Healthcare Covidential: is the solution for our healthcare problems already amongst us?
The Covid19-pandemic doesn’t only puts our focus on the vulnerability of man (or woman) as individual, but also on the vulnerability of our healthcare. Although Covid19 is a unique ‘case on it’s own, the regular challenges in healthcare have been known for years. So why didn’t we prepare ourselves better? Didn’t we invest enough in capacity on IC’s or preventive healthcare? Or have the seeds for the solution already been planted and tested, but haven’t found enough time and opportunity to grow? And if so, why is that and what are the advantages for patients, healthcare insurers, hospitals, investors, all of us, to let these seeds grow? In the last months we all have seen and felt what the effects on our lives are when our healthcare is at risk. I am convinced that with impact investing in healthcare a big difference can be made to benefit all stakeholders.
The ‘regular’ healthcare challenges are well-known. Waiting lists for patients is one of the most pressing ones. The lack of intensive care units was the most ‘eyecatching’ during the first phase of the Covid19-pandemic, but it is only a little piece of the far bigger healthcare picture. Nevertheless a good starting point. The Dutch government saw the necessity for more efficiency and innovation for keeping healthcare affordable and accessible with a rising demand due to an aging population. It therefore started the Society Impact ‘worktank’ to encourage new ways of thinking and working(1). One of the most important instruments that Society Impact put into practice is a health impact bond, an instrument to connect all stakeholders and to share the gains amongst all stakeholders.
How does it work?
With a Health Impact Bond (HIB, or Pay for Success contract) impact investors invest in a project that delivers societal gains in (investing in more intensive care units for example resulting in reduced waiting lists). The investors get their return if saving targets are met. In this way healthcare organisations and the government can test more new innovations and scale up the ones that are effective.
So if a government budget is limited, private investors looking for societal and or financial return can take part in improving healthcare, benefitting everybody. That is promising because in this way not only lives can be saved in times of crisis, but also in the future by reducing waiting lists, improving working (circumstances) for healthcare personnel, so all-round improvements in care, for all.
The (achieved) savings are used to payback the investors by the so-called outcome payer, in most cases a healthcare-insurer or outcome-fund. Savings can be for a example less hospital stays. The Jeroen Pit-House in Amsterdam, where seriously ill children in need of longterm hospital care are treated is a good example. The children are now treated on intensive care units, because there is no special care for them, but intensive care is not really necessary. The Jeroen Pit-House is especially built to help these children and their families, providing a better ‘transfer’ from hospital to eventual home care. By using a Health Impact Bond it will be easier to built more of these facilities around the country. The result: healthcare is improved by helping the children and their families, but also by freeing up expensive intensive care units, reducing waiting lists.
Healthcare can be improved, with the help of investors. This example from the United States proves it. The Ashtma-bond-pilot (“Aim4fresno”) in Florida is designed to give Asthma-patients better care at home via coaching received from a non-profit-coach. Ashtma-patients have to go less often to the Emergency (Eerste Hulp) of the hospital. This improves the wellbeing of Ashtma-patients and reduces costs at emergency rooms, which can be invested in better patient care elsewhere or scale-up the non-profit coaches, helping even more Ashtma-patients.
Result: a drop of 68% in EH-visits by Ashtma-patients, 84% less hospital admittances and a return of around 180% for social investors. Although these figures were realised on the basis of a small sample, it has lead to more similar projects in the U.S. But also in the UK and the Netherlands more of these projects are coming.
Challenges and possibilities
If this concept works so well, why hasn’t it been used more often? Although it has been piloted on small scale in the Netherlands since 2015, there are still many professionals in healthcare, health-insurance and investments that are not familiar with the concept. The most important challenge is that investors can’t find enough projects that fit their existing portfolios and the idea that higher costs are involved (measuring the impact) than other investments. The Ashtma-bond example shows that the societal and financial advantages are big enough to easily make up for the extra costs of measuring the impacts.
Another challenge is that healthcare budgets are mainly focussed on curing and caring for sick patients, not on the prevention of becoming sick. The National Prevention Agreement agreed upon in 2018 is a good start for planning and budgetting more towards prevention. A new way of looking at prevention by the agreement-partners will lead to more projects that are suitable for (co-)investment by private investors. That is a challenge often heard from investors, that there aren’t enough suitable projects (size, investment-horizon) (made) available to invest in for social impact. The instrument health impact bond is ideal for bringing all stakeholders working on prevention together. With the government spending 83 Billion Euros on healthcare every year ( forecast to rise to 127 Billion in the coming years (without Covid-investments(3) there is ample room to use the health impact bond more and help all stakeholders.
Areas where Health impact bonds can be of further uses besides more intensive care units are for instance(4):
- Preventable Asthma, COPD, Diabetes
- ‘super-users’ of emergency rooms at hospitals etcetera
- Preventive oral health
- Preventing readmissions
- Prevention of Mental illness
Benefits for all
For investors it is a diversification from the turmoil on financial markets and an opportunity to invest in the UN’s Sustainable Development Goals (SDG 3 health care and well-being). Many pension funds are still busy rearranging their portfolio’s according to the UN’s SDG’s so not much information is available. But the ABP fund, one of the biggest in the Netherlands, invested between 2015–2019 65 billion Euros into the SDG’s, of which 15 billion in SDG 3. Until 2025 it aims to grow the SDG-part of the entire portfolio to 20% . That gives an indication of the good opportunities. Health care insurers can do more for their clients and healthcare in general will benefit, patients waiting lists will be reduced, more patients will be helped in the coming years and sickness prevented and allround more care, time for patients.
How can we change this?
So how can we improve the current healthcare system for the better? By piloting more health impact bonds and upscaling those with positive results. More organizations need to learn about thinking different about funding health care projects. With the signing of the National Prevention Deal national parties have made a good step forward to better health and wellbeing in the Netherlands, focusing more on preventing illness than healing the sick, where most of the health care budget is still spent. But even more is needed with the expected growth in government spending from 83 Billion to E 127 Billion Euros in 2040. I’m convinced that with all creativity available and the investment funds looking for opportunities we will be able to make big changes for the better in health care, for all.
The last weeks and months have shown all of us how important healthcare is. If this isn’t the time to invest more in it, to improve healthcare and share benefits with all stakeholders, will there ever be a better time?
Harald Machielse is founder of Chuva Consulting and on a mission to reinvent healthcare by facilitating impact investments to secure waiting lists are a thing of the past and everyone has access to the help they need. For the City of Amsterdam he worked on a health impact bond business case. Want to know more? Send an e-mail to email@example.com
 They are not a standard think-tank, they also put their ideas into practice.
 National Library of Medicine: https://pediatrics.aappublications.org/content/129/3/465
 RIVM (Dutch Healthcare Research Institute: Future forecast healthcare spending 2015–2060
 ‘Building the Foundation for Health Impact Investing’, Collective Health(US) LLC, May 2013
 Sustainable Investment Policy ABP since 2020 https://www.abp.nl/images/abp-dvb-beleid-samenvatting.pdf