Fondazione Don Gnocchi

Furio Gramatica

Around 20 years ago, Michael Porter at Harvard Business School introduced the concept of value-based healthcare (VBH). At that time, the signs of a crisis in the sustainability of health services were already there, but the strategic value of the new theory was not yet evident in its practical correlates.

The fight against acute pathologies and the so-called ‘big killers’—first of all cancer—have partially diverted the attention from the silent growth of the elderly population and of the number of chronic patients, in a word, from the new wave of long-term care. This is a heritage from the big advancements of acute medicine, which is positive in terms of survival, but often is not counterbalanced by the availability of treatments, resources, and management approaches to keep a good quality of life.

Today, due to this unprecedented shift towards chronic city, we are forced to look for criteria as objective as possible for the allocation of the economic resources available to all the stakeholders who try to face this situation: public and private payers, policymakers, health providers, companies as well as patients and their families.

What value-based healthcare offers, compared to classic evaluations used previously, such as health technology assessment (HTA), is the objectivity of a number, the ‘value’ precisely defined as the ratio between the outcome that is the patient improvement— in clinical terms and in terms of function or quality of life— determined by the use of an innovative technique and the cost of the process linked to the provision of the service.

Porter suggested some fundamental steps: reorganize clinical and assistance services in ‘strands’ of related pathologies for clinical-assistance and care-taking needs, organize ‘integrated practice units’ to multidisciplinary teams that accompany the patient from the acute phase—if present—to home assistance, measure outcomes and costs for each patient, adopt reimbursement models based on value and refer to the entire ‘package’ of the process of patient care (bundle payment) and not to individual services, build a network of the service delivery systems that include the hospitals or institutions that deal with the same group of interrelated diseases—even in vast geographical areas, and finally, of crucial importance, adopt a technologically-advanced IT platform that is able to manage the entire system and is easily usable by all the actors of the clinical-assistance practice.

In order to apply the VBH in the real-world and with tangible and objective consequences, health technology is the key (be careful, the key, not the full solution). In fact, it is intrinsically able to measure functional, physiological, and pathology-related data; to store and send them in a suitable network on which real chronic-disease data bank can be built and made available, as it was for tissue bio bank, for instance, in cancer research. These data banks are of paramount importance to shorten, in future studies, the observation time of a long-term care patient, profiting from previous similar cases, and administer in shorter times and with lower costs the most effective rehabilitation and assistance treatments to keep her/his quality of life as high as possible. The use of artificial intelligence will greatly help in mining the right information from these data and offer first- or second-opinion to physiatrists and therapists, as well as suggest a set of behaviors to be applied to make the life of elderly people easier and more pleasant by assisting them at home or in nursing homes, based on their preference analysis.

"In order to apply the VBH in the real-world and with tangible and objective consequences, health technology is the key"

A major obstacle to this new approach, at the moment, is given by the scarce networking model connecting SMEs—the main owner of health technology innovation, but with a limited access to large-scale patient populations—and large industries, which have a high marketing capacity and can easily access healthcare providers and their patients. The classical ‘food chain’ model of large companies fishing small ones to absorb their know-how is at risk, and someone should guide SMEs to strongly improve the value (in terms of VBH) of their technology during the development phase, when the final solution is not yet fully-defined and frozen. The best candidates to do so are what I call ‘smart healthcare providers,’ individuals that have a VBH unit and a real-world data bank on board, able to liaise with SMEs to, first, co-finalize their solutions and to showcase them to large companies, and then, to optimize the final sustainability steps by up scaling the delivery model of the tested solutions.

In definitive, it is a matter of ecosystem building and of taking metrics very seriously, based on real-world data. Above in my text, I mentioned that technology is the key, but not the full solution. What I meant is that we also need, particularly in building a virtuous ecosystem among the healthcare stakeholders, a leap forward in the caregiver culture, especially in the medical class: data scientists cannot interpret clinical or behavioral data on their own without a thorough discussion with healthcare experts, who will need to be, in the next future, increasingly ‘well-educated’ to an awkward but precious technology.

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