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COM/WSNWS
VALUE-BASED
HEALTHCARE
IN SWEDEN
Reaching the next level
Commissioned by
РЕЛИЗ ПОДГОТОВИЛА ГРУППА "What's News" VK.COM/WSNWS
Value-based healthcare in Sweden

1
Contents
2 List of abbreviations
3 About this report
4 Executive summary and key findings
6 Introduction
7 Chapter 1: The Swedish model and lessons for others
14 Chapter 2: The backlash and obstacles to further
progress
21 Chapter 3: Overcoming limitations and potential
steps forward
29 Conclusion
© The Economist Intelligence Unit Limited 2019


2
List of abbreviations
AI: artificial intelligence
EHR: electronic health record
EUnetHTA: European Network for Health Technology Assessment
NQR: Swedish national healthcare quality registry
RWD: real-world data
RWE: real-world evidence
SALAR: Swedish Association of Local Authorities and Regions
TLV: Tandvårds-Och Läkemedelsförmånsverket (Dental and

Pharmaceutical Benefits Agency)
VBHC: value-based healthcare
VBP: value-based payment


3
About this report

Value-based healthcare in Sweden: Reaching the next level is an
Economist Intelligence Unit report, commissioned by Takeda. It looks
at Sweden’s progress on implementing the principles of value-based
healthcare (VBHC) throughout the country and care pathways.
The findings of the report are based on desk research and ten in-
depth interviews with experts on VBHC in Sweden, including health
economists, healthcare providers and policymakers. Our thanks are
due to the following for their time and insights (listed alphabetically):
• K arin Göransson, policy analyst, Swedish Association of Local

Authorities and Regions (SALAR)
• P eter Graf, CEO, Tiohundra
• N iklas Hedberg, chief pharmacist, Dental and Pharmaceutical
Benefits Agency/Tandvårds-Och Läkemedelsförmånsverket
(TLV); and chair of the executive board, European HTA Network
(EUnetHTA)
• M orten Kildal, consultant plastic surgeon, head of value-based
healthcare and associate professor, Uppsala University Hospital
• P eter Lindgren, managing director, Swedish Institute for Health
Economics
• T obias Nilsson, chief of strategy, Västra Götaland healthcare region
• Jörgen Nordenström, emeritus professor of surgery, and freelance
consultant in healthcare quality improvement projects, VBMCare.com
• F redrik Öhrn, senior innovation manager, Karolinska University
Hospital
• Johan Thor, associate professor, Jönkoping Academy for
Improvement of Health and Welfare
• F redrik Westander, senior policy analyst, SALAR
• Jonas Wohlin, founder, Ivbar
The report was written by Andrea Chipman and edited by Martin

Koehring of The Economist Intelligence Unit.
January 2019


4
Executive summary
The need to get better value from healthcare investment has never
been more important as ageing populations and increasing numbers
of people with multiple chronic conditions force governments to make
limited financial resources go further.
These pressures, along with a greater focus on patient-centred care,

have raised the profile of value-based healthcare (VBHC), especially in
European healthcare systems. Sweden, with its highly comprehensive
and egalitarian healthcare system, has been a leader in implementing
VBHC from the beginning, a fact that was underscored in a 2016 global
assessment of VBHC published by The Economist Intelligence Unit.1
This paper looks at the ways in which Sweden has implemented VBHC,
the areas in which it has faced obstacles and the lessons that it can
teach other countries and health systems looking to improve the value
of their own healthcare investments.
Key findings
Defining VBHC is still a challenge. Finding a single definition of VBHC,
let alone a policy that can command widespread support, has been a
challenge in Sweden, as elsewhere. The country has been a pioneer in
experimentation with organisational restructuring designed to improve
efficiency and patient satisfaction. There have also been some efforts
to link remuneration of healthcare providers and reimbursement of
medicines to outcomes. Yet, although there is little disagreement that
more successful outcomes for patients and doctors alike should be a key
priority, there is significant disagreement on the steps needed to get to
that point.
Integrated care delivery is a key part of providing value. Policies

that lead to greater integration of healthcare pathways and closer
co-ordination of care between different stakeholders (and payors) in
the Swedish system have been welcomed by patients. In some notable
cases, such as through the closer co-ordination of home care between
hospitals and community care agencies, these policies have made
healthcare delivery more efficient.
Getting buy-in from health providers is vital. The most successful

experiments with VBHC in the Swedish system, including initiatives in
Uppsala, the Västra Götaland region and Stockholm County, so far have
been done gradually, with close consultation with healthcare providers,
1
The Economist Intelligence Unit, The enabling environment for value-based healthcare, http://vbhcglobalassessment.eiu.com/


5
patients and other stakeholders. Other, more radical attempts at

reform have met with criticism, which has undermined support for
them. Achieving “buy-in” from those charged with implementing new
policies, and those they are meant to benefit, is critical.
Good data are key to effective value-based pricing. Accurate

and comprehensive health data are a major part of VBHC in that they
enable policymakers to measure the impact of treatment, evaluate
where both care and processes can be improved, and ultimately
provide the information that can underpin value-based pricing. Sweden
has benefited immensely from its long history of quality registers for a
variety of diseases, including hip arthroplasty and cardiac care. Yet the
quality and coverage of these registries are uneven. More consistent
gathering of data, as well as more efficient integration of information
from registries with that collected in electronic health records, could
help to underpin efforts to extend value-based pricing.
VBHC is not always “one size fits all”. Although there have been
some efforts to pilot VBHC experiments in multiple regions of Sweden,
the country’s decentralised healthcare structure means that there is
unlikely to be a comprehensive national VBHC policy imposed from
the centre. At the same time, there are numerous instances of co-
operation between regions and national working groups dedicated
to making it easier to share information about best practices. These
include a platform between the country’s health ministry and seven
county councils to monitor value in healthcare and reimbursement, and
more recent efforts to come up with a common infrastructure for using
registry data.


6
Introduction
Sweden has long been a global leader in value-based healthcare (VBHC),
helped by its highly developed system of disease registries, outcome-
based reimbursement for some specialised care and a decentralised
health system that helps to encourage experimentation at the local level.
Delivery of healthcare is the responsibility of Sweden’s 21 regions,

creating a range of opportunities for local authorities to pilot reforms
within a smaller population before looking to scale them up.
Yet advocates for greater organisational change to support these

measures have faced increasing criticism in recent years, driven in part
by the fragmented and uneven degree to which these changes have
been pursued. As a result, public and clinical perceptions of VBHC have
been somewhat tarnished.
“If you are talking about registering outcomes data, there has been
investment from national funds in building better infrastructure,” says
Peter Lindgren, managing director of the Swedish Institute for Health
Economics. “If you are talking about organisational principles, there is
quite a bit of a backlash at the moment.”
Sweden provides a number of examples of how value-based

propositions can be implemented successfully, as well as lessons on
how to better engage stakeholders in the process.
This report will first look at what Sweden does well and what other
countries can learn from Sweden’s experience with VBHC. The second
chapter will then highlight some of the challenges the country has faced
in implementing VBHC. Chapter 3 will look at how to overcome the
limitations and examine some of the potential steps forward.


7
Chapter 1: The Swedish model and lessons

for others
Part of the difficulty in assessing the success process design. Better adaptation of process
of countries at implementing VBHC is and health pathways is another element that
agreeing on a definition in the first place. could lead to greater progress on detecting
and treating serious health conditions.
The concept of VBHC delivery originated
with Harvard University Professor Michael Finally, in some cases, payment systems
Porter, who envisioned it as a structure themselves are being altered to reflect
for rebuilding global healthcare systems these priorities, with Sweden and the UK
“with the overarching goal of value for leading the way in Europe. In contrast
patients—not access, cost containment, with the UK, however, where value-based
convenience, or customer service”. The payments (VBPs) are being piloted on a
formula for assessing value is patient national level, in Sweden’s decentralised
health outcomes per dollar spent.2 system they are largely regional agreements
with county councils. In addition, most
In this understanding, only an evaluation are still focused on efforts to connect
of the ways in which a specific health health provider remuneration to patient
intervention, treatment or entire care pathway outcomes. This difference, and the fact that
clearly benefits patients and contributes connection of VBP systems to Sweden’s
to better outcomes can determine their disease registries is still a work in progress,
value. From a cost perspective, meanwhile, makes it more challenging to expand
employing all of the elements that make up the use of VBPs around the country.
VBHC—better data, processes and care—
leads to better outcomes that create value. Over the past decade, a number of European
countries have implemented a variety of
Yet, in Sweden, as elsewhere, there are a value-based measures in their healthcare
number of components that contribute delivery, and Sweden has arguably been one
to patient outcomes and value that are of the continent’s leaders in this process, as
important to understand and go beyond highlighted by The Economist Intelligence
costs. Access to high-quality data is one Unit’s 2016 global assessment of VBHC.3
element that is crucial to evaluating value in
healthcare, and Sweden’s pioneering quality Sweden has long had one of the most
health registries and digital health records progressive healthcare systems in Europe,
provide significant opportunities to compile underpinned by its social democratic
and share real-world evidence (RWE) about traditions and explicit protection of
health outcomes. Integration and use of those egalitarianism in the legislation supporting
data could offer future benefits in the form healthcare. Yet the country faces many of
of improved diagnosis, therapy and health the same problems as other developed
2
Harvard Business School, Value-Based Health Care Delivery, https://www.isc.hbs.edu/health-care/vbhcd/Pages/default.
aspx
3
The Economist Intelligence Unit, The enabling environment for value-based healthcare, http://vbhcglobalassessment.eiu.
com/


8
economies—an ageing population, growing Health registries, evidence-

numbers of people with chronic medical based treatment guidelines and
conditions and limited budgets—all of which digitalisation
are putting stress on its healthcare system.
Sweden’s healthcare system is unique in its
Sweden’s 21 regions are responsible for long tradition of being able to access data
providing and paying for most healthcare from a wide range of quality-based health
delivery, with costs financed primarily through registries, some of which have been collecting
taxation at the county level. As a result, data for more than 20 years. The registries
experimentation has been primarily at the provide quality indicators designed both to
regional, and even local, level. enable further improvement and to allow
for the evaluation of healthcare delivery. The
“The regions are free to organise the
registries have their own publications but
delivery of healthcare within the bounds
also post data on the main website of the
of the law”, says Mr Lindgren. “Otherwise,
Swedish Association of Local Authorities and
there is a free mandate as to whether
Regions (SALAR) for publicly presented health
to provide it themselves or to rely upon
quality indicators, Vården i siffror (healthcare
private providers. If we talk about organising
in numbers). Close to 50 of Sweden’s 100
healthcare along value-based lines,
national quality registries currently provide
there is nothing at the national level.”
data to the website, according to Karin
Göransson, a policy analyst at SALAR.
Decentralised Sweden
21 290
County councils Municipalities
Source: Ministry of Health and Social Affairs Sweden.


9
Policymakers are hoping to use the registries is no requirement to have these registries,”
to underpin more evidence-based treatment he adds. “They have different coverage and
and real-time medical research. Yet levels of degrees of acceptance; they are very good in
coverage of the registries vary by medical the areas of cardiology and hip replacement,
speciality, according to Mr Lindgren. and in other areas cover just a fraction of care.”
Nevertheless, the existence of the

registries is already influencing clinical
approaches outside Sweden, with the
In Sweden, the national country’s hip arthroplasty registry helping
quality registries give a unique to define international best practice.4
possibility to achieve the goal Against this backdrop of vast data availability,
of equal care and treatment.” digitalisation in Swedish healthcare is
Karin Göransson, policy analyst, SALAR
advancing. The Swedish government
and SALAR recently launched a joint
vision for digitalisation in health.5 With its
Sweden’s ability to track its population and disease registries, electronic records and
compile a few hundred national quality plenty of real-world data (RWD), Sweden
registries helped make it attractive to has been labelled a “data gold mine” for
Harvard University’s Mr Porter, says Jörgen healthcare;6 the potential for further
Nordenström, emeritus professor of surgery, development of the use of predictive
and freelance consultant in healthcare analytics, machine learning and applications
quality improvement projects at VBMCare. for artificial intelligence (AI) is enormous.
com. But, he notes that the process of
updating registries is time-consuming “In Sweden, the national quality registries
for doctors, and there are too many give a unique possibility to achieve the
assumptions that the available information goal of equal care and treatment,” says Ms
will automatically help units with poor Göransson. “They provide knowledge of
ratings to improve their performance. how healthcare works and can be improved.
These registries, together with the traditional
“Professions set up the registries in different health data registries, have helped save many
disease areas to measure quality, and there lives and improve healthcare in Sweden.”
4
“Swedish National Quality Registries and their Contribution to the Best Possible Care for Patients,” presentation by Thor,
J., et al to the International Forum on Quality & Safety in Healthcare, Gothenburg, April 15th 2016, p. 32, http://aws-cdn.
internationalforum.bmj.com/pdfs/2016_G2.pdf
5
Government Offices of Sweden and SALAR, Vision for eHealth 2025 – common starting points for digitisation of social
services and health care, March 2016, https://ehalsa2025.se/wp-content/uploads/2018/03/Handlingsplan-e-h%C3%A4lsa-
engelsk-version.pdf
6
Webster, P. C., “Sweden’s health data goldmine”, CMAJ, 2014 Jun 10; 186(9): E310.


10
Another project, Primary Care Quality has developed different ways of approaching
Sweden, seeks to improve co-ordination on the problem. The country is already using
the primary care level. The project is a quality bundled payment systems in different
improvement system comprising around 150 regions, where health providers are paid for a
quality measures and technical methods for complete episode of care lasting for a year or
collecting data automatically, so healthcare longer, giving the provider full responsibility
providers do not need to spend time compiling for the care cycle, including complications.
additional documentation, and making it This package price is adjusted based on the
available at both the local and national levels.7 preconditions of the patients and expected
The data are real-time, evidence-based and cost for each, based on demographic factors.
updated annually. It covers primary care-
specific indicators such as comorbidities, Different payment models are also being
lifestyle habits and pharmaceutical treatment, applied in the primary care sector. Payments
diagnosis-specific indicators for 12 categories are generally based on capitation for
of conditions commonly seen in primary registered patients, based on an estimated
care, as well as patient-reported data.8 “illness burden” as well as some fee-for-
service and performance-based payments.10
The system currently covers half of Sweden’s In addition, 15 of Sweden’s 21 county councils
1,200 health centres and can answer have put in place risk-adjusted capitation
questions such as what proportion of patients based on the country’s Care Need Index
with atrial fibrillation are not treated with (according to research published in 2018),
anticoagulants and which patients with which increases capitation payments to
chronic disease have not had a check-up primary-care centres with a large number of
within the past 18 months.9 patients with “unfavourable socioeconomic or
demographic characteristics”.11
Value-based pricing
In both Stockholm (the capital region) and
Meanwhile, value-based pricing models are some parts of western Sweden, there have
also progressing in Sweden. Value-based been experiments in reimbursing health
pricing for pharmaceuticals and medical providers for so-called bundled care, an entire
devices has been in operation since 2002 in episode of care in which remuneration is
some regions of Sweden, those interviewed based in part on outcomes. Stockholm County
say. Sweden, together with the UK, was one has introduced bundled care programmes for
of the first countries to adopt value-based spinal surgery and hip replacements (see the
pricing as a decision-making framework, but it case study on the next page). Meanwhile, in
7
Swedish Association of Local Authorities and Regions, Primary Care Quality Sweden, https://skl.se/tjanster/englishpages/activities/
primarycarequality.10073.html
8
Elmroth, U., Primary Care Quality Sweden: Made by primary care, for primary care, presentation to Amsterdam International Forum on Quality and Safety
in Healthcare, May 2nd-4th 2018, https://www.nfgp.org/files/29/nfgp_august_2018_presentation_sweden_1_of_2_.pdf
9
Ibid.
10
European Forum for Primary Care, Primary Care in Sweden, http://www.euprimarycare.org/column/primary-care-sweden
11
Anell, A., et al., “Does risk-adjusted payment influence primary care providers’ decision on where to set up practices”, BMC Health Services Research, 2018
Mar 14;18(1):179.


11
Case Study: OrthoChoice A number of other regions in Sweden have

adopted similar agreements for bundled
OrthoChoice was one of the earliest
payments with a value component for
examples of a bundled payment system
discrete procedures, such as hip and
in Sweden, in which healthcare providers
knee replacements and bariatric surgery.
receive reimbursement based on outcomes
Agreements are based on achievement
and undergo close health monitoring of
and the extent to which patients were
healthcare delivery introduced in Sweden.
satisfied a few months, or one year, after
Launched in all major hospitals and three
their operation. In the case of spinal
private specialised orthopaedic centres in
surgery, these measurements focus on pain
Stockholm County in 2009, OrthoChoice
reduction, as this is the principal reason
involved knee and hip replacement
for surgery.
surgery, and was ultimately extended to
spinal surgery. “Initially, there were higher expectations,
with most people positive toward changing
Under the terms of the programme, a
from production-based reimbursement
small portion of the bundled payment,
to something that had to do with
around 3.2%, is withheld and paid
outcomes and patient values,” says
retroactively only if the provider meets
Jörgen Nordenström, emeritus professor
previously agreed outcome goals. By 2011,
of surgery, and freelance consultant in
complications and revisions had declined
healthcare quality improvement projects at
by around 20% compared with a control
VBMCare.com.
group using traditional reimbursement
plans, and the county’s total cost per Ultimately, he adds, the programme has
patient also declined.12 been considered successful, with analysts
concluding that complication rates and
In 2013 the OrthoChoice model was
costs fell as a result.
extended to spinal surgery, with a much
higher outcomes-based payment of 10%.13
western Sweden, health providers are running toolbox, but it’s a usable framework,” said
a trial for the same two procedures, as well Niklas Hedberg, chief pharmacist at Sweden’s
as for bariatric surgery, with 10% of total Dental and Pharmaceutical Benefits Agency
payments based on health outcomes.14 Tandvårds-Och Läkemedelsförmånsverket
(TLV) and chair of the European Health
“Most partners would agree that [value-based Technology Assessment Network (EUnetHTA).
pricing] is not the only tool you need in your “When it comes to VBHC, I think it remains
12
Clawson, J., et al., “Competing on Outcomes: Winning Strategies for Value-Based Healthcare”, Boston Consulting Group,
January 2014.
13
Ibid.
14
OECD Expert Group Meeting on Payment Systems, SVEUS – National collaboration for value-based reimbursement and
monitoring of health care in Sweden, April 7th 2014, http://www.oecd.org/els/health-systems/Item7a_ SVEUS-National-
collaboration-for-value-based-reimbursement-and-monitoring-of-health-care-in-Sweden_Wohlin.pdf


12
to be defined and discussed in more detail quality-adjusted life year basis, although
before we can draw any firm conclusions.” there is no specific threshold for approving
reimbursement that is enshrined in law,
TLV assesses drugs for outpatient care and Mr Hedberg adds. Instead, the threshold can
makes reimbursement decisions, but must be overridden depending on the severity
ensure that decisions conform to the Swedish of the disease, with higher costs approved
parliament’s ethical platform, which is based for conditions such as terminal cancer or
on the principle of equal human value, says Mr Gaucher’s disease, a rare and severe condition.
Hedberg. Medical need and conformity with If treatments can fulfil several conditions—
the solidarity principle must also be balanced substantial effectiveness, high severity of
with cost-effectiveness. In the case of hospital disease and no treatment alternative—the
medicines, although health assessment TLV board is prepared to pay a higher cost.
is done in the same way, TLV delivers its At the same time, concepts such as medical
assessment straight to the county boards need carry a certain amount of ambiguity, and
that make decisions on what medicines and a reference group of European researchers
devices their own hospitals will use. based in the Netherlands is trying to sort out a
“Since county councils are responsible for more consistent approach.
delivering care in all these sectors, they are
trying to come together in a more structured, Dr Nordenström gives the example of a
knowledge-based and evidence-based new biological drug used to treat metastatic
approach,” Mr Hedberg explains, adding that melanoma, which has a cure rate in 20% of
the regions have formed national committees, cases. At a cost of SEK800,000 (US$89,109)
including a new therapies council that works per treated patient, health providers were
closely with TLV. reluctant to prescribe it, but drug companies
offered to provide the drug for free to any
patients, with the condition that insurance
companies would have to fully reimburse the
cost for those who were cured.
[County councils] are trying
to come together in a more Ultimately, Mr Hedberg says, Sweden could
structured, knowledge-based follow in the steps of other countries, such as
and evidence-based approach.” Italy, and enter into so-called managed entry
agreements with pharmaceutical companies,
Niklas Hedberg, chief pharmacist, TLV; and chair
where both the payer and the manufacturer
of the executive board, EUnetHTA
accept the fact that final data on a treatment
Like some other European countries, the won’t be available for some time after it is
Swedish system in theory assesses new desirable to make it accessible to patients, and
drugs or devices according to a cost per where both sides agree to share that risk.


13
Summary box: lessons for the are already having an influence on

rest of Europe and the world international care practice.
• S
weden’s advanced and • W
ith its disease registries, electronic
interconnected system of electronic records and plenty of real-world data,
health records, along with its emphasis Sweden’s potential for predictive
on egalitarianism in its health system, analytics, machine learning and
put a great emphasis on improving and applications for AI is enormous and
standardising care. has already been piloted in several
collaborations.
• T
he country’s quality health
registries create a foundation for the • S
weden’s digitalisation has empowered
collection and management of data, patients to become part of their own
and provide a basis for clinicians to care, making them an active partner
measure health outcomes. Although in collecting their patient-reported
there are differences in the level of outcomes.
coverage in individual registries, the
infrastructure provides a solid basis • Sweden’s decentralised health
that is likely to be improved on with the system has provided opportunities for
further development of technologies, experimentation, including different
such as artificial intelligence (AI). The forms of value-based pricing and
data provided to registries in Sweden reimbursement.


14
Chapter 2: The backlash and obstacles to

further progress
While Sweden has marked up a number of University Hospital (see case study on page
successes in experiments in VBHC, not all 18) and Sahlgrenska University Hospital in
have been sufficiently developed. There is Gothenburg, have triggered a fair amount
a need for further progress in digitalisation of backlash.
in order to help connect the dots between
information from data registries’ RWE. Incomplete digitalisation process
As is the case in many other countries in
Meanwhile, Johan Thor, associate professor
Europe and North America, information
at Jönkoping Academy for Improvement of
technology (IT) systems in Sweden are both
Health and Welfare, says it remains difficult
a boon and a barrier to helping to share the
to identify a broader VBP model that can be
comparatively large amount of health data on
scaled up easily, despite the success of some
the Swedish population.
of the VBP experiments discussed earlier.
The country’s 21 regions have 21 different IT
“It’s a laudable idea at the drawing board, but
environments, including systems for electronic
when you try to operationalise the whole thing
health records (EHRs) that vary both within
and find quality indicators and a payment
and between regions. Moreover, there is a
portfolio, it is hard to get that working,”
variety of collaborations between regions, but
he adds.
little on the national level. Previous efforts to
In addition, not everyone is convinced of the get larger healthcare regions to purchase IT
potential merits of these new structures, functions jointly failed, as they saw their needs
according to Mr Lindgren. as too divergent, according to Mr Lindgren.
“Payers have been more reluctant, primarily Similar work being done by the National
due to a fear of the administrative burden on Board of Health and Welfare is supporting
physicians and administrators,” he explains. co-ordination, but there is a lack of legal
Meanwhile, “the coverage in registries is requirements to organise systems in a
of varying quality, entry into the system is particular way.
voluntary and some registries don’t want a “I think there is a need for more investment in
financial component being tied to the data, national IT infrastructure, in terms of having
feeling it might pollute the quality of the data,” an information backbone,” says Mr Lindgren.
Mr Lindgren adds. “We are never going to have one national
system, but there needs to be a better and
Indeed, those interviewed say that VBP
easier system to exchange data.”
models are likely to be more applicable
to isolated healthcare events or relatively Data-sharing issues also remain unresolved,
straightforward treatments and surgeries, as something that has yet to be a priority on the
opposed to more complex cases involving legislative level.
multiple chronic conditions, for example.
Although Sweden’s quality registries and well-
Finally, Dr Thor notes that some of the entrenched medical records system make
more ambitious and radical experiments, its population one of the most well tracked,
such as reforms implemented at Karolinska health-wise, in Europe, extricating valuable


15
RWE from these systems in a form that can be comparing your results when you are done.”
used to assess the value of healthcare is still a EUnetHTA is consulting on this process from
longer-term goal. early 2019.
“It’s more obvious now that we are facing Regional variation and data banks
decision problems where we cannot expect
to have our answers from random controlled A key underlying issue, Dr Thor says, is that
trials or to make decisions within a relevant Sweden’s quality registries remain incomplete,
time frame,” Mr Hedberg explains. At the making it difficult to use them for determining
same time, he notes, variation in the “amount payment for providers.
of data, coverage levels of data, and quality
“There are competing and incompatible
and accessibility of data” constitute obstacles
motivations for using that kind of data,” he
to relying on the registries in the short term,
explains. “Using them for payment purposes
especially given that most patients have
is sometimes in conflict with using them for
consented to their data being stored for
learning purposes because we know that
narrow purposes in the first place.
payment incentives are very powerful.”
Ultimately, however, RWE has great potential
Although data quality “varies greatly”
to provide substantial amounts of data that
between different quality registries, there
could help inform care, include larger and
are continuing efforts to improve quality, Ms
more inclusive populations of patients, current
Göransson says, adding that an increasing
methods of treatment, outcomes and risk of
number of registries are receiving higher
treatment, sub-populations that might be at
scores, indicating that they are improving
greatest risk, and the cost of treating or not
their content and relevance. Research based
treating them.15 And it has the capability to
on data from the quality registries is also
provide similar information about new drugs.
steadily increasing, she notes. The number
“We need to come to a point where there are of scientific articles based on data from 69
no practical or technical hurdles, given that quality registers in Sweden and published in
there will still be privacy and legal issues,” Mr peer-reviewed journals rose to 496 in 2016,
Hedberg adds, something that will require from 121 in 2009.16
the strengthening of national and regional
structures and international collaboration. “In general, you could say that when the
diagnosis or procedure is well defined and
“We need to start gathering data together,” the patient group not too big, we have higher
he demands. “Now, more and more people NQR [Swedish national healthcare quality
are talking about federated analysis for registry] coverage and better data,” says
distribution, gathering all data, sharing it and Fredrik Westander, senior policy analyst at
15
See Cavlan, C., Chilukuri, S., et al., “Real-world evidence From activity to impact in healthcare decision-making,” https://
www.mckinsey.com/industries/pharmaceuticals-and-medical-products/our-insights/real-world-evidence-from-activity-
to-impact-in-healthcare-decision-making
16
Lysholm J. and Lindahl B., “Strong development of research based on national quality registries in Sweden”, Ups J Med Sci.,
2018 Oct 1:1-3.


16
SALAR. “But large areas of healthcare needs survival rates for the country’s 74 cardiac
and volume are not covered very well or at hospitals and a quality index tracking the
all, for example, hypertension in the general hospitals’ success in complying with clinical
population, mental health and primary guidelines, improvement rates in the average
care in general.” A national project, the quality-index score rose from 13% to 22% per
PrimärvårdsKvalitet (Primary Care Quality), is year. In addition, providers with the highest
likely to improve the availability of clinical data mortality improved their quality scores by
for follow-up use at the primary care level, 40%, narrowing the gap between the best and
he adds. worst performers.17
“Also, there is this trade-off of interests

between the health system and the authorities
paying for it in requiring efforts to build and
[L]arge areas of healthcare use these registries and an important sense
of ownership on the behalf of clinicians who
needs and volume are not
will enter, analyse and share the data to guide
covered very well or at all [by
future practice,” Dr Thor adds. “That’s an
the Swedish national healthcare
interesting contrast with the UK situation,
quality registry].”
where there are audits. They are slightly less
Fredrik Westander, senior policy analyst, SALAR voluntary, and seen as less peer-to-peer.”
The data are more applicable when it comes Moreover, the time it takes to accumulate
to enabling clinicians and managers to sufficient outcomes data across registries
understand how their system and own service makes it harder to use them to back up
perform, Dr Thor says. Extra investment shorter-term changes in clinical practice,
in registries for the five years to 2016 according to those interviewed and some
contributed to their enhancement. recent studies.18
EHRs, which have existed for the past two

Registries differ in the level of agreement decades, are also not always transferrable into
between different specialists around the aggregate data that can be analysed.
country and their willingness or ability to share
data. Some have been leaders, such as the “It depends on how you set up the systems
SWEDEHEART Registry in cardiology, which and how you enter the data,” Dr Thor says.
has helped to influence clinical practice and “Many health systems around the country
been involved in high-profile clinical studies have just signed new agreements with EHR
and new treatments. When the registry began, providers, and one thing they all look for is a
after extensive professional debate, to publish way to capture data in a way that lends itself
17
Clawson, J., et al., “Competing on Outcomes: Winning Strategies for Value-Based Healthcare”, Boston Consulting Group, January 2014.
18
Nilsson, K., et al., “Experiences from implementing value-based healthcare at a Swedish University Hospital – a longitudinal interview study”, BMC Health
Services Research, 2017 Feb 28;17(1):169.


17
to intelligent analysis.” Ultimately, he adds, is the result of good healthcare? So for

there are hopes that medical records can 90% of all diseases, it doesn’t work as a
replace registries. payment system.”
Yet, for that to happen, clinicians and patients Policymakers need to make sure that VBP is
will need to identify which outcome measures used in areas where it can be most effective,
are important, and put procedures in place to those interviewed say, such as orthopaedic
monitor them. surgeries, obesity management and prostate
cancer, where it is easier to reach agreement
In the case of widespread efforts to
on how to measure outcomes.
restructure entire care pathways in order to
improve outcomes, perceptions of success In his own consulting business, Dr
appear to be closely connected to how Nordenström says he has found that
innovators lay the groundwork. In the case of looking at process measures is a vital part of
Stockholm’s Karolinska University Hospital changing outcomes.
(see case study), the stated goal of improving
value was overshadowed by a complex “If you have a problem with outcomes, there
restructuring of care delivery that fuelled is something wrong with the way people
perceptions of heavy-handed management work,” he explains. “Looking how it should
that did not adequately listen to the concerns ideally be done according to scientific
of clinicians. In Uppsala University Hospital, knowledge is much more a question of
by contrast, careful planning and a slow quality improvements.”
roll-out has kept stakeholders engaged
with the project and provided a catalyst for Measurements such as waiting lists, infection
continued improvement. rates and patient experience of pain help
healthcare providers focus on quality, he says.
One lesson is that even when a concept, such And they are already in use. The US Institute
as payment for results rather than process, is of Medicine has outlined a framework that
popular, it is complex to implement in cases can be used to evaluate quality: care that is
where there are complex care pathways or safe, timely, effective, efficient, equitable and
patients are suffering from multiple conditions. patient-centred.19
“It works for simple procedures, like hip

replacements, but if you look at liver The challenge of radical reform
transplants, it’s not just dependent on the Although external consultants played
surgeon, but on the patient not drinking a role in many of the value-based
alcohol or taking their medicine,” says Dr experiments undertaken in Sweden, their
Nordenström. “How can you say that this role was particularly controversial in the
19
Agency for Healthcare Research and Quality (US), Six Domains of Health Care Quality, https://www.ahrq.gov/
talkingquality/measures/six-domains.html.


18
transformational case of the Karolinska restructuring of processes took place, was

hospital in Stockholm, as the following case that they rejected patients’ ideas of valuable
study will show. measurements because they were considered
“impossible to execute”, with advisers often
A key criticism of the external consultants, choosing measurements based on the ease of
especially in hospitals where more significant access to data.20
Case Study: Karolinska approach it as a framework, something

hospital transformation that shines through all the work and
activities being done, and the organisation
In the wake of the creation of OrthoChoice,
and the strategy; something that can be
Karolinska University Hospital
larger than that, a framework in which the
management opted to reorganise its
pathways make it possible to follow the
healthcare delivery in 2015, based on
patient from the moment they enter the
patient and disease pathways, rather
healthcare system,” says Fredrik Öhrn,
than the traditional structure based on
senior innovation manager at Karolinska
department and medical specialty.
University Hospital. “This is still difficult to
wrap our head around—that the pathway
The process identified 100 adult and 70
starts and finishes outside the hospital.”
paediatric “themes”, which in turn were
divided into patient groups and patient One of the central ideas of organisational
pathways. Under the new structure, for change in VBHC is to remove the
example, breast cancer constituted one appointment part of the process, with
pathway, with surgeons, oncologists health providers going to the patient
and radiologists required to work more and conferring together. In the case of
closely together. This meant new chains a prostate-cancer patient, surgeons,
of command, with the possibility of an oncologists and urologists, as well
oncologist leading a team including as physical therapists, nurses and
surgeons, who would need to adjust to psychologists, would know immediately
having someone from another specialty, when a patient had entered the pathway
rather than a senior surgeon, as their and communicate immediately, rather
boss. For general surgeons, the new than waiting for patients to consult
structure could mean that they were each individual professional.
working in several different pathways.
Medical residents who were training in
“To make value-based healthcare [VBHC] different pathways of surgery had to
work in a Swedish setting, you need to participate in multiple patient flows,
20
Nilsson, K., et al., “Experiences from implementing value-based healthcare”


19
frequently leaving it unclear who was in centric lines, and there were a lot of
charge of their training. “The pathways problems, both in terms of construction
are a very good idea for these patients, and consultants being contracted on
but for some of the residents, they sketchy grounds,” says Mr Lindgren. “This
made life more complicated for them,” reorganisation was not particularly popular
says Jörgen Nordenström, emeritus among professional groups and unions,
professor of surgery, and freelance and VBHC has become the blame centre.”
consultant in healthcare quality
Karolinska is split into two sites, north
improvement projects at VBMCare.com.
and south, and the new hospital, in
Yet the abandonment of traditional the north of the campus, is designated
departments involved particular for specialist care and has fewer beds
change for senior physicians, stirring a by design. Stockholm’s other three
considerable amount of resistance, those hospitals will by necessity provide
interviewed say. The main doctors’ union for those who do not need the highly
personified this opposition, approaching specialised care that Karolinska can
the country’s most powerful newspapers offer. Indeed, the emergency room in
claiming that the reorganisation concept the new Karolinska site is only accessible
“hadn’t been tried anywhere else and to patients arriving by ambulance or
that there was no evidence that it helicopter, not those arriving by foot.
works,” Dr Nordenström explains.
“People falling between pathways are
“One of the criticisms that has been still a challenge, and they were often a
leveraged in Stockholm is that challenge in the old system,” Mr Öhrn
VBHC is another form of new public observes. “In a perfect world, you
management and another way for would have patients [for whom it is]
payers to measure and oversee always obvious where they belong. You
[providers’] work,” says Mr Lindgren. can’t always compare to an industry
setting—a patient is a human being.”
“In Stockholm, they were trying to
reorganise departments along patient-
In addition, physicians complained that the The hospital’s IT system also provided
consultants did not have sufficient knowledge insufficient support to analyse health
about the hospital’s clinical practice but were outcome measurements, with the result that
nevertheless “driving and controlling”, and “measurements were frequently chosen based
that the teams were forced to stick to a rapid upon ease of access to data”, according to a
change timeline imposed by the consultants.21 2017 longitudinal study.22
21
Ibid.
22
Ibid.


20
The case of Karolinska shows that reformers The reorganisation forced clinicians who
had tried to implement two complex had previously worked at different clinics to
series of changes in parallel, notes Jonas apply for new jobs, raising more opposition
Wohlin, founder of Ivbar, a Swedish from doctors than from nurses, with large
health technology advisory and product newspapers chiming in to the backlash against
company: building a new hospital and the reformers.
changing the structure of care delivery so
that it was organised around themes and “The term value-based healthcare was used
patient groups rather than using traditional as the main term of the debate”, Mr Wohlin
models. An argument could be made for says. “They put all the changes going on at
implementing both changes simultaneously, Karolinska—challenges with reorganisation,
Mr Wohlin adds, as that allowed hospital new building and discussions around
managers to “build the hospital around procurement practices, etc—in the VBHC
how you want to operate”. However, so bucket. This has also affected VBHC-related
far it has proved to be challenging. initiatives outside Karolinska.”
Summary box: Sweden’s • Q

uality registries also differ significantly
limitations in terms of the amount of data
available, its completeness and
While Sweden has been a leader in
utility. This has contributed to a lack of
experimentation, as well as in the
data sharing.
implementation of value-based initiatives,
it has not been immune to the challenges • E
fforts to restructure care pathways
that face other systems that take on in at least two large Swedish hospitals,
entrenched interests and ways of the most ambitious of which was in
doing things. Karolinska, engendered a backlash
among staff and made value-based
• D
ifferent information technology
healthcare (VBHC) as a whole the
systems have complicated the
focus of protests against specific
digitalisation process, preventing full
initiatives. This was despite the
interoperability and hampering the
success of VBHC projects elsewhere in
exchange of information.
the country.


21
Chapter 3: Overcoming limitations and

potential steps forward
The backlash against the perceived flaws Mr Kildal adds. This involved looking at
of VBHC had a reverberating effect on patient-reported experience measures
at least one of the other hospitals that (PREMs) and patient-reported outcome
had aimed to follow Karolinska’s lead. In measures (PROMs), in addition to measures
Gothenburg, Sahlgrenska University Hospital from the quality registries, with patients
had duplicated some of the organisational themselves involved in the working groups.
changes imposed in Karolinska, although only
“Process measures are still important for
across some departments. A newly arrived
monitoring daily improvements in addition
chief executive (in mid-2018) has decided
to outcome measures, but only if they are
to bring the reform process to a halt.
closely connected to outcomes important
“They had done lots of good things there, for patients. The lead time for a cancer
tested things, wrote articles, but she halted diagnosis or compliance with guidelines
the process,” says Dr Nordenström. “She are examples of such process measures,
decided it was an organisational fad.” but the number of hours in the emergency
room or number of operations we can
By contrast, in Uppsala, innovators presented do every day does not say much about
the adjustments as less of a revolutionary the quality of patient care,” he adds.
change than an approach designed to
keep the hospital’s high-quality care while Those responsible for the Uppsala project
answering patient concerns, says Morten initially started with just three patient
Kildal, a consultant plastic surgeon and processes, expanding gradually to seven
associate professor at Uppsala University and then nine. The hospital had applied
Hospital and head of value-based healthcare. the changes to only 45 patient processes
by the end of 2018, with plans to gradually
“We saw it as a natural development of add additional processes each year. By
what we had done previously, but with a declining to introduce reforms on an
new and much stronger focus on patient organisation-wide basis, and by getting
engagement, whereas the focus on buy-in from stakeholders, Uppsala staff
interprofessional team-based care was managed to avoid a backlash. The Uppsala
more of a ‘back-to-basics’,” he says. value-based care team has also focused
on how to engage primary and community
The new approach was designed to care providers in the process of reform.
eliminate the medical silo mentality that
had led to a lack of co-operation between Introducing team-based care and involving
different specialties and parts of care patients in value-creation is key to building
pathways. It did not aim to identify new a solid and engaged group of stakeholders,
reimbursement processes or undertake Mr Kildal says. “In the beginning, we almost
a dramatic reorganisation of healthcare always talked about ‘why’. The focus was
delivery. Instead, it sought to improve patient on the fact that we in Sweden deliver really
outcomes by improving the processes good medical outcomes and should be
that were important for those outcomes proud of that, but the patients’ experience
and gradually adjusting care pathways, is that we don’t deliver well-connected


22
care with continuity between different The region set up a mobile care pilot
healthcare providers over time,” he adds. programme in which health providers from
“The ‘what’ was figuring out how to organise. both hospitals and primary care provide
‘How’ is last. You don’t start with ‘how’.” care to patients at home, allowing them
to avoid emergency hospitalisations.
Organisational reform, from
tentative to radical “By going home to patients in teams, we
In the Västra Götaland region, local healthcare can avoid 80-90% of hospital admissions,”
providers were already implementing Mr Nilsson explains. “We can co-ordinate
the limited bundled care projects around pharmaceuticals, additional care and
orthopaedic and bariatric surgery taking internal medicine, and much of that
place in several other regions in the country. care can be provided at home as well.
Yet they had also identified a different We can avoid spontaneous and, to
problem that was undermining efforts to some extent, unnecessary visits.”
keep older, frail patients and those with
The project is innovative, both in the fact
complex health needs out of hospital.
that it involves hospital teams working
“We had to do something, because we outside their normal environment, and
were not using the resources we have as because it bridges a key communications gap
efficiently as we could,” says Tobias Nilsson, between hospital and primary care, which
chief of healthcare strategy for the region. is traditionally organised by the regions, and
“Too often, citizens have to co-ordinate elderly home care, which is operated by local
care themselves, and once we get care municipalities, allowing greater co-ordination
there, we haven’t incorporated what is between them. The programme has shown a
important to the patients enough.” decrease in emergency admissions and gets
Model for hospital care at home in the Västra Götaland region

Hospital
care
“Hospital care at home” team

Mobile care
(project)
NEW
Inclusion criteria
• >3 more chronic disease
• >3 in hospital (last year)
• >6 pharmaceuticals
Primary care
• Lack of ability to care for personal hygiene

• >75 years
• Use of minicipal/nurse care at home
At least four of the criteria => included in team
Source: Nilsson, T., “Learnings on an holistic integrated care model to tackle pertinent challenges for a sustainable health system of the future”,
presentation for Singapore-Sweden Dialogue: The Swedish Example – an Integrated Health Care Model, April 18th 2018.


23
regular feedback from patients about their The programme’s goals are defined as
daily living experience. supporting greater efficiency and integration,
including an increased focus on patient
“[Health teams] weren’t used to working value, and securing an attractive working
like that,” Mr Nilsson says. “Once they environment for healthcare professionals.23
understand it, they welcome it, so
It is also designed to contribute to knowledge
we don’t have to convince them, but
about different populations, hospitals and
we have to show them the tools.”
regions, including what types of patients
Nationwide adoption of VBHC are being treated, their health outcomes
and costs.
While Sweden’s decentralised healthcare
system has made it more challenging to The programme organisers have worked with
introduce value-based reform initiatives on a medical organisations, patient organisations,
national level, there have been isolated cross- universities, the private sector and the regions
regional projects. themselves to determine how to monitor
populations and build technology to allow for
Sweden’s health ministry and seven county continuous monitoring.
councils, representing 70% of the country’s
population, launched the Swedish national The SVEUS platform includes algorithms
collaboration for value-based reimbursement analysing performance and treatments and
and monitoring of health care (SVEUS) identifying areas on which to improve. There
platform in 2013. The initial phase of are plans eventually to scale up the platform
SVEUS was organised around eight medical across the entire country. Based on combined
conditions and financed by the health analytics and payments platforms, the system
ministry. The platform is designed to support is already being used in both Sweden and
improved population health, better resource Finland and is being tested by the French
use, improved equality and increased clinician state payer. Mr Westander at SALAR notes
satisfaction with how the health system that the SVEUS project is one of the initiatives
is governed. contributing to efforts to build structures in
Sweden for collecting and presenting data
“The starting point was that Sweden is unique on healthcare performance. “There are also
in terms of the amount of data we have, linked others, even apart from the national quality
with personal identification numbers,” says Mr registries, and there is a national ambition to
Wohlin. “But we have not been using the data co-ordinate different initiatives,” he adds.
to its full potential to support development in
the healthcare system. And one of the things Today, the SVEUS platform covers 7m people
we haven’t been able to do is monitor value; and continuously monitors outcomes and
ie, outcomes and cost over entire treatment costs for a growing number of patient groups.
cycles for specific populations.” The platform applies advanced analytics
23
OECD Expert Group Meeting on Payment Systems, SVEUS – National collaboration for value-based
reimbursement and monitoring of health care in Sweden, April 7th 2014, http://www.oecd.org/els/health-systems/Item7a_
SVEUS-National-collaboration-for-value-based-reimbursement-and-monitoring-of-health-care-in-Sweden_Wohlin.pdf


24
to automatically identify improvement benchmarking within Sweden is applicable

potential, adjust comparisons between also between countries, Mr Wohlin explains.
provider organisations for differences in
patient preconditions and identify risk “Different patient groups will have different
groups. It is also possible for providers to preconditions, and if you are moving from
track the effects of local improvement monitoring productivity to monitoring
programmes on outcomes and cost in real value, it becomes much more important to
time. Over 30,000 healthcare professionals monitor the inputs—the patients,” he adds.
have access to the platform today, and “Now, when comparing different populations
education efforts are currently under way. between hospitals and regions, this new
system can adjust for differences in [the]
patient case mix, identify preconditions
that are relevant and understand expected
and actual outcomes and costs.”
[I]f you are moving from
In the case of breast-cancer patients, for
monitoring productivity to
example, the system can compare treatment
monitoring value, it becomes across regions and countries, determine
much more important to monitor how preconditions relate to different
the inputs—the patients.” outcomes and identify sub-populations.
Jonas Wohlin, founder, Ivbar
Meanwhile, the Swedish government
Moreover, health authorities in other countries approved a research and innovation bill in
have showed interest in the technology 2016 with the aim of supporting register-
developed in Sweden, which opens up new based research and biobank infrastructure,
possibilities for international comparisons. A including a national research agenda for
pilot study was presented at the OECD Health register-based research. The Swedish
Care Quality and Outcomes meeting in May Research Council in 2017 called for a common
2018, showcasing that detailed continuous infrastructure for using databases and co-
benchmarking of entire cycles of care could ordinating biobanks and associated data.
be performed between the French, Swedish
and Finnish health systems. As Swedish And Sweden is continuing a longstanding
regions, just as different countries, are not tradition of exchanging ideas and experiences
allowed to share patient-level data with on the national level regarding the system
each other, the technology developed for of national quality registries with other


25
Case study: Tiohundra Mr Graf is in regular contact with the head

of each department at the hospital, the
In northern Stockholm County, the
head of psychiatry, and chief of six primary
Tiohundra, or 10100 system, an initiative
care units, as well as ten elderly homes, the
for municipal care including both hospital
head of home care, and head of personal
and home care, has been going on for 15
assistance and social psychiatry, creating
years. The integrated company, Tiohundra,
an integrated leadership with the aim of
includes hospitals, primary care,
keeping patients out of hospital unless they
psychiatry, elderly homes and home care,
truly need to be there.
as well as other services.
“Because I have all of the leaders in my
This public health company located
leadership group, after five years we
in Norrtälje, in the northern part of
have a situation where they solve their
Stockholm County, started with structural
own problems,” he says. He points to
problems in the system for providing home
a recent case of a 90-year-old Finnish-
healthcare for the elderly and disabled,
speaking dementia patient who was
a problem that still affects many parts of
hospitalised with a broken hip. The day
Sweden, according to its chief executive,
after her surgery on a Thursday, she was
Peter Graf.
disoriented, causing problems for hospital
While home healthcare and homes for the staff. The head of the department called
disabled are provided by the municipality, her care home, which agreed to take her
hospitals, primary care and psychiatry fall home that day as long as the hospital
under county control, undermining the provided back-up medication. She was
integration of both systems, according back in the home by Friday afternoon,
to Mr Graf. Moreover, both systems are and quickly settled. Before the Tiohundra
funded with three separate taxes on the system was in place, such a resolution
municipality, county and national level. would have been unimaginable, Mr Graf
says. The company holds a monthly
“We have a problem with many aspects of meeting to follow up on elderly homes,
this system—IT, information flow between attended not only by the head of the
county and elderly homes, and different psychiatry team and her deputy managers,
reimbursement systems,” he explains. but also ordinary staff nurses and doctors.
Patients get stuck in county hospitals
even when they are well enough to be The funding is also shared between the
discharged, because municipal care homes municipality and the county, with money
are unwilling to take them. put into a specially designed common
fund run by six politicians from each
In 2006 Stockholm County Council and branch of the government. Although there
the Municipality of Norrtälje, with 60,000 are still debates about who should pay
residents across a large distance, founded more for individual services, it is easier
Tiohundra, which is 50% owned by the to demonstrate the advantages of the
municipality and 50% by the county system.
council. Mr Graf’s assignment was to
encourage better integration between all “We can show excellent results because it
of the departments so as to make care as is a flat organisation with good leadership,”
efficient and effective as possible from the Mr Graf says.
patient’s perspective.


26
countries, most recently with the Netherlands for elderly patients who are uncertain
and Norway, Ms Göransson adds. about leaving their homes for treatment.
Still, Fredrik Öhrn, senior innovation manager Ultimately, Mr Nilsson says, sharing
at Karolinska University Hospital, says he is information between providers has
sceptical that there will be a single approach improved, but on the individual health
for a value-based system extended to the provider level a mind shift is needed.
entire country. Providing patient outcome
“We’re used to thinking about physical places
data will also be more important to changing
and patients are supposed to come here,
the health culture on the regional and national
and then we might have waiting times, but
level than merely working together, he adds.
that is the problem of the patients, not us,”
Harnessing technology for he says. Showing the impact of changes
on outcomes can go a long way toward
integrated healthcare
validating reforms, with many patients
Better use of technology could help to reporting higher levels of security and
harness results and reduce the extent to feelings of being cared for since the mobile
which patients have to co-ordinate their own home programme was implemented.
care and follow-up, according to Mr Nilsson.
Diagnosis tests that can be done at home and Ultimately, continued evaluation of such
digitally transferred to hospitals help patients programmes is also likely to support calls for
avoid having to go there themselves unless fewer hospitals and more concentrated care,
it is absolutely necessary, he notes. Swedish Mr Nilsson says. “Do we use the resources
patients have already been able to get kidney more efficiently? We need to constantly
dialysis and blood transfusions at home for a evaluate if the new method of working is
couple of decades, he says. Now, those with better than the old, and if we find the new
inflammatory bowel disease can use digital way is better, we have to stop the old.”
tools to measure the degree of inflammation
Providing patient outcome data will also
they are suffering from. Health providers are
be more important to changing the health
increasingly looking at other tools that can be
culture on the regional and national level
used with chronic disease patients.
than merely working together, he adds.
Meanwhile, digitalisation is playing a Sweden’s quality-based registers could also

bigger role in the more remote regions of be used better and in real time, Mr Öhrn
Sweden, such as the most northern regions, says. Newer technologies, such as AI, could
where video consultation increasingly be used to make use of data more efficiently.
allows meetings between patients and Blockchain, a technology that creates data
healthcare staff, something that enables records that can never be changed and can
both greater co-ordination between be shared peer-to-peer between networked
health providers and offers reassurance database systems, could help protect data


27
from security threats and help speed up used to answer specific research questions,
the process of exchanging information. she said in the presentation.
“Data loss makes it difficult with the existing The need for political will and
system; that’s why we are exploring blockchain
collaboration
as a possible step forward,” he adds. “We’ve
built a system where data collected from Yet having the political will is also important,
patients’ homes can be shared with doctors. those interviewed say, at a time when most
politicians are focusing on waiting lists and
Ultimately, those interviewed say, better
health budgets rather than value.
linkage between the registers, patient-
outcome data and RWE from EHRs could
“The Swedish system is a politically driven
help expand VBHC in Sweden and make
system, and what is still lacking is the political
the country the leader in transforming
focus on health outcomes,” says Mr Wohlin of
health systems based on value measures.
Ivbar. “It’s easier if it comes from the centre.
The government has already invested in I think if the politicians were clearer in saying
a Register Utiliser Tool, the prototype of they want there to be a system in place
which contains two registers from Statistics that monitors both outcomes and costs for
Sweden and a healthcare quality register for different patients, allowing comparison and
hand surgery. In a presentation in Helsinki in learning from one another, we could follow
2016, Maria Nilsson, of the Swedish Research up on that.”
Council’s Unit for Register-based Research,
highlighted that the tool would include an Getting stakeholders on board is also a crucial
interface for register holders to use to manage precondition for focusing more closely on
metadata. The tool provides for harmonisation value measures. In this respect, Uppsala
between databanks, allowing analysis of University Hospital may be a better model
differences and similarities of different than Karolinska’s top-down approach. Uppsala
variables, including PREMs and PROMs.24 took a bottom-up approach with strong
Ultimately, the register utiliser tool should be management support and engagement of
able to help investigators understand what different patient groups to implement greater
kinds of data exist and where, whether data integration. “We don’t know which will be
from different registers can be compared, and more successful, says Mr Wohlin. “The jury is
identify whether there are data that can be still out.”
Nilsson, M., “Infrastructure for Register-based Research”, presentation to the Nordic Conference on Real World Data,
24
Helsinki Finland, November 29th 2016


28
Summary box: overcoming bodies that previously acted as silos.

Sweden’s limitations Mobile home healthcare is one such
example, and better co-operation is
Several initiatives are helping Swedish
expected to ultimately help improve
stakeholders to overcome the barriers and
data harmonisation.
limitations discussed in Chapter 2.
• Better use of technology, such as
• Cross-regional co-operation is
telemedicine, blockchain and artificial
helping Sweden’s successful value-
intelligence, will help to keep the
based healthcare initiatives to be
integration of healthcare delivery and
shared elsewhere in the country.
sharing of data on track.
• Some of the most successful projects
• There have been improvements in
in Sweden have involved better
stakeholder collaboration, but the
integration of care systems
political will is lacking in some parts of
between municipal and county
the country.


29
Conclusion
Sweden’s consideration of value in a number of different aspects of
healthcare makes it a leader globally in VBHC, at the same time as its
quality registries offer a model of how population data can be collected
and potentially shared. Some of its registries are viewed as international
examples of best practice, and the country’s experiments with a variety
of payment and reimbursement models are viewed as case studies for
other countries looking to introduce value-based payment models.
At the same time, Sweden provides lessons about the potential

pitfalls of instituting major changes in the way healthcare is delivered.
In particular, the disparate experiences of Karolinska, Sahlgrenska
and Uppsala university hospitals provide notable of examples of
how to introduce care pathways based on value measures.
Sweden’s experience with instituting VBHC underscores a number of

key challenges: the need to understand what VBHC is and how best to
measure it; the importance of political will and careful consultation with
all stakeholders; the importance of technology; and the need to tread
carefully when introducing new payments systems or care pathways.
First, there is the need to carefully define terminology

when we talk about VBHC, in order to avoid a meaningless
one-size-fits-all concept and understand where value-
based measures can be employed most successfully.
Moreover, the Swedish case studies outlined in this paper show that
there is clearly a need for close engagement from clinicians and
other stakeholders in order to build sufficient support for reforms.
This process should also include greater involvement of patients in
consultations about changes in care pathways, as well as in defining
the kinds of outcomes measurements that will be used. The experience
of Uppsala University Hospital shows how this can work in practice.
The country’s ageing population will require both top-down and

bottom-up solutions, as well as improvements in IT systems and
better use of technology such as telemedicine to provide care
in more remote regions, says Mr Graf. In addition, the evolution
of predictive technology, such as AI, should make it easier for
Sweden’s quality registers to be used to their full potential.


30
[Value-based payment] is a field where there

probably is no one right answer.”
Johan Thor, associate professor, Jönkoping Academy for Improvement of
Health and Welfare
Value-based payment programmes for healthcare delivery,

while laudable, must be applied selectively, says Dr Thor, given
some built-in contradictions associated with the approach. “We
will probably end up with a blending of different approaches,”
he says. “There are certain conditions and groups of patients
where VBP works well, in defined procedures. But when it
comes to chronic conditions and caring for people with multiple
conditions, then I think that’s not going to work so well and will
need other components such as capitation and fee-for-service.
This is a field where there probably is no one right answer.”
Finally, Sweden’s key strength is the data collection structures it

has in place, both in terms of its quality registries and extensive
electronic health records. Better co-ordination between regions
and specialties could make data collection more efficient and
enable a better trove of information that will make it easier for
the Swedish system to assess value, use it to underpin investment
decisions and share these lessons with other countries.

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Email: london@eiu.com Email: geneva@eiu.com
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РЕЛИЗ ПОДГОТОВИЛА ГРУППА "What's News" VK.

Value-based healthcare in Sweden

© The Economist Intelligence Unit Limited 2019

Value-based healthcare in Sweden

EHR: electronic health record

EUnetHTA: European Network for Health Technology Assessment

NQR: Swedish national healthcare quality registry

RWD: real-world data

RWE: real-world evidence

SALAR: Swedish Association of Local Authorities and Regions

TLV: Tandvårds-Och Läkemedelsförmånsverket (Dental and

VBHC: value-based healthcare

VBP: value-based payment

© The Economist Intelligence Unit Limited 2019

Value-based healthcare in Sweden

About this report

• K arin Göransson, policy analyst, Swedish Association of Local

The report was written by Andrea Chipman and edited by Martin

© The Economist Intelligence Unit Limited 2019

Value-based healthcare in Sweden

These pressures, along with a greater focus on patient-centred care,

Integrated care delivery is a key part of providing value. Policies

Getting buy-in from health providers is vital. The most successful

© The Economist Intelligence Unit Limited 2019

Value-based healthcare in Sweden

patients and other stakeholders. Other, more radical attempts at

Good data are key to effective value-based pricing. Accurate

© The Economist Intelligence Unit Limited 2019

Value-based healthcare in Sweden

Delivery of healthcare is the responsibility of Sweden’s 21 regions,

Yet advocates for greater organisational change to support these

Sweden provides a number of examples of how value-based

© The Economist Intelligence Unit Limited 2019

Value-based healthcare in Sweden

Chapter 1: The Swedish model and lessons

© The Economist Intelligence Unit Limited 2019

Value-based healthcare in Sweden

economies—an ageing population, growing Health registries, evidence-

© The Economist Intelligence Unit Limited 2019

Value-based healthcare in Sweden

Nevertheless, the existence of the

© The Economist Intelligence Unit Limited 2019

Value-based healthcare in Sweden

© The Economist Intelligence Unit Limited 2019

Value-based healthcare in Sweden

Case Study: OrthoChoice A number of other regions in Sweden have

© The Economist Intelligence Unit Limited 2019

Value-based healthcare in Sweden

© The Economist Intelligence Unit Limited 2019

Value-based healthcare in Sweden

Summary box: lessons for the are already having an influence on

© The Economist Intelligence Unit Limited 2019

Value-based healthcare in Sweden

Chapter 2: The backlash and obstacles to

© The Economist Intelligence Unit Limited 2019

Value-based healthcare in Sweden

© The Economist Intelligence Unit Limited 2019

Value-based healthcare in Sweden

“Also, there is this trade-off of interests

• K arin Göransson, policy analyst, Swedish Association of Local