2019 Global health care outlook Shaping the future 2019 Global health care outlook l Shaping the future

Overview and outlook 3 Global health care sector issues in 2019 7 Creating financial sustainability in an uncertain health economy 7 Using new care delivery models to improve access and affordability 10 Adapting to changing consumer needs, demands, and expectations 16 Investing in digital innovation and transformation 19 Maintaining regulatory compliance and cybersecurity 24 Recruiting, developing, and retaining top talent 28 Appendix 33 Endnotes 35 Contacts 40

2 2019 Global health care outlook l Shaping the future

Overview and outlook

The adage, “What goes up, must come down,” isn’t likely to apply to the global health care sector in 2019. Aging and growing populations, greater prevalence of chronic diseases, exponential advances in innovative, but costly, digital technologies—these and other developments continue to increase health care demand and expenditures.

3 2019 Global health care outlook l Shaping the future

Snapshot: Global health care by the numbers

Global health care spending is projected to increase at an annual rate of 5.4% in 2018–2022, a considerable rise from 2.9% in 2013–2017. This increase reflects the strengthening of the dollar against the euro and other currencies, the expansion of health care coverage in developing markets, the growing care needs of elderly populations, advances in treatments and health technologies, and rising health care labor costs.1

Per-person health care spending is expected to continue to vary widely, ranging from $11,674 in the United States to just $54 in Pakistan in 2022. Efforts to close this gap will be constrained by higher population growth in developing economies.2

Higher per-person spending does not always equate to higher-quality health care. When compared to 10 developed countries, the United States ranks last in overall health care performance, highlighted by per capita spending that is 50% greater than the next country and last place rankings in efficiency, equity, and healthy lives.3

Life expectancy appears to continue to climb. It is projected to increase from 73.5 years in 2018 to 74.4 in 2022—bringing the number of people aged over 65 globally to more than 668 million, or 11.6% of the total global population. Increasing life expectancy and years of productive life is a major achievement for health care, because increased output per worker is associated with increased real GDP per capita. The effect is expected to be most noticeable in Japan, where this share will likely reach almost 29%; in Western Europe it is estimated near 22%. Even some developing countries, such as Argentina, Thailand, and China, are starting to experience similar situations.4

The fight against communicable diseases—through better sanitation, improved living conditions, and wider access to health care—is making notable gains. The number of AIDS-related deaths dropped from 2.3 million in 2005 to an estimated 940,000 in 2017, largely due to the successful rollout of treatment.5 Infections from tuberculosis are falling by around 2% a year.6 The estimated number of malaria deaths worldwide fell to 445,000 in 2016, down from nearly one million in 2000. New vaccines and wider use of treated nets have cut infection and death rates for all mosquito-borne diseases.7

Non-communicable diseases (NCDs)—most prominently, cancer, heart disease, and diabetes—accounted for 71% of the 56.9 million deaths reported worldwide in 2016; that share increases to over 80% in the most developed markets. NCDs’ rise in both developed and developing markets is fueled by urbanization, sedentary lifestyles, changing diets, and rising obesity levels.8

Ambient pollution contributed to 4.2 million deaths worldwide in 2016, with the Western Pacific region among the worst affected.9 In China, the effort to fight pollution is a focus of the government’s health care policy due, in part, to its negative impact on GDP (e.g., decreased worker productivity and the cost burden of disease). One culprit drawing increased attention: diesel-powered vehicles, which are now known to emit more pollution than previously thought.10

4 2019 Global health care outlook l Shaping the future

Health care stakeholders—providers, which requires a philosophical shift in platform interoperability. governments, payers, consumers, and other focus away from a system of sick care, in companies/organizations—struggling to which we treat patients after they fall ill, to It’s expected that health care’s evolution will manage clinical, operational, and financial one of health care,11 which supports well- have far-reaching impacts as new business challenges envision a future in which new being, prevention, and early intervention. models emerge that blur boundaries and business and care delivery models, aided It is unlikely, however, that today’s health drive cross-sector and cross-industry by digital technologies, may help to solve care system and players will be able convergence. The resulting “superclusters” today’s problems and to build a sustainable to make this shift alone. They likely will of public-private providers, payers, and foundation for affordable, accessible, high- need to partner with other traditional market disruptors could then use a smart quality health care. sectors such as employment, housing, health community approach (figure 1) to education, and transportation to address collectively drive innovation, increase access This vision may have a greater probability the social determinants of health, and with and affordability, improve quality, and of becoming a reality if all stakeholders new sectors such as retail, banking, and lower costs through more efficient delivery actively participate in shaping the future— technology giants to improve data and models.

ure 1 haractertc o a art health cout

Appropriate treatments are delivered at the appropriate time, in the appropriate place, for the appropriate patient

Clinicians use technology to more accurately diagnose and treat illness and deliver care

All care delivery stakeholders across the ecosystem effectively and efficiently communicate and use information

The correct individuals do the correct work (e.g., nurses handle patient care, not administrative tasks)

Patients are informed and actively involved in their treatment plan

New, cost-effective delivery models bring health care to places and people that don’t have it

Efficiency improves; waste declines12

Standing at the epicenter of the new health health care delivery model from business- as consumers join other stakeholders care value system will likely be informed and to-consumer (B2C) to consumer-to-business in accessing, analyzing, and sharing empowered consumers—change agents (C2B). In response, stakeholders are information. In addition, disruptive trends and active caretakers of their health who expected to use innovative technologies in health care delivery and mobility may have high expectations of their health care and personalized programs to engage radically alter everything from the site of ecosystem. These consumers will likely with consumers and improve the patient care to who delivers care and how.13 be “pulling” solutions rather than being experience. Data interoperability, security, “pushed” services, flipping the current and ownership should move to the forefront

5 2019 Global health care outlook l Shaping the future

Is there a road map to this future state? Are care system? It’s highly likely that every and diverge. There is, however, a common there directions to guide stakeholders’ steps organization’s journey will be unique; they departure point: Responding to the issues along the path to an accessible, affordable, may be traveling with companions at times impacting the global health care community high-quality, and sustainable health and alone at others; paths may converge in 2019 (figure 2).

Figure 2: Global health care sector issues in 2019

Creating financial Maintaining reulator utaablt in an colace and cberecurt uncertain health economy

Adapting to changing Investing in tal couer ee ea oato a a eectato traorato

Using e care eler Recruiting, developing, to improve oel and retaining to talet access and affordability

This outlook reviews the current state of patients, and other stakeholders; and the global health care sector; explores suggests considerations for them as they trends and issues in 2019 impacting health seek to shape the future of health care. care providers, governments, other payers,

6 2019 Global health care outlook l Shaping the future

Global health care sector issues in 2019

Creating financial sustainability in an uncertain health economy

The emergence of personalized medicine, or niche player—to remain relevant and annual rate of 5.4 percent in 2017–2022, exponential technologies, disruptive financially viable. from USD $7.724 trillion to USD $10.059 competitors, expanded delivery sites, and trillion (figure 3), although cost-containment revamped payment models is injecting Battling health system cost pressures efforts combined with faster economic uncertainty into the global health economy Global health care expenditures continue to growth should maintain the share of GDP and increasing the urgency for organizations escalate, shining a light on health systems’ devoted to health care at around 10.4 to plan when and how to make future need to reduce costs and increase efficiency. percent over the five-year period to 2022.14 moves—as a market leader, fast follower, Spending is projected to increase at an

Figure 3: Health care spending (USD billion), and CAGR 2017 - 2022

1009 Global 2

1 orth erca 09

eter uroe 229 1

22 a utralaa 1

at erca 0

29 le at rca 19

29 rato ecooe 2022 1 2017

Source: The Economic Intelligence Unit, Data Tool accessed on 16 August 2018

7 2019 Global health care outlook l Shaping the future

Similar with recent years, health care appear to be falling short of what is in 2016 and the subsequent creation of spending in 2019 will likely be driven by needed to counter persistent challenges Integrated Sustainability and Transformation the shared factors of aging and growing in accessibility (imbalanced distribution, Partnerships comprising both health and populations, developing market expansion, including a rural-urban divide), affordability social care services, aimed at helping to clinical and technology advances, and (especially for patients with low economic improve care quality and efficiency of rising labor costs. In addition, the trend status), awareness (of lifestyle diseases, risk services, develop new models of care, and toward universal health care is expected to factors, vaccinations), absent or inadequate prioritize prevention and public health.21 continue, with more countries expanding or infrastructure, and skilled human resources. deepening their public health care systems Australian states, for example, appear to Cost pressures aren’t confined to the public to reduce out-of-pocket (OOP) expenses.15 be struggling with increasing public health health care sector. As an example, private Still, the short-term outlook for health care care costs. Australia’s federal government hospitals in India appear to be caught in spending is expected to vary by region/ and state-based treasury departments are a pricing squeeze; as a result, many are country: putting pressure on state-based health emphasizing financial management and systems and public health networks operational efficiency by closely watching •• Population aging, rising wealth, and the (PHNs) to drive innovation that can lead to costs, using technology to become more expansion of China’s health care system sustainable cost-bending. efficient, and testing different channel will likely drive increased spending in that and product mix strategies to maximize country, as will the rollout of a new health The UK’s National Health Service (NHS) per-bed metrics. In Australia, a drop in insurance program in India.16 is illustrative of the public health system the number of people holding private •• A recovery in global commodity prices cost and funding conundrum: For health insurance is challenging private appears to be helping to repair public example, in 2010–2011, just 5 percent of hospitals and insurers already dealing finances and boost health care spending NHS providers in England overspent their with the systemic cost increases. The in many resource-dependent countries; annual budgets. By 2015–2016, two-thirds decline in private insurance policies is notably, in the Middle East, Latin America, of trusts (66 percent) were in deficit as a especially prevalent among younger, and the former Soviet Union.17 slowdown in NHS funding took its toll. The healthier individuals who, in response to 2015 Spending Review provided additional increasing out-of-pocket expenses and •• The United Kingdom’s economy and health funding for the NHS, which contributed to lack of transparency in product coverage, care spending could be dampened by its a fall in deficits, but 44 percent of trusts are choosing to invest their income in decision to leave the European Union (EU) still overspent their budgets in 2017–2018. well-being: sports, recreational activities, in 2019. Other EU health economies also The NHS provider sector in total ended nutritional supplements and the like. may be negatively affected by “Brexit,” as the year with a deficit of £960 million.20 Looking ahead, Australia is expected to see well as the long-running migration crisis.18 The situation is exacerbated by the UK’s consolidation in the private hospital sector •• Tax reform and health policy changes continuing and unrelenting increase in to retain scale and drive efficiencies, along in the United States will likely continue demand for hospital care despite initiatives with potential purchases by Asian hospital to undercut the Affordable Care Act’s to reduce over-reliance on hospitals. groups. Private insurers, meanwhile, are (ACA) programs to expand health care Concurrently, there is an increase in looking to offset decreasing policyholder access and affordability. The end of the the number of people unable to get an numbers with claims reduction programs individual mandate in January 2019 should appointment with a general practitioner with a focus on prevention and early allow companies to offer their employees (GP) and a lack of community and district intervention, organizational redesign, and cheaper, less comprehensive policies. services that limits NHS capacity to respond new revenue streams (e.g., stepping into the While these changes will expand choice, to the growing demand. To address these provider space, running dental practices they are likely to reduce coverage.19 challenges, England has embarked on that aren’t covered by public insurance, longer-term transformational changes with buying optometry clinics and home health Despite funding increases in numerous the creation of 44 geographically focused care services providers). countries, public health systems’ budgets NHS Sustainable Transformation Plans

8 2019 Global health care outlook l Shaping the future

Competing with disruptive market •• Verily is also looking for opportunities to (NHC), which will enable Luye to cater entrants enter the health insurance market through to the rising demand for cardiovascular Health care profits have been eroding partnerships; initially, in the population treatment.32 Fullerton Health China became over time and, in parallel, new entrants health market. Alphabet planned to invest a major shareholder in Shanghai Redleaf are threatening to redefine fundamental USD $375 million in 2018 in the health International Women’s & Children’s Hospital, aspects of the health care business. The insurance start-up, Oscar Health.28 its first investment in the specialty hospital health technology sector is expected to sector.33 Ramsay Générale de Santé, •• Philips’ “Connected Care Solutions” is an reach USD $280.25 billion by 2021, at a the largest operator of private hospitals intelligent health care service that collects CAGR of 15.9 percent between 2016 and in France, announced in July 2018 its patient data (generally related to chronic 2021.22 Among initiatives by top technology acquisition of Capio AB, a Sweden-based diseases) and allows providers to monitor companies to disrupt the health care sector: health care provider. The combined group and deliver round-the-clock solutions by would become a leading pan-European •• Apple23 is working with startup Health linking patient data with hospitals.29 private health care services operator Gorilla to add diagnostic data to the spanning six countries.34 iPhone, including blood work, by Pursuing mergers, acquisitions, and integrating with hospitals, lab-testing partnering The search for alternative revenue sources companies, and imaging centers. The Some health care organizations looking is propelling vertical industry integration offering is primarily geared to physicians to optimize financial and operational as well. Grab, the leading ride-hailing app and serves as a marketplace for them performance continue to turn to mergers, in Southeast Asia, recently ventured into to place orders and share medical acquisitions, and partnering to add health care by partnering with Ping An Good records. But it also has a free offering for capabilities and build scale. While horizontal Doctor, an e-health platform in China, aiming patients that promises to gather medical integration in the United States has to deliver transformative online health information in 10 minutes. The goal is somewhat slowed—government regulators care services in Southeast Asia. The duo to give iPhone users the tools to review, with a “big-is-big-enough” mind-set have will provide an array of integrated medical store, and share their medical information, denied some mergers—activity is brisk in services, such as AI-assisted online medical including lab results, allergy lists, and other regions of the world. For example, consultations, medicine delivery, and more.24 Malaysia’s IHH Healthcare Berhad acquired appointment bookings through an online India’s second-largest provider, Fortis •• Alphabet’s Google unit has acquired platform.35 Similarly, Indonesian ride-hailing Healthcare, which operates a network of application program interface (API) giant Go-Jek announced the integration of 34 hospitals. The four-month-long bidding management company Apigee to help its medicine delivery service Go-Med into war saw interest from both domestic and it create data pipes that will enhance the HaloDoc app, a platform that enables international suitors.30 Additional deals interoperability among hospitals, online consultation with doctors.36 have included Life Healthcare, one of South physicians, and patients.25 The company Africa’s largest private health care providers, is also applying artificial intelligence (AI) The United States is seeing mergers selling its 49.7 percent stake in Max to tackle disease, from monitoring, to between health care insurance companies Healthcare Institute Limited to KKR.31 detection, to lifestyle management.26 and pharmacy chains—especially those with retail clinics. The combined company •• Alphabet’s health care unit, Verily, is In other deals, Singapore-based Luye could provide direct care to the insurers’ working on detecting diabetic retinopathy Medical Group, which owns 53 health members and offer its workers one-stop via a partnership with Nikon’s subsidiary care facilities across 26 cities in Singapore, shopping for health insurance. In one 2018 Optos, which makes the machines for Australia, South Korea, and China, example, health insurer giant Cigna agreed retinal imaging tests and eye disease completed a majority equity investment to acquire Express Scripts, the nation’s detection.27 in Singapore’s Novena Heart Centre

9 2019 Global health care outlook l Shaping the future

largest pharmacy benefit manager (PBM), care; community- and home-based care. align their cost structure and care models for $52 billion.37 In India, for instance, private clinics and with reimbursement trends and payment start-ups are targeting select clientele by models, respectively. Acquisitions by the world’s largest e-retailers offering high-end diagnostics, maternity have the potential to dramatically disrupt care, oncology care, senior day care, and Health plans that focus on affordability and health care product and service delivery: other specialties. The UK’s Moorfields Eye create differentiation through innovation Amazon’s 2018 purchase of online US Hospital is a specialist NHS eye hospital (i.e., member-focused digital service pharmacy PillPack, which lets users buy and a center of excellence for ophthalmic offerings) could reduce the cost of care medications in pre-made doses,38 is being research and education. Moorfields’ 2,300 provided to members and maintain strong echoed by Alibaba Group’s investments staff treat people at over 30 sites in and margins. in pharmaceutical companies. In August around London.41 2018, subsidiary Alibaba Health Information Providers and payers that embrace new Technology acquired a stake in local Stakeholder considerations business, care delivery, and risk models pharmaceutical company Guizhou Ensure Shrinking margins and rising costs are could offset the disruptive potential of Chain Pharmacy Company Limited. driving public and private health systems powerful market entrants and emerge as Ali Health engages in pharmaceutical to use technology innovations, M&A, leaders in the new ecosystem of affordable e-commerce, intelligent medicine, and and other partnering arrangements to health care solutions. One suggestion is to product tracking platform businesses in improve operational efficiencies and learn from industries outside of health care, China, operating in the B2C pharmacy reduce expenses; however, doing so can be where we see technological and business business. Guizhou Ensure Chain, along with complicated by price controls, misaligned process innovations that are applicable in its subsidiaries, is principally engaged in incentives, and disruptive market entrants. a health care setting. For example, the use pharmaceutical retail chain business.39 Yet there are ways to shape a more positive of robotic process automation to improve fiscal future. claims time without overtime or increased We also see continued convergence staffing is growing. Also, some offshore between the health care and life sciences Governments that leverage private sector vendors handling health care providers’ sectors (often in cross-border deals) as strengths in cost-efficient operations, revenue cycle processes are replacing both seek new business models and through public-private partnerships and full-time equivalent (FTEs) employees with revenue sources. For example, the purchase other collaborations, could help bolster bots.42 While some leaders may be reluctant of NxStage Medical, Inc., by Germany’s underfunded and/or underperforming to change the status quo, assessing and Fresenius Medical Care, the world’s largest public health systems. Also, positioning taking risks will be an important part of provider of dialysis products and services, requested investments in prevention and shaping a more sustainable global health establishes Fresenius’s presence in the well-being as providing benefits in terms of care system. US critical care space and positions the economically active citizens and improved company as a global leader in home GDP may register more favorably with Using new care delivery models to dialysis.40 These transactions reflect government treasury departments. improve access and affordability the increasingly blurred lines between traditionally separate spheres of the rapidly Health care providers that stress rigorous Focusing on value- and outcomes-based changing health care ecosystem. financial management, efficient operational reimbursement performance, outcomes-based care, and Health care systems will likely need to Some organizations are sidestepping the innovative solutions development (e.g., innovate and embrace new business, care “bigger-is-better” path to sustainability in moving certain procedures to outpatient delivery, and risk models to potentially favor of single-specialty, niche areas: centers settings) could improve care provision, shape affordable, high-quality health of excellence; low-cost/high-quality elective reduce costs, counter declining margins, and care solutions for the future. And while

10 2019 Global health care outlook l Shaping the future

change is never easy, a very important one •• The advanced alternative payment first year that other clinicians will receive is already underway: the transition from model (AAPM) for Qualifying Participants QP incentive payments based on their volume-based/fee-for-service (FFS) models (QPs), which allows clinicians who have participation in AAPMs. Additionally, for to value-based care (VBC). Emerging VBC significant percentages of their practices in the first time, performance information reimbursement models are edging out FFS risk-bearing, coordinated care models to for clinicians participating in MIPS will be arrangements and creating a new paradigm receive temporary financial bonuses and publicly available via the Medicare Physician in which health care services are delivered higher payment updates in the long term. Compare website.46 by a coordinated care community sharing in the responsibility—and risk—of outcomes MIPS is budget-neutral; it produces savings Across Europe there is growing recognition and costs.43 in comparison to the baseline through of the need to adopt a more value-based minimal annual increases in the standard approach to health care; although adoption Building an outcomes-based financial rates under the Medicare Physician Fee of VBC appears to be currently low, it model and data infrastructure to maximize Schedule through 2026. AAPMs are more seems to be increasing.47 Likewise, local VBC reimbursement pathways will likely wide-reaching and may involve both governments in Asia appear to be shifting be fundamental to many health systems’ commercial and government payers, with their focus from volume-based to value- sustainable growth. It’s expected that one potential to generate significant savings based care, although uptake is still slow.48 key to prospering in this volume-to-value both to Medicare and to the American Australia’s public health system appears shift will be business integration and data health system at large. The AAPM’s risk- to be embracing the idea of a value- and aggregation—both inside and outside of bearing coordinated care models are outcomes-based payment model but the an organization, and across sectors and largely products of the Accountable Care country is likely a couple of years away from models of care. Transformative actions Organization (ACO) movement, where getting real traction; efforts to date have could include adopting a coordinated care providers that exceed quality and cost been confined to pilots and discrete groups model, improving clinician engagement benchmarks receive financial incentives of patients. One example is the HealthLinks and alignment, and building the technology such as retaining a portion of any savings or chronic care initiative in Victoria, which aims infrastructure for sophisticated data receiving quality bonuses. In order to qualify to improve care for patients at high risk of analytics and financial modeling. While the as an AAPM, an ACO needs to assume risk, multiple unplanned hospital admissions. level of investment is likely to be substantial, meaning that failure to meet benchmarks HealthLinks is testing whether a flexible the market shift toward VBC is anticipated to results in penalties or losses. Recent funding model can remove some of the present unprecedented financial and clinical changes mean that a greater percentage barriers that inhibit effective and integrated opportunities.44 of ACOs will be required to take on risk models of care, and promote innovative over the next two years, and therefore models that produce better outcomes for The shift to value-based care appears to be qualify as AAPMs under MACRA. While little patients at no additional cost to the public most active in the United States, where a information is currently available on AAPMs’ health system.49 visible example is the Medicare Access and specific savings to date, ACOs in general CHIP Reauthorization Act of 2015 (MACRA), were found to have saved Medicare $314 A successful value-based payments which created two new Medicare Part B million in 2017.45 MACRA’s incentives for strategy likely requires payer/provider payment tracks for clinicians participating in greater ACO participation may accelerate collaboration, sharing of patients’ health its Quality Payment Program (QPP): this trend across all US payers. data, and IT and analytical support. Given the interdependencies of public and •• The merit-based incentive payment It’s expected that 2019 will mark an private sector stakeholders operating in system (MIPS), which provides positive important milestone for MACRA: It is the a VBC ecosystem, it is logical to expect or negative payment adjustments for first year that payment adjustments under that coming years will likely see new and clinicians whose practices are more closely MIPS will be applied to Medicare Part B novel public-private partnership models tied to FFS reimbursement; and payments to participating clinicians and the emerge that promote risk-sharing, allow

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for blended financing of critical health care infrastructures and programs, and maintain Social determinants of health include factors system sustainability.50 like socioeconomic status, education,

Shifting health focus neighborhood and physical environment, Aging populations and the rise of non- communicable diseases are driving an employment, and social support networks, industry shift away from curing disease in the short term toward preventing and as well as access to health care, including managing disease and promoting overall well-being in the long term. Emphasizing income, education, and housing conditions. these proactive measures, generally Addressing social determinants of health is grouped under the umbrella of population health, will likely require a corresponding important for improving health and reducing shift in the way governments, providers, payers, and other community partners longstanding disparities in health and health interact: Instead of operating in silos that create structural and cultural barriers care that are often rooted in social and to care, they should work together to 54 coordinate care and services for the most economic disadvantages. vulnerable people in the population. This Coordinating efforts across government, can make it difficult to coordinate efforts, may only be achieved, however, if there is societal, and health care institutions integrate data, and assess shared impact. a supportive financial incentive structure and programs can be essential to and rebalanced professional power across •• Although investments in one sector can solving problems arising from the social caregiving groups. affect outcomes and generate cost savings determinants of health. This can be in another, individual sectors generally challenging, however, for the following An important part of this approach is consider only their own investments and reasons: addressing the social determinants of benefits. health—the conditions in which people •• There can be inadequate leadership •• The multiple sectors that affect are born, grow, live, work, and age— capacity and a lack of sustainable funding health—often driven by a variety of because they often have a greater impact mechanisms for health improvement stakeholder and interest groups—may on health outcomes than does health efforts. Current funding processes often have different cultures, values, and care.51 Health inequalities resulting from fragment the distribution of resources, vocabularies and generally lack experience negative socioeconomic circumstances discourage the coordination of funds, and working together. This can likely impede have a substantial economic impact, hitting can potentially limit the ability to jointly partnership and collaboration.55 labor productivity and accounting for an address common risk and protective estimated 20 percent of European health factors. care costs (€177bn).52 They also take a social •• Health care, public health, social services, toll, having a cumulative effect throughout and other sectors typically function and a person’s life. Unemployment and financial are funded in silos, with different funding disadvantages pass between generations, requirements and often-incompatible data as vulnerable children become vulnerable collection and information systems. This adults.53

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Moving health care outside hospital settings. Many surgeries and medical and and robotic surgery—and new anesthesia walls diagnostic procedures that once required techniques that reduce complications and Clinical innovations, patient preferences, and an inpatient stay can now be performed allow patients to return home sooner.56 financial incentives are prompting hospitals safely in an outpatient setting, thanks to Figure 4 describes the primary types of and health systems to move certain improvements including minimally invasive hospital-based outpatient facilities.57 inpatient services to lower-acuity/outpatient surgical procedures—such as laparoscopy

Figure 4: Types of outpatient care

erec eartet a erce aclte Also known as emergency rooms (ERs). Facilities where imaging services such as -rays, They provide a broad range of emergency MRIs, CT scans, and ultrasounds are performed. services to higher-acuity patients.

ecale outatet clc rar care clc Facilities for providing care in specialty These are settings where patients are areas such as cardiology and urology, seen by their primary care physicians among others. (PCPs).

bulator urer ceter etal clc Facilities that specialize in same-day Also known as convenient care clinics, discharge of patients post-surgery. these are walk-in clinics offering ASCs can be either hospital-associated preventive health service and treatment or freestanding. for uncomplicated illnesses.

ret care ceter out health clc Facilities that provide medical services to Typically offer primary care services to patients patients needing immediate care for certain with limited access to health care, including lower-acuity illnesses and injuries that do not homeless individuals or migrants, and patients require a trip to an emergency department. with low income or no health insurance.

Source: Deloitte Center for Health Solutions research.

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Patients appear to be embracing treatment substitute, for care based on the needs of providers’ understanding of patients’ in outpatient facilities, as they tend to the patient population, capabilities of the health and medical data cost less—and be more convenient— organization, and availability of resources. •• Care management process to improve than inpatient services. Health plans and The overall goal is to improve access to patients’ understanding of and government program payment policies are critical services and reduce cost constraints engagement with their treatment plans also supportive of lower-cost outpatient across the continuum of care.60 Common surgical facilities58 and community- and applications of virtual health include: •• Patient adherence to improve medication home-based care. Factors critical to the adherence, health tracking, and patient •• Synchronous care to improve patients’ future growth of these care delivery options accountability ease of access to providers are scale and responsivity: Scale often helps •• Care coordination to improve payer/ providers secure a lower cost-per-activity/ •• Physician-to-physician communication to provider relationships61 service from other partners. Responsivity improve patient care through information builds patients’ confidence in the quality sharing Several key factors appear to be elevating and timeliness of the services they receive in •• Chronic disease management to improve consumer and provider interest in outpatient settings. monitoring and alerts for chronic disease implementing virtual health programs: patients expected physician shortages, increased Investing in virtual health/telehealth patient demand, and the evolving policy could expand outpatient services while also •• Virtual social work to improve landscape. One big game-changer: helping hospitals bend the cost curve and communication and care for underserved Internet access and connectivity, which has boost revenue.59 Virtual health is the use of populations increased 1,066 percent since 2000.62 As teleconferencing, mobile apps, and other •• Telehealth care to improve patient of June 30, 2018, there were 4,208,571,287 digital technologies to enable continuous, monitoring (e.g., eICU, telepsychology, Internet users around the globe—55.1 connected health care. Virtual health goes telestroke) percent of the total population.63 Asia beyond simply enabling video visits; it can dominates the world’s regions in Internet act as a complement, or even a complete •• Remote patient monitoring to improve usage (figure 5).

Figure 5:

teret uer the orl b reo ue 201

uroe at ercaarbbea rca orth erca a le at ceaautrala 16.8 % 10.4 % 11.0 % 8.2 % 49.0 % 3.9 % 0.7 %

Source: Internet World Stats - https://www.internetworldstats.com/stats.htm.

14 2019 Global health care outlook l Shaping the future

Also spurring provider uptake of virtual In China, remote registration appears to Stakeholder considerations health is continued growth in advanced be the only telehealth element that is fully It appears that it’s time to hit “refresh” technologies. For example, an AI-powered developed. on health care financing and operational nurse avatar by Sensely is being piloted at models if we intend for the system to be Mayo Clinic. It interacts with patients by The Deloitte 2018 Surveys of US Health sustainable for future generations. Clinging asking questions and collecting data from Care Consumers and Physicians have found to fee-for-service as the basis for provider wearables, sensors, and biometric devices; that both stakeholder groups agree on the reimbursement could burn a deep hole in assesses the symptoms and medical benefits of virtual health. Consumers point any country’s budget, as the cumulative history; and analyzes the combined data to convenience and access (64 percent) as costs of managing elderly and chronic for the physician to consider before the important benefits.69 Physicians agree that disease patients are simply too high for in-person patient examination.64 In South virtual care supports the goals of patient- individuals, governments, and payers to Australia, Clevertar’s intelligent virtual centricity. The top three benefits from bear. Similarly, continuing to use hospital agents (IVAs) offer personalized health care physicians’ perspective are improved patient facilities to conduct low-risk, routine coaching and support for patients with type access to care (66 percent); improved surgeries drives up costs for payers and 2 diabetes and individuals suffering from patient satisfaction (52 percent); and staying patients. mild to moderate depression and anxiety.65 connected with patients and their caregivers Consumers using the Helfie app can take (45 percent).70 As they look beyond hospital walls to shape a picture of any spot, mole, or mark on a more cost-efficient future, public and their skin and get it checked by a doctor Despite seeing eye to eye on the benefits, private health systems—especially those instantly.66 Singapore AI start-up KroniKare consumers and physicians diverge in their that receive a large portion of their revenue has developed a mobile app that assesses intent to use virtual care. While only 23 from value-based contracts—will likely chronic wounds and presents a preliminary percent of consumers have had video need to expand outpatient services. Doing assessment to nurses or other health care visits, 57 percent of those who have not so may require investments in facilities, workers.67 used them yet are willing to try them in the staff, and technology to grow capacity and future. The interest from physicians is much infrastructure for outpatient services. A Importantly, virtual health has an ability lower: 14 percent of physicians have video good place to start is partnering with or to expand access to care for patients in visit capability today and only 18 percent acquiring health care organizations and rural and underserved areas that may of the rest plan to add this capability in the physician networks that already have the lack medical facilities. Telehealth, often next year or two.71 Lack of reimbursement, capacity (e.g., ambulatory surgery centers, considered the heart of the “smart hospital” complex licensing requirements,72 and outpatient clinics, and retail centers) and model, has five main elements: remote the high cost of the technologies73 have people to support care in outpatient registration, remote diagnosis, remote contributed to slow adoption. Reliability and settings and grow the volume of services consultation, remote medical treatment, and security are also issues: The survey found performed there.75 Upgrading health telecare. Regions including the Americas, that physicians are concerned about medical information technology (HIT) also may Europe, and Africa are implementing errors (36 percent) and data security and enhance outpatient capabilities: Health telehealth backed by technologies like AI privacy (33 percent).74 An implication is that systems can use case management, and analytics—in the United States, for health systems likely will need to work on supported by analytics, to help decide which example, 3,000 rural sites are connected overcoming physician-related barriers as a care setting is the most effective, safe, and to 200 telehealth networks for specialty strategy for wider adoption. Developing an efficient for a patient’s procedure. consultations, continuing medical education appropriate infrastructure and operating (CME), and other services.68 Meanwhile, the model along with the technology is likely to Adopting a whole-system, whole-life Middle East and parts of Asia appear to still be a key differentiator. approach to funding and delivering health be in the initial stages of implementing basic care likely increases the potential to reduce tele-consulting for health care accessibility. costs, boost quality, and improve access and

15 2019 Global health care outlook l Shaping the future

affordability—if all members of the health consumers are expecting solutions that are As patients care ecosystem unite behind the common coordinated, convenient, customized, and goal of long-term sustainability. Each accessible78—and they are making their increasingly “shop” stakeholder group has an important role to opinions known. Numerous factors are play in this effort: contributing to this shift: for health care •• Governments—Position preventive •• The increasing prevalence of chronic services, enhancing health care, wellness, and social care diseases that require long-term patient- funding as an essential driver for broader provider engagement and management patient experience economic growth; leverage public- and •• Financial scrutiny due to high-deductible private-sector strengths in cost-efficient is regarded insurance plans and other cost-sharing partnerships and programs that could models that push more costs onto the reduce health care inequalities. as a potential patient •• Providers—Complete the transition to driver of hospital •• An explosion of digital tools to inform, value- and outcomes-based business educate, and empower patients with the models; also, move certain services performance, since ability to actively manage their well-being outside hospital walls using less-costly and their costs it may strengthen care delivery options. •• Customers’ product and service •• Payers—Make effective use of customer loyalty, experiences in other industries, leading to increasingly available population health a rise in classic consumerism data to measure the return on investment build reputation and offered by interventions and suggest •• Emerging competition from consumer- brand, and boost process improvements that could centric, technology-savvy companies that potentially lower costs of insurance bring a nontraditional mind-set to health utilization of hospital coverage. care delivery. services through •• Patients—Improve health literacy and As patients’ role and influence in their health actively contribute to the design of local care increase, providers and payers must increased referrals and national programs that support likely shift accordingly and take advantage prevention, care management, and of emerging opportunities to establish to family and friends. wellness. more direct, personal relationships with Deloitte research •• All stakeholders—Embrace analytics the consumer.79 Digital technologies can and digital technology to provide more improve engagement, enable convenience- shows that good efficient and cost-effective health care.76 driven access to care, and nurture a two-way relationship for the long term. Organizations patient experience Adapting to changing consumer needs, that understand and act on how consumers demands, and expectations would like to use digital health, telehealth, is associated with wearable monitoring and fitness devices, higher hospital Providing consumer-centric care online resources, social media, and other Not only are regulatory policy and payment technologies will likely be well-positioned profitability.83 reform driving some of the transformation to develop patient engagement strategies to value- and outcomes-based health that help individuals make informed care, patients and caregivers appear to be health care decisions.80 These engagement demanding change.77 Dissatisfied with poor strategies, in turn, could help health care service and lack of transparency around organizations improve effectiveness, price, quality, and safety, today’s health care efficiency, and value in service delivery;

16 2019 Global health care outlook l Shaping the future

excel on quality measures that reflect the •• Apple85 announced it is entering the which coordination between stakeholders, patient experience; and outperform their personal health record (PHR) space with therapy, and care is limited or ad hoc, to competition by attracting and retaining Apple Health,86 a new platform that will a proactive model in which engagement actively engaged customers. interface with electronic health records tools and support bolster both patients and (EHRs) at 12 US hospitals.87 health care providers.91 Effective patient A challenge is developing engagement engagement could improve self-care •• Amazon joined with J.P. Morgan Chase strategies, products, and services that could and help achieve better outcomes; many and Berkshire Hathaway to establish bridge gaps between providers, payers, and health care stakeholders are investing in an independent, not-for-profit health patients and work across myriad consumer solutions to address this issue. In addition, care company for their one million US segments.81 In some cases, consumers some researchers are trying to understand employees. The trio’s goal is to improve are taking matters into their own hands what motivates individual patients and are health care services and cost efficiency for by subscribing to tools such as b.well, a working on developing tailored solutions their employees. With these corporations personal health app that allows individuals that incorporate individualized goals.92 For being closely monitored in the market, to safely and securely store, manage, and example, women typically are the drivers their success could act as a model that share their medical records and family of health care spending—not only for their other businesses can embrace.88 health history in one place; view financial own health but for that of their spouses, information about their benefit plan, co- •• Walmart signed a deal with Anthem, one children, and aging parents. Yet most pays, deductibles, and prescription costs; of the United States’ largest insurers, to traditional engagement practices have not integrate and sync wearables and other entice more Medicare enrollees to buy been designed with women in mind. self-reported data to track sleep, fitness, over-the-counter medications and health nutrition, and more; and take a personalized supplies at its stores.89 Even with a wealth of new digital tools health assessment and use genomic and buy-in from governments, providers, •• Amazon rolled out a line of private label screening to learn how to make healthy and payers, establishing and sustaining over-the-counter medicines, the Basic decisions.82 consumer relationships remain a challenge. Care line, and is building a business Among hurdles to overcome: providers selling a wide array of medical supplies to Adding another wrinkle to patient and payers will need to boost the currently doctors, dentists, and hospitals.90 engagement—and introducing a major low levels of health literacy and find more disruptor into the health care value chain— effective ways to motivate or “nudge” Beyond guiding health care purchases, is the well-funded market entry of non- consumers to take ownership of their patient engagement strategies may traditional companies from the consumer, health (see sidebar, next page). Unlike many positively influence patient behavior, retail, and technology sectors, as well as employer-provided health plans, the current one of the key components of disease increased activity in the retail pharmacy US Medicare and Medicaid health systems, management amid an increasing prevalence space.84 The rise of these alternatives for example, have no financial penalty for of chronic conditions. There is emerging to traditional providers and payers was consumers who make lifestyle choices that support for moving away from a reactive particularly notable in 2018: negatively impact their health (e.g., smoking, approach to chronic care management, in overeating, excessive alcohol consumption).

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“Nudging” toward better health93

No matter how effective a medication, Sometimes this engagement requires a team embedded within a health system. protective a vaccine, or beneficial a little “nudge,” a change in the way choices Led by Dr. Mitesh Patel, professor of lifestyle modification, clinicians must are presented or information is framed Medicine and Health Care Management at recommend a treatment and patients that alters people’s behavior in a the Perelman School of Medicine at the must follow through on it to achieve predictable way without restricting choice. University of Pennsylvania, the Nudge Unit desired health improvements. But both For example, small changes within an EHR uses behavioral economics and traditional and precision medicine have a can lead to significant differences in the psychology to design and test approaches “last mile problem” involving patient way clinicians order tests and treatments. to steer medical decision-making and behavior change. The annual cost of Similarly, social networks can give subtle behaviors toward higher-value and medication nonadherence in the United nudges that influence how individuals eat improved patient outcomes.95 Among the States is estimated at more than $250 and exercise. Nudge Unit’s projects: billion, and most post-surgical hospital readmissions are due to patient The Penn Medicine Nudge Unit, created in nonadherence to discharge protocols.94 2016, is the world’s first behavioral design

able choce Gue choce throuh cha eault

Prompting clinicians to make an Changing health system-wide active choice in the EHR led to a EHR prescription default settings 0 creae orer creae eerc recrb influenza vaccination, rate ro to 9 colonoscopy, and mammography

Gue choce throuh cete rae orato

Framing financial incentives Displaying prices for inpatient as a loss creae hcal laboratory tests acte actt oal acheeet clca behaor differently b 0 among overweight based on how they were and obese adults targeted and framed in the EHR

Source: Penn Medicine Nudge Unit website, http://nudgeunit.upenn.edu/about.

Effective nudge projects need buy-in. The design also needs to be scalable to a Physicians want to have autonomy over large population, not just a handful of how they practice medicine, so they patients; that calls for top health system should be part of the process and have leadership at the table, as well as the IT input on the design of the intervention. team.

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Stakeholder considerations helps consumers compare cost and quality As health care becomes more “shoppable” information and enables them to make Digital’s potential and consumers increasingly pay a larger confident decisions about health care in a percentage of their care with their own manner that more closely mimics alternative in “heart of the money, enhancing patient experience is purchasing and customer service models business” operations regarded as a potential driver of hospital like retail. Technology that lives out performance. Hospitals’ reimbursements front—where patients, members, are increasingly tied to quality performance Given the new emphasis on patient and customers can see it—can help metrics that capture patient experience as experience as a core element of care quality a health care organization shine. But well as clinical outcomes, and many public and value, health systems should consider the technology at the core—which and private payers have begun to recognize investing in the tools and technologies to most people never see—makes an patient experience as a core element of better engage patients and enhance patient organization work. Back-office 96 quality. experience. Also important is delivering systems, and the quality of their educational insights to inform patient connections with front-end Being patient-centered and taking steps decision-making and behaviors. Possible enterprise functions, are the critical to engage patients in their own health solutions include medical information and infrastructure that make pricing, care is not simple, but it is seen as an pharmacovigilance, nursing educational product availability, logistics, quality, 97 industry imperative. Organizations should support, and between-visit care. financials, and other “heart of the understand how consumer behaviors business” information available and expectations are transforming care Investing in digital innovation and where it is needed. Although health delivery and adopt a more consumer-driven, transformation care organizations are approaching retail mind-set and approach—with a the digital mandate from numerous focus on greater convenience, service, and “Being digital” angles, one issue remains support. Again, women use their family and Major advances in wireless technology, consistently important: harnessing social networks to recommend services miniaturization, and computing power are emerging technologies to enable and physicians, yet health systems don’t fueling an exponential increase in the pace core systems and back-office routinely take this into consideration when and scale with which digital health care processes to reinvent how daily 98 planning their engagement strategies. innovations are emerging and impacting work gets done.99 Some provider both clinical and business operations (see organizations are already taking Both providers and payers may need sidebar). These advances are also driving an steps toward using machine learning to re-orient themselves around greater increase in the expectations of consumers and robotic process automation transparency—of costs, quality, processes, that “going digital” is not enough—“being (RPA), cloud-based and services. Organizations also should digital” appears to be the new necessity for software-as-a-service (SaaS) more effectively communicate the value all health care organizations. offerings, and predictive tools to of products and services in a way that improve two primary core functions: revenue cycle and supply chain.100

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Digital innovations such as blockchain, •• The United Kingdom recently announced •• Patient-centered health care enabled by cloud-based computing, virtual health, AI a £37.5 million investment in Digital e-health solutions is on top of the agenda and robotics, digital reality, the Internet Innovation Hubs to tackle Britain’s biggest within hospitals and care organizations of Medical Things (IoMT), and others are health challenges.103 In other digital in the Netherlands. The health system’s helping reshape the future by making health developments, the country is seeing struggle, however, is to get beyond pilots care delivery more efficient and more increasing uptake of the disrupter Babylon and move to mainstream adoption. accessible. Already, increased data access Health as a way of accessing primary care; •• Some company human resources and data sharing via digital solutions are new entrants are entering the EHR market, (HR) departments in Brazil are using improving personalization, self-service, potentially driving down the overall costs gamification to improve employees’ and patient experience. And more benefits of implementations; and there are pockets engagement in wellness and chronic care may be just over the horizon: Blockchain, of activity in automated AI-assisted programs. for example, has the potential to enhance diagnostics, telehealth, and consolidated collaboration, trust, interoperability, health records. •• India’s health system is seeing a lot of traceability, and auditability across a range ideating and cutting-edge, small-scale •• In 2017, China’s central government of functions such as clinical trials, supply pilot programs around mobile health issued the 13th Five Year National Science chain management, financial transactions, (m-health), telemedicine, and IoMT, and Technology Innovation Plan, which credentialing, and claims processing. The although few are being taken to scale. aims to develop technologies for precision shift from blockchain to blockchains—to Numerous public and private hospitals medicine, integrate them into a multi- networks of networks—is particularly are moving to online patient registration level knowledge database, and create a compelling in life sciences and health care, and service delivery systems, and digital national platform to share biomedical where the distinct sectors work together in marketing is becoming more common via big data.104 Over time, with the support one broadly interdependent ecosystem.101 mobile apps for appointment booking, of evidence-based technologies, patients Industry adoption of blockchain is still in its paying online, downloading test reports, who are about to receive or are under infancy, but in a Deloitte survey, the number sharing health tips, and more. treatment will benefit from better quality of life sciences and health care organizations and personalized care. that said they planned to deploy blockchain The list of digital technologies that can in 2017 (35 percent) outpaced similar •• A new law in Japan is expected to help health care providers, payers, and outlooks from other industries.102 significantly increase shared use of governments achieve the triple aim— Electronic Medical Records (EMR) improving care, improving health, and Health systems around the world are data. Almost all hospitals in Japan have reducing spending—continues to expand investing in digital technologies with varying EMRs; the problem is that each hospital and evolve. Let’s take a closer look at three degrees of enthusiasm and success: implements slightly different systems and, of these innovations: AI and robotics, digital therefore, the data is not designed to be reality, and IoMT. •• Australia is rolling out My Health Record, aggregated at the national level and not which links patient data in a personalized optimally used for improving the national health record (PHR) across different parts health system. In addition, hospital EMRs of the health care value chain. (Patients should be linked to primary care data sets can opt-out of participating.) to provide a true understanding of patient pathways.

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Spotlight on digital health innovations AliveCor, maker of the KardiaMobile electrocardiogram monitor for iPhone and the KardiaBand EKG recorder AI and robotics—Artificial intelligence, 109 the theory and development of computer for the Apple Watch, is gathering data from its devices systems able to perform tasks that normally that could someday feed a machine-learning system to require human intelligence, is anticipated to transform health care by performing clinical help physicians spot disease. In one potential application, and business tasks currently performed by a “bloodless blood test” would look at a subtle shift in humans with greater speed and accuracy, and by using fewer resources.105 the EKG that’s characteristic of a potential potassium blood-level elevation, which the AI is uniquely skilled at AI can provide decision support and practitioner assistance for tasks such identifying. Measuring this marker in real time, from the as diagnosing patients and spotting convenience of a phone or smartwatch, could transform disease outbreaks earlier; accelerating the development of new drugs and devices;106 how clinicians treat people after a heart attack or while on and streamlining middle- and back-office certain medications.110 functions such as making physician referrals, coding patient pathways, and approving claims.107 An example of not replace them, allowing highly trained The cost of these technologies remains AI-assisted workflow management is resources to focus on more valuable, a challenge in some applications, such DeloitteASSIST, a patient communication patient-facing activities.111 For instance, as surgery, and it is unclear if leveraging solution that combines the capabilities robotics could improve drug compounding robotics will improve efficiencies and of speech recognition, natural language preparation, decontaminate and sterilize outcomes enough to justify the additional processing, and AI to enable patients to medical equipment, and reallocate cost.112 request assistance without the need to personnel resources to more high-value press a button. Simply by speaking their areas (e.g., allow nurses to spend more AI and robotics applications are still at request, nurses are alerted to their need, time directly with patients). Driverless cars the early-adoption stage among health with AI prioritizing and smart-routing could take patients to their appointments, care stakeholders and patients. Increased requests to the right resource (orderlies, improving continuity of care. Drones could uptake may depend on innovators’ ability patient support assistants, volunteers) to pick up medication that an elderly patient to reduce cost and improve accuracy of meet the patient’s needs.108 may have dropped on the floor. Robotic technologies such as natural language applications in pharmacies and surgery are processing, big data, and cognitive It is important for health care stakeholders being used today, though the full potential technologies; and health care professionals’ to realize that AI techniques are designed of the technology has not yet been reached. and patients’ acceptance and trust of the to support and augment workers and new tools.

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Digital reality (DR) is the umbrella term Among providers, the use of AR and VR for augmented reality (AR), virtual reality is currently focused in several discrete VR training for (VR), mixed reality (MR), 360-degree, and areas. For patients, these technologies immersive technologies. “Immersive” can speed education about conditions or physicians describes the deeply engaging, treatment plans. They can even be therapies Virtual reality technology is multisensory, digital experiences that can be themselves when used in visualization transforming the process of medical delivered using DR. As with many new digital and relaxation exercises. Applications training with its immersive experience capabilities, these technologies made their in opioid addiction therapy, phantom and realistic scenarios for physicians first inroads in the consumer world as forms limb treatment, phobia therapies, cancer in surgeries and emergency care. of gaming and entertainment. Now they’re therapy planning, peri-operative planning, Among recent developments in VR reaching a tipping point at which enterprise post-traumatic stress disorder, and general training: and organizational adoption is beginning pain management are some established •• Surgical Theater, a company to outpace entertainment uses. Initial examples. DR tools can be used to help specializing in VR, provides a pre-op barriers in technology, cost, and content maintain mental acuity through participation rehearsal platform for complex are beginning to fall, and early adopters are in situations that limitations such as physical surgeries.119 already hard at work creating solutions to mobility may otherwise make difficult, and help transform health care.113 some VR-based therapies are beginning to •• The Johnson & Johnson Institute appear as ways to help Alzheimer’s disease recently launched a VR training Deloitte and McLaren are working patients improve their memory.116 program to help prepare orthopedic together to build data-driven solutions surgeons and nurses on total knee that combine specialist hardware and In the clinical setting, AR and VR can help replacement and hip fracture software with sophisticated algorithms to physicians and care teams at the point treatment procedures, with plans to 120 improve performance across functions and of care. For example, surgeons can use a further expand to other surgeries. organizations. A health care application heads-up display to provide a data overlay •• Oculus VR is running a pilot to could include creating a digital copy of a on the patient’s body during surgery, or test VR simulation on emergency hospital process, such as patient flow, then to visualize the entire procedure during department (ED) staff in high-risk applying advanced analytics and running pre-surgical planning. Combined with pediatric trauma situations.121 millions of potential scenarios to identify medical imaging, AR is beginning to provide root cause and test different interventions clinicians with the ability to project medical •• London-based Fundamental VR before applying them.114 images, such as CT scans, directly onto the developed a “Fundamental Surgery” patient and in alignment with the patient’s VR application that mimics the In the life sciences and body—even as the person moves—to environment as well as the physical 122 provide clinicians with clearer lines of sight sensations of an operation. health care fields, the 117 into internal anatomy. In the educational •• Embodied Labs created a VR market for virtual patient setting, curricula across undergraduate, program called “We Are Alfred” in simulations is expected to graduate, and continuing medical education which Alfred is a 74-year old man programs and institutions are increasingly with macular degeneration. The 118 grow almost 20 percent a incorporating AR and VR enablement device puts the future nurse or year to become a billion- (see sidebar). doctor in the place of an extremely ill individual so that they can learn to and-a-half-dollar industry empathize with their condition.123 115 by 2025. •• An AR-enhanced smartphone can extend use of virtual cadavers in anatomy training practice sessions.124

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IoMT is a connected infrastructure of The rise of the IoMT is being fueled by and effectively. It enables remote clinical medical devices, software applications, and an increase in the number of connected monitoring, chronic disease and medication health systems and services. IoMT brings medical devices that can generate, management and preventive care, and it together people (patients, caregivers, and collect, analyze, or transmit health data supports people who require assistance clinicians) data (patient or performance or images and connect to provider with daily living, like the elderly and disabled, data) processes (care delivery and patient networks, transmitting data to either a to live independent lives for as long as support), and enablers (sensors, connected cloud repository or internal servers.125 possible (see figure 6). IoMT also has the medical devices—such as wrist bands and Importantly, the IoMT generates intelligent potential to lower costs, improve efficiency, smart clothing—and mobile apps) to deliver and measurable information to help improve and deliver better patient outcomes.126 improved patient outcomes more efficiently. the speed and accuracy of diagnostics and target treatments more efficiently

Figure 6: The seven main ways the IoMT impacts health care

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hace roe eae atet eerece aaeet

eote otor o chroc eae

Source: Medtech and the Internet of Medical Things: How connected medical devices are transforming health care, Deloitte Centre for Health Solutions, July 2018. Adapted from “The Internet-of-Things: A revolutionary tool for the health care industry,” Inside Magazine, Deloitte LLP, 2017.

23 2019 Global health care outlook l Shaping the future

Stakeholder considerations of data from connected devices. Such The Royal Commission may produce strong Digital technologies are supporting health collaborations could allow all stakeholders markers around what is good conduct for systems’ efforts to transition to new models to improve their understanding of patient health care and other industries in the of patient-centered care and “smart health” needs and deliver more proactive, cost- corporate and public sectors. For example, approaches to drive innovation, increase effective care.128 acute care, elder care, and disability care access and affordability, improve quality, facilities may have to prove that their and lower costs. Digital solutions also have Maintaining regulatory compliance and conduct meets community standards and the potential to enable better use of health cybersecurity expectations in delivering those services. data in research and innovation to support personalized health care, better health Managing impacts from changing China—The number of private hospitals in interventions, and health and wellness regulations China doubled to a total of 18,759 in just six services.127 Health care—already one of the world’s years, from 2011–2017; they now account most heavily regulated industries—is for 60.4 percent of Chinese hospitals.132 Increasing health system digitization does likely to become even more so, as clinical However, it appears that quality concerns have some challenges to overcome— innovations, digital interconnectivity, and are also growing, and with it, the frequency among them, solving interoperability market complexity heighten the need of medical accidents. As a result, regulatory issues and risks around connected devices; for new government policies, regulatory supervision of the private health care sector standardizing disparate systems and oversight, and risk management. Although is a primary focus area. China’s government processes; and taking pilot models to scale certain regulatory issues are of universal also is trying to improve overall medical to facilitate system-wide adoption. Health concern—cybersecurity currently heads the quality; in April 2018, the Ministry of Health systems and payers also need to be careful list—others vary by country and/or region: released 18 policies to improve quality and not to hard-wire in (possibly erroneous) safety in hospitals.133 analytics-generated assumptions about Australia—The Royal Commission into data patterns that supposedly indicate how misconduct in the Australian financial European Union—The General Data different populations should be treated in services industry, a government inquiry into Protection Regulation (GDPR) is intended an integrated health care model. conduct, practices, behavior, and business to strengthen and unify data protection activity that falls short of community for all individuals within the EU. As of May Adopting many of these innovations requires standards and expectations,129 may have 25, 2018, GDPR is automatically applicable capabilities that fall beyond the traditional ramifications for health care. After months across all member states. It also applies purview of health care organizations. Health of public hearings, the Commission issued to any company that does business with, care leaders should consider building an interim report on September 28, 2018, or has customers in, EU member states. ecosystems that embrace non-traditional that was highly critical of financial services GDPR enactment is intended to ensure that players and sources of knowledge outside companies’ focus on “profits before people” citizens will now have secure access to a their own four walls. Cross-sector and cross- and of corporate, industry, and government comprehensive electronic record of their industry partnerships and joint ventures regulators’ insufficient response to pervasive health data, have control of the data, and can help minimize capabilities gaps (e.g., misconduct.130 The report also signals are able to share their data securely with technology development, data capture, or the need for more diligent enforcement authorized parties for medical treatment, patient engagement), achieve connectivity at of existing regulations via a culture of preventive services, research, or for any scale, and ensure the effective transmission, enforcement and a culture of compliance.131 other purpose they deem appropriate.134 aggregation, analysis, and management

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Southeast Asia—The rapid growth of will no longer face a penalty if they do Countering cyber crime “consumptive” health services—medical not buy health insurance.137 Eliminating cosmetology, medical tourism, assisted the individual mandate will widen choice, The legacy of the Wannacry attack reproduction services, high-end birth but it will also weaken the risk-sharing continues to resonate across the health delivery/prenatal and postpartum care assumptions that underpinned the ACA. As care landscape, as cyber criminals plan and services, and rehabilitation services—in a result, private insurers are likely to focus execute increasingly sophisticated attacks at lower-cost countries is increasing calls for on selling lower-cost policies for younger a growing rate. Unfortunately, the things that stepped-up regulatory oversight to heighten and healthier clients, leaving public sector health care organizations do to innovate and quality standards and safeguard patients. plans (Medicare and Medicaid) struggling to drive patient experience, care delivery, to cover costly care for the elderly and low- and performance improvements are the United Kingdom—Brexit has considerable income families.138 very things that tend to create cyber risk. regulatory implications for the health care Health care’s large volume of high-value sector. While terms of the United Kingdom’s Prescription drug pricing is another area data, growing demand for interconnected IT exit are still being negotiated, there of US health care policy that has received environments, and cybersecurity program could be a risk of considerable disruption significant attention.139 US regulators have immaturity make it an attractive target. to staff recruitment and the supply of proposed or finalized regulation to reduce IOT-enabled medical devices (implantables, pharmaceuticals and other health care the costs of drugs in public programs wearables, pacemakers) are also exposed goods and services.135 Brexit also has raised through a variety of mechanisms, including to data security issues—over the last 10 risks for economies and health care systems increased price transparency, and clinically years, there have been numerous incidents across the Western European region.136 informed formulary restrictions. Other revealing the security vulnerabilities regulatory and legislative activity aims at of connected devices.141 Yet, despite United States—US health care policies changing the role of pharmacy benefits increasing attention and investment, many have changed considerably under the managers (PBMs), which negotiate prices on organizations remain unprepared for cyber current administration that took office in behalf of commercial payers. Most notably, attacks and other crises (see sidebar, next January 2017. The administration has used the US government has proposed a policy to page). piecemeal legislation to reverse some test pricing for certain drugs according to an important provisions of the 2010 Patient international index of drug prices, showing a Protection and Affordable Care Act (ACA). willingness to set prices more directly where Most notably, tax reforms in December 2017 other mechanisms remain unavailable.140 mean that, as of January 2019, Americans

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Crises are on the rise. Are organizations prepared?

Despite the perception that crises including cyberattacks are becoming more frequent, a 2018 Deloitte survey142 of more than 500 crisis management executives found that organizations’ confidence exceeds crisis preparedness. The analysis of survey responses revealed five central insights of value to health care stakeholders working to safeguard their digital assets:

Experiencing a crisis teaches organizations to avoid them. Undergoing a crisis galvanizes organizations to prioritize detecting and preventing crises in addition to managing them.

Leaders need more development for crisis management. Helping leaders display their full range of competencies under the extreme pressures of a crisis can support effective decision-making and communication when they are most needed.

Confidence outstrips preparedness. An organization’s confidence in its crisis management capabilities is not always commensurate with its level of preparedness.

Being at the ready significantly reduces the negative impact of a crisis. This is especially true if senior management and board members have been involved in creating a crisis plan and participate in crisis simulations.

Third parties are part of the problem—and the solution. Numerous companies are including partners and other outside organizations in crisis planning.

While acknowledging organizations’ need for effective crisis management, focusing security efforts on cyber resilience—investing in protective technologies and cultivating workforce behaviors, including anticipating and monitoring potential threats—may be more important. Being vigilant may help prevent cyberattacks; or, if an attack occurs, a prepared workforce may better implement a fast, effective response to contain it and ensure measures are in place to help build resilience to future incursions.143

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Moreover, as health care data becomes With no single global agreement on data Stakeholder considerations increasingly valuable and accessible, there is protection, regulators around the world are Managing the impact of new and changing an ever-present and growing debate around taking different positions on the issue.145 health care regulations requires that the right to data privacy (e.g., genomic Several countries have introduced new laws organizations public and private, large and sequencing) versus the right to data access and ethical standards around data privacy small, take a proactive, well-planned and to create higher-quality health care products and control. In May 2018 the Brazilian collaborative approach to compliance. and services. We appear to be witnessing a Senate approved a bill that creates a legal What is also critical—especially in the generational cultural change in how much framework for the protection, processing, increasingly digitized and connected health people value their data privacy over more and use of personal data. Once the law is care environment—is adopting a systematic personalized health care, which indicates enacted, it will give citizens greater control approach to protect systems and data from a need to implement security standards over their personal information: it requires cyber threats. to protect against identity theft and deep- explicit consent for data collection and fake information-creation, and to establish use by both public authorities and private While government policies and regulations corporate social responsibility/ethical companies, and options for individuals to seek to strengthen health care security decision-making around data use. view, correct, and delete such information.146 and safety on a macro level, individual organizations should focus executive Although new technologies The Government of India’s use of biometrics, attention on compliance, ethics, and Aadhar cards (a 12-digit unique identification risk—and drive awareness throughout and government initiatives card for each Indian citizen), and DigiLocker the enterprise. Many cyber incidents can to improve cybersecurity (a service that enables citizens to store be avoided if health care organizations certain official documents—including invest in crisis management capabilities are on the rise, the value of detailed health records—in the cloud)147 is that make their cyber-diligence stronger, patient data is increasing showing considerable promise in changing fitter, and better, such as establishing real- the way public health programs are time monitoring, cyber-threat modeling as well, and with it, the delivered. To address associated data safety and analysis, and threat mitigation and amount of cybercrime. and privacy concerns, the government remediation.148 And since many hospital, has come out with a comprehensive data health plan, and government employees Recently, a number of protection policy that sets standards for the may lack awareness of and training to large data breaches have collection, processing, and use of personal manage financial, operational, compliance, data of beneficiaries and other individuals and cyber risks, staff education should be occurred, with as many as as part of the national insurance scheme an important part of every risk management 79 million people affected (PMJAY). program. in one such health care breach.144

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Recruiting, developing, and retaining 8 percent) remain uncovered, increasing top talent pressure on existing staff and potentially impacting care quality152 and employee Closing the talent supply-demand gap health, well-being, and retention.

Health care is a people business, and quality Expanding the view of this issue of care depends greatly on having the right geographically, the World Health professionals with the right skills in the right Organization (WHO) predicts a shortfall place at the right time.149 However, an aging of up to two million health professionals workforce, rising demand for health care (or 15 percent of the workforce) across services, and reduction in physician working the European Union by 2020.153 China hours are driving shortages of appropriately is facing a serious deficiency of general skilled staff in both developed countries practitioners (GPs): According to data from (e.g., urban versus rural areas, specialists the Organisation for Economic Co-operation in some fields) and developing economies and Development (OECD) and the National (global mobility). Health and Family Planning Commission of the People’s Republic of China (NHFPC), only Talent challenges at the United Kingdom’s 6 percent of Chinese doctors are GPs, which NHS illustrate the seriousness of the is much lower than other major countries. situation: The NHS spends nearly 65 percent In Japan, hospital doctors in rural areas of its operational budget on staff.150 While are working excessive hours due to staff almost all clinical professions in the NHS shortages. Because Japan cannot import have grown in the last five years, they have doctors due to the language and license failed to keep up with demand. For example, limitations, the health system will need to current total NHS vacancies for nurses, develop alternative solutions. Indeed, many midwives, and allied health professionals countries are battling excessive demands (AHPs) are almost 42,000 (9.4 percent).151 on their health care workforce, raising While temporary employees can cover most important questions about the sustainability vacant shifts, using these workers is typically of current staffing models (see sidebar, next expensive and may compromise continuity page). of care. Also, some vacant shifts (about

28 2019 Global health care outlook l Shaping the future

Time to care: Securing a future for the hospital workforce in Europe

Are current hospital workforce models sustainable? New research released by the Deloitte UK Centre for Health Solutions154 explores the current state of hospital workforces across Europe and their key challenges; it also provides recommendations to transform the workforce to remain fit for the future.

Based on interviews with more than 50 senior stakeholders and a crowdsourced survey of over 1,350 doctors and nurses across 11 European countries, the report points to a workforce buckling under the strain of a heavy workload, poor work-life balance, and declining morale and well-being. Beyond pure numbers, respondents identified numerous common challenges (figure 7):

Figure 7.

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A lack of the right level and type of skills to respond • Changing demographics of the talent pool due to aging effectively to increasing patient complexity and a critical of the current workforce, combined with an increasingly lack of time for hands-on care competitive market for people with the required skills and talent • Emerging views and evidence on safe staffing levels, particularly for nursing • Entry of millennials into the workforce, with different expectations around work-life balance, flexible careers, • Shortages of certain clinical specialties such as emergency rewards and incentives, and relationships with their departments, intensive care and operating theater staff, employer radiologists and pediatricians • Increasing patient complexity and expectations of the • A lack of access to, or gaps in, performance monitoring medical treatments available to diagnose and treat each information and availability of real-time data patient

• Limited influence at organizational level on training models • Increasing pressure on the funding available for health care that are too rigid and lengthy and fail to equip todays workforce with more flexible skills for the emerging • Al, robotics, automation, and advanced digital and digital age cognitive technologies disrupting health care delivery models. • An increasing need to re-design care pathways, with implications for the workforce and for new ways of working

Source: Time to care: Securing a future for the hospital workforce in Europe, Deloitte UK Centre for Health Solutions, 2018, https://www2.deloitte.com/global/en/pages/life-sciences-and-healthcare/articles/time-to-care.html.

Despite decades of health workforce planning, education, recruitment, and retention initiatives, most European countries are facing increasing challenges around the demands placed on the workforce. Maintaining high-quality care requires a focus on staff retention, including health and well-being, as well as support to develop new skills and competencies in response to advances in scientific knowledge.

The research findings suggest that future workforce shortages could be tackled more cost-effectively if the efficiency and productivity of clinical activities were addressed through innovative approaches to workforce planning, recruitment, skills development, and technology use—most of which may also require institutional reforms. 29 2019 Global health care outlook l Shaping the future

Since a hospital’s workforce is a significant Using digital technology to augment and—in continuum that includes full- and part-time investment—clinical staff account for the some cases—replace human workers frees employees, contractors and freelancers, biggest proportion of hospital costs, up health care professionals from repetitive, and crowdsourced and automated labor;163 to 70 percent155—health care leaders who mundane tasks and enables them to focus and for redefined roles for health care leverage technology-enabled opportunities on their core responsibilities; this can practitioners, such as allowing nurses to to address talent challenges may both solve improve physician and staff productivity prescribe certain drugs. Also likely needed near-term staff shortfalls and create the and result in higher-quality patient care and will be technologies that enable more building blocks for a sustainable future. enhanced patient and visitor experiences. efficient care delivery models; for example, Three dimensions that are shaping the Australian community care provider Silver future of work—the “what” (automation), 2. Who can do the work? Chain Group recently introduced a Microsoft “who” (the open talent continuum), and Recognizing current and projected HoloLens-powered holographic doctor with “where” (workplaces, location)—should aid health care workforce shortages, many Enhanced Medical Mixed Reality (EMMR) health care organizations’ attempts to close governments have acted to increase the capabilities to empower nurses on home the talent demand-supply gap. supply of physicians and nurses. According visits with hands-free data and access to to Deloitte research, between 2010 and specialist advice and assessment from 1. What work can be automated? 2015, the number of graduates leaving remote specialist doctors.164 The nature of work is becoming more digital medical school, per 1,000 population, and automated, as technologies such as increased in eight out of 13 European 3. Where is the work done? AI, cognitive computing, and robotics help countries.159 Ireland introduced a new Today, care is mainly provided in the hospital health care professionals make better graduate-entry level into medical training in or clinic setting, which can be a detriment decisions, reduce errors, and increase 2009, which contributed to a 38.8 percent to speed and frequency of care and puts productivity in both clinical and business increase in the number of doctors, per 1,000 limitations on the number of patients a settings. AI-based diagnosis for heart population, by 2015.160 In its 13th five–year clinician is able to assist. Telehealth and diseases has proved to be more accurate plan, China’s government intends to train digital medicine tools are enabling a “care than doctors at least 80 percent of the 150,000 more general practitioners by 2020. anywhere” model. This new model enables time.156 Robotics are automating many organizations to build and deploy new aspects of health care, from administrative International recruitment continues as a staffing models, such as allowing nurses processes (e.g., documentation, insurance method of supplementing countries’ rosters to work remotely, while still building strong processing, scheduling) to logistic tasks of domestically trained clinicians; however, patient relationships and having high-value (e.g., delivering linens, meals, and medical this practice’s competitive approach is interactions, thus reducing nurse burnout supplies) to surgery.157 undergoing increasing scrutiny. Low-income and potentially creating more workplace countries are particularly vulnerable to large fulfillment. A notable example is the numbers of professionals exiting; those introduction of remote monitoring through who remain are left with a larger share voice-activated solutions (e.g., oral chemo In Japan, Panasonic has created a of the workload, increasing the potential at home). This could be relevant for chronic nursing care bed, Reysone, an assist for dissatisfaction, burnout, and further care and rehab patients.165 robot that combines an electric emigrations.161 Some countries likely will nursing care bed and an electric need to increase clinician training to match This change to the proximity of where care full-reclining wheelchair, to help domestic needs and improve pay and can be provided—remotely, in a patient’s elderly patients and their caregivers. working conditions to strengthen domestic home, or even over the phone—allows Reysone became the world’s first retention.162 certain clinical roles to optimize their time product to receive the ISO13482 to see more patients, provide care for certification, the new global safety The challenges of closing the demand- even more complex patients, and serve standard for personal care robots.158 supply gap through traditional employment populations in hard-to-reach locations.166 methods point to the need for a talent

30 2019 Global health care outlook l Shaping the future

Stakeholder considerations of service users, the current workforce, and workforce will evolve not along a single In technological terms, the future of health their employers about the resources and linear path, but in response to a collection care is already here. But for many providers, skills required in the rapidly evolving health of forces. Rather than fearing this wave payers, and governments, the plan for care environment. New ways of working of change as an overwhelming challenge, working in that future is still on the drawing augmented by digital technologies can provider organizations should proactively board.167 How do organizations procure and enable task-shifting and role enrichment to seek out the opportunities for augmentation sustain the new skills and capabilities they create a sustainable and flexible workforce and automation in clinical workflows—and need? How do they recruit the right people, that is able to respond efficiently and pinpoint where both clinicians and patients manage, and develop them? How do they effectively to users’ needs.168 will benefit from an aligned financial support and guide the current workforce reimbursement system, new technologies, into the new reality of a digital world? All As each organization seeks to map out its innovative talent models, and expanded stakeholders should come together in an own workforce strategy, it should adopt locations where care is delivered.169 iterative process that integrates the views an exponential mind-set: Each part of the

31 2019 Global health care outlook l Shaping the future

Parting thoughts

This outlook envisions a future in which the situation; and where people understand the care stakeholders—providers, governments, global health care system is organized to cost and impact of their options for care. payers, and consumers—in 2019 and years keep people well—not just cure when they to come to turn opportunities into realities. are ill; where technology-enabled care is The opportunities to shape this future available when and where people need it; have never been more promising and where drugs and devices are personalized abundant. But it will take participation, and based on an individual’s needs and collaboration, and investment by all health

32 2019 Global health care outlook l Shaping the future

Appendix

Explore the latest health care sector The future awakens: Life sciences and Stronger, fitter, better: Crisis management research from Deloitte members or visit: health care predictions 2022 for the resilient enterprise www.deloitte.com/us/healthsolutions The year is 2022. The quantified self is Despite the perception that crises are www.deloitte.co.uk/centreforhealthsolutions alive and well, digital technologies have becoming more frequent, a 2018 Deloitte www.deloitte.com/healthcare transformed the culture of health care, study finds that organizations’ confidence and new entrants have disrupted delivery exceeds crisis preparedness. 2018 Global health care outlook: The models. We offer some predictions that, evolution of smart health care if they come true, will shake up the life Supporting healthy communities With quality, outcomes, and value being sciences and health care industry in the next As health care shifts toward treating people the watchwords for health care in the 21st five years. before they get sick, community partners century, sector stakeholders around the and government agencies are becoming globe are looking for innovative and cost- The future is here: The future of work involved, aiming to address social factors effective ways to deliver patient-centered, The future of work is poised to bring better such as education and housing. More technology-enabled “smart” health care, jobs and more fulfillment to the practice of players, though, means more complications, both inside and outside hospital walls. health care—if provider organizations adapt particularly in funding. One possible fast enough solution: a hub model. A life sciences and health care perspective: Tech Trends 2018 The digital hospital of the future Addressing social determinants of health From “doing digital” to “being digital,” that’s In 10 years, technology may change the face in hospitals: How are hospitals and health where the life sciences and health care of global health care delivery. As the cost of systems investing in social needs? industry needs to go. To help your business care continues to rise, many hospitals are Our survey of 300 hospitals and health navigate digital disruption, this series looking for long-term solutions to minimize systems explores how factors outside the provides a life sciences and health care inpatient services. Learn how technology health care system—the social determinants perspective on Deloitte’s 2018 Tech Trends and health care delivery will merge to of health—affect patients’ long-term well- report. From blockchain to digital reality to influence the future of hospital design and being and what health care organizations the no-collar workforce, explore the trends the patient experience across the globe. can do to address these challenges. that are shaping strategic and operational transformations and redefining life sciences Breaking the dependency cycle: Tackling Deloitte 2017 survey of US health system and health care. health inequalities of vulnerable families CEOs: Moving forward in an uncertain Vulnerable families face significant health environment Time to care: Securing a future for the inequalities, despite rising life expectancy CEOs at hospitals and health systems hospital workforce in the UK across Western Europe. While access are faced with increasing headwinds as There is widespread recognition across to good health care is important, it only they look to move forward in an uncertain Europe of the growing mismatch between accounts for 15–25 percent of health environment. So what are the key issues and demand for hospital care and the supply inequalities. A range of social determinants trends CEOs are facing? While none of the of staff and other resources to meet that crucially drive trends around mortality and key themes emerging from our interviews demand. The quality of care is dependent ill-health, including quality of education, have really changed since we last spoke with on having the right professionals with the housing, employment, working conditions, health system CEOs in 2015, the urgency right skills in the right place at the right time; and welfare. certainly has. Instead of thinking about however, there are concerns that the current these issues in a futuristic sense, CEOs are workforce model is unsustainable. ready to address and tackle them now.

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Can emerging technologies improve Hospital mergers and acquisitions: When hospital performance? Strategies for done well, M&A can achieve valuable healthier operating margins outcomes Hospitals are anticipating tighter operating With a rise in the number of mergers and margins in 2017 and beyond, due to acquisitions in the health care industry, increasing financial pressure from policy, we conducted a study with the Healthcare industry, and market changes. This report Financial Management Association to discusses innovative technologies and learn more about the factors that lead to cost-reduction strategies that hospitals increased value following a hospital merger can consider to enhance revenue, increase or acquisition. efficiency, and achieve long-term financial stability. Cognitive health care in 2027: Harnessing a data-driven approach in personalized The value of patient experience: Hospitals health care with better patient-reported experience “Precision medicine” or care that is highly perform better financially personalized for each person’s genome Deloitte research shows good patient is likely to revolutionize health care of the experience is associated with higher hospital future. And cognitive technologies will play profitability. This association is strongest for a pivotal role, as handling the enormous aspects of patient experience most closely amounts of data—one of the imperatives of associated with better care—in particular, cognitive health care—requires much more nurse-patient engagement. than just “artisanal” analytic capabilities.

Value of patient experience: Hospitals with Medtech and the Internet of Medical higher patient experience scores have Things: How connected medical devices are higher clinical quality transforming health care Making investments in patient experience With the Internet of Medical Things (IoMT) can be a tough call. But new Deloitte Center market estimated to be worth $158.1 billion for Health Solutions research suggests in 2022, how can medtech companies get executives may want to give this investment IoMT right from a business perspective and real consideration. Coupled with previous how they can use the opportunity to deliver research that found hospitals with better more value to health care? patient-reported experience perform better financially, new findings give ammunition Nudging toward better health to the business case: There is a positive This podcast explores how nudges are being correlation between patient experience and used today in increasingly varied ways to clinical quality measures. drive consumer behavior. Similar strategies in health care can lead to better medical decisions and improved patient outcomes.

34 2019 Global health care outlook l Shaping the future Endnotes

1. World Industry Outlook, Healthcare and 20. Moorfields Eye Hospital, https://www.moorfields. 33. “Fullerton Health China closes investment in Pharmaceuticals, The Economic Intelligence Unit, nhs.uk/content/whatwe-do. Redleaf Hospital, accelerating its growth in September 2018. China’s sophisticated health care market,” news 21. The King’s Fund, https://www.kingsfund.org.uk/ release, 25 October 2018, https://markets. 2. Ibid. sites/default/files/field/field_publication_file/ businessinsider.com/news/stocks/fullerton- STPs_in_NHS_Kings_Fund_Nov_2016.pdf. 3. Improving health care affordability: Achieving health-china-closes-investment-in-redleaf- quality improvement while bending the cost 22. “Healthcare IT Market worth 280.25 Billion USD hospital-accelerating-its-growth-in-china-s- curve, https://www2.deloitte.com/us/en/ by 2021,” MarketsandMarkets, 2018, https:// sophisticated-healthcare-market-1027651958. pages/lifesciences-and-health-care/articles/ www.marketsandmarkets.com/PressReleases/ 34. “Ramsay Générale de Santé announces a public improvinghealth-care-affordability.html. healthcare-it-market.asp. offer to the shareholders of Capio,” news release, 4. Ibid. 23. Apple is a trademark of Apple Inc., registered in 13 July 2018, https://globenewswire.com/news- the U.S. and other countries. release/2018/07/13/1536995/0/en/RAMSAY- 5. World Industry Outlook, Healthcare and GENERALE-DE-SANTE-OPA-CAPIO.html. Pharmaceuticals, The Economic Intelligence Unit, 24. “Apple is working with this small start-up to September 2018, citing the Joint UN Programme change how we track our health,” CNBC, 19 June 35. “Ping An Good Doctor and Grab Form Joint on HIV/AIDS (UNAIDS). 2017, https://www.cnbc.com/2017/06/19/apple- Venture to Deliver Transformative O2O working-with-start-up-health-gorilla-on-iphone- Healthcare Solutions in Southeast Asia,” Grab 6. World Industry Outlook, Healthcare and ehr-plan.html. Press Centre, 16 August 2018, https://www. Pharmaceuticals, The Economic Intelligence Unit, grab.com/sg/press/business/ping-an-good- September 2018. 25. “Why healthcare needs to care about Google’s doctor-and-grab-form-joint-venture-to-deliver- acquisition of Apigee”, CIO, 15 September 2016, transformative-o2o-healthcare-solutions-in- 7. World Industry Outlook, Healthcare and https://www.cio.com/article/3120434/healthcare/ southeast-asia/. Pharmaceuticals , The Economic Intelligence why-healthcare-needs-to-care-about-googles- Unit, September 2018, citing the World Health acquisition-of-apigee.html. 36. “Go-Jek integrates Go-Med into HaloDoc app as Organization (WHO). the two companies strengthen collaboration,” The 26. How Google Plans to use AI to Reinvent the $3 Independent, 17 May 2017, theindependent.sg/go- 8. Ibid. Trillion US Healthcare Industry, CBInsights. jek-integrates-go-med-into-halodoc-app-as-the- two-companies-strengthen-collaboration/. 9. Ibid. 27. Ibid. 37. “Cigna to Buy Express Scripts in $52 Billion Health 10. Ibid. 28. “Why Apple, Amazon, and Google are making Care Deal, The New York Times, 8 March 2018, big health care moves”, Vox, 6 March 2018, last 11. Supporting healthy communities: How rethinking the https://www.nytimes.com/2018/03/08/business/ accessed on 21 August 2018 (https://www.vox. funding approach can break down silos and promote dealbook/cigna-express-scripts.html. health and health equity, Deloitte, 2017, https:// com/technology/2018/3/6/17071750/amazon- www2.deloitte.com/insights/us/en/industry/ health-care-apple-google-uber). 38. “Amazon buys PillPack, an online pharmacy, for just under $1B,” 28 June 2018, Techcrunch.com, health-care/building-and-funding-healthy- 29. “Let the disruption in health tech begin,” Philips, https://techcrunch.com/2018/06/28/amazon- communities.html. 2 February 2018, https://www.philips.com/a-w/ buys-pillpack-an-online-pharmacy-that-was- about/news/archive/blogs/innovation-matters/ 12. 2018 Global health care outlook: The evolution of rumored-to-be-talking-to-walmart/. smart health care, Deloitte, 2018, www2.deloitte. let-the-disruption-in-health-tech-begin.html. 39. “Alibaba Health to acquire 14% stake in pharma com/insights/us/../global-health-care-sector- 30. “IHH wins race to acquire Fortis with Rs 40-bn firm for $61.3m,” Deal Street Asia, 21 August 2018, outlook.html. bid, beats TPG-Manipal,” Canton Caller, 12 August https://www.dealstreetasia.com/stories/alibaba- 2018, https://cantoncaller.com/ihh-wins-race- 13. Mobility will change the future of health care, health-pharma-105109/. Deloitte, 2018. to-acquire-fortis-with-rs-40-bn-bid-beats-tpg- manipal/113752/. 40. “Fresenius Medical Care to Acquire NxStage 14. World Industry Outlook, Healthcare and Medical, Inc. to Strengthen its Vertically 31. Life Healthcare, “Life Healthcare accepts offer Pharmaceuticals, The Economic Intelligence Unit, Integrated Dialysis Business,” Markets Insider, 7 for its stake in Max Healthcare, 21 September September 2018. August 2017, https://markets.businessinsider. 2018, https://www.lifehealthcare.co.za/news- com/news/stocks/fresenius-medical- 15. Ibid. and-infohub/latest-news/life-healthcare-accepts- care-to-acquire-nxstage-medical-inc-to- offer-forits-stake-in-max-healthcare/. 16. Ibid. strengthen-its-vertically-integrated-dialysis- 32. “Luye Medical Group acquires majority stake in business-1002236124. 17. Ibid. Novena Heart Centre,” The Straits Times, 10 April 41. Moorfields Eye Hospital, https://www.moorfields. 2018, https://www.straitstimes.com/business/ 18. Ibid. nhs.uk/content/whatwe-do. companies-markets/luye-medical-group- 19. Ibid. acquires-majority-stake-in-novena-heart-centre.

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42. “Combine RPA with BPO to improve revenue 55. “Moving from sick care to health care,” A View from 68. American Telemedicine Association, http:// cycle performance and reduce costs,” Becker’s the Center, Deloitte Center for Health Solutions, www.americantelemed.org/main/about/about- Hospital CFO Report, 12 February 2018, https:// 24 August 2017, https://blogs.deloitte.com/ telemedicine/delivery-mechanisms. www.beckershospitalreview.com/finance/ centerforhealthsolutions/moving-from-sick-care- 69. Deloitte Insights, How to create people-focused combine-rpa-with-bpo-to-improve-revenue- to-healthcare/. workplaces, https://www2.deloitte.com/insights/ cycle-performance-and-reduce-costs.html. 56. Growth in outpatient care: The role of quality us/en/industry/health-care/virtual-health-care- 43. Time to care: Securing a future for the hospital and value incentives, Deloitte Center for Health healthconsumer-and-physician-surveys.l?id=us:2 workforce in Europe, Deloitte UK Centre for Health Solutions, 2018, https://www2.deloitte.com/ el:3dc:4di4407:5awa:6di:&pkid=1005419. Solutions, 2018, https://www2.deloitte.com/ insights/us/en/industry/health-care/outpatient- 70. Ibid. global/en/pages/life-sciences-and-healthcare/ hospital-services-medicare-incentives-value- articles/time-to-care.html. quality.html. 71. Ibid.

44. Ibid. 57. Ibid. 72. Jennifer Bresnick, “What is limiting the widespread adoption of telehealth?” mHealthIntelligence, 45. 2017 Medicare Shared Savings Program (SSP) 58. Ibid. February 13, 2015; National Organization of State Accountable Care Organizations (ACO) Public 59. Growth in outpatient care: The role of quality Offices of Rural Health, Telehealth policy barriers, Use File, https://data.cms.gov/Special-Programs- and value incentives, Deloitte Center for Health August 2016; Cynthia LeRouge and Monica J. Initiatives-Medicare-Shared-Savin/2017-Shared- Solutions, 2018, https://www2.deloitte.com/ Garfield, “Crossing the telemedicine chasm: Savings-Program-SSP-Accountable-Care-O/ insights/us/en/industry/health-care/outpatient- Have the U.S. barriers to widespread adoption gk7c-vejx. hospital-services-medicare-incentives-value- of telemedicine been significantly reduced?” 46. “MACRA final rule raises performance standards quality.html. International Journal of Environmental Research for 2019,” Deloitte Perspectives, 8 November and Public Health, 10, no.12 (2013): p. 6472, 60. Transforming care delivery through virtual health, 2018, https://www2.deloitte.com/us/en/ DOI:10.3390/ijerph10126472. Deloitte 2017, https://www2.deloitte.com/us/en/ pages/regulatory/articles/macra-final-rule- pages/life-sciences-and-health-care/articles/ 73. Rachel Z. Arndt, “Chief information officers understanding-revisions-for-cy-2019.html. virtual-health-health-care-providers.html; citing roundtable: As technology drives consumerism, 47. Ibid. Deb Hunt, RN, Marc Scheinrock, Saurabh Vyas, consumerism drives technology,” Modern MD, Virtual Health: Can it help your organization Healthcare, March 17, 2018. 48. Reaching the Unreached: Opportunities for Life create a transformational culture while bending Science Companies Within Asia Pacific 74. Deloitte Insights, How to create people-focused , Deloitte US- the cost curve?, Deloitte, August 2014, https:// workplaces, https://www2.deloitte.com/insights/ Global & Deloitte Southeast Asia, July 2018. www2.deloitte.com/content/dam/Deloitte/us/ us/en/industry/health-care/virtual-health-care- Documents/life-sciences-health-care/us-virtual- 49. Victoria State Government, HealthLinks: Chronic healthconsumer-and-physician-surveys.l?id=us:2 health.pdf. Care, https://www2.health.vic.gov.au/hospitals- el:3dc:4di4407:5awa:6di:&pkid=1005419. andhealth-services/patient-care/healthlinks. 61. Deloitte virtual health iPad application, https:// 75. Ibid. 50. Ibid. marvelapp.com/81ce021/screen/39109287. 76. Breaking the dependency cycle: How health 62. Internet World Stats, https://www. 51. “Moving from sick care to health care,” A View from inequalities of vulnerable families can be tackled internetworldstats.com/stats.htm. the Center, Deloitte Center for Health Solutions, in Western Europe, Deloitte UK Centre for Health 24 August 2017, https://blogs.deloitte.com/ 63. Ibid. Solutions, 2017, https://www2.deloitte.com/uk/ centerforhealthsolutions/moving-from-sick-care- en/pages/life-sciences-and-healthcare/articles/ to-healthcare/. 64. ”Virtual Health Care Could Save the U.S. Billions breaking-dependency-cycling.html. Each Year,” Harvard Business Review, April 2018, 52. Breaking the dependency cycle: How health https://hbr.org/2018/04/virtual-health-care- 77. “Growth of consumerism in health care: inequalities of vulnerable families can be tackled could-save-the-u-s-billions-each-year). Rethinking customer engagement strategies to in Western Europe, Deloitte UK Centre for Health address changing expectations and behaviors,” Solutions, 2017, https://www2.deloitte.com/uk/ 65. Clevetar, Meet your virtual support team, https:// Deloitte, 2018, https://www2.deloitte.com/us/ en/pages/life-sciences-and-healthcare/articles/ www.clevertar.com/; and Intelligent Virtual en/pages/life-sciences-and-health-care/articles/ breaking-dependency-cycling.html. agents: A better way to engage with people, consumerism-in-health-care-and-patient- Clevertar. 53. Ibid. experience.html. 66. Helfie Skin, https://helfie.ai/. 54. “Beyond Health Care: The Role of Social 78. “Patient engagement strategies in a digital Determinants in Promoting Health and Health 67. “AI startup KroniKare diagnoses wounds with environment: Life sciences companies respond Equity,” Henry J. Kaiser Family Foundation, 10 smartphones,” The Edge Singapore, 31 May 2017, to changing patient expectations,” Deloitte May 2018, https://www.kff.org/disparities-policy/ https://www.theedgesingapore.com/ai-startup- Review, 26 January 2016, https://www2.deloitte. issue-brief/beyond-health-care-the-role-of- kronikare-diagnoses-wounds-smartphones. com/insights/us/en/deloitte-review/issue-18/ social-determinants-in-promoting-health-and- patient-engagement-strategies-changing-patient- health-equity/. expectations.html.

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79. Ibid. 92. Top 10 health care innovations: Achieving more 104. “Precision medicine and cancer immunology for less, Deloitte Center for Health Solutions, in China,” Science Magazine, 2018, http://www. 80. “Growth of consumerism in health care: 2016, https://www2.deloitte.com/content/dam/ sciencemag.org/sites/default/files/GiantCRO_ Rethinking customer engagement strategies to Deloitte/global/Documents/Life-Sciences-Health- supplement.pdf. address changing expectations and behaviors,” Care/gx-lshc-top-10-health-care-innovations- 105. Top 10 health care innovations: Achieving more Deloitte, 2018, https://www2.deloitte.com/us/ web-friendly.pdf. en/pages/life-sciences-and-health-care/articles/ for less, Deloitte Center for Health Solutions, consumerism-in-health-care-and-patient- 93. Deloitte: Nudging toward better health podcast, 2016, https://www2.deloitte.com/content/dam/ experience.html. www2.deloitte.com/insights/us/../nudging- Deloitte/global/Documents/Life-Sciences-Health- toward-better-health.html. Care/gx-lshc-top-10-health-care-innovations- 81. Ibid. web-friendly.pdf. 94. “Using Behavioral Nudges to Treat Diabetes,” 82. b.well, Putting consumers at the center of Harvard Business Review, October 10, 2018, https:// 106. Top 10 health care innovations: Achieving more their healthcare, https://www.icanbwell. hbr.org/2018/10/using-behavioral-nudges-to- for less, Deloitte Center for Health Solutions, com/#download. treat-diabetes?utm_source=linkedin&utm_ 2016, https://www2.deloitte.com/content/dam/ 83. The value of patient experience: Hospitals with medium=social&utm_campaign=hbr. Deloitte/global/Documents/Life-Sciences-Health- better patient-reported experience perform better Care/gx-lshc-top-10-health-care-innovations- 95. Penn Medicine Nudge Unit website, http:// financially web-friendly.pdf. ,” Deloitte Center for Health Solutions, nudgeunit.upenn.edu/about. 2016, https://www2.deloitte.com/us/en/pages/ 107. Video: Artificial intelligence in health care, 96. The value of patient experience: Hospitals with life-sciences-and-health-care/articles/hospitals- Deloitte, 2018, https://www2.deloitte.com/global/ better patient-reported experience perform better patient-experience.html. en/pages/life-sciences-and-healthcare/articles/ financially , Deloitte Center for Health Solutions, artificial-intelligence-health-care-video.html. 84. “Patient engagement strategies in a digital 2016, https://www2.deloitte.com/us/en/pages/ environment: Life sciences companies respond life-sciences-and-health-care/articles/hospitals- 108. DeloitteASSIST: Transforming patient Deloitte to changing patient expectations,” patient-experience.html. communication through artificial intelligence, Review, 26 January 2016, https://www2.deloitte. https://www2.deloitte.com/au/en/pages/ com/insights/us/en/deloitte-review/issue-18/ 97. “Patient engagement strategies in a digital publicsector/solutions/dassist.html. patient-engagement-strategies-changing-patient- environment: Life sciences companies respond expectations.html. to changing patient expectations,” Deloitte 109. Apple Watch is a trademark of Apple Inc., Review, 26 January 2016, https://www2.deloitte. registered in the U.S. and other countries. 85. Apple is a trademark of Apple Inc., registered in com/insights/us/en/deloitte-review/issue-18/ 110. “The AI doctor will see you now, The Wall the U.S. and other countries. patient-engagement-strategies-changing-patient- Street Journal, 20 May, 2018, https://www.wsj. expectations.html. 86. 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37 2019 Global health care outlook l Shaping the future

116. Tech Trends 2018: A life sciences and health care 126. Ibid. July 2018, https://www2.deloitte.com/global/ perspective, Deloitte, 2018, https://www2.deloitte. en/pages/life-sciences-and-healthcare/ 127. Medtech and the Internet of Medical Things: How com/us/en/pages/life-sciences-and-health-care/ articles/medtech-internet-of-medical-things. connected medical devices are transforming health articles/life-sciences-health-care-tech-trends. html; citing Burns AJ et al. A brief chronology care, Deloitte UK Centre for Health Solutions, html; citing Paul J.F. White, Zahra Moussavi, of medical device security. Communications July 2018, https://www2.deloitte.com/global/ Neurocognitive treatment for a patient with of the ACM, 2016, https://cacm.acm.org/ en/pages/life-sciences-and-healthcare/articles/ Alzheimer’s Disease using a virtual reality magazines/2016/10/207766-a-brief-chronology- medtech-internet-of-medical-things.html. navigational environment, http://journals. of-medical-device-security/fulltext. sagepub.com/doi/abs/10.4137/JEN.S40827. 128. Ibid. 142. Stronger, fitter, better: Crisis management for the 117. Tech Trends 2018: A life sciences and health care 129. Royal Commission into Misconduct in Financial resilient enterprise, Deloitte Touche Tohmatsu perspective, Deloitte, 2018, https://www2.deloitte. Services, Financial Services: Regulation tomorrow, Limited, 2018, https://www2.deloitte.com/ com/us/en/pages/life-sciences-and-health-care/ Norton Rose Fulbright, 30 November 2017, insights/us/en/topics/risk-management/crisis- articles/life-sciences-health-care-tech-trends. https://www.regulationtomorrow.com/au/royal- management-plan-resilient-enterprise.html. html; citing Augmented reality system lets commission-into-misconduct-in-fiancial-services/. 143. https://www2.deloitte.com/au/en/pages/risk/ doctors see under patients’ skin without the articles/protecting-businesses-cyber-criminals- scalpel, University of Alberta, https://www. 130. “Banking royal commission condemns greed cyber-attacks.html. ualberta.ca/science/science-news/2018/january/ of financial sector in first report,” The Guardian, augmented-reality-techsee-under-skin-without- 28 September 2018, https://www.theguardian. 144. 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Medtech and the Internet of Medical Things: How 120. “VR for Training Orthopedic Surgeons,” VR Focus, connected medical devices are transforming 146. “Brazilian Senate Approves Bill to Protect 19 July 2018, https://www.vrfocus.com/2018/07/ health care, Deloitte UK Centre for Health Personal Data,” Folha De S.Paulo, 11 July 2018, vr-for-training-orthopaedic-surgeons/. Solutions, July 2018, https://www2.deloitte.com/ https://www1.folha.uol.com.br/internacional/ 121. ”Virtual Reality: Transforming Medical global/en/pages/life-sciences-and-healthcare/ en/business/2018/07/1974318-brazilian-senate- Training, Medical Training, July 2017, https:// articles/medtech-internet-of-medical-things.html. approves-bill-to-protect-personal-data.shtml. medicalsimulation.training/university/virtual- 135. World Industry Outlook, Healthcare and 147. National Portal of India, https://www.india.gov.in/ reality-medical-training/. Pharmaceuticals, The Economic Intelligence Unit, spotlight/digilockeronline-document. 122. ”VR and AR in Medical Education New tools can September 2018. 148. Stronger, fitter, better: Crisis management for the assist students in preparing for pressure-filled 136. Ibid. resilient enterprise, Deloitte Touche Tohmatsu situations both in technique and disposition,” Limited, 2018, https://www2.deloitte.com/ Haptic.Al, 17 July, 2018, https://haptic.al/vr-and- 137. Ibid. insights/us/en/topics/risk-management/crisis- ar-in-medical-education-cd1c90cc3de3. 138. Ibid. management-plan-resilient-enterprise.html. 123. Ibid. 139. Trump Administration releases broad plan to 149. A Universal Truth: No health without a workforce. 124. “Digital reality in life sciences and health care,” address drug prices, https://www2.deloitte.com/ Global Health Workforce Alliance and WHO, Deloitte insights, Tech Trends 2018: A life sciences us/en/pages/regulatory/articles/2018-trump- 2014. See also http://who.int/healthforcealliance/ and health care perspective, 2018, https://www2. administration-releases-broad-plan-to-address- knowledge/resources/hrhreport2013/en/. deloitte.com/us/en/pages/life-sciences-and- drug-prices.html. 150. Facing the Facts, Shaping the Future: A draft health health-care/articles/consumerism-in-health-care- and care workforce strategy for England to 2027, and-patient-experience.html. 140. Trump Medicare proposal: International Pricing Index model, https://www2.deloitte.com/us/en/ NHS, 2017, https://www.hee.nhs.uk/sites/default/ 125. Medtech and the Internet of Medical Things: How pages/regulatory/articles/international-pricing- files/documents/Facing%20the%20Facts%2C%20 connected medical devices are transforming health index-model.html. Shaping%20the%20Future%20%E2%80%93%20 care, Deloitte UK Centre for Health Solutions, a%20draft%20health%20and%20care%20 July 2018, https://www2.deloitte.com/global/ 141. 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38 2019 Global health care outlook l Shaping the future

151. Facing the Facts, Shaping the Future: A draft health 160. Medical Education in Ireland. A New Direction. 166. The future is here: The future of work, Deloitte, and care workforce strategy for England to 2027, Report of the Working Group on Undergraduate 2018, https://www2.deloitte.com/us/en/pages/ NHS, 2017, https://www.hee.nhs.uk/sites/default/ Education and Training, Department of Education life-sciences-and-health-care/articles/healthcare- files/documents/Facing%20the%20Facts%2C%20 and Skills, 2006, https://www.education.ie/en/ workforce-technology.html. Shaping%20the%20Future%20%E2%80%93%20 Publications/Policy-Reports/Medical-Education- 167. Ibid. a%20draft%20health%20and%20care%20 in-Ireland-A-New-Direction-Report-of-the- workforce%20strategy%20for%20England%20 Working-Group-on-Undergraduate-Medical- 168. Ibid. to%202027.pdf. Education-and-Training.pdf. 169. The future is here: The future of work, Deloitte, 152. Ibid. 161. International Migration Outlook 2015, Changing 2018, https://www2.deloitte.com/us/en/pages/ patterns in the international migration of doctors 153. Time to care: Securing a future for the hospital life-sciences-and-health-care/articles/healthcare- and nurses to OECD countries, OECD, 2015, http:// workforce in Europe workforce-technology.html. , Deloitte UK Centre for Health dx/doi.org/10.1787/miht_outlook-2016-6-en. Solutions, 2018, https://www2.deloitte.com/ global/en/pages/life-sciences-and-healthcare/ 162. The Code of Practice and its enduring relevance in articles/time-to-care.html. Europe and Eastern and Southern Africa, Human Resources for Health, 2016. See also: https:// 154. Ibid. human-resources-health.biomedcentral. 155. Final Report Summary-HEALTH PROMETHEUS com/track/pdf/10.1186/s12960-016-0122- (Health professional mobility in the European y?site=human-resources-health.biomedcentral. Union Study, Community Research and com. Development Service, 2013, http://cordis.europa. 163. The future is here: The future of work, Deloitte, eu/result/rcn/56024_en.html. 2018, https://www2.deloitte.com/us/en/pages/ 156. “Why Apple, Amazon, and Google are making big life-sciences-and-health-care/articles/healthcare- health care moves,” Vox, 6 March 2018, https:// workforce-technology.html. www.vox.com/technology/2018/3/6/17071750/ 164. Silver Chain Group reveals HoloLens-powered amazon-health-care-apple-google-uber). Holographic doctor for remote specialist 157. The digital hospital of the future, Deloitte, October consultations, 2 October 2017, https:// 2017, https://www2.deloitte.com/global/en/ mspoweruser.com/silver-chain-groupunveils- pages/life-sciences-andhealthcare/articles/ hololens-powered-holographic-doctorremote- global-digital-hospital-of-the-future.html; also, specialist-consultations/. The future is here: The future of work , Deloitte, 165. The future is here: The future of work, Deloitte, 2018, https://www2.deloitte.com/us/en/pages/ 2018, https://www2.deloitte.com/us/en/ life-sciences-and-health-care/articles/healthcare- pages/life-sciences-and-health-care/articles/ workforce-technology.html. healthcare-workforce-technology.html; citing 158. No More Power Barriers with Panasonic Assist Kofoed, Sarah; Breen, Sibilah; Gough, Karla; Robots, Panasonic, 23 March 2016, https://news. Aranda, Sanchia. “Benefits of remote real-time panasonic.com/global/stories/2016/44969.html. side-effect monitoring systems for patients,” Oncology Reviews 2012; volume 6:e7, June 2012, 159. Ibid. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4419632/.

39 2019 Global health care outlook l Shaping the future Contacts

Stephanie Allen, PhD Global Public Sector Health Care Leader [email protected]

Dr. Rohan Hammett Yoritomo Wada Asia Pacific Co-Regional Leader Health Care Sector Leader [email protected] Deloitte Japan [email protected]

Enrico de Vettori Mathieu Van Bergen LSHC Industry Leader EMEA Health Care Leader Deloitte Brazil Health Care & Social Care Sector Leader [email protected] Deloitte Netherlands [email protected]

Lisa Purdy Abdelhamid Suboh LSHC Industry Leader LSHC Industry Leader Deloitte Canada Deloitte Middle East [email protected] [email protected]

Zheng Qun Dr. Wai Chiong Loke Health Care Sector Leader Health Care Sector Leader Deloitte China Deloitte Southeast Asia [email protected] [email protected]

Sebastian Krolop Sara Siegel LSHC Industry Leader Public Sector Health Care Leader Deloitte Germany Deloitte United Kingdom [email protected] [email protected]

Charu Sehgal Steve Burrill LSHC Industry Leader Health Care Sector Leader Deloitte India Deloitte United States [email protected] [email protected]

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