Around the world health policymakers are struggling to ensure high quality, affordable and accessible health care. Technological progress has the potential for further extramuralisation and personalisation of healthcare (`higher quality’) yet often makes health care more expensive (‘affordable’) and may challenge social cohesion, as not all citizens are equally capable of responding to these changes (‘accessible’). This health policy trilemma of balancing quality, affordability and equity is only further exacerbated and highlighted by the Covid-crisis. Rising health care costs reveal that sharp and smart choices must be made to ensure that health care remains affordable while not compromising on quality or accessibility.
EUR and Erasmus MC bring together a combined breadth and depth of expertise concerning health and health care that make them uniquely positioned to make scientific and societal contributions on this theme. To stimulate collaboration between the various schools and departments that provide new, compelling answers to wicked problems in society, the Erasmus Initiative “Smarter Choices for Better Health” (SCBH) was founded in 2017. As we have just started a second round, this is an appropriate moment to take a step back and reflect on the specific role SCBH can play in the landscape of health research at Erasmus University and beyond.
From its start, SCBH has focused on three core research themes: prevention, equity and efficiency. Within our ambition of enabling smarter choices for better health, prioritizing prevention is a natural focus. Smoking, obesity, and excessive alcohol consumption are the three leading preventable causes of death, and the three core targets of the National Prevention Agreement. However, many of those who intend to reduce weight or quit smoking fail to achieve their objective. Why? In a large-scale Randomized Controlled Trial (RCT) among ~650 patients of the Erasmus MC we are currently testing whether combining psychological ‘skills’ with economic ‘stakes’ helps to reduce the gap between intentions and behaviour in physical activity.
Unhealthy behaviours and early disease and mortality are not equally distributed across society. Sharp differences in health do not only exist between countries, but also inside countries and even inside cities. Within Rotterdam for instance, life expectancy can differ by more than 10 years across neighbourhoods (such as Kralingen and Nesselande versus Charlois and Feyenoord), and these disparities tend to grow rather than shrink. Given these disturbing trends, the second core theme of SCBH is equity in health and health care. The theme builds upon the long history of research on health inequalities at both the department of Public Health at Erasmus MC as well as the Health Economics group at EUR. Using large data sets and state-of-the-art empirical tools, the theme measures inequality, and evaluates the effect of policy reforms on health inequality. All this is done to conceive actionable recommendations for policy makers, insurance companies and others to effectively improve health equity.
Finally, the new Dutch cabinet has committed itself to cost containment in health care: ever growing shares of public spending on health care imply the need to make smart choices in care itself, to steer on cost-effectiveness and efficiency. In SCBH, we study efficiency in two ways. First, by incorporating individual preferences in the evaluation of health care, e.g., through measuring the full benefits of interventions and medical technology in terms of well-being. Second, efficiency is enhanced by using quality indicators in provider feedback and payment models to render health care more outcome- and value-based.
The past five years have shown that SCBH can effectively bring together talented researchers from various schools into enthusiastic teams, where the whole is more than the sum of its parts. By building interdisciplinary connections SCBH has opened up new avenues for innovative research in an area of great societal relevance. Figure 1 (see below) is an illustration of the connections that were developed across schools, most of which would not have existed without the funds and opportunities of SCBH. Apart from internal collaborations, SCBH also created links with leading other universities, such as McGill University and Cornell University by appointing two Erasmus Initiative Professors (John Cawley at ESE and Sam Harper at Erasmus MC). This has provided extra leverage to the research inside SCBH and it has also increased the international visibility of EUR’s activities in this domain.
Future research plans
We believe there are ample opportunities to conduct innovative research by continuation of the core themes: prevention, equity and efficiency. For example, whereas the focus of prevention in the first round was mainly on individual barriers to act upon one’s intentions (e.g., self-control, lack of willpower), the ambition now is to pay more attention to the social context in which behaviour is grounded. Likewise, outcome-based health care is still in its infancy, and there are ample opportunities for further experimentation and evaluation.
Arguably the most innovative and policy-relevant work however lies in the integration of the research themes prevention, equity and efficiency. One promising example we foresee is incorporating equity considerations in the evaluation of health and healthcare. Traditional economic evaluations of medical technology and interventions narrowly measure benefits by the effects on average quality-adjusted life years (QALYs). As mentioned, colleagues have started to develop a richer measure of benefits, also including well-being. The idea of SCBH 2.0 is to take this even further by not just studying the effect on average well-being, but also taking into account distributional consequences. How should we think about new medical technology that marginally improves life expectancy but considerably increases inequalities?
A second cross-theme collaboration could lie in alternative payment models to encourage prevention. Currently, provider payment models are exclusively focused on care and cure. Whereas these payment models are increasingly rewarding quality rather than volume, they do not do justice to the call to focus more on prevention. Why can we see a specialist only after we fall ill? Everyone is in favor of more prevention, but can we really expect a societal shift if health care providers remain to be rewarded for treating patients only?
SCBH’s role in the wider landscape
Apart from cutting-edge research within the traditional branches of SCBH, we envision that SCBH can also play an important role in broader initiatives such as Medical Delta and Convergence initiatives such as Health & Technology, Resilient Delta and Healthy Start. Essentially, SCBH entails a mini-convergence between the social and health sciences, and we have developed considerable expertise in conducting interdisciplinary research over the past years. As a result, SCBH is a natural partner in other initiatives who are seeking expertise on prevention, efficiency and equity, and provides an accessible starting point for external researchers from Erasmus MC, Leiden or TU Delft who are struggling to find their way on the Campus of Erasmus University Rotterdam.
More focus on Societal Impact
All in all, SCBH has created a promising position for further development. While its first years were mostly devoted to the development of interdisciplinary connections, in the next phase more effort will be put in enhancing the external visibility and creating more societal impact. This newsletter is a first step towards achieving that goal. However, there many more ongoing initiatives for societal impact, including secondments of junior researchers with societal partners and involvement of SCBH researchers in lifestyle interventions such as “Lekker Fit!” and “Samen Sportief in Beweging”.
In sum, we are looking forward to an exciting future for Smarter Choices for Better Health, where talented researchers develop themselves into thought leaders in health and health care, and where high-quality academic research naturally meets societal impact, either now or in the future.