Investing in value-based primary care: a pathway to sustainable healthcare

The existing primary healthcare systems in most industrialized countries primarily focus on treating diseases reactively, a model ill-suited to address the growing epidemic of lifestyle-related chronic diseases in an aging population. Currently, >65% of people over 65 have two or more chronic diseases such as cardiovascular disease, stroke, cancer, fatty liver disease, chronic kidney disease, and cognitive impairment, predominantly driven by abdominal obesity, unhealthy diets, sedentary lifestyles, smoking, and poor sleep.1,2 Up to 80% of these common chronic diseases can be avoided,3 yet they are frequently not effectively prevented or managed according to clinical best practices once diagnosed. This mismanagement has led to unsustainable, escalating healthcare costs, threatening to cannibalize state revenues entirely by 2050, leaving no government funding for other essential services.4 A pioneering value-based primary care model, the Osana experiment, was piloted in Sydney (Australia) between 2018 and 2021, demonstrating superior health outcomes and a positive return on investment if scaled across Australia’s healthcare system. Philanthropic funding established a social enterprise, which operated three prevention-based medical centres and a centralized lifestyle medicine clinical facility. Over 6000 patients participated in this three-year, ethics-approved trial, signing informed consent to test the impact of this innovative primary care model on patient outcomes and system sustainability. As summarized in Figure 1, the three key elements of this model are as follows: Preventative medical approach: this value-based primary care model emphasized proactive health assessments, risk stratification, chronic disease planning, regular check-ups, and continuous support from a care team that includes a general practitioner, a care manager (nurse or allied health professional), a health assistant, and a health coach. Patient activation: a suite of services and resources, including educational workshops, lifestyle classes (exercise, nutrition, and meditation), shared medical appointments, community groups, and home support, were provided to activate patients in managing their own health and well-being. Data science and gamification: routine collection and analysis of metrics such as hospital admissions, chronic disease biomarkers, wellness measurements (activity levels, nutrition, sleep, and mental health), and patient activation measures were collected via an app-based e-health platform and used for proactive population management. Value-based, preventative primary healthcare model Clinicians received a salary and bonuses for improving predefined patient outcomes, while patients were rewarded for achieving set health goals. One of the most striking preliminary outcomes of the Osana experiment was a 51% annual reduction in hospital admissions (Figure 2). Significant improvements were also observed across various cardiometabolic, lifestyle, and clinical outcomes. For example, patients with chronic conditions such as diabetes, hypertension, and cardiovascular disease showed marked improvements in the following measurements: HbA1c: the proportion of patients meeting a 7% target for HbA1c increased from the Australian diabetes population average of 25% to 81% among diabetes patients enrolled in the Osana experiment. Blood pressure (BP): the percentage of patients with hypertension achieving a clinical target of BP <140/90 mmHg rose from the Australian hypertension population average of 32% to 69% among those enrolled in the Osana experiment. Cholesterol and blood pressure: the percentage of patients with cardiovascular disease achieving clinical targets of total cholesterol <5 mmol/L and of BP <140/90 mmHg increased from the Australian cardiovascular disease population average of 42% to 81% among those enrolled in the Osana experiment. Clinical outcomes of the Osana experiment. 1Admissions were weighted by type: intensive care unit admission (2), in-patient admission (1), and ED short stay admission (0.5). 2Individual-specific exercise goals were set according to national exercise standards, appropriate for each individual’s age and capacity, and defined as moderate performance based on the International Physical Activity Questionnaire survey. For our predominantly elderly patient cohort, meeting exercise targets was generally defined as moderate level exercise on the International Physical Activity Questionnaire, which includes any of the following: (i) 3 or more days of vigorous intensity activity and/or walking for at least 30 min per day; (ii) 5 or more days of moderate intensity activity and/or walking for at least 30 min per day; (iii) 5 or more days of any combination of walking, moderate-intensity, or vigorous-intensity activities achieving a minimum total physical activity of at least 600 metabolic equivalent minutes per week. 3Patient Activation Measure is a validated health activation survey (UK-PAM). Each 1-point increase in Patient Activation Measure is equivalent to a 3% reduction in healthcare costs. TC, total cholesterol; BP, blood pressure in mmHg Additionally, the rate of obesity decreased by 11% among those with a body mass index >30. There was also a 21% improvement in functional arthritis scores, as measured by the Oxford hip and knee survey. Patients increased their clinically recommended exercise levels from 15% to 60%, reduced psychological distress by 21% (as measured by K10 scores), and lowered smoking and alcohol dependency by 21% among those with moderate to severe dependency (Figure 2). The Patient Activation Measure (UK-13 PAM survey) improved by 26%, translating into reduced long-term hospital admission risk, lower chronic disease exacerbation, improved quality of life, and reduced premature death rates. Despite the positive health outcomes, the experimental Osana model of care costed ∼A$2000 per patient annually compared to a mean A$500 per annum in Medicare reimbursement for the average Australian. The total expenditure of A$10 million in philanthropic funding resulted in a net operating loss of A$1.5 million per year, even though patients paid annual membership fees of A$200–400. However, the model still delivered a positive return on investment due to its significant reduction in healthcare utilization, particularly hospital services. With an estimated average hospital visit in Australia costing A$6,000, the model’s ability to lower hospital admissions and improve health outcomes translates to estimated savings of over A$9 million per annum with 6000 patients. This results in an ∼6× return on investment per annum. Applied across the entire Australian healthcare system, this innovative, value-based, preventative primary healthcare model may save over A$30 billion annually, enough to manage two COVID-19 pandemics each year. The preliminary findings of the Osana experiment that need to be replicated in a larger randomized clinical trial support the efficacy of preventative, personalized care, and the urgent need to reconfigure and adequately fund healthcare systems that promote ‘chronic health’. Ensuring financial sustainability requires vertical integration with hospital systems and health insurers, allowing savings from reduced downstream services to support this holistic, preventative, value-based model. As the world contends with aging populations and a new pandemic characterized by extended morbidity among younger generations due to rising obesity and unhealthy lifestyles,5–7 care models like the one implemented in the Osana experiment may offer a viable solution. Integrating such models with early health education pathways in primary, secondary, and tertiary schools, as well as in community health centres, adds significant value.8 Shifting from a reactive approach, which primarily treats diseases after they occur, to one that promotes health throughout life via value-based preventative care9 in primary settings can lead to better health outcomes, reduced hospitalization, increased patient and doctor satisfaction,10 a healthier society, and substantial cost savings. This transition is crucial for promoting equitable access to high-quality care and ensuring the future sustainability of our healthcare systems. All authors declare no disclosure of interest for this contribution. Data available on request. L.F. is supported by grants from the Australian NHMRC Investigator Grant (APP1177797), Australian Youth and Health Foundation, and Bakewell Foundation. Osana was established as a B-Corporation social enterprise solely to seed research and develop a new preventative, value-based primary care model; its clinics have since been sold. An independent data analyst, Tim Rogers, was contracted to review results from 6000 participants during this experimental phase, culminating in the outcomes described in this paper.