The healthcare sector defies the logic that governs most industries. Where growth elsewhere signals success, in healthcare it drives the demand for transformation. Growth is not only about patient needs. It is for a large part because organizational structures and incentives push it to grow, not necessarily in line with patient needs. This unpleasant reality has been the foundation of Sander Visser’s career as Managing Partner at PwC Strategy&, who has turned it into a road map for real change.
The Genesis of a Different Vision
Healthcare transformation has been Sander’s constant companion throughout his career. The calls for change have accumulated like sediment- warnings about rising costs consuming GDP, staff shortages threatening service delivery, digitization promising revolution, artificial intelligence offering salvation, and defense expenditures squeezing public budgets. Yet beneath this chorus of concern, Sander recognized that they were missing something fundamental. Without grasping the underlying forces driving healthcare cost growth, any transformation attempt risks shooting at shadows.
His breakthrough moment arrived in 2012. Strategy& was still operating under its former identity as Booz & Company when Sander and his team published “Kwaliteit als Medicijn”- Quality as Medicine. The report didn’t offer incremental solutions or minor adjustments. It challenged the entire framework through which healthcare systems think about cost control.
The thesis was deceptively simple: to curb healthcare costs and not merely chase incremental efficiency gains, we need to focus instead on healthcare volume. If one wants to reduce volume without harming patients, the solution is quality- specifically, clinician-led efforts that stop low-value interventions before they occur. Sander called this approach “Affordable Care,” channeling President Obama’s elegant phrase “saving lives and saving costs.” The counterintuitive heart of his argument remains powerful: less care often becomes the pathway to better care and lower costs.
Dismantling Comfortable Myths
Sander approaches healthcare economics like a detective examining a crime scene where everyone thinks they know the culprit, but nobody has checked the evidence. Take aging populations. People treat rising healthcare demand as an inevitable external force-populations age; aging populations need more care; and costs rise accordingly. The logic appears to be airtight.
The data tells a different story. In the Netherlands, the pure demographic effect of aging, holding medical practice intensity constant, explains only around half a percentage point of yearly growth in total curative care spending. Aging matters, certainly, but it explains far less than what healthcare professionals intuitively believe. Yet this myth persists, maybe because it offers a convenient explanation that requires no uncomfortable introspection.
Innovation presents the second comfortable culprit. Healthcare systems often criticize themselves for being slow to adopt change, yet they can move at a remarkable speed when clinical benefits are clear. Endovascular treatments illustrate this dynamic perfectly. These less invasive procedures benefit patients, but they also expand treatment options to older and sicker individuals who previously would not have been candidates. Innovation therefore doesn’t simply replace existing care. It creates new care by making more care possible. The innovation story contains truth, but again, only part of the truth.
The Grey Zone Revolution
Sander’s deeper insight cuts to healthcare’s core: there is no single, objectively “right” amount of healthcare. Medical practice contains a vast grey area stretching between clear underuse and clear overuse. This grey zone manifests in practice variation that spans countries, hospitals, and even physicians working in the same facility.
The numbers reveal something startling. The spread in practice styles typically dwarfs the incremental, year-on year growth that dominates system-level debates. Practice variation is so pervasive that finding an area without it proves genuinely difficult. John Wennberg, who pioneered variation studies, famously identified hip fractures as one of the few exceptions, precisely because broken hips reflect “true” demand rather than discretionary care.
This perspective fundamentally transforms cost control. It reveals a path to savings that doesn’t sacrifice patients and avoids politically explosive moves like banning innovation, raising co-payments, narrowing coverage, or rationing care for older people or those with chronic illness. The realistic lever lies in reducing overconsumption and low-value care- interventions that don’t improve outcomes or align with informed patient choice.
Sander emphasizes a practical truth: while quality proves hard to define abstractly, professionals often easily recognize the opposite: low-value care in their daily work. This recognition becomes transformative when incentives shift. Systems that reward activity encourage providers to drift upward within the grey zone. Systems that protect and reward appropriate care transform that same grey zone into a wellspring of sustainable improvement.
When Patients Choose Less
Theory becomes reality in stories like Bernhoven Hospital. Sander’s team supported this Dutch facility in implementing shared decision-making- the systematic practice of informing patients about benefits, risks, and alternatives while genuinely inviting them to choose. This represents more than a procedural shift. It transforms the relationship from informed consent to informed choice.
The impact materialized immediately. Surgery rates declined by 15 to 20 percent on average. This wasn’t rationing or denial. Fully informed patients simply chose less invasive options more frequently when they understood their choices. Patient experience improved. Outcome measures held steadily or improved. The quality went up while the volume went down.
Then the existential question emerged. A 15 to 20 percent volume reduction might delight health economists, but for an individual hospital it threatens survival. Dutch hospitals operate as not-for-profit organizations with margins of just 2 to 3 percent. A sudden volume drop can destabilize the entire enterprise.
Sander’s response extended beyond quality initiatives into economic architecture. His team supported payer-provider partnerships that guaranteed income stability, allowing hospitals to reduce volume without facing financial collapse. The approach changed the fundamental economic conditions so that doing the right thing became financially viable rather than suicidal.
A national macro-economic government body later confirmed that 10 to 15 percent volume reductions across the entire bandwidth of provider care are achievable, opening up a tested and credible pathways to sustainable health care. The potential isn’t theoretical. Sander’s team has worked with dozens of providers and payers to capture these benefits, scaling the approach from individual contracts to full regional healthcare systems like Zeeland in the southwestern Netherlands.
The Incentive Puzzle
Experience since 2012 has taught Sander humility alongside success. Two “loose ends” particularly occupy his thinking. The first concerns incentives themselves. Protecting providers from the financial consequences of doing the right thing, through lump sum guarantees or multi-year income stability regardless of volume, encourages appropriate care. The results often match hopes: volumes decline while quality rises. Clinicians exercise professional judgment without organizational punishment.
Yet a deeper problem lurks beneath this success. Systems cannot guarantee budgets indefinitely. Hard lump sum budgeting eventually creates access problems and efficiency pressures. Steering efficiency requires basing payments on resource consumption. The moment payments link to activity levels, volume incentives quietly return through the back door. Fee-for-service represents the clearest case, but even softer systems like DRGs or per-patient payments preserve the basic logic that more activity generates more income.
Sander has made considerable effort in improving healthcare incentives and costing models balancing incentives for appropriate care and efficiency. Yet he has reached a sobering conclusion: payment models alone cannot simultaneously encourage both efficiency and appropriate care to the degree needed to achieve system level equilibrium. The solution requires more.
The Unstoppable Growth Machine
The second loose end proves equally illuminating. Even where incentives improve and volumes decline, the organizational urge to grow persists with surprising force. In payer-provider partnerships that Sander’s team supported, DRG-weighted production fell significantly, sometimes by 20 percent. Costs and capacity did not follow the same trajectory.
Sander never expected a perfect correlation between volume and cost reductions. What startled him was this: even after delivering substantially less care, hospitals continued experiencing nearly identical numbers of requests for additional staff positions. Somehow, fewer treatments, admissions, and visits still translate into growth pressure.
This revealed the power of organizational reality. Consider night and weekend shifts. Workload doesn’t depend solely on patient numbers or treatments; it depends to a large extent on shifts themselves. Reducing volume doesn’t eliminate nights and weekends. Hiring more professionals makes the burden simply bearable. Beyond shifts, innovation capacity grows with organizational size. Also, quality standards continuously rise, driving demands on the number of staff and the number of subspecialties that need to be present at any time.
Hence, organizations need growth for organizational needs, and the grey zone puts little restrictions from a demand perspective on that growth.
Building the Future Framework
The next transformation wave requires more than technology, Sander believes. He believes in the enormous potential of digitization and AI. But, if not properly managed, it will be destined to racket health care up into the grey zone leading to overexpansion It demands governance models that empower professionals and reward appropriate care. At PwC Strategy&, he works to guide organizations through this transition with two primary focus areas.
First, healthcare systems must reward providers who consistently deliver appropriate care, not just through payment but by channeling patients toward them. This addresses a genuine paradox: doing the right thing often means becoming smaller, with cascading consequences. Scale diminishes, staffing becomes fragile, covering subspecialties and shifts grows difficult, and investment capacity shrinks. For the best providers to lead transformation, systems must enable them to grow through appropriate care by shifting contracts and patient flows without increasing wait times or sacrificing quality. This requires system-wide transparency on quality and appropriate care.
Second, healthcare systems need practical mechanisms to replace obsolete infrastructure with modern digital infrastructure while limiting political and economic friction. Healthcare struggles to wind down ineffective infrastructure, simply because ineffective infrastructure also tends to attract demand in the grey zone. In the absence of wind-down, the economic burden on health systems doubles as new infrastructure arises alongside existing infrastructure.
The Governance Imperative
Healthcare transformation is fundamentally a governance challenge. The task involves designing systems where better care produces less care and where superior care models scale. Meaningful transformation begins with a deceptively simple question: why does healthcare grow, and what is that growth compensating for?
Sander’s work reveals that answers are complex but not mysterious. Healthcare grows because organizational realities exist alongside patients’ needs. It grows because incentives reward activity over appropriateness. It grows because quality improvements consume resources, and professionals deserve sustainable working conditions. It grows because innovation creates possibilities, and the grey zone of medical practice permits substantial variation in what qualifies as necessary care.
Understanding these dynamics redirects leadership focus. The path forward isn’t primarily about payment models or digital tools, though both matter. It’s about creating conditions, where doing right by patients becomes financially viable for providers. It’s about building transparency into practice variation so that professionals can identify low-value care. It’s about governance structures that enable the best providers to expand while others adapt or transition.
Through PwC Strategy&, Sander continues refining and implementing this vision across healthcare systems. His approach offers something increasingly rare in healthcare policy: a path to lower costs without rationing, a strategy for improvement that empowers rather than constrains professionals, and a framework for transformation that acknowledges rather than denies organizational realities. He poses the question that should guide all transformation efforts- not how to do more with less, but how to do better with appropriate. In answering it, he’s rewriting healthcare’s fundamental equation, one counterintuitive truth at a time.
