Inger Ekman 1,2 , Reinhard Busse 3,4 , Ewout van Ginneken 3,4 , Chris Van Hoof 5 , Linde van Ittersum 6 , Ab
Klink 6 , Jan A. Kremer 7 , Marisa Miraldo 8 , Anders Olauson 9 , Walter De Raedt 5 , Michal Rosen-Zvi 10 ,
Valentina Strammiello 9 , Jan Törnell 2 , Karl Swedberg 2,11,12
1 Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg,
Sweden
2 University of Gothenburg Centre for Person Centred Care (GPCC).
3 Department of Health Care Management, Berlin University of Technology, Germany
4 Berlin School of Public Health, Germany
5 imec, Wearable Health Solutions, Leuven, Belgium
6 Talma Institute, Faculty of Social Sciences, VU University Amsterdam, The Netherlands
7 Radboud University Nijmegen Medical Centre, The Netherlands
8 Imperial College Business School London, United Kingdom
9 European Patients´ Forum (EPF), Luxembourg
10 Healthcare Informatics Department, IBM Research Lab - Haifa, Israel
11 Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
12 National Heart and Lung Institute, Imperial College, London, United Kingdom
Correspondence: Professor Inger Ekman
Address: Institute of Health and Care Sciences, Box 457, 405 30 Gothenburg, Sweden
Phone: 0046317866014 e-mail:
Inger.ekman@gu.se
Words: 1635
Key words: Health care quality; containment, cost; health policy; access to health care
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Introduction

Healthcare spending as percent of GNP in the five largest economies of the
EU has grown by 27% from 2005 to 2010. A continued increase threatens future healthcare.

WE CARE is an EU-funded consortium of European key-players. WE
CARE proposes a strategic plan on how research and innovation can facilitate a breakthrough in cost containment while simultaneously improving the quality of care and population health.

Seven themes have been defined to be addressed in a concerted action to be explored in order to achieve cost-containment while maintaining the quality in care
How to tackle the galloping increase of healthcare costs in Europe?
In 2006, the European Council agreed on several common values and operating principles that
are shared across the healthcare systems of member states [1]. These values
include universality, access to good quality care, equity, and solidarity . At that time, the common values did not explicitly address costs or affordability, although they are important issues in any system whose aim is to safeguard mutual healthcare. The European Council therefore stated that it is essential to make our healthcare systems financially sustainable in a way that protects these values into the future. However, health expenditure in all EU countries between
2000 and 2009 increased from 8.0% of the GNP to 9.9%, and in the “old” EU-15 countries
alone from 8.6% to 10.6% [2].
The global financial crisis since 2008 has changed this situation in two ways. First, the focus shifted towards sustainability of health financing, which appeared on the policy agendas in virtually all European countries as well as internationally. Second, the financial crisis reverted
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the growth rates in health expenditure, at least initially [3]. Because this was often achieved
through short-term measures, such as cutting pharmaceutical prices, salaries, and hospital
budgets instead of efficiency gains [4], this trend is likely to reverse. The latest OECD
projections (from 2013) of health expenditure growth until 2060 conclude that public expenditure on health as a percentage of GDP will more than double by 2060 if growth trends
continue to be unchanged (“cost-pressure scenario”)[5]. The societal and economic impact of
these projections are enormous. Jeopardising the affordability and accessibility of quality health care for all EU citizens compromises the values European health systems are based on.
The biggest challenge is to embrace the constant development of health care, to improve quality, and at the same time, to contain increasing costs. Such an endeavour should ensure that all EU citizens have equal access to future health care services.
Naturally, the topic has not escaped the attention of both researchers and policymakers.
Approaches to address this challenge are most often labelled “increasing efficiency” (such as changing payment systems towards capitation or diagnosis-related groups (DRGs)) or increasing “value-for-money” (such as economic analysis or health technology assessment,
HTA). We argue that these actions alone will not lead to overall cost containment, although this is a common expectation held by most policymakers.
Reality often reveals that more “value for money” for individual technologies or patients is accompanied by higher aggregate costs of health care provision to European citizens. This increase is primarily caused by the reactive mechanisms in the entire healthcare system and its
environment [6]. For example, while the prospective payments that are using DRGs increase
the efficiency of inpatient care, they also translate into more unused beds and an incentive for hospitals to treat more patients and thereby contribute to an overall increase in expenditures
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(and threatening quality because of possible inappropriate admissions). Related to this problem is the need to reduce “waste”, i.e. all not value-added practices in patient care and administration. Berwick and Hackbarth have estimated that in the USA reducing only 30% of
the waste would fully compensate for increases in health expenditures until 2020 [7].
Facts to consider

The healthcare sector (with an estimated system value of $4.27 trillion (€3.2 trillion) has
the highest percentage of inefficiency, estimated to be over 40% [8].

Co-creation of care between patients, their families and health professionals has been identified by several national agencies as one of the core components for more efficient
care [9-12].
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A response from key players in the healthcare sector
WE CARE is a consortium responding to the EU 7th Framework Programme tasked to propose a roadmap for cost containment with maintained or improved quality in Europe, including research gaps and innovation needs.
WE CARE ( www.we-do-care.eu) invited key players from the pharmaceutical industry, technology sector, academic researchers, health professionals from hospital, primary and community care together with patient representatives and politicians to contribute their views and ideas in five workshops in 2014 and at a Conference in April 2015 in order to set the stage and identify the principal areas of where interventions and policies are required to address the major challenges faced by healthcare systems in Europe.
The WE CARE roadmap on how research and innovation can facilitate cost-containment should not only consider efficacy as demonstrated in clinical trials but also “community effectiveness” as achieved in actual implementation of services including the appropriateness of services provided. Because of the complexity of the healthcare sector, fundamental knowledge of institutional mechanisms, healthcare systems, methods, and paradigms for change are needed. The challenge is enhanced by the factual knowledge that a multidisciplinary approach is a precondition for successfully bringing about change.
Furthermore, the operating principles as agreed by the Council, i.e. quality of care, safety, ethical aspects, patient involvement (person-centred care) and confidentiality should be considered while carrying out research.
Containing costs and improving health care quality are often viewed as different and conflicting aims. R&D and innovation within the health care area over the past 20 years has led to significant improvements in healthcare but it has not
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contributed noticeably in keeping health care sustainable and affordable. Future research will have to find effective ways to improve quality while concurrently controlling the growth of health care spending.
In interactive thematic discussions the participants (28 European countries were represented) identified seven themes in which more research and innovation were called for to achieve the following objectives (Figure 1):
1.
Quality measures of healthcare
2.
Patient/Person engagement
3.
Health promotion and disease prevention
4.
Infrastructure, service delivery, and organisational models
5.
Information technology to support quality, effectiveness, and efficiency
6.
Incentive systems that give new impetus to innovation
7.
Contracting strategies that promote efficient and high quality care
If future cost containment with maintained or improved quality of care is to be achieved, all the above themes need to be addressed within a concerted action across stakeholders and
EU’s member states.
This action needs a large investment of probably 100 Million Euro to explore the challenges and be able to produce actions for solutions. This figure may seem like a large sum but in fact is a very small part of the annual expenditure on health care (less than 0.01% or about 20 cents per EU citizen) Previous failures have been the result of limited actions on only one or a couple of these themes. In such attempts, any cost containment in the involved institutions
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or in one whole sector will probably result in cost expenditures in other institutions or sectors.
Thus, the need for a large programme to address the most important question for future health care for EU citizens was expressed by an overwhelming majority of the participants.
How to do it?
A few preconditions are vital:

A multi-disciplinary approach to overcome problems in the innovations, i.e. close collaboration between medicine, care science, health economics, health policy, and technology sciences.

Cross-sectoral interaction to overcome barriers that are due to fragmentation in the structure of the healthcare sector.

Collaboration with all stakeholders (e.g., patients and funders) in order to approach R&D from a “patient pull” instead of a technology/science push perspective.

Collaborative action between health systems in policy formulation, piloting, and evaluation .
The proposed approach presented in this paper is inspired by design thinking. Central to this practice is to create enclosed, miniature health care systems limited to well-defined geographical areas. Within these miniature healthcare systems, which we call “health care labs”, new healthcare systems will be designed, explicitly taking all relevant actors and their interrelationships into account and thus avoid the trap that perceived benefits in costs or outcomes in one area are outweighed in another.
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A proposal for future WE CARE research is to establish several health care labs across
Europe and prototype completely new ways of conducting health care. The labs should run in parallel in order to be able to learn from each other; optimally, the labs should have some features in common while also differentiating from each other on other aspects. They should render their first short-term results within the first 5 years of their existence, while larger, more comprehensive outcomes and policy propositions could be formulated in a more realistic long-term timeframe. The first 3 years will serve as a period of experimentation, iteration, and learning to help ensure that the new healthcare system functions well. To evaluate the outcomes on utilisation and costs, patient and professional experience, and ultimately health in a methodologically sound manner, each lab will be evaluated using an area outside the labs, which is comparable in terms of population and health care provision
(but without the innovation developed in the lab) as a control for the years.
Because the magnitude of the proposed research programme is very large (but small compared with cost for inefficiencies, waste, and individual suffering that are caused by inadequate health care), it will require the support at the highest level, both in the EU and at member state level. We need to act on cost-containment with maintained or improved quality.
The future is certainly challenging but one that is full of opportunities to improve health care delivery in Europe.
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Key Messages

Increase in spending on healthcare has grown substantially during the last 10-15 years both in absolute spending as well as in relative to Gross National Product (GNP).

The increase threatens future healthcare for EU-citizens.

More knowledge is needed about how cost containment can be achieved with maintained or increased quality

WE CARE proposes several healthcare test labs across Europe to increase research on cost-containment.
Acknowledgment
WE CARE is funded by a grant from the European Commission HEALTH-F3-2013-602131.
University of Gothenburg Centre for Person Centred Care (GPCC) is supported by a grant from the Swedish Government.
All authors report support from the EU HEALTH Grant stated above.
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Legend Figure 1:
The relationship between the seven themes identified by WE CARE to be important for costcontainment of future healthcare.
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