Stefan Larsson - The Patient Priority (McGraw-Hill, 2023) ***½

An excellent book on Value-Based Healthcare written by three consultants of the Boston Consulting Group. Many of the ideas they suggest, I agree with, and they can also be found in my own book "De Stem van de Patiënt" (Lannoo, 2025). As the former co-chair of the European Alliance for Value in Health, I can only support the angle of approach to look at healthcare from an outcomes-based model instead of a service-based model. Originally, healthcare consisted of individual physicians offering care to individual patients, using technology that had been approved by the autorities. Today, healthcare has become much more complex, with many more interventions, stakeholders and integration of care services. All the costs were evaluated by the service provided and the cost of the technology. This is absolutely unsustainable, and other forms of payments are needed: bundled payments, capitation or other approaches that look more at the total picture, more collectively and based on the results obtained. 

They also plead for better integration of care, by type of disease or condition, and based on solid registries. 

"In the past, outcomes measures have traditionally been developed by spe­cialty societies and, therefore, tend to focus on specific interventions or procedures. Sometimes, focusing on a specific procedure makes sense. Cataract surgery is probably the best example, because it is the only treat­ment for patients suffering from cataracts. But in most situations, the ideal health outcomes to track for a given condition should reflect the overall care for a patient's medical condition, in which multiple specialties are usu­ally involved and multiple treatment options are available, so clinicians can assess the relative effectiveness of different types of treatment. Procedure­-based registries have played an important role in improving hip and knee arthroplasty, but they can't really address the broader question about the optimal treatment for the underlying disease of osteoarthritis. Or consider a patient suffering from back pain: for that condition, the relevant out­comes measures should be broad enough to assess the comparative impact of, say, physical therapy versus surgery." (p.56)

This approach should look at the entire patient pathway from prevention to end of treatment. Today, care is really a step-by-step approach, with none of the steps seen as being part of a disease continuum. Obviously the reality is different, and patients also live in a world where they are confronted with other problems that does not always make treatment optimal.  

"An approach to care delivery that integrates both clinical interventions along the entire treatment pathway and nonclinical interventions that encourage prevention and address the social and behavioral determinants of health is not only a more effective way to monitor and treat patients, it also allows for better coordination across multiple stakeholders and gives health systems full visibility of the system costs to make informed trade­offs-for example, investing in preventive care to avoid high treatment costs at later points in the care-delivery value chain." (p. 74)

The Netherlands for instance, had a visionary idea, that we can fully support, based on the following four essential points. Whether this has actually been done, I have not been able to verify. 

1. "To reach a consensus among key stakeholders by 2022 on the out­comes to be measured for conditions representing 50% of the total disease burden, both by adapting international standards for use in the Netherlands and by developing new metrics
2. To support shared decision-making on treatment choices between providers and patients, by making health information more under­standable for patients, and· by equipping health professionals with the necessary skills and information to have meaningful conversa­tions about treatment choices with their patients
3. To promote the outcome-based reorganization of care delivery and reimbursement through the sharing of best practices, the devel­opment of more integrated care chains, and the encouragement of more outcome-based contracts between insurers and providers
4. To facilitate better access to relevant and up-to-date outcome information, through the development of a state-of-the-art health informatics infrastructure, with the goal of making it easy for patients to report data, ensuring that data is well-organized and scalable, promoting access for all relevant parties for the purposes of benchmarking and research, and maintaining privacy and security" (p. 216)

Even if I can agree on most of what the authors write, they still cannot capture the patient perspective on things. Their approach is one of change management for the healthcare system, and of course they are self-interested consultants hoping to get clients among governments to help reorganise their healthcare towards better outcomes and more financially sustainable, yet they somehow miss the essence: patients and the patient community by disease are the real decision-makers when it comes to determining key performance indicators for outcomes, and to assess whether the expected results have been achieved. Without a solid and formal integration of the voice of patients in healthcare, it will remain a structure with one blind spot, and a big one: what patients need. Without systematic and robust feedback from the end users, no system can properly function. 

Because of this lack of patient perspective, there is also barely any mention of patient advocacy or patient organisations in their analysis, which is disturbing to say the least. As representatives of the 'lived experience' we can advocate for better adherence, better alignment with the life goals of individuals, helping to capture patient satisfaction data, etc, etc. 

That is what we are advocating for. That is where the low-hanging fruit is to be found.