcare systems, the United States and western Europe have a tremendous amount in common. And we, on both sides of the Atlantic, can learn a great deal from each other. What’s more, there is tremendous diversity within individual European nations, as well as between and among them, just as there is in the U.S. between different local healthcare markets and regions. And sometimes, in that regard, one encounters surprises. For example, Moncho Mas told me that, as much as an educated American might assume that certain types of technology adoption would be more common—and more advanced—in, say, Germany, than in Spain, the reality is that some Spanish patient care organizations and healthcare regional authorities have created broader collaboration, including in terms of clinical IT, between inpatient and outpatient care environments, than is common in Germany, where inpatient and outpatient physicians retain a strong operational separation.
Collaboration across entire regions was certainly a major theme of the presentation of Juan Lucas Retamar Gentil, CIO of the Sistema Sanitario Público y de Bienestar Social de Andalucía (Andalusian Health Service), a regional health authority that encompasses one of the largest regions of Spain. Retamar Gentil and his colleagues have been working to improve healthcare delivery, following principles of equity, accessibility, and transparency, across Andalusia, one of the largest regions of Spain. Retamar was one of four senior healthcare CIOs whom I heard speak about their initiatives on the first full day of the conference, the others being Olivier Boussekey, M.D., CIO of the Groupe Hospitalier Paris St. Joseph in Paris, France; Antonio Fumagalli, CIO of ASST Papa Giovanni XXIII in Bergamo, Italy; and Philippe Kolh, M.D., CIO of the Centre Hospitalier Universitaire de Liège (University Hospital of Liege), in Belgium.
Listening to all of these CIOs and other healthcare leaders speak of their challenges and opportunities absolutely brought home to me the universality of many of the core challenges—and opportunities—facing healthcare and healthcare IT leaders on both sides of the Atlantic. I also heard from healthcare leaders from countries outside western Europe, including from leaders from Latin America, who face challenges at least as significant—and in many cases considerably more significant—than those faced by healthcare leaders in the U.S. and Europe. In any case, looking just as the U.S and Europe, it is clear how very much we all have to learn from one another, and also to be reminded once again how many great case studies there are from numerous countries and healthcare systems.
I look forward to learning about and reporting on innovations from around the world, and I know that my fellow editors at Healthcare Informatics do as well. This is such an important moment for healthcare—in the United States, of course, but all over the world, too—and it is a great time to keep our perspectives and our radar screens as broad as humanly possible, because cross-fertilization can be—and I am confident, will be—an important element in global advancements in healthcare policy, delivery, and operations, in the coming years. So, let’s welcome this global moment in healthcare, for everything we can learn from each other, and from it.