The value of innovation in Healthcare by Gesaworld Group

SEMINARS

The value of innovation in Healthcare A global debate

Central elements of the 2nd Health & Sustainability Seminar held at Harvard Faculty Club (Cambridge, MA, US), April 2012.

The 2nd Health & Sustainability International Seminar was held on the 18th and 19th April 2012 at the Harvard Faculty Club (Cambridge, Massachusetts, USA). The seminar was attended by scientists, health professionals, managers of health institutions as well as representatives of governments and public administrations from the sector that took a close look at the role that innovation has to play in the sustainability of the health sector. This paper is a structured summary of the main themes, central ideas and approaches that were dealt with during the seminar.

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ÂŠ 2012 Gesaworld Group www.gesaworld.com Published by: Gesaworld Group Editorial coordination: Elkano Data First edition: Barcelona, June 2012

INDEX.

INTRODUCTION. 1. Health and sustainability: a global debate.

2. 2nd Health & Sustainability International Seminar.

PART I: THE ROUTE MAP TOWARDS SUSTAINABLE INNOVATION IN CLINICAL PRACTICE. Introduction.

A. Key points and challenges*.

B. Trends in biomedical innovation.

C. The value of innovation in health technology.

PART II: INNOVATION IN MANAGEMENT AND CLINICAL ORGANIZATION.

Introduction.

A. Key points and challenges*.

B. Strong Primary care.

C. Towards more integrated organizations.

D. Information as a means of improving integral process management.

E. The system of payment as a driver of efficiency.

F. Some experiences that demonstrate outcomes.

PART III: THE ROLE OF GOVERNMENT. Introduction.

A. Key points and challenges*.

B. JudyAnn Bigby, Secretary of Health and Human Services of the Commonwealth of Massachusetts.

C. Januรกrio Montone, Municipal Secretary of Health of the City of Sรฃo Paulo, Brazil.

D. Joan Guanyabens, ICT Coordinator of the Catalan Ministry of Health.

PART IV: INNOVATION TO IMPROVE THE SUSTAINABILITY OF THE HEALTH SYSTEM: MAIN IDEAS OF THE DEBATE. Introduction.

Defining the value of technologies and innovation in health.

Building bridges between researchers, clinical professionals and regulators.

Key Information and evaluation for innovation and reducing costs.

The need for strong primary care.

The way to integrated care.

Patient-centeredness.

The role of professionals.

The intensive use of ICT, an important lever of change.

Health care payment systems as drivers of efficiency.

Implementing innovation that has shown results.

The challenges of public policies.

ANNEXES About Gesaworld.

Seminar's program.

Participants.

Bibliography and references.

THE VALUE OF INNOVATION IN HEALTHCARE .

INTRODUCTION.

Health and sustainability: a global debateSeminar. In 2011 Gesaworld launched its initiative to promote the edition of debate seminars focused around the challenges that health faces at a global level. The activity of our company has allowed us to acquire first hand knowledge of the most important transformations in the way we provide and care for the health of our citizens. This initial idea led to the creation of the International Health & Sustainability Seminars. Right from the start these seminars were linked to the debate concerning the principle of sustainable development. We were convinced that these debates would help us to find the answers to many of our current problems. Accordingly, we wanted to make a contribution to the reflections into the way that the activities of the health sector can contribute to making sure that the development of our societies satisfies the needs of the present day without compromising the ability of future generations to satisfy their own needs. This is the principle that spurs us on as we search for answers that can allow health systems, institutions and their professionals to find efficient and effective solutions to meet the challenges that current societies face in matters of health promotion, health care and health protection. All of this starts with an exchange of the experiences and know-how that we produce in very diverse contexts and this can help generate new ideas and solutions. The 1st International Health & Sustainability Seminars was held in Washington D.C. in April 2011. This forum focused on the impact that health systems have on the environment in which they develop their activity. The emphasis of the forum was placed on the environmental impact but without forgetting the need to discuss the profound impact that the health sector has within the social and economic spheres of our countries. Debates were held with world experts on matters such as reducing COÂ˛ emissions, sustainable architecture, transport, training in environmental protection focused on the health sector,

and on all matters related to sustainable and economically efficient development. Experts met with representatives of governments, international multilateral financing institutions and representatives of the private sector.

2nd Health & Sustainability International Seminar. The 2nd Health & Sustainability International Seminar was held at the Harvard Faculty Club (Cambridge, Massachusetts) and it was attended by scientists, health professionals, managers of health institutions as well as representatives of governments and public administrations from the sector. This second edition took a closer look at the role that innovation has to play in the sustainability of the health sector. Consequently, this edition centered more on aspects that emphasize the economic and social spheres in the sustainable development of the health sector. We believe that innovation can provide the answers to many of the challenges that health care systems face today. Technological and scientific innovations to develop new clinical processes and improve care are commonly accepted. We would also like to analyze new health care models and the changes in the way that citizens use health care; one final and crucial point concerns the manner in which innovation fits into public policies.

Objectives. A. To establish a collective way of thinking about three aspects of innovation within the health care sector: â&#x20AC;˘ Central elements in the debate on the evaluation of clinical practices and their role in driving innovation in health care processes. â&#x20AC;˘ Innovation and the management of health care institutions: approaches and practices in different environments. â&#x20AC;˘ Innovative health care systems: strategies to promote continuous improvements in health care technology, processes and models.

THE VALUE OF INNOVATION IN HEALTHCARE .

INTRODUCCION.

B. To promote an exchange of ideas and practical experiences among scientists, clinicians, managers and key decision makers within the health care sector from different countries and organizations. C. To develop and publish a final summary document that includes the key elements from the debates at the seminar, as an element for dissemination and as a means of contributing to more generalized reflection.

Vision. The aim of the Health & Sustainability seminars is to make a contribution to the global debate on how to improve health systems. We are aware that this debate is built upon the foundations of the realities that are generated in each of the countries, in each of the health centers and each contact that a patient has with a health professional. Accordingly, the debate on improving the systems is based on experiences that have been accumulated at a clinical, management and policy level. In recognizing the diversity of contexts and solutions we also believe that knowledge is global, and that experiences which have been successful can help in the search for solutions before similar problems. It is for this reason that the Seminar started by identifying some common challenges that all systems have to confront. By exchanging opinions and knowledge we can reflect on how we have dealt with them, and above all we can look at how we can improve planning for them in the future.

Methodology. We proposed a discussion which was divided into three thematic panels. A Chairman introduced and moderated each panel and 10 minute intervals were then reserved for various speakers. Following this framework, the discussion was then opened up to all participants*.

* You will find the complete Seminar program and a list of the attendees in the annexes to this document.

The structure was intended to ensure that all guests could contribute with their knowledge, experience and thoughts on different topics, and that this would lead to an active and dynamic discussion.

A Working Paper was prepared prior to the seminar as a conceptual guide to the methodology and objectives of the Seminar and it also helped to provide a structure for the key issues and questions. A short introduction was prepared for each panel together with a list of the questions and challenges that health systems face in relation to a particular topic.

The final document. This document is intended as a response to the last of the objectives established by the Seminar and it comes in the form of a structured summary of the main themes that were dealt with during the seminar. This information has been supplemented with contributions that were received at a later stage. The document sets out some of the central elements of the debate at a global level and it illustrates these with approaches and experiences from various contexts. Following the spirit of the Health & Sustainability Seminars our desire was to reflect the ideas, opinions and reflections as well as the experiences that came to the fore during the work sessions. Therefore, it is a document that reflects the concerns and experience of an international and multidisciplinary group involved in the process of providing health services. Consequently, it provides a global perspective and establishes common elements and experiences that have been shown to have an impact within a certain context. However, the edition of this document does not represent a final point, but rather it is the expression of the desire to continue with the debate and to continue exchanging experiences among all the participants.

THE VALUE OF INNOVATION IN HEALTHCARE .

PART I.

THE ROUTE MAP TOWARDS SUSTAINABLE INNOVATION IN CLINICAL PRACTICE.

Introduction. A . Key points and challenges. 1. What do we understand by an innovative HT? 2. Stakeholders. 3. Early stages of innovation in HT. 4. Introducing innovative HT in the market. 5. Innovation in a managed care environment.

B . Trends in biomedical innovation. 1. Financing innovation. 2. Pharmaceutical companies. 3. Building bridges between scientists, clinicians, patients and policymakers.

C . The value of innovation in health technology. 1. Defining Health Care value from a HT perspective. 2. Other aspects of HT value. 3. The process for the introduction of innovative technology.

PART I. THE ROUTE MAP TOWARDS SUSTAINABLE INNOVATION IN CLINICAL PRACTICE. Introduction. The spread of innovation in Health Technologies (HT) is a complex process and the central elements of the debate on the sustainability of health systems depend on it. Effectiveness and efficiency are directly related to the type of technology that we use in our health care processes and they are also linked to those that we reject.

" Effectiveness and efficiency are directly related to the type of technology that we use in our health care processes and they are also linked to those that we reject ". One of the challenges raised by the global approach to introducing HT into health systems is how to conduct the process for introducing the most efficient HT with the highest health care and social value in such a way that the most suitable technology from a scientific, health care, organizational and economic perspective â&#x20AC;&#x201C; can be spread throughout the health system in the quickest possible way. A large number of stakeholders with different interests and objectives participate in this process. These include researchers, clinical professionals, universities, companies, regulators, health technology assessment analysts, health service providers, patients, technology consultants etc. This is one of the key elements of its complexity and it highlights the need to share the different visions and their implications. We would like to encourage people to reflect on each phase of the process and on the impacts they have on the overall results: starting with the generation of the idea with generic scientific know-how, through the introduction of a new technology into a health service, and finally its withdrawal from the market once it has been considered obsolete.

A . Key points and challenges*.

1. What do we understand by an innovative HT?

2. Stakeholders. • Coherence between research, innovation and industrial/health care policies: the role of the government both in promoting innovation and as a final client.

• How can value best be defined? • What attributes/impacts of technology comprise value for the different decision-makers?

• Rights and duties of different stakeholders in shortening development cycles. • Re-inventing public-private relationships.

3. Early stages of innovation in HT. • “From silos to bridges”: building bridges between, researchers, and clinicians and policymakers.

5. Innovation in a managed care environment.

• The cost of new innovations: who should assume the risk? • What mechanisms (intellectual property, technology, transfer, pricing etc.) can be developed or improved to reward value and enhance innovation?

* We will set out the key points and challenges that the health systems face with regard to the subject matter of this first part. All of these were proposed as elements for reflection and the discussion by the experts attending the debate session.

4. Introducing innovative HT in the market. • What mechanisms need to be established to promote the introduction of high value innovation without threatening the clinical safety and sustainability of health care systems? • What inhibits the uptake of new technology after positive HT Assessment (HTA), or disinvestment after a negative recommendation? • How can we assure sustainability when an innovative HT has been introduced in the market?

• How can we manage the introduction of innovation in an everyday clinical setting? • How can we ensure that innovation reaches those who can benefit the most? • What are the sources and forms for the post coverage “monitoring of information” that would be helpful in terms of determining the optimal use of technology?

PART I. THE ROUTE MAP TOWARDS SUSTAINABLE INNOVATION IN CLINICAL PRACTICE .

B . Trends in biomedical innovation. Innovation in technology and clinical practice is a widereaching process, which begins with the first phases of scientific research. Some time will pass from that moment until an innovation is introduced into a health system and the intervention of numerous stakeholders will be required. These include researchers, clinical professionals, universities, companies, regulators, health technology assessment analysts, health service providers, patients, technology consultants etc. This is one of the key elements of its complexity and it highlights the need to share the different visions and their implications. The first phase that we know with the concepts of Investigation, Development and Innovation (I+D+i) has not remained on the margin of the economic and social changes that the health sciences sector is experiencing. In this section we look at the elements that define the roles that the various actors are establishing to adapt to the new context.

Diffusion of Health Technology innovations :

From idea to market.

Early adopters

HTA Obsolete

Time. I+D & I.

Emerging.

Now Tech.

Established technology. Technology maturity.

Innovation.

Regulatory approval decisions.

Coverage reimburse decisions.

Heath Care provider adoption.

Source: Sampietro-Colom, L. Adapted from Rogers, E. M (2003).

Optimal use.

Desinvestment decisions.

Financing innovation. Today Bio-technology companies have problems financing their innovation. Public incentives for innovation are increasingly challenging and are closed to most biotech initiatives. Venture Capital (VC), in turn, has shifted to larger and established companies (1). At the same time VC companies are showing a tendency to shift their interest to less risky later-stage financing, leaving room for corporate finance, angel investors (who often form syndicates) or non-profit organizations. In order to diminish risk, traditional investors are moving away from the creation of companies and are opting to invest in the development of products that can be licensed or sold (project funding, virtual companies).

Barriers to financing innovation :

Public Incentives. Increasingly challenging and closed to most.

Bio-Tech Companies

Traditional Investors. Moving to less risk. Investing in products that can be licensed or sold.

Pharmaceutical companies. The Pharmaceutical Industry has also started to reach out and work with payers early in the drug development process. They need to do this in order to ensure that the therapies they are developing will meet the demand of payers; in essence, they will not just be safe and efficient; they will also deliver value. Pharmaceutical companies also need to learn to work in a more equitable way with diagnostic companies, as companion diagnostics become more common. Diagnostics account for less than 2% of health care spending but they affect more than 60% of critical decisions (2). This means that early stages of drug development should incorporate diagnostic companies.

Challenges for Pharmaceutical Companies :

Working with Payers. Therapies not only safe And efficient but also Deliver value.

Pharma Companies

Working with diagnostic companies. Diagnostic accounts for 2% of spending but affects 6% of critical decisions. THE VALUE OF INNOVATION IN HEALTHCARE .

PART I. THE ROUTE MAP TOWARDS SUSTAINABLE INNOVATION IN CLINICAL PRACTICE .

Building bridges between scientists, clinicians, patients and policymakers. * An example of this philosophy involving the integration of the various stakeholders in innovation is the Garfield Innovation Center of Kaiser Permanente â&#x20AC;&#x153;a living laboratory where ideas are tested and solutions are developed in a hands-on, mocked-up clinical environment. Many aspects of delivering health care can be innovated and examined at the Center using real-world scenarios and activities, such as simulations, technology testing, prototyping, product evaluations, and training. http://xnet.kp.org/innovationcenter/

Academia and basic research institutions will need to contribute more in moving basic science discoveries into the clinical sphere. One example of this tendency is the new National Institute of Health, NCATS (National Center for Advancing Translational Sciences (3)), whose aim is to accelerate the preclinical development of new drugs and diagnostics (biobanks linked to clinical outcomes, therapeutics for rare and neglected diseases)*. Governments will have to look at ways of paying for value rather than paying for treatment. Public procurement of innovative technology should be better used as a lever for innovation. On the other hand, biotech industries should also be aware early on in their development of the requirements of payers and regulator and they should establish closer relationships with pharmaceutical business developers and strategic leaders. Physicians should be involved in the process early on. They can bring valuable insights regarding the identification of unmet clinical needs, targets to choose or the design of clinical trials. At the same time, thanks to unprecedented access to new technologies, patients take a more active role in their own health care, ranging from research to disease management.

Building Bridges between scientists, clinicians, patients and policymakers :

Moving Basic discoveries into the clinical sphere. Research Governments

Paying for value rather than paying for treatment. Physicians Patients Being envolved in the process early on.

Take a more active role in their own health care.

C . The value of innovation in health technology. Innovation is no longer just simply the introduction of “new health technology (HT)” but rather it involves the introduction of the most valuable innovation. However, the concept of most valuable innovation can have different meanings in the health care markets as there are many stakeholders (e.g. regulatory agencies, governments, payers, providers, patients, industry) with conflicting goals and incentives (e.g. efficacy/safety, access to services, profitability, high quality, cost containment, convenience, patient centeredness, satisfaction…). Therefore, what is defined as relevant to the definition and assessment of the “value” of an innovation could differ depending on the perspective taken.

" what is defined as relevant to the definition and assessment of the “value” of an innovation could differ depending on the perspective taken ". Defining Health Care value from a HT perspective. Health Care Value has different definitions ranging from the Neoclassical Economics perspective (what consumers would be willing to pay or to give up for a good or service) to more specific health care perspectives. • Health outcome achieved per dollar spent. • Opportunity cost: whether the benefits from the investment in this particular HT (resulting in an expected gain) are greater than the expected benefits forgone elsewhere in the health care system due to other HTs being displaced. * NICE also considers the severity of the patient’s condition; whether the patient is close to the end of his/her life; stakeholder perception that the impact of treatment includes aspects that are not adequately covered by other evidence; significant innovation leading to distinct benefits of a substantive nature; whether the treavted population is a socially disadvantaged group – children, ethnic minorities.

Today, health systems vary according to how they seek to ascertain value. Some (e.g. Australia, Canada, UK) seek to estimate the cost per QALY and they use this as an indicator of value, with other dimensions of value also being qualitatively factored in as appropriate for coverage decisions*. Others (e.g. France, Italy, Germany and the USA - at least up to now) seek to judge value by comparing the clinical outcomes produced by the HT compared to alternatives that are currently available for the clinical condition (4). Either approach to measuring value, whether it uses QALYs or any other natural measures of clinical effectiveness, equates THE VALUE OF INNOVATION IN HEALTHCARE .

PART I. THE ROUTE MAP TOWARDS SUSTAINABLE INNOVATION IN CLINICAL PRACTICE .

“value” with health gain. However, it is recognized that current approaches do not comprehensively embrace all the components that can define the “value” of an innovation from the point of view of society. There is a rising debate on the following limitations of current approaches (4) (5): • The need to include patient preferences in the assessment of value and ways to carry it out. • The case of innovation having a value over and above the health benefits it delivers in the short term. • The need to assess value based on society’s own values (e.g. the society’s view that avoiding death may carry more value than relieving a chronic condition – QOL). • The limitations due to current outcomes measurements being used in isolated fashion. e.g.: QALY: each QALY has equal weight and there is no distinction by age (additional health gained by a very old person, who has precious little health remaining- could be more relevant than that gained by a young person); or severity (the very sick may value small health gains to a greater extent); or natural measures (e.g. adverse reactions avoided or readmissions avoided) are not comprehensive measures of benefits. • The need to consider unmet needs (placing greater value on HTs that treat diseases for which no therapy is available). • Considering the absence of any previous effective treatment for a disease (particularly in the case of rare diseases).

Defining Healthcare Value from a HT perspective :

Cost / Benedit Approach. Health Outcome achieved Per dollar spent Cost per QALY.

Health Care Value

Opportunity Cost Approach. Clinical Outcomes compared to alternatives currently available.

Other aspects of HT value. There are other “non-health” (but health-care process-related) aspects that may be taken into account when considering the value of innovation. These include aspects such us being treated with dignity, at a convenient time and location, after only a short wait; the degree of risk attached to a health care intervention (less risky interventions with the same expected outcome are preferred) (5) (6).

" The externalities of innovation beyond healthcare introduce a broader view of value: the social perspective of HT ". Moreover, innovation can lead to other costs and benefits beyond the health and health care gain, e.g. the patient’s ability to go back to work or to work more productively, benefits for careers in terms of enjoyment, leisure time or the ability to work etc. These externalities of innovation beyond health care introduce a broader view of “valuing innovation” and they introduce the social perspective of HT. What is considered as being of value for an innovation, which preferences/perspectives are relevant when deciding the “value” of an innovation, and how to combine this multidimensional criteria, are still matters for research and debate.

The process for the introduction of innovative technology. The moment of selecting and acquiring HT is equally important in the process for the introduction of the most valuable technology within the health services. It is important for the health professionals who are going to use this technology to be present when these decisions are made. For this to happen, it is necessary to involve them in the negotiation process, to offer them tools to evaluate the technology so that they can make an objective analysis of the product from an economic perspective as well. Similarly, it is important for them to be present when the terms of acquisition, maintenance and replacement are being negotiated.

THE VALUE OF INNOVATION IN HEALTHCARE .

PART I. THE ROUTE MAP TOWARDS SUSTAINABLE INNOVATION IN CLINICAL PRACTICE .

One critical element of this process is deciding whether we are concerned with the introduction/acquisition of a new product or if we are dealing with innovative technology. Innovative technology can be understood as. • New products developed on a new technical paradigm. • Existing technologies that have been adapted to deal with new populations and which have not been considered up to now. • Technologies that are going to have an impact in terms of efficiency and effectiveness for the organization and for the whole of the system as a result of their introduction. Types of Innovative technology :

New products based on a new technical paradigm.

Existing Technologies adapted to new populations.

Technologies with an impact in terms of efficiency and effectiveness..

THE VALUE OF INNOVATION IN HEALTHCARE .

PART II.

INNOVATION IN MANAGEMENT AND CLINICAL ORGANIZATION.

Introduction. A . Key points and challenges. 1. Towards more intergrated organizations. 2. ICT as a way of improving integral process management. 3. The system of payment as a driver for efficiency.

B . Strong Primary care. 1. Integrated and multidisciplinary Primary Health care. 2. Quality. 3. Cost-effectiveness. 4. Patient-centered.

C . Towards more integrated organizations. D . Information as a means of improving integral process management. 1. An instrument for change. 2. Electronic health records, an example.

E . The system of payment as a driver of efficiency. F . Some experiences that demonstrate outcomes. 1. Primary Care. 2. Reduction in demand and inadequate hospitals stays. 3. Giving better care to long-term complex chronic patients. 4.Reducing Waste, reducing costs.

PART II. INNOVATION IN MANAGEMENT AND CLINICAL ORGANIZATION. Introduction. Innovation in the organization and management of the entities that provide health is a second key area in the configuration of the systems that are better and cheaper at resolving health problems. Within the theoretical arena, putting an end to the disintegrated organizations that developed from a model of airtight compartments, which functionally divided the first level of specialized care from the other health care departments, is something that has been recommended for many years.

" Putting an end to desintegrated organizations is something that has been highly recommended. But there is still strong resistance to change ". There are many experiences in this line, and the results of these points to greater efficiency in terms of resources, and greater effectiveness in terms of the citizens who receive treatment. However, there is still some strong resistance to change, and consequently, the objectives of this panel are to share experiences, their results and to contribute implementation strategies.

A . Key points and challenges*.

1. Towards more integrated organizations.

2. ICT as a way of improving integral process management.

• What are the areas of resistance to the integration of health care service levels?

• E-health, m-health & health 2.0: results and limitations.

• Are systems more oriented towards primary care? What is the new role of the hospital?

• Strategies for the successful implementation of electronic clinical records.

• In the case of patient-centeredness: what are the implications for clinical organization?

• Convergence between the ICT industry and the health sector.

• The innovation managing of chronic diseases.

• Economic impact of IT: Better accessibility and more population coverage at what cost?

3. The system of payment as a driver for efficiency. The role of payment and incentive systems: benefits and limitations: • The shared management of risks. • The payment for global process-management • Capitation payments.

* We will look at the key points and challenges that health systems are faced with in regard to the subject matter of this first part. All of these were proposed as elements for reflection and debate by the experts attending the debating session.

• Measuring health outcomes and their link to the payment system.

PART II. INNOVATION IN MANAGEMENT AND CLINICAL ORGANIZATION .

B . Strong Primary care. The structuring and availability of a level of primary health care, as the point of entry to the system and the level responsible for guaranteeing the continuity of the care, is providing significant results in different contexts that reinforce its importance as a central element in the effectiveness, fairness and efficiency of health systems.

Integrated and multidisciplinary Primary Health care. In addition to the logical interaction with other levels, continuity in care requires several instruments and approach strategies that favor better care in terms of value in health, starting with clinical leadership, which prioritizes clinical effectiveness through cooperative actions at each moment in the natural history of the processes and the lives of people (7). In this context, primary health care must carry out and actively facilitate actions to detect situations of risk among the people in their charge, as well as to elaborate different care strategies according to the degree to which the patients are affected. The joint elaboration of derivation and return criteria has been shown to be of great use with regard to cost and clinical effectiveness.

Instruments and aprroach strategies for better Primary Health Care :

Clinical leadership.

Interdisciplinary work.

Detect situations of risk.

Ellaborate different care strategies.

Strengthening primary health care also requires interdisciplinary work in which family doctors as well as nursing professionals, pharmacists, social workers and educators and other professionals, who are experts in communication and changing habits, all have their space to help guarantee the monitoring of the therapeutic recommendations that often go beyond the pharmacological treatment.

Quality. Research into the quality of care has consistently shown that primary care physicians provide higher quality of care for generic (person-focused) measures of care. While specialists may do better on certain disease-specific and guideline-directed aspects of disease management, person-focused care is better when performed by primary care physicians (8). A recent US study showed that generalists are more likely to spot clinically-important drug-drug interactions than specialists â&#x20AC;&#x201C; a phenomenon that indicates safer care (9).

" Research has shown that primary care physicians provide higher quality of care for person-focused measures of care ". Large medical groups that score higher on quality in the management of selected chronic illnesses also register higher scores in primary care attributes. In other words, better overall care for patients is associated with better care for their individual problems (10). Moreover, continuity of care over time is associated with better coordination (11) of care and with the comprehensiveness (12) of care.

Cost-effectiveness. With regard to cost effectiveness, the availability of structured primary care with a defined population base and multisector teamwork using a comprehensive approach (with preventative actions of all types) and integrated with other health care levels, provides better results in terms of the value in health at a cost defined by the percentage of GDP dedicated to a health system (13).

THE VALUE OF INNOVATION IN HEALTHCARE .

PART II. INNOVATION IN MANAGEMENT AND CLINICAL ORGANIZATION .

Instruments and aprroach strategies for better Primary Health Care :

Structured PHc. Better results in terms of value in health.

Defined Population. Multisector Framework. Integrated with other Hc levels.

Patient-centered. Likewise the mobilization of community resources and facilitating the involvement and the participation of patients, in varying degrees, from self-care to the dissemination of knowledge on the handling of the illness, through educational actions led by expert patients have shown their use, and they should be promoted from primary care.

" Time-based patient orientation is associated with better effectiveness in achieving overall well-being and increasing equity ". Patient-centeredness in visits should be a feature of all care, whether it be primary care or specialty care. The person-focus is a feature of primary care: individual visits can address only a limited number of patient concerns but the essence of primary care is a process of care that takes place over time and across a variety of problems that patients experience over time. The “patient-centered medical home” innovation broadens the “patient centered” concept to interactions over time, not just in a single visit. Recent work indicates that time-based patient orientation is associated with better effectiveness in achieving overall well-being, reducing disparities (increasing equity) across patient subgroups, and with greater efficiency (spending less time on visits), greater safety of services rendered, and fewer malpractice suits (14).

C. Towards more integrated organizations. ‘Integrated care’ is a term that reflects a concern to improve patient experience and achieve greater efficiency and value from health delivery systems. The aim is to address fragmentation in patient services, and enable better coordinated and more continuous care, often for an ageing population that has increasing incidence of chronic disease (15).

" Better overall care for patients is associated with better care for their individual problems ". Institutions, both public and private, profit and non-profit, adopting models of integrated care, have reported better results in the efficiency, cost containment, and health outcomes (16). Integrated care models are characterized by: • Identification of a reference population. This might be geographic or a set or range of the population predefined or with prepaid membership. • Prepaid financing systems therefore encourage preventive activities and better use. • Existence of a primary care level as the preferred gateway and structuring of the entire network, ensuring the integrity of performances and dimensions of longitudinality, continuity and coordination of care throughout the life of the people and the history of processes. • Multi-professional teamwork and clinical leadership of professionals in their areas of responsibility. • Availability and implementation of integrated health information system includes all information necessary for informed decision-making, identification of the population, clinical and economic data, support systems for decision making for individual care and preventive activities. Increased use of technology to facilitate adoption of health behaviors, access to services and coordination between levels of care.

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PART II. INNOVATION IN MANAGEMENT AND CLINICAL ORGANIZATION .

â&#x20AC;˘ Availability of management care programs for those with chronic problems, the aged, those who are dependent or in need of social support. These programs allow care proposals that are tailored to the level of severity and which have the potential to stratify and adjust care plans and which have a better ability to respond. â&#x20AC;˘ Availability of integrated incentives where professionals, physicians and non-physicians share the same incentives as the organization to keep members healthy. Integration should not only be applied within the system, between levels, primary care vs. specialist / hospital but also outside the system, among the various networks, the health and social system, physical and mental health care, etc. Vertical integration is very useful for the integration of units and services focused on specific health problems.

Interactions between integrative processes :

Skilled leadership. Organizational integrative processes. High-trust relationships.

Consistent comunication.

Informational integrative processes.

Integrated care focused on patient needs.

Financial integrative processes.

Clinical integrative processes. Administrative integrative processes. Normative integrative processes.

D. Information as a means of improving integral process management. The convergence of IT and life sciences is fertile ground for disruptive innovation. It can revolutionize the way health care is accessed and delivered: mobile computer power, online social networks, wireless technologies etc. They can certainly have an impact in bending the cost curve of health care spending by not only improving care but helping people stay well.

" The convergence of IT and life sciences can have an impact in bending the cost curve by improving care and helping people stay well ". An instrument for change. The ICT are first of all an instrument for introducing the major principles of the lines to improve health systems: accessibility and proximity, integration, reduction of costs and time, proximity, patient-centered… Among other processes ICT should: • Give support to innovation and the reorganization of processes, which will change clinical practice: “extramural care”.

Improvement of health systems through ICT : Increased accesibility and safety.

Innovation and reorganization of processes.

More integrated and better coordinated care.

More efficient solutions to HH.RR and equipment.

THE VALUE OF INNOVATION IN HEALTHCARE .

PART II. INNOVATION IN MANAGEMENT AND CLINICAL ORGANIZATION .

• Provide more efficient solutions in relation to human resources and equipment. • Increase accessibility and the safety of patients. • Provide more integrated and better coordinated care (between levels and intra-levels). A specific example of how to apply the new technologies to one of the critical areas of the system can be found in the innovation processes developed around care of the elderly, chronicity and dependence. These three challenges cannot be approached from the traditional conception and technology has already shown before that it can be instrumental in improving care and providing savings in the use of resources.

Electronic health records, an example. Electronic health records (EHR) have to evolve to become a more precise tool reflecting the clinical processes. All the EHR currently available are used to draw patient information on health episode encounters between professionals and patients. This way of representing the personal health information in the electronic records is useful for a specific encounter and it provides some valuable information for further episodes. However, it does not constitute valuable and efficient help for the long-term follow-up of a chronic condition, especially if the patient is using different health care levels at different institutions. The only way to solve this drawback is to design the EHR as a problem-oriented system, where all the health care actions taken with the patient are associated with a specific health problem, and the patient is viewed as the conjunction of several health problems (acute, chronic, or even as a risk factor).

“ EHR can help to transform health care from hospital-based to patient-centered and from late-disease to early-health “. This way to represent the patient health information will easily allow us to build additional programs into the EHR for chronic diseases management, to apply computer-based decision-making tools for the efficient use of telemedicine and to build preventive strategies based on personal and environmental risk factors. 32

The EHR designed under such terms will help to transform health care from ‘hospital-based’ to ‘patient-centered’ and from ‘late disease’ to ‘early health’. Particularly relevant are the domains of preventive medicine that empower the patient with training, monitoring and predictive medicine, which implies predicting the onset of a disease through personalized computer-based models.

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E. The system of payment as a driver of efficiency. In recent times a significant volume of literature has appeared analyzing the various pay-for-performance (P4P) models, and these refer both to mechanisms for the purchase of health services as well as the systems for the payment or retribution of professionals. The pay-for-performance model has been extended among the various health systems: including those of public financing, based on compulsory contributions, taxes or social security contributions - and privately financed ones based on voluntary contributions.

“ The results of the evaluation studies conclude that pay-for-performance financing systems have displayed more appropiate use than capitations of fee-for-use systems “. The results of the evaluation studies conclude that pay-for-performance financing systems have displayed more appropriate use than capitation or fee-for-service systems (17). The adaptation of the use has been evaluated by taking both process indicators and outcome measures into consideration. Similarly, the results are evaluated by taking the aspects linked to the characteristics of the health care systems, payment systems, the characteristics of the supplier and the patient into account. In all cases the “Pay-for-Performance” systems have shown improvements in one or several of the dimensions of the study. The decisions and choices regarding the design of the payment by performance system (P4P) and the context of the health care system model have a major influence and impact on the results obtained. The aspects of the five study dimensions that have been evaluated are as follows (18): • Clinical effectiveness. In this dimension we can see significant differences in the improvements, considering the results in the care of acute processes or chronic processes. In the latter case, better results have not been obtained due to the importance of continuity and the coordination of the care in the various states or moments of the processes.

â&#x20AC;˘ Access and fairness of care. The pay-for-performance systems offer their best results and contributions in this aspect since they reduce the barriers to access the services. They achieve improvements in the coverage of larger collectives of the population and facilitate care for collectives that are usually discriminated against because of their greater vulnerability and high cost for health care systems (those with less acquisitive power, the elderly, those affected by chronic illnesses, etc.). â&#x20AC;˘ Coordination/Continuity and cost effectiveness. There are no conclusive results for the works as a whole, and consequently there is reduced evidence in the results that need to be contrasted with subsequent studies. â&#x20AC;˘ Patient orientation. No definitive results were appreciated in this dimension.

Performance of P4P systems in th five study dimensions for evaluation :

Clinical Effectiveness. Better results in accute process. Not better results in chronic processes.

Access and fairness. Better results in this aspects.. Reduces barriers to access the services. Coordination / Continuity and cost effectiveness. No conclusive results.

Patient Orientation. Result depending on typology of objectives.

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The financial incentives must connect with the clinical logic of value in terms of health, and better results are observed in those that are based on attaining previously determined objectives from this angle, with health care professionals participating in their elaboration and definition, more than those that are based on competitive terms. Depending on the typology of the objectives, improvements in efficiency in individual terms are observed, although it is also useful to adopt a collective approach that takes the overall action of the team multi-professional as a whole into account. In this case it does not only affect the results in the performance but also the organizational dynamic as an intermediate element in the process to obtain better results in terms of health value (outcomes).

F. Some experiences that demonstrate outcomes. Having outlined the importance of evaluation and having shown impacts that can be applied to different contexts, we will now provide some examples of this type of experiences that have been evaluated. The list does not attempt to be exhaustive, but rather it only seeks to highlight the fact that there are opportunities for improvement based on experiences that have been able to show results in terms of improving health conditions and reducing costs.

Primary Care. • The US studies demonstrate that an increase of one primary care doctor (PCP) per 10,000 of the population is associated with 1.44 fewer deaths per 10,000 of the population, a 2.5% reduction in infant mortality, and a 3.2% reduction in low birth weight (19). • Americans with a family physician –rather than a general internist, pediatrician or specialist- as their regular source of care had lower annual costs of care. About half of the excess cost is in hospital and ER spending; 20% in physician payments and about 30% for medication (20). • In Brazil, a tax-based health services system has been built since 1990. It is strongly based on primary care. During the period 1990-2007, this system led to an annual 5% decrease in hospitalizations, an accumulated 40% decrease in infant mortality through a strong decline in post neonatal mortality and infectious diseases (21). • In Thailand, from 2000 onwards, a strong network of primary health care centers has been deployed in rural areas, reducing under-5 mortality by 44% in the poorest quintile and 13% in the richest. (22) (23) (24) (25). • Primary Prevention: More systematic primary prevention in primary care has the potential to improve health outcomes and save costs in many areas of primary care (26).

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• In Spain the activities for the prevention and control of diabetes patients are the competence of Primary Health Care and there is a long tradition of programs for the comprehensive monitoring of this chronic illness. This country has the lowest indices in the rates of avoidable admissions for type 2 diabetes among all the OECD countries (27).

Reduction in demand and inadequate hospitals stays. • Nursing care programs (Evercare-Medicare) in homes for the elderly in the United States reduce hospitalizations of geriatric patients by half (28). • Similar programs in Catalonia also showed a notable reduction in visits to emergency wards, hospitalizations and pharmaceutical spending (29). • The last 30 studies based on the Appropriateness Evaluation Protocol (AEP) have shown that in all countries and specialties the margins of inappropriate admissions to hospitals are higher than 10% (30). • Reducing variations in Ambulatory Care Sensitive Condition (ACS) admissions, by spreading existing good practices, could produce cost savings of £170 to £250 million across England (31). This variationbased calculation may significantly underestimate the potential savings from managing ACS more effectively as admission rates in all areas are significantly above what should be achievable.

Giving better care to long-term complex chronic patients. • A meta-analysis of acute geriatric units in Spain shows that they are more efficient than conventional units: they reduce the risk of functional decline, they improve the probability of returning home and they reduce stays and costs (32).

• Robust evidence on health outcomes is limited, but improved care co-ordination can have a significant effect on the quality of life of the frail and elderly and people with multiple long-term conditions (33). • Health systems that employ chronic care management models – in which care co-ordination is a central component – tend to be associated with lower costs, as well as better outcomes and higher patient satisfaction (34).

Reducing Waste, reducing costs. • Given the levels of drug wastage, there are opportunities to improve the cost-effectiveness of prescribing certain drugs and the high numbers of preventable drug-related emergency hospital admissions. For example, standardizing prescribing practices for certain treatments (such as low-cost statins) could save the NHS more than £200 million a year (35) (NAO 2007). • A population-based study in Canada showed that 50% of the population had done one laboratory test or other during the past year; in 30% of cases they were redundant tests. The costs of these were estimated to be between Can$ 13.9 million and Can$ 35.9 million (36).

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-13%

Primary prevention has the potential to improve health outcomes and save costs.

in richest quintile. PHc in rural areas

Thailand Primary Care

-44% reduction under-5 mortality in poorest quintile.

Brazil USA +1Primary Care Physicians / 10.000 habitants.

-1,44 deaths / 10.000 habitants

(1990-2007), system strongly based on PHc.

-5% in hospitalization per year.

-40% accumulated decrease in infant mortality.

-2,5% Americans with family physicians

-50% of excess costs in

infant mortatility.

-30% in medication.

-3,2%

low birth wieght.

-20% in physicians payments. >10%

hospital and ER spending.

margins of inappropiate adminissions to hospitals.

Nursing care in home programs for the elder.

USA

Globally

-50% reduction of hospitalization.

Estimated savings reducing variations in ambulatory care sensitive conditions adminissions.

170 M to 250 M 40

England

Reduction in demand and inadequate hospital stays

acute geriatric units.

Improved care co-ordination can have significant effect on the quality of life of the frail and elderly.

Spain Giving better care to long-term complex chronic patients

more efficient than conventional units....

risk of functional decline.

better outcomes.

stays and costs. Chronic care management models.

probability of returning home.

lower costs.

higher satisfaction.

EXPERIENCES THAT DEMONSTRATE OUTCOMES Potential savings to the NHS by standarazing prescribing practices for certain treatments.

200 M ÂŁ / year.

England

50%

of population has done one laboratory test during the past year.

Canada

Reducing waste, reducing costs

30% were redundant. Savings

13,9 M CAN $ to 35,9

M CAN $

THE VALUE OF INNOVATION IN HEALTHCARE .

PART III.

THE ROLE OF GOVERNMENT.

Introduction. A . Key points and challenges. 1. Coverage. 2. Cost Control. 3. Coordination and integration of health care. 4. Choice.

B . JudyAnn Bigby, Secretary of Health and Human Services of the Commonwealth of Massachusetts. 1. Universal coverage. 2. Cost containment. 3. The challenge of an integrated health care system. 4. The value in health care. 5. Primary care. 6. The role of the Government.

C . Januรกrio Montone, Municipal Secretary of Health of the City of Sรฃo Paulo, Brazil. 1. Extending access. 2. Innovation in management. 3. Public Private Partnership to extend the hospital offer.

D . Joan Guanyabens, ICT Coordinator of the Catalan Ministry of Health. 1. Ensurring universal coverage. 2. The importance of the IT in the governance of the health system. 3. Priorities in the IT Strategy.

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Introduction. One of the priority functions in the political management of health systems is that of defining, planning and evaluating the relationship model between the different actors involved in the provision of services. At the present time, reforms of these models are on the agenda of many governments throughout the world, regardless of their context.

" At the present time, reforms of healthcare models are on the agenda of many governments throughout the world. We will look at the challenges faced by three health systems in very different contexts ". In some cases, these agendas for change are based on controlling costs and maintaining the levels of quality and coverage that have been achieved over the past few decades. In other contexts, the agenda is unquestionably a case of broadening coverage, thereby guaranteeing the sustainability and quality of the health systems. This framework of action of policymakers presents a wide variety of specific answers to the challenges with regard to changing and improving health systems. In order to tackle this notion, we proposed an approach structured around the â&#x20AC;&#x153;Four Csâ&#x20AC;? put forward by Victor Fuchs (2009) in his analysis of the reform of the US health system: Coverage, Cost control, Coordinated care and Choice to three top rank political decision makers. We will now look at some of the reflections they outlined during their interventions at the seminar, which are examples of the challenges faced by three health systems in very different contexts.

A . Key points and challenges*.

1. Coverage.

2. Cost Control.

• Sustainability of the system to reach universal coverage: challenges & limitations.

• The role of innovation in increasing quality and reducing costs.

• Which are options to maintain universal coverage, the sustainability of the system and the quality of the healthcare?

• Delivering care at the right place: a way to economic efficiency.

• New managing approaches to extend el universal coverage.

4. Choice. • Guarantee equity in the access to health services. • Individual responsibility in the sustainability of the system. • Tendencies in utilization of health services.

• How to face cronicity and the aging population?

3. Coordination and integration of health care. • The role of the government in fixing standards for quality and information. • How to arrange the payment systems with the pursued health objectives. • The role of primary care in a framework of integrated healthcare delivery services.

PART III. THE ROLE OF GOVERNMENT .

B. JudyAnn Bigby, Secretary of Health and Human Services of the Commonwealth of Massachusetts.

" Value is not defined by the price of one unit of care but by the patient´s outcome across the full circle of care ".

JudyAnn Bigby, Secretary of Health and Human Services of the Commonwealth of Massachusetts, Health and Sustainability seminars, 2012.

Universal coverage. “…I’m going to talk to you for just a few minutes about what we’ve done in Massachusetts to really try to get to universal coverage in terms of insurance coverage for people. I know that for some of you, you might think, What's the big deal about that? Where we are we get that all the time”. But in the US 16% of the population has no insurance, that’s more than 50 million people, and you all know that we actually spend more on health care than any other nation, and not just slightly more but double what other people spend. In addition to the impact that health care coverage has had on the health of residents and we can document things such as

people having better access to primary care, people getting preventive services, people actually filling out their prescriptions for drugs it means there is a positive effect on many layers of our economy, and we are very proud of that. We also know that we are saving lives…”

Cost containment. “We spend 62 billion dollars on health care every year in Massachusetts. I understand that there are some countries whose total budget is dwarfed by this amount. We know that in order to sustain universal coverage in Massachusetts we have to improve access and quality, and bring down costs, and we believe that innovation can play a huge role in solving this problem. The predictions are that if health care costs keep rising the rate they are at the moment, we will see spending doubled in just 10 years. This is at a time when many agree that 30% of what we spend right now could be avoided or spent in ways that improve the efficiency, quality and safety of care. And so the question is: how do we recognize that 30 percent? How do we capture the savings from that 30% and use it to either improve health care, support innovations or for other purposes?”

The challenge of an integrated health care system. “It is increasingly clear that we need to transform the health care delivery system from a system with uncoordinated care to an integrated system with care that is coordinated and well managed with a bigger emphasis on wellness. So rather than focus on the price of an admission or test or procedure or how many of these things we are paying for, our belief is that we need to focus on processes of care, on clinical practice improvement and on improving quality.

" Instead of focusing on prices we need to focus on processes of care, clinical practice improvement and higher quality ".

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We know that we have a combination of too little care delivered, or too little care delivered in the right place, such as in the case of primary care instead of the emergency department. We know that some people are receiving too much care, and the wrong care, and not only does this drive up the cost but it is also harmful. All this goes on and as I said, the cost to consumers, employers and the government keeps going up.”

The value in health care. “We need to introduce incentives to achieve the outcomes that we want: access, quality, and lower costs. Value in health care is not determined by the price of one unit of care and the quality measure that approximates whether an outcome for that unit of care is acceptable. Rather it should be determined by the patient's outcome across the full cycle of care. In order to realize this value we need integrated systems and we must pay for that integration”.

Primary care. “In this country, primary care is often seen as undervalued. We know that in other countries there is a much stronger foundation for primary care, and we know that in communities where primary care is strong, you can actually save money and the outcomes may be better.”

The role of the Government. “And now I’ll speak about the other question I was asked to address during the session, and that is: “what is the role of Government?”. Government can help to set uniform standards by which progress can be measured. A process for establishing common definitions of the types of payments that we want to use, minimum standards for how we define what integrated care is under what we call accountable care organizations… are the types of things where Government can play a role. Government can also play a role in making sure that there are common administrative functions and standards related to payments, data reporting, quality measurement, risk assessment and other procedures.

Government should also have sufficient oversight of any financial risk taken on by providers. So these phenomena of having providers accept payment and being at risk if they donâ&#x20AC;&#x2122;t perform in the right way is something that has been tried in the US in the past. Under the circumstances that we had in the past, many providers actually became financially insolvent, and this was because there were no mechanisms to make sure that that they didnâ&#x20AC;&#x2122;t become financially insolvent if they had a very sick patient or several very sick patients. Finally, the Government must ensure that the most vulnerable people have the same access to health care as others, and that the system responds to their unique needs. Innovation can play an important role in this goal and Government should incentivize innovators to address the unique concerns of the vulnerable population and those who care for those populations. Unfortunately, without this, in the US we do not have the assurance that we are doing all that we need to do to eliminate the very significant health disparities that have been well described in this country.â&#x20AC;?

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C. Januário Montone, Municipal Secretary of Health of the City of São Paulo, Brazil.

" We are looking for integrated care and increasing the capacity of the public area ".

Januário Montone, Municipal Secretary of Health of the City of Sāo Paulo, Brazil, Health and Sustainability seminars, 2012.

“The city of Sao Paulo represents almost 12% of Brazilian GNP (data from 2008), which is equivalent to half the GNP of the State of Massachusetts. The city has 11.2 million inhabitants and 6.2 million of these are only covered by the public health system, while 5 million have both public and private cover. One of the most important challenges of our municipal management is that of reducing inequality. In our city, we have 1.2 million poor people who live in sub standard housing (favelas, shanty towns and other types of low quality housing).

Extending access. Within the area of health, reducing inequality has meant extending access to the public health system to the part of the population that is most in need, looking for integrated care and increasing the capacity of the public area to provide health services. We began to face up to this challenge by extending the primary care network, and now we are extending the network of medical specialties. It is interesting to look at some of the figures we have used as indicators of the advances that we have made during this first period 2004 -2011: • Our own service units (hospitals, among others): 68% growth; • Medical consultations: a 54% increase; in the case of primary care they grew by 91% in this period while laboratory tests went up by more than 300%. • There was a 143% increase in the budget in historical numbers.

Innovation in management. “Innovation in São Paulo has also comes hand in hand with the partnership with non-profit entities and social organizations that receive finance from the state and which carry out the actions that are contracted with this resource. With this, we are accelerating the process of improvement in a region, such as for example the region of the city of Tiradentes/ Guaianases. In this zone, 34 of the 41 health units in the municipality are managed by social organizations and this includes one public hospital. This has allowed us to achieve very quick growth in terms of the health professionals available in the city of Sao Paulo. Between 2004 and 20011 there was a growth of 68% in the number of doctors and an increase of 62% in the number of all health professionals. This growth is due to the greater facility of social organizations to contract professionals”.

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Public Private Partnership to extend the hospital offer. â&#x20AC;&#x153;At this moment, we are facing the challenge of hospital care and once again we are following the public private partnership model, but we are trying to attract private investment to solve our problem. We have this project in progress for 12 hospitals with a budget of 650 million dollars from private investments under a concession process of more than 15 years. The governance model that we are proposing unites the current model, where we have a non-profit entity in the area of clinical management and the private investor building the hospitals and units, obtaining the concession for this period. Accordingly, there are two private partners: one is a non-profit partner while the other is an investor within the system. With this, we hope to have 8 new hospitals available in the network within two years. We believe that the public private partnership model allows us to move forward more quickly. Under the Brazilian model we would have taken at least 20 years to do what we have done in 6.

" With the PPP Model, we hope to have 8 new hospitals within 2 years. Under the Brazilian model, we would have taken 20 years to do what we have done in 6 ". This model allows us to make better use of public resources, and now, during this new phase, we can attract private investment in health. It is not a simple process; it has to be a state project that requires very strong political leadership with a high capacity in technical aspects and project management. I think that we have been successful during the first phase and I am sure that we will also be successful during the second phase of the process. At the end of all this process we will create 25 new installations in a period of between 8 to 10 years, reaching our limit. At this point, we will have to discuss a new model of the Brazilian health system to cope with the entry of 50 million new consumers into the health marketâ&#x20AC;?.

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PART III. THE ROLE OF GOVERNMENT .

D. Joan Guanyabens, ICT Coordinator of the Catalan Ministry of Health.

" The new ICT Strategic Plan places the citizen at the center of the healthcare model ".

Joan Guanyabens,ITC Coordinator of the Catalan Ministry of Health, Health and Sustainability seminars, 2012.

â&#x20AC;&#x153;Catalonia has always been an innovative country, and a pioneer in management experiences and medical research. Our health care model is a good example of this. It was established in 1990 as a mixed health care model that integrated the public use of all health resources into a single network, regardless of whether they were publicly owned or not. The particular organization of the Catalan health care model requires a great effort of co-operation between the different providers to guarantee the quality and sustainability of health care for Catalan citizens. What does this effort mean? The Health Survey of Catalonia shows that 83.7% of Catalan citizens were either satisfied or very satisfied with their health services and this percentage has increased over the past few yearsâ&#x20AC;?. 54

Ensuring universal coverage. “Although, our health care system shows results that placed it at the forefront of European health systems in terms of satisfaction, efficiency and sustainability, we face different challenges and our health system is not entirely prepared to deal with them. Continuous growth, an aging population and the increase in cardiovascular and chronic diseases, as well as the economic context have added even more pressure, and this has forced us to promote tools to ensure a universal health care model with high levels of quality, and we have had to work hard in order not give up and to ensure the excellence that characterizes it.

" Catalonia has always been an innovative country. Our model requires a great effort of co-operation to guarantee quality and sustainability. 83,7% of Catalans are satisfied or very satisfied with health services ". The importance of the IT in the governance of the health system. “One of the priorities of this new Health Plan is the importance of the governance of the information throughout its life cycle. This entire process is managed by the Catalan Agency for Health Information, Assessment and Quality, the organization responsible for generating relevant knowledge to improve the quality, safety and sustainability of the health care system, and to facilitate decision making for citizens, professionals, managers and planners and also facilitate the integration of health professionals into the system and the responsibility to achieve common goals and high quality care”.

Priorities in the IT Strategy. “This year we launched the new ICT Strategic Plan for 2012-2015. This plan reflects our commitment to consolidating our ICT strategic projects, and it places the citizen at the center of the health care model. The actions included in this Plan are structured along three strategic lines:

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PART III. THE ROLE OF GOVERNMENT .

• The transformation of the medical record system of Catalonia into a network of information and shared services. • The deployment of a multichannel communication and attention network for citizens. • The provision of infrastructures and services needed to build a new health care model.

THE VALUE OF INNOVATION IN HEALTHCARE .

PART IV.

INNOVATION TO IMPROVE THE SUSTAINABILITY OF THE HEALTH SYSTEM: MAIN IDEAS OF THE DEBATE.

Introduction. 1.“Defining the value of technologies and innovation in health”. 2.“Building bridges between researchers, clinical professionals and regulators”. 3.“Key Information and evaluation for innovation and reducing costs”. 4.“The need for strong primary care”. 5.“The way to integrated care”. 6.“Patient-centeredness”. 7.“The role of professionals”. 8.“The intensive use of ICT, an important lever of change”. 9.“Health care payment systems as drivers of efficiency”. 10.“Implementing innovation that has shown results”. 11.“The challenges of public policies”.

THE VALUE OF INNOVATION IN HEALTHCARE .

PART IV. INNOVATION TO IMPROVE THE SUSTAINABILITY OF THE HEALTH SYSTEM: MAIN IDEAS OF THE DEBATE. Introduction. Based on the three topics of the debate (clinical practice, management and public policies) the participants dealt with many of the elements that are defining the agendas for the transformation of health systems, offering opinions, experiences and results. This final section seeks to provide a summary of the main ideas that came out of this exercise and to establish a coherent though not necessarily exhaustive list of the challenges that are the subject of debate throughout the world.

“Defining the value of technologies and innovation in health”. • Innovation implies investment and it is for this reason that it is necessary to have prior information for decision making and to evaluate both the economic and the health results. • It is obvious that there is a need to incorporate other dimensions into the process for evaluating health technologies, such as costs, the preferences of patients, the time impact (short-term/longterm) of the benefits in health and social values (for example with regard to chronicity or palliative care). • Innovation has different meanings for the different stakeholders in the process (regulators, governments, funders, suppliers, patients, industry…) with various objectives and incentives (efficiency/safety, access, profitability, quality, containing costs, patient satisfaction …). The challenge of sustainable innovation is to achieve an integrated vision that links scientific development with the health care needs of the population as much as possible. • Industry and Government/payers should look for win to win market entry approaches that prompt quick patient access to high value innovations while keeping the financial sustainability of the system.

“Building bridges between researchers, clinical professionals and regulators”. • During the initial scientific research phase it is essential to have greater dialogue between basic researchers and the clinical professionals in charge of looking after patients. • In turn, the relationship with regulators and funders is also important since the entry of innovative products onto the market depends on them.

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PART IV. INNOVATION TO IMPROVE THE SUSTAINABILITY OF THE HEALTH SYSTEM: MAIN IDEAS OF THE DEBATE .

• Finally it is essential to incorporate the voice of patients into the technological innovation process; their values, lifestyles or attitudes towards the illness should be borne in mind for the generation of innovations adapted to the reality to which it will be applied.

“Key Information and evaluation for innovation and reducing costs”. • We need to develop processes not only to report data, but the data needs to be information that can be practically implemented to improve the system and demonstrate better outcomes. • High quality recording data from clinical practice is needed to monitor and evaluate the results. This information has to be as structured as possible in order to accurately measure outcomes that have to reflect long term health outputs rather than short term episode indicators. • The information systems must respond to this challenge, provide the relevant information at the right time to allow efficient decision making. • The evaluation must be based on clinical criteria, which have been shown to have an impact in terms of efficiency, quality and safety and also in terms of economic efficiency criteria. • By adhering to best clinical practices, health care providers can demonstrate better outcomes with less variability, less use of resources and consequently they can deliver more cost effective and safer health care.

“The need for strong primary care”. • Primary health care is providing results in different contexts that reinforce its importance as a central element in the strategy to improve the effectiveness, fairness and efficiency of health systems.

• Most health system reforms evaluate the role of primary health care in terms of the level of proximity and care for the main health problems. • The structuring of primary care must be based on a multi-professional approach that facilitates the implication and the involvement of persons. This approach has been shown to be useful both for the detection of sectors of the population that are at greater risk and for the adoption of therapeutic recommendations and the adoption of healthier habits. • The information systems must jointly evaluate, but analyze separately, the actions of each of the levels and the professionals participating in the care.

“The way to integrated care”. • The integration of health care is first of all a strategy to improve the care of the patient, starting from the principle that the organizations and professionals in charge of the different phases of the illness must work synchronously to guarantee the continuity of care. • Integration entails specific forms of a professional approach: multidisciplinary and clinical leadership. • Primary care must facilitate the creation of units of integrated practice, together with specialized care for the handling of certain groups of patients who are highly vulnerable because of their health or social conditions. • Information systems, and especially the clinical history as an accessible register of ongoing care, are critical elements for the success of the integration processes. • Likewise payment systems are a strong enabling factor for integration insofar as they introduce organizational as well as professional incentives.

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• Health care integration has been shown to have impacts in terms of efficiency, effectiveness, quality and patient satisfaction. If this is true in general, it is in the case of the care of chronic patients – where the health-care continuum is a clinical imperative – that this paradigm of professional organization has its greatest potential.

“Patient-centeredness”. • Here the emphasis is placed on the importance of putting the patient at the center of the health care process, but this is also connected to the processes to introduce new technologies to evaluate the impact. • A key element of this link is the patient’s involvement in the objectives to improve his/her own health. • There are numerous innovative initiatives that link the patient/citizen to the clinical process and to the organizations that provide health, which have been shown to have positive impacts on the health conditions of the patient: Expert patient programs and technological platforms for the socialization and dissemination of experiences and results in patients.

“The role of professionals”. • To incentivize the willingness and the commitment of the professionals to change behavior and attitudes and to accept responsibilities not only in achieving quality results but also in cost limitation. • To promote education for professionals who are learning how to work in multidisciplinary environments. Search for coordinated and efficient work aimed at real patient needs and planned in advance by means of agreed clinical evidence-based guidelines. • Health care organizations must encourage physi-

cians, nurses and other health care professionals to embrace a culture of safety and transparency. One way of doing so is by creating multidisciplinary teams that work together to attain small but consistent changes in order to reach specific goals such as reporting, transparency and an overall environment of safety within an organization. • To redesign professional roles bearing in mind that when clinical plans are anticipated using clinical pathways, structured triage and scoring systems, the majority of the tasks can be performed by less trained or experienced professionals using decision-making electronic supports.

“The intensive use of ICT, an important lever of change”. • Information Technologies are resulting in a true revolution in the way that information is accessed and how clinical care processes are organized. • The deployment of innovations based on ICT generates synergies in communication within the providing institutions, and also among these, and between them and the administration. • Their impacts are being noted in the lowering of provision costs, in improvements to health care conditions, and also, in the maintenance of health and the prevention of diseases. • Electronic Health Records as an instrument for reinforcing the integration and continuity of care need to provide information for the monitoring of long term chronic illnesses, especially if the patient requires care at different levels and in different institutions.

“Health care payment systems as drivers of efficiency”. • The importance of finance methods in terms of strengthening the transformation of the system,

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PART IV. INNOVATION TO IMPROVE THE SUSTAINABILITY OF THE HEALTH SYSTEM: MAIN IDEAS OF THE DEBATE .

moving from a payment-per-service method to a pay-for-performance system. • Furthermore, payment-for-performance systems introduce incentives to facilitate the integration of the various health care structures. Sharing risks among the different actors who intervene in the health care process is seen as one of the lines to be strengthened. • The definition of the results to be evaluated for financing must respond to a clinical logic of value in terms of health, with the participation of the actors involved in the health care process, more than to an administrative logic. • The results must incorporate the various dimensions and characteristics of the health care systems that facilitate health improvements in the overall sense (accessibility, fairness, coordination and integration in addition to the clinical cost effectiveness). • Transparency and the dissemination of the results is an essential requisite for the correct implantation of pay-for-performance systems.

“Implementing innovation that has shown results”. • There are many experiences of reorganization, the introduction of new technologies or therapeutic procedures that have been introduced and evaluated, showing positive impacts and results for different stakeholders in the health system. • The benchmarking of experiences is a path that is beyond discussion as far as introducing innovations that have already been successful in other contexts is concerned. • From this series of successful experiences, we would single out those related to the expansion and strengthening of primary health care networks, reducing the demand and inappropriate hospital stays, improvements in the clinical handling of hospitalized geriatric patients, the perfor-

mance of unnecessary tests and improvements in pharmaceutical prescription due to their relevance with regard to the sustainability of the systems.

“The challenges of public policies”. • Universal coverage of health services is a challenge that the majority of health systems have to face. In some cases the challenge is specified in terms of how it can be achieved while in others it is a question of knowing how to maintain it. • Managing the universal coverage of services generates system level costs that can only be tackled by introducing technological innovations to the way patients are managed, the services they are provided with and the care they are given. These challenges concern both the systems that have already achieved universal coverage as well as those that have it as an objective. • Introducing innovations into management through collaborations with non-profit entities and the broad spectrum of alliances with the industry and the organizations that provide health services are examples of how to move towards universal coverage. • Governments have the function of guaranteeing the flexible and efficient exchange of information among the different agents in the health system and making sure that citizens can access basic data concerning their state of health. • Public private collaboration within the framework of a global strategy for the deployment or reorganization of public health services is an instrument that allows us to speed up the processes related to the construction of infrastructures and the management of clinical and non-clinical services.

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PART IV. INNOVATION TO IMPROVE THE SUSTAINABILITY OF THE HEALTH SYSTEM: MAIN IDEAS OF THE DEBATE .

Challenges for the transformation of health systems : Integrated vision.

Information.

Incorporate the voice of patients. Basic research and clinical professionals.

Evaluation.

Regulators and funders.

Technology Market approaches.

Universal coverage: achieving and maintaining.

High quality data form clinical practice. Allow efficient decision making.

Public private partnerships.

PUBLIC POLICIES

From data to meaning.

Flexible and efficient exchange of information. Best clinical practices.

Results

Evaluation based on clincal criteria.

Collaboration with non-profit, industry and health organizations. Technological innovations for managin, providing and giving care to patients.

Reducing demand and inappropiate hospital stays.

Reducing waste.

Geriatric patients.

Benchmarking. Improvements in pharmaceutical prescriptions.

Expansion and strengthening of primary care networks.

Embrace a culture of safety and transparence.

Promote education.

Incentivize change and responsibilities.

People Redesign professional roles.

Dissemination of knowledge.

EHR as an instrument for integration and continuity.

ICT = revolution in access and clinical processes. Synergies in communication.

Patient centered Medical-home. Lower provision costs.

Patient + new technologies + impact evaluation.

Payment systems.

Management

Continuity of care.

Proximity and care.

Chronic patients.

Evaluate actions of each level.

Medical records. Multidisciplinary and clinical leadership.

Multiprofessional approach.

Finance methods as a driver for transformation.

Central element of strategy.

Definition of results on a clinical logic.

Incentives to integration of the various structures.

Defining the value of technologies and innovation in health.

Health care payment systems as drivers of efficiency.

Building bridges between researchers, clinical professionals and regulators.

The way to integrated care.

Key information and evaluation for innovation and reducing costs.

The intensive use of ICT, an important lever of change.

Implementing innovation that has shown results.

Patient-centeredness.

The need for strong primary care.

The role of professionals.

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ANNEXES.

About Gesaworld. 1.We aim to help, innovate and simplify. 2.The way to integrated care. 3.Clients for Gesaworld Group are. 4.Markets. 5.Main trademarks, products and services.

Seminar's program. 1.Wednesday April 18th 2012. 2.Thursday April 19th 2012.

Participants. Bibliography and references. 1.Recommended Bibligraphy. 2.References.

About Gesaworld. We aim to help, innovate and simplify. Since our inception 12 years ago in 1999, our consultancy company has striven to take knowledge wherever it could be useful. At Gesaworld Group, our vocation has always been to help improve life for people in healthcare and social development. Our professional savvy allows us to simplify so people, companies and organizations can make good decisions. We facilitate the hardest part and provide exclusive, innovative and quality solutions. We have established an international network in Europe and America with branches in Brazil, Mexico, Panama, Nicaragua, Portugal, Chile and the USA. Our experience includes over 200 projects developed for 90 clients in 20 different countries. The management and consulting team at Gesaworld Group is formed by domestic professional people with ample and firsthand expertise in matters concerning their environment and social reality.

Washington D.C.

Madrid. Lisboa.

Barcelona.

México D.F. Managua. Panama. São Paulo. Santiago de Ghile.

Gesaworld´s offices.

The way to integrated care. • Commitment and trust: we are a strategic partner for our clients. • Technical accuracy: we always rely on renowned experts for each project. • Proximity: we listen to our clients and provide custom-made solutions. • Global and interdisciplinary approach: we consider each project holistically and from all angles dictated by knowledge.

Clients for Gesaworld Group are. • Public administrations. • Organizations. • International bodies. • Healthcare institutions. • Universities and training centers.

Markets. In the past 12 years Gesaworld Group has worked for the following markets: Spain, Portugal, the USA, Nicaragua, Canada, Belize, Honduras, France, Costa Rica, El Salvador, Panama, Colombia, Brazil, Paraguay, Chile, Morocco, Guatemala, Mexico, Tayikistan and Dominican Republic.

Main trademarks, products and services. A. Institutions and healthcare centers: • Strategic and functional planning. • Care protocols and process reorganization.

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ANNEXE.

• Auditing, evaluation and analysis concerning economic, organizational and care complexities. • Interim management in management contracts. • Quality management (evaluation, models and certifications). • Models to back decision-making (balanced scorecard and key indicators). B. Public programs and policies: • Public policy planning, development and evaluation. • Observatory for health and social sector. • Healthcare models: primary and hospital healthcare, public and community health. • Dependence and social services. • Financing: insurance models and public-private partnership (PPP). C. Health and sustainability: • Sizing, design and functional plans for equipments and infrastructures following sustainable criteria. • Technological models (telemedicine, digital hospital and clinical information systems). • Work and project management. • Sustainable care networks (Carbon Finance, energy models and environmental regulation). • Sustainability plans and certifications. • Sustainability culture and communication. • Research to uncover financial sources for sustainable projects.

D. GSW Classroom: • In-company training (regular classes and elearning). • Training programs in healthcare and management. • Technical support for management teams. • Training curricula in healthcare and management. • Organization and participation in seminars and congresses.

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ANNEXE.

Seminar's program. Wednesday April 18th 2012. 08:30 Registration. 09:00 Opening Remarks. Roser Vicente, Managing Director of Gesaworld Group.

09:15 Conference: "Value of inovation in Health Care system: Oncology as a case point". Keynote introducer: Pedro Nueno, Professor of Entrepreneurship at IESE Business School Barcelona, Spain. President and Professor at CEIBS, Shanghai, P.R. of China. Speaker: Josep Baselga, Chief, Division of Hematology/ Oncology. Associate Director of the Massachusetts General Cancer Center, Boston, (MA), US.

10:15 Break. 10:30 Introduction to the Session. José Maria Pérez, Director of Gesaworld Group in the USA.

10:45 First Panel: The path towards sustainable innovation in clinical practice.

Chairwoman, Susan Windham-Bannister, President and CEO, Massachusets Life Science Center, Boston (MA), U.S. Speakers: Robin Cisneros, National Director, Medical Technology Assessment & Products, Kaiser Permanente, U.S. Laura Sampietro-Colom, Deputy Director of innovation, Hospital Clínic de Barcelona, Spain. Montserrat Vendrell, Managing Director of BioCat (BioRegion of Catalonia), Spain.

11:45 Break. 12:00 Debate. 13:00 Lunch.

14:00 Second Panel: Clinical Organization & Management: Innovation & Efficiency.

Chairman, Mike Taylor, Senior Vice President, Reporting and Insights, OptumHealth, U.S. Speakers: Carlos A. Ariza, AVP, International Market Analysis and Development, Baptist South Floorida, Florida, U.S. Szabolcs Dorotovics, Managing Director, Europe, Johns Hopkins Medicine International. Josep Maria Piqué, CEO of Hospital Clínic de Barcelona, Spain. José Carlos de Souza Abrahão, Immediate Past President of international Hospital Federation (IHF), and President of the Confederaçao Nacional de Saúde (CNS), Brasilia DF, Brazil.

15:00 Break. 15:15 Debate. 16:45 Closing Remarks. 18:00 Dinner Session: The Role of Health Policy & Regulators. Moderator, Pedro Nueno, Professor of Entrepreneurship at IESE Business School, Barcelona, Spain. President and Professor at CEIBS, Shanghai, P.R. of China. Speakers: JudyAnn Bigby, Secretary of Health and Human Services of the Commonwealth of Massachusetts. Januário Montone, Municipal Secretary of Health of the City of São Paulo, Brasil. Joan Guanyabens i Calvet, ICT Coordinator of the Catalan Ministry of Health CEO Catalan Agency for Health information, Assessment and Quality.

Thursday April 19th 2012. 09:00 Post-Seminar Sessions: Chairmen & Speakers' Meeting.

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ANNEXE.

Participants.

Abrahão.

José Carlos.

Ariza.

Carlos A.

Balcacer Estevez. Héctor.

Barreneche. Clara.

Baselga. Jose.

Bigby.

JudyAnn.

Cisneros. Robin.

Cohen.

Gary.

Davis.

Andrew.

Donoso. Lluís.

Dorotovics.

Szabolcs.

Frenk. Nelson.

Granados. Alicia.

Guanyabens. Joan.

Hsu. John.

Jaimovich.

David.

Lazaro. Josep.

President.

Confederação Nacional de Saúde CNS, Brasil. AVP, International Market Analysis and Development.

Baptist Health South Florida, US.

Comisión Ejecutiva para la Reforma del Sector Salud (CERSS), Dominican Republic. ACC10, Spain. Chief, Division of Hematology / Oncology, Associate Director.

Massachusetts General Hospital Cancer Center, US. Secretary of Health and Human Services of the Commonwealth of Massachusetts, US. National Director, Medical Technology Assessment & Products.

Kaiser Permanente, US.

President & Executive Directo.

Health Care Without Harm, US. Head of Delegation.

Delegació del Govern de Catalunya EE UU, Spain. Director.

Diagnostic Imaging Department, Hospital Clínic Barcelona. Managing Director, Europe.

Johns Hopkins Medicine International, US. Supervisor.

Hospital Estadual Vila Alpina - Seconci - OSS, Brasil. Head of Global Evidence Definition / HTA.

Genzyme, US. CEO.

Catalan Agency for Health Information, Assessment and Quality - AIAQS , Spain. Director, Clinical Economics and Policy Analysis (CEPA). Harvard Medical School, US. President.

Quality Resources International, US. CEO.

Gesaworld Group, Spain.

Llauger de Salazar. Elizabeth.

McDonough. John E.

Meeker. David.

Montone.

Comisión Ejecutiva para la Reforma del Sector Salud (CERSS), Dominican Republic. Director of coverage and acess.

Center for Health Care Strategies, Inc, US. President and CEO .

Genzyme Corporation, US. Municipal secretary of Health of the City of São Paulo .

Januário.

Secretary of Health of the City of São Paulo, Brasil.

Nueno.

Professor of Entrepreneurship.

Pedro.

IESE Business School, Spain.

Pérez.

U. S. Director.

Piqué.

CEO.

José M.

Josep Maria.

Sampietro-Colom. Laura.

Tarrats. Albert.

Taylor. Mike.

Gesaworld Group, Spain. Hospital Clínic de Barcelona, Spain. Deputy Director of Innovation.

Hospital Clínic de Barcelona, Spain. CEO.

HLL, Spain. Senior Vice President Reporting & Insights.

Optum US, US.

Ternullo.

Associate Director.

Vendrell.

Managing Director.

Vicente.

Managing Director.

Joseph L.

Montserrat.

Partners for Healthcare, Center for Connected Health, US. BioCat (BioRegion of Catalonia), Spain.

Roser.

Gesaworld Group, Spain.

Wadhwa.

Healthier Hospitals, US.

Seema.

Weissman. Joel S.

Windham-Bannister. Susan.

Center for Surgery and Public Health - Brigham and Women's Hospital, US. President & CEO.

Massachusetts Life Sciences Center, US.

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ANNEXE.

Bibliography and references. Recommended Bibliography. • Bodenheimer, T. and Margolius, D. (2010) Transforming Primary Care: From Past Practice To The Practice Of The Future. Health Affairs, 29/5:779-784. • Bohmer, Richard M.J. (2011) The Four Habits of High-Value Health Care Organizations. The New England Journal of Medicine 365:2045-2047. http://www.nejm.org/doi/full/10.1056/NEJMp1111087 • Cawston, T.; Haldenby. A; Seddon, N. (2012) Healthy competition. [Online] Reform. http://www.reform.co.uk/pages/4271/view • Christensen, C.M. and Hwang, J. (2007) Disruptive Innovation In Health Care Delivery: A Framework For Business-Model Innovation. Health Affairs, 27/5:1329-1335. • Dixon, Ronald (2010) Enhancing Primary Care Through Online Communication. Health Affairs, 29/7:1364-1369. • Eurobioimaging. Development of an European research infrastructure for clinical trials and evaluation for biomedical imaging technology. http://www.eurobioimaging.eu/content-page/wp10-mi-patient-population • Fuchs, Victor R. (2009) Four Health Care Reforms for 2009. The New England Journal of Medicine 361:1720-1722. http://www.nejm.org/doi/full/10.1056/NEJMp0907979 • Gold, Jenny (2011) Accountable Care Organizations, Explained. [Online] National Public Radio. http://www.npr.org/2011/04/01/132937232/accountable-careorganizations-explained • Lundvall, K.; Okholm, H. B.; Marcusson, M.; Jespersen, S. T. and Birkeland M. E. (2009) Can Public Procurement spur Innovations in Health Care. Copenhagen Economics Informed Decisions, VINNOVA Sweden’s Innovation Agency. http://www.vinnova.se/en/Publications-and events/Publications/Products/Can-Public-Procurement-spur-Innovationsin-Health-Care/

• Macinko, J.; Starfield, B. and Shi, L. (2003) The Contribution of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 1970–1998. Health Services Research 38/3: 831-865. • National Health Service (UK) Accelerating adoption and diffusion in the NHS. [Online] Department of Health, NHS Improvement & Efficiency Directorate, Innovation and Service Improvement (2011) Innovation Health and Wealth. http://www.dh.gov.uk/health/2011/12/nhs-adopting-innovation/ • Porter, M.E. (2009) A Strategy for Health Care Reform — Toward a Value-Based System. The New England Journal of Medicine 361:109-112.

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ANNEXE.

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“E&Y (2011) Beyond Borders, Global Biotechnology Report”.

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Health Technology Assessment International (HTAi) Policy Forum. HTA and value: Topic abstract (Draft Document). To be held in HTAi Annual Meeting 2012 Bilbao (Spain).

Husereau D et al. The Use of Health Technology Assessment to Inform the Value of Providers Fees: Current Challenges and Future Opportunities. Canadian Health Services Research Foundation Series of reports on cost drivers and health system efficiency: paper 6. October 2011.

Huserau D et al. Value-based Pricing of Pharmaceuticals in Canada: Opportunities to expand the Role of Health Technology Assessment? Canadian Health Services Research Foundation Series of reports on cost drivers and health system efficiency: paper 5. December 2011.

Macinko, J.; Starfield, B. and Shi, L. (2003) The Contribution of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 1970–1998. Health Services Research 38/3: 831-865.

Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457–502.

Ko Y, Malone DC, D’Agostino JV, et al. Potential determinants of prescribers’ drug-drug interaction knowledge. Res Social Adm Pharm. 2008;4:355–66.

10. Schmittdiel JA, Shortell SM, Rundall TG, et al. Effect of primary health care orientation on chronic care management. Ann Fam Med. 2006;4:117–23. 11. Christakis DA, Wright JA, Zimmerman FJ, et al. Continuity of care is associated with well-coordinated care. Ambul Pediatr. 2003;3:82–6.

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Pieter Van Herck, Delphine De Smedt, Lieven Annemans, Roy Remmen, Meredith B Rosenthal, Walter Sermeus “Systematic review: Effects, design choices, and context of pay-for-performance in health care”, BMC Health Services Research 2010, 10:247.

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21. Macinko J, Dourado I, Aquino R, et al. Major expansion of primary care in Brazil linked to decline in unnecessary hospitalization. Health Aff. 2010;29:2149–60. 22. Vapattanawong P, Hogan MC, Hanvoravongchai P, et al. Reductions in child mortality levels and inequalities in Thailand: analysis of two censuses. Lancet. 2007;369:850–5. 23. Kemper KJ Medically Inappropriate hospital use in a pediatric population. NEJM 1988:318:1033-7. 24. Ollero M. Adecuación y utilidad del ingreso hospitalario (Ed) Med Clin 2001;116(17);665-7. 25. Brabrand M, Knudsen T, Hallas J. Do acutely admitted medical patients comply with the appropriateness Evaluation Protocol? Scandinavian Journal of Trauma. Resuscitation and Emergency Medicine 2010;18(Suppl):9. 26. Health England (2009) “Incentives for Prevention” Report nº3. 27. OECD Health Data 2011. http://www.oecd.org/document/30/0,3746, en_2649_37407_12968734_1_1_1_37407,00.html 28. J Am Geriatr Soc. 2003 Oct;51(10):1427-34. The effect of Evercare on hospital use. Kane RL, Keckhafer G, Flood S, Bershadsky B, Siadaty MS. 29. Evaluación de un programa de intervención en residencias geriátricas para reducir la frecuentación hospitalaria Díaz-Gegúndez, Mercedes; Paluzie, Guillem; Sanz-Ballester, Carme; Boada-Mejorana, Mercè; Terré-Ohme, Susanna; Ruiz-Poza, Dolors. Rev Esp Geriatr Gerontol. 2011;46:261-4. - vol.46 núm 05. 30. Payne SMC. Identifying and managing inappropriate hospital utilization: a policy synthesis. Health serv Res 1987:22:709-69 31. National Gold Standards Framework Centre (2011). Gold standards website. Available at www.goldstandardsframework.nhs. uk/.

32. Eficiencia de las unidades geriátricas de agudos: metaanálisis de estudios controlados. Baztán, Juan J.; Suárez-García, Francisco M.; López-Arrieta, Jesús; Rodríguez-Mañas, Leocadio Publicado en Rev Esp Geriatr Gerontol. 2011;46:186-92. - vol.46 núm 04. 33. Hofmarcher, Oxley H, Rusticelli E (2007). Improved Health System Performance through Better Care Coordination. Health Working Paper No. 30. Paris: Organisation for Economic Co-operation and Development (OECD). 34. Singh D, Ham C (2005). Transforming Chronic Care: Evidence about improving care for people with long-term conditions. Birmingham: University of Birmingham, Health Services Management Centre. 35. National Audit Office (2007). Prescribing Costs in Primary Care. London: National Audit Office. Available at: www.nao.org.uk/ publications/0607/costs_in_primary_care.aspx (accessed on 28 October 2010). 36. Walraven CV, Raymond M. Population-based study of repeat laboratory testing. Clinical Chemistry 2003;49(12):1997-2005.

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