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VALUE-BASEDHEALTHCAREINSWEDENReachingthenextlevelCommissionedby©TheEconomistIntelligenceUnitLimited20191Value-basedhealthcareinSwedenReachingthenextlevelContents2Listofabbreviations3Aboutthisreport4Executivesummaryandkeyfindings6Introduction7Chapter1:TheSwedishmodelandlessonsforothers14Chapter2:Thebacklashandobstaclestofurtherprogress21Chapter3:Overcominglimitationsandpotentialstepsforward29Conclusion©TheEconomistIntelligenceUnitLimited20192Value-basedhealthcareinSwedenReachingthenextlevelListofabbreviationsAI:artificialintelligenceEHR:electronichealthrecordEUnetHTA:EuropeanNetworkforHealthTechnologyAssessmentNQR:SwedishnationalhealthcarequalityregistryRWD:real-worlddataRWE:real-worldevidenceSALAR:SwedishAssociationofLocalAuthoritiesandRegionsTLV:Tandvårds-OchLäkemedelsförmånsverket(DentalandPharmaceuticalBenefitsAgency)VBHC:value-basedhealthcareVBP:value-basedpayment©TheEconomistIntelligenceUnitLimited20193Value-basedhealthcareinSwedenReachingthenextlevelAboutthisreportValue-basedhealthcareinSweden:ReachingthenextlevelisanEconomistIntelligenceUnitreport,commissionedbyTakeda.ItlooksatSweden’sprogressonimplementingtheprinciplesofvalue-basedhealthcare(VBHC)throughoutthecountryandcarepathways.Thefindingsofthereportarebasedondeskresearchandtenin-depthinterviewswithexpertsonVBHCinSweden,includinghealtheconomists,healthcareprovidersandpolicymakers.Ourthanksareduetothefollowingfortheirtimeandinsights(listedalphabetically):•KarinGöransson,policyanalyst,SwedishAssociationofLocalAuthoritiesandRegions(SALAR)•PeterGraf,CEO,Tiohundra•NiklasHedberg,chiefpharmacist,DentalandPharmaceuticalBenefitsAgency/Tandvårds-OchLäkemedelsförmånsverket(TLV);andchairoftheexecutiveboard,EuropeanHTANetwork(EUnetHTA)•MortenKildal,consultantplasticsurgeon,headofvalue-basedhealthcareandassociateprofessor,UppsalaUniversityHospital•PeterLindgren,managingdirector,SwedishInstituteforHealthEconomics•TobiasNilsson,chiefofstrategy,VästraGötalandhealthcareregion•JörgenNordenström,emeritusprofessorofsurgery,andfreelanceconsultantinhealthcarequalityimprovementprojects,VBMCare.com•FredrikÖhrn,seniorinnovationmanager,KarolinskaUniversityHospital•JohanThor,associateprofessor,JönkopingAcademyforImprovementofHealthandWelfare•FredrikWestander,seniorpolicyanalyst,SALAR•JonasWohlin,founder,IvbarThereportwaswrittenbyAndreaChipmanandeditedbyMartinKoehringofTheEconomistIntelligenceUnit.January2019©TheEconomistIntelligenceUnitLimited20194Value-basedhealthcareinSwedenReachingthenextlevelExecutivesummaryTheneedtogetbettervaluefromhealthcareinvestmenthasneverbeenmoreimportantasageingpopulationsandincreasingnumbersofpeoplewithmultiplechronicconditionsforcegovernmentstomakelimitedfinancialresourcesgofurther.Thesepressures,alongwithagreaterfocusonpatient-centredcare,haveraisedtheprofileofvalue-basedhealthcare(VBHC),especiallyinEuropeanhealthcaresystems.Sweden,withitshighlycomprehensiveandegalitarianhealthcaresystem,hasbeenaleaderinimplementingVBHCfromthebeginning,afactthatwasunderscoredina2016globalassessmentofVBHCpublishedbyTheEconomistIntelligenceUnit.1ThispaperlooksatthewaysinwhichSwedenhasimplementedVBHC,theareasinwhichithasfacedobstaclesandthelessonsthatitcanteachothercountriesandhealthsystemslookingtoimprovethevalueoftheirownhealthcareinvestments.KeyfindingsDefiningVBHCisstillachallenge.FindingasingledefinitionofVBHC,letaloneapolicythatcancommandwidespreadsupport,hasbeenachallengeinSweden,aselsewhere.Thecountryhasbeenapioneerinexperimentationwithorganisationalrestructuringdesignedtoimproveefficiencyandpatientsatisfaction.Therehavealsobeensomeeffortstolinkremunerationofhealthcareprovidersandreimbursementofmedicinestooutcomes.Yet,althoughthereislittledisagreementthatmoresuccessfuloutcomesforpatientsanddoctorsalikeshouldbeakeypriority,thereissignificantdisagreementonthestepsneededtogettothatpoint.Integratedcaredeliveryisakeypartofprovidingvalue.Policiesthatleadtogreaterintegrationofhealthcarepathwaysandcloserco-ordinationofcarebetweendifferentstakeholders(andpayors)intheSwedishsystemhavebeenwelcomedbypatients.Insomenotablecases,suchasthroughthecloserco-ordinationofhomecarebetweenhospitalsandcommunitycareagencies,thesepolicieshavemadehealthcaredeliverymoreefficient.Gettingbuy-infromhealthprovidersisvital.ThemostsuccessfulexperimentswithVBHCintheSwedishsystem,includinginitiativesinUppsala,theVästraGötalandregionandStockholmCounty,sofarhavebeendonegradually,withcloseconsultationwithhealthcareproviders,1TheEconomistIntelligenceUnit,Theenablingenvironmentforvalue-basedhealthcare,©TheEconomistIntelligenceUnitLimited20195Value-basedhealthcareinSwedenReachingthenextlevelpatientsandotherstakeholders.Other,moreradicalattemptsatreformhavemetwithcriticism,whichhasunderminedsupportforthem.Achieving“buy-in”fromthosechargedwithimplementingnewpolicies,andthosetheyaremeanttobenefit,iscritical.Gooddataarekeytoeffectivevalue-basedpricing.AccurateandcomprehensivehealthdataareamajorpartofVBHCinthattheyenablepolicymakerstomeasuretheimpactoftreatment,ev