The value
of health

 

How value-based health care benefits patients

 

Value-based health care is a concept that opens up new prospects for the health care system: it focuses attention on the patient as the central figure, it exploits the opportunities offered by digitalization, and it combines disease prevention, treatment and convalescence.

In Hippokrates' footsteps

THE HISTORY OF MEDICINE

Medicine in the ancient world

Everyone wants to be healthy, and to stay that way. Today, medicine aims to heal the sick – just as it did 2,000 years ago. What has changed is the status accorded to the patient. Here are some insights into an ever-changing cultural history.

 

 

Your good health! Santé! We often wish other people good health. On their birthday, and on many other occasions. "To your health" is the typical French toast, and Germans say "Good health!" if someone sneezes. There has been a globally valid definition of health ever since 1948, when the Word Health Organization (WHO) was founded: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."

The father of all medics: Hippocrates.

Since ancient times, we've known that the priceless asset of health is not predestined by fate, or even gifted to us by God. Hippocrates (460-370 B.C.), the Greek doctor known as the "father of all medics", urged all human beings to take charge of their own health. According to his teachings that have been handed down to us, this requires a healthy lifestyle combined with preventive actions. Illnesses and diseases, he believed, should be identified as soon as possible and treated medically so that their consequences can be nipped in the bud. He prescribed "therapeia" for his patients – and that Greek word certainly meant more to him than our modern understanding of therapy: "therapeia" includes not only healing, but also long-term aftercare following recovery. Hippocrates wanted to know how far his "therapeia" could have a sustained positive impact on his patients' quality of life. He was willing to learn from his mistakes.

"Nobody can enjoy full physical health if a part of the body is not healthy; on the contrary – all the organs, or at least the most important ones, must be in the same condition as the whole body."

 

Aristoteles (384 - 322 B.C.), Greek philosopher, pupil of Plato, teacher of Alexander the Great of Macedonia

The principle of taking personal responsibility

 

The doctor, the therapy and the patient form a trinity where each of them must play their part in the success of the recovery process. The doctor has to arrive at the correct diagnosis; the therapy must produce results; and the patient needs to take on personal responsibility for the healing process. Hippocrates' appeal to the patient's personal responsibility was also echoed by other intellectual giants of the ancient Greek world. The philosopher Aristotle (384-322 B.C.) was convinced that a society could only function properly if it took a disciplined approach to health care. However, he assigned responsibility for a healthy lifestyle not only to society but also – and above all – to each and every individual.

"Nine tenths of our happiness is based solely on health. With it, everything becomes a source of pleasure: but without it, we cannot take pleasure in any external stimulus, irrespective of its nature."

 

Arthur Schopenhauer
(1788–1860)

MEDICINE TAKES THE LEAD

 

The 19th century ushered in a dramatic change in the way health was perceived. The Industrial Revolution, coupled with triumphant progress in the natural sciences, opened the way for medicine to develop spectacular new treatments for illnesses. By introducing the division of labor in manufacturing, the Industrial Revolution encouraged a focus on the individual components of a production chain. Advances in the natural sciences prompted the invention of groundbreaking medicines and medical techniques. Taken together, these developments also impacted treatment methods: illnesses were no longer viewed in an overall context, as Hippocrates had suggested – instead, they were treated in isolation. Medicine took over the responsibility for the patient.

Broken down into individual components: car production at Volkswagen.

Medical breakthrough: penicillin.

From the 20th century onwards, researchers broke the human body down into individual components such as the organs, the extremities or the mind, and medical interventions now took place at these levels. Highly effective medicines developed in laboratories – such as penicillin – conquered bacterial infections such as cholera or plague. Medication has become more specific and individual since the turn of the millennium. Pharmaceutical companies are now talking about "personalized medicine".

In orthopedics, artificial joints help patients with conditions such as arthrosis of the knees, shoulders or hips to lead their lives free from painful symptoms. Highly effective medicines, optimized minimally invasive surgical interventions, and short periods of convalescence: cutting-edge medical services underpinned by technology and the vast reserves of knowledge in the pharmaceutical industry are delivering multiple benefits for patients.

LOSING SIGHT OF THE BIG PICTURE

 

Medical care has made enormous progress. But even so, something has been lost amid the myriad of therapeutic options that are now available: the view advanced by Hippocrates of a human being as one holistic entity. Doctors specializing in different disciplines record the patient's medical history within their own particular fields. But this information is not pooled centrally to yield a holistic picture – leading to costly duplication of work. Both medics and economists are using modern technology to point us back towards a holistic approach to prevention, treatment and convalescence – you could even call it Hippokrates 2.0.

Value-based health care

 

PUTTING THE FOCUS BACK ON THE PATIENT

HEALTH CARE TODAY

The new world of medicine

A concept developed on the basis of science opens the way to enhancing the quality of patient treatment in the health care sector, and also makes it possible to cut costs.

 

 

When the American economist Michael Porter stepped onto the stage at the World Economic Forum (WEF) in Davos, Switzerland, in 2017, "Value-based health care" (VBHC) was already a globally established concept that advocates restructuring of the health care sector. This will have pleased Porter, who laid the foundations for VBHC with the research work he undertook back in the 1990s. This scientist and Harvard professor focused on the cost-effectiveness of health care systems. His conclusion: they are too expensive and inefficient. How, he asked, can a high standard of medical care be combined with lower costs?

292,000,000 million

Google hits for "health"

The father of value-based health care: Michael E. Porter.

"The concept of disease urgently needs to be replaced by a new concept of health."

 

Christa Schyboll, author and columnist

"Constantly worrying about health is an illness in its own right."

 

Plato, (428 – 348 B.C.), Greek philosopher, pupil of Socrates, teacher of Aristotle.

Porter investigated the economic processes in the American health care system; based on an analysis of their weak points, he developed "Value-based health care". The model devised by Porter works in a fundamentally different way than existing models. This is because the focus is no longer on the doctor, his or her instructions, findings and decisions: instead, the value that the treatment gives the patient is now the central factor. Porter's book on this subject was published in 2006: "Redefining Health Care".

 

"Quality comes at a price" is the usual justification given for the costs of existing health care systems. Porter adopts a radically different approach: a health care system has to achieve the best possible result for the patient – and it must do so at low cost. His call to restore the patient's status as the central focus of health care is in line with economic principles. Porter's analysis: amid competition between health insurers, hospitals and doctors, the patient's wellbeing is relegated to the background.

 

A key issue in the entire process is the value of treatment – measured in the currency of the patient's long-term quality of life. This should be ascertained with the help of surveys before and after treatment, including questions such as: What is life like two years after a hip replacement implant? How quickly can the patient return to work? How many follow-up treatments were needed? Consistent tracking of the entire patient pathway is the only way to arrive at a qualitative analysis. Digitalization makes it easier to collect, record and evaluate all the personal data for this purpose. Patients themselves move from being passive participants to active players – just as Hippocrates advocated – and they have to take on personal responsibility.

A REVOLUTIONARY CONCEPT

 

Health reformers have seized upon Porter's idea and continued to develop it; modern data processing systems make analysis easier. "Value-based health care works!" – that was the verdict of Gregory Katz at the annual congress of the European Institute of Innovation and Technology (EIT). Katz, who comes from France, is the Director of the EIT Health Trends Report. He is working on the publication of a report titled "Implementing Value-Based Health Care in Europe: Handbook for Pioneers".

 

Benefits for patients: Gregory Katz.

Gregory Katz, Director of the EIT Health Trends Report

The EIT is an EU body where researchers work together on an interdisciplinary and international basis. "We measure quality of life before and after treatment, with the help of calibrated instruments: we use questionnaires to do this," according to Katz, who holds a professorship at the University of Paris.

He advocates results-oriented medicine with a strong focus on benefits for the patient. According to Katz, it is crucial for all health care institutions to engage in interconnected data exchange so they can respond more precisely to patients' specific needs. Medicine ought to be measurable by its results.

 

Johnson & Johnson sees VBHC as the health care of the future.

For many years, the company has joined with other health care providers such as clinical centers to carry out practice-based projects on VBHC. "Through its programs for value-based health care, J&J aims to offer patients a better quality of treatment, and to combat negative financial trends in the health care sector," says Roman Iselin, Country Lead Medical Devices at J&J Switzerland.

«Mens sana in corpore sano»

Juvenal, Roman satirical poet (60-140 A.D.)

Roman Iselin, Country Lead Medical Devices at J&J Switzerland

Experience gained thus far is encouraging. For example, costs for patients undergoing hip and knee operations at a Neuchâtel clinic were cut by 40 percent thanks to faster recovery and mobilization. For bariatric surgeries such as a gastric bypass operation at a defined phase of severe overweight, there was a drastic reduction in the costs incurred due to diabetes and high blood pressure in connection with severe overweight. Scarring of the heart during catheter ablation makes antihypertensive drugs obsolete. Roman Iselin views these cooperative approaches as "urgently necessary so that VBHC can revolutionize the health care system".

Two examples
of patients

Beatrice K. lost 30 kilograms in weight – and her type 2 diabetes disappeared; Christian G. lost his cardiac arrhythmias.

Together through thick and thin: Beatrice K. and her bulldog Oskar.

"I've been going on diets for decades, but they never lasted."

 

Beatrice K.

"Obesity is a chronic condition."

 

Professor Ralph Peterli

11%

of the Swiss population suffer from obesity.

GASTRIC BYPASS

"I'm active again."

Bariatric interventions show what can be achieved when an efficient and timely medical therapy brings about a definitive turning-point, so costs are cut on a long-term basis. For severely overweight individuals, a gastric bypass can prevent secondary conditions in the long term – or can even eliminate them completely.

 

 

Beatrice finally reached breaking point during an outing with her family, when even a gentle uphill slope left her out of breath and she could no longer manage without help from others: "I knew that the time had come for something to happen," says Beatrice (who is now 72). Back then, she weighed in at 96 kilograms – distributed over a body height of 1.50 meters. The consequences of being overweight were making her life difficult: joint pains, shortness of breath and type 2 diabetes. Beatrice K. numbered among the eleven percent of obese individuals in Switzerland.

 

"Obesity is a chronic condition," according to Professor Ralph Peterli. For many years, this surgeon has undertaken research on obesity and its consequences at the Obesity Center of Clarunis (the University Center for Gastrointestinal and Liver Diseases) on the Claraspital site in Basel. "The idea that obese individuals eat too much simply because they lack discipline and willpower is wrong," the specialist points out. In his day-to-day work, he sees that many factors are conducive to obesity: they include genetic and psychological factors as well as an unhealthy lifestyle or a metabolic disease. "Individuals with this condition can take as many slimming cures as they like – but through their own efforts, they rarely shed enough weight to restore them to normal levels."

 

Beatrice K. also had this experience. "I went on diets for decades," she says, "but they never lasted – I always put on weight again afterwards and became even heavier." And then the secondary conditions began to appear. A normal, active life was out of the question without medicines and therapies. The psychological strain kept on increasing. "You feel so ashamed," she recalls. "When you take your seat in a plane, you have to ask for an extension for the safety belt because it won't fit round your belly."

 

The story of Beatrice K. and her gastric bypass

According to the Swiss Federal Statistical Office (SFSO), 12% of men and 10% of women in Switzerland are obese. These figures have doubled over the last 25 years. And the Federal Office of Public Health (FOPH) also notes a breathtaking increase in the cost to the national economy over the same period: overweight individuals cost society CHF 8 billion in 2012. This makes it a matter of urgency to discover how obese individuals can be helped without a constant increase in costs.

Everything about obesity

Obesity (adiposity) is regarded medically as a chronic condition. A body-mass index (BMI) of over 30 qualifies as obese; individuals with a BMI of over 35 are severely obese. The normal range for the BMI is between 18 and 25. Those affected suffer dramatic consequences: morbid obesity curtails their quality of life and causes serious damage to their health. The consequences of obesity include (but are not limited to) type 2 diabetes, lipid metabolism disorders (increased cholesterol and triglyceride levels in the blood), cardiovascular diseases and joint pain.

During a gastric bypass operation: Professor Ralph Peterli

Gastric bypass

A gastric bypass is a surgical intervention that involves amputation of the stomach just below its entrance. The small residual stomach is connected to the small intestine. Digestion then begins directly in the small intestine. As well as reducing the intake capacity and lowering the absorption of food, the operation has a positive influence on the hormones produced in the small intestine that control satiety (the feeling of being replete). For the vast majority of patients, all of these effects result in a loss of weight. A gastric bypass is regarded as the last resort if conservative methods of inducing long-term weight loss fail to produce results. It is only performed on patients with a BMI of 35 or more. The period of the patient's stay in hospital after the operation is between three and five days.

CUTTING COSTS IN THE LONG TERM

 

Ralph Peterli sees surgical interventions such as the gastric bypass as a potential way of liberating obese individuals from their overweight on a long-term basis. He has already performed around 3,000 operations of this sort. The results are encouraging: in most cases, the bypass leads not only to a massive loss of weight but also to a reduction of the costs incurred due to obesity. "Even just a short time after the operation, diabetes is reduced and can even disappear in some cases; hypertension is brought under control, and there is less joint pain thanks to the loss of weight – the list of positive effects could go on."

Beatrice K. had read about the possibilities offered by a gastric bypass, and she had also learned that it could cure diabetes. At age 70, Beatrice was admitted to the Claraspital in Basel where she was examined by a team of nutritionists, psychologists and physicians to determine whether she was suitable for an intervention. She has nothing but positive experiences to recount: "I felt that I was being taken care of and understood. At last, I could take a positive view of the future, and I knew that everything would be all right," she recalls. The minimally invasive intervention, which involves massively reducing the size of the stomach and connecting it directly to the small intestine, takes about one hour. Even so, she points out, it is a serious operation – but she was happy to accept the inconvenience it entailed: "Staying fat wasn't an option for me." Everything went according to plan, and she was discharged after five days.

 

She has since lost 30 kilos. She is healthy. Her diabetes has vanished. She no longer gulps down medicines. She feels as if she has given herself the gift of a new life: "I'm active again, I often go for a walk with my dog, and I meet up with friends." Surgeon Peterli views the entire process as an interaction between the interdisciplinary medical treatment team, the patient, and the operating method. "In the preparatory phase, we investigate in detail whether the patient is ready to adapt his or her eating behavior and exercise patterns after the operation so that we can all collaborate to achieve the best possible result." He believes it is essential for patients to receive ongoing support from his team – for their entire lifetimes.

Actively enjoying riding again: heart patient Christian G.

"Atrial fibrillation, the most frequent type of cardiac arrhythmia, is a chronic condition that requires lifetime treatment with medications."

 

Professor Etienne Delacrétaz

"It happened while I was sitting in front of the TV after dinner – my heart suddenly started beating like crazy."

 

Christian G.

Catheter ablation

"I feel young again."

Cardiac arrhythmias are classified as chronic diseases of the heart, and various methods are available to treat them. When carried out promptly, catheter ablation of the heart can practically eliminate these conditions – and can also avoid follow-on costs. This is what happened in Christian G's case.

 

 

At breakneck speed, the cursor flits across the screen where little pink balls are turning red and something resembling a snake is prancing about. This is the computerized graphic view of a catheter during an intervention in the atrium of a patient's heart. A closer look reveals an outline that resembles a gray stone. "This", Charlotte Vivet explains, "is the 3D view of the inside of the heart." This 25-year-old engineer, a graduate of the École Polytechnique Fédérale de Lausanne (EPFL), has been working at Johnson & Johnson as a Clinical Support Specialist for well over a year. She is one of a team of 15 highly specialized staff in Switzerland who act as partners to doctors when they perform high-tech cardiac surgeries. This morning, she is working in tandem with Professor Etienne Delacrétaz at the Hirslanden, Clinique Cecil in Lausanne.

 

Behind Charlotte's screen, separated by a pane of glass, is the operating theater. On the table lies a young man, fast asleep. In front of him at waist level sits the doctor, whose quiet comments and instructions are relayed from the loudspeaker set up in front of Charlotte. Professor Etienne Delacrétaz is at work. This specialist in cardiology and electrophysiology is performing a catheter ablation of the patient's heart. This is a minimally invasive procedure that involves scarring of the heart tissue with the help of a catheter. It is an exceptionally efficient method of eliminating dangerous cardiac arrhythmias.

Clinical Support Specialist: Charlotte Vivet.

FEAR AS A CONSTANT COMPANION

 

"Atrial fibrillation is the most frequent type of cardiac arrhythmia," Delacrétaz explains, "and it's a chronic condition that requires lifetime treatment with medications." There is no cure. Left untreated, it leads to disorders such as palpitations and shortness of breath; in extreme cases, it can even result in strokes and cardiac insufficiency. And the consequences for those affected can be dramatic – they may even become disabled. According to the Swiss Heart Foundation, about 100,000 people suffer from atrial fibrillation in this country – and the trend is upward.

100,000

people in Switzerland suffer from atrial fibrillation, according to the Swiss Heart Foundation. And the trend is upward.

Atrial fibrillation

Atrial fibrillation is the most frequent type of cardiac arrhythmia. It is caused by the faulty transmission of electrical signals in the atrium of the heart. As a result, the atria and ventricles can no longer pump in unison, and they are usually too fast. The irregular pumping movements can cause more blood clots to form in the heart. If one of these clots is released into the bloodstream and blocks an artery in the brain, it will cause a stroke. Many patients are therefore treated with anticoagulants as a precaution. Cardiac insufficiency can also develop as a delayed consequence of the permanently high heart rate.

As well as putting life at risk, cardiac arrhythmias are extremely frightening for the sufferer. That was the case for 56-year-old Christian G, so he underwent catheter ablation performed by Professor Delacrétaz. This was after his heart suddenly started beating irregularly from one day to the next. "It happened while I was sitting in front of the TV after dinner – my heart suddenly started beating like crazy." Christian, a heating fitter, went to consult his cardiologist. "We tried to calm my heart down with medications, but that didn't really help," he explains. Although he is normally quite athletic, Christian felt listless, constantly tired and somewhat depressed due to his condition. He was afraid that he would have to give up his hobby of riding. "But the worst thing of all was the fear," he recalls. He knew that his father and uncle had suffered from high blood pressure, and both of them had died before their 60th birthdays. He too had been taking antihypertensive drugs for years.

 

The story of Christian G. and his catheter ablation

A specialist in catheter ablations: Professor Etienne Delacrétaz.

Catheter ablation

The method of scarring heart tissue with catheters and high-frequency current was first used 40 years ago, since when it has been continuously refined. Today, the intervention is quite short – it only takes one to one and a half hours. The doctor inserts a catheter through the vein into the atrium, locates the diseased tissue and then destroys it by heating. The catheter ablation rate in Switzerland is increasing by eight to twelve percent every year, and the trend is upwards.

"I hardly felt any pain – but I could already feel the positive consequences on the second day after the operation."

 

Christian G.

A catheter ablation is an intervention involving targeted scarring of the tissue that causes heart arrhythmias. It is performed via catheters that are introduced into the heart through the vein. Etienne Delacrétaz has been performing catheter ablations for over 20 years. Catheter ablation is not a surgery on the heart, he explains: it is a minimally invasive intervention that leaves no external traces behind. The doctor treating the patient must have very nimble fingers – "but most of all, he must understand the technical procedures and have plenty of practice." The doctor concentrates his attention on the large screen behind the operating table to see the exact location of the tip of the catheter as he steers it with his hand. Charlotte, his supporter, provides him with all the data he needs to guide him. She rotates the 3D images so the doctor can see the places that he has to scar. In the graphic view, they are marked by dots that becomes redder as the scarring becomes more intense. Of course, the heart must never be damaged as the procedure takes place.

QUICKLY BACK TO WORK

 

After well over an hour, the operation is over as far as the patient is concerned. He is wheeled out of the operating theater. With latest-generation catheters, the procedure takes no more than one and a half hours. Delacrétaz recalls that it wasn't always like this: "It used to take up to four hours." About five percent of all heart patients are currently treated with cardiac catheter ablations. As well as elderly patients, they include children and young people – who are often competitive athletes. After the procedure, the patient has to take a few medicines that drastically reduce the risk of cardiac insufficiency or a stroke, which could lead to irreparable damage. There is a spectacular improvement in the patient's quality of life, accompanied by a reduction of the subsequent costs that would be incurred without the intervention. Long-term chances of a successful outcome decrease with age, so patients should not be older than 70.

 

It is now six months since Christian G. had his catheter ablation. The surgery passed off without any complications whatsoever. Christian's entire face is radiant: "I hardly felt any pain – but I could already feel the positive consequences on the second day after the operation." He was even able to resume work immediately. The atrial fibrillation has disappeared and although his blood pressure is still slightly high, he has it under control thanks to medications. He feels fit and vigorous, and he is taking part in equestrian competitions once more. "It's as if I was young again," he says.

 

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© Johnson & Johnson AG 2020 Last updated on 10.06.2020

Catheter ablation

The method of scarring heart tissue with catheters and high-frequency current was first used 40 years ago, since when it has been continuously refined. Today, the intervention is quite short – it only takes one to one and a half hours. The doctor inserts a catheter through the vein into the atrium, locates the diseased tissue and then destroys it by heating. The catheter ablation rate in Switzerland is increasing by eight to twelve percent every year, and the trend is upwards.