Abstract Introduction - Porter and Olmsted Teisberg suggested that the value of healthcare should be measured by treatment outcomes related to costs. Policy should financially reward treatment effects and in an outline of value-based healthcare, they predicted: 1. State control policy yields variable effects, increasing costs 2. Low price policy decreases effects, increasing costs 3. Research and Development (R&D) policy increases effects, decreasing costs Methods - The treatment of eating disorders in Region Stockholm, Sweden, in years 2012-2016 makes it possible to test these predictions because a State control, a Low price, and an R&D provider were contracted and the effects and costs of their treatments are publically available from Region Stockholm. Results - The State control provider was contracted to provide more care services than the other providers. The average yearly number of patients treated to remission/patients treated was 164/714 (23%) at the State control provider, 41/170 (24%) at the Low price provider, and 152/192 (79%) at the R&D provider. The average yearly budget was 73 M Swedish crowns (SEK) compared to 49 MSEK at the R&D provider and 32 MSEK at the Low price provider (on average 30% lower per care service than the two other providers). The average cost to treat a patient to remission/patients treated was highest at the Low price provider (859 KSEK), followed by the State control provider (464 KSEK) and the R&D provider (327 KSEK). Conclusions - The results confirm Porter and Olmsted Teisbergs three predictions and suggest that an R&D policy increases the value of healthcare.

Complete openness concerning financial arrangements is intended here. Brodin declares that he has no financial interests associated with this manuscript. Our research is carried out at the Karolinska Institute, where Sodersten is an emeritus professor. The research is translated clinically by Mando Group AB, a company started by Sodersten and Bergh, who have 47.5% of the stock each. Professor Michael Leon of the University of California at Irvine has 5%. Mando Group AB contracts with Region Stockholm every 4-6 years to treat patients with eating disorders. Mando Groups AB signed its first contract in 1997 with Region Stockholm and, since then, its treatment is one of the standards of care treatments offered to the citizens of Stockholm. This arrangement is the same as when Region Stockholm contracts with its own clinics to treat patients with all kinds of disease, including eating disorders. That is to say, Region Stockholm provides eating disorder services to the citizens of Stockholm both through a clinic of its own and through Mando Group AB. Until recently, there was a third provider of care for patients with eating disorders in Stockholm, which was a private clinic. Mando Group AB is the biggest provider of eating disorders services in Sweden as of 2019. All healthcare in Sweden is funded through the tax system; private pay is extremely uncommon. It should be added firstly, that Mando Group AB is in compliance with the recommendation of the International Committee of Medical Journal Editors on Author Responsibilities-Conflicts of Interest http://www.icmje.org/recommendations/browse/roles-and-responsibilities/author-responsibilities--conflicts-of-interest.html. Secondly, it should also be added that all profit that Mando Group AB has made has been re-invested in research and development and that there have been no dividends to stock owners. All of the above is declared in all manuscript submissions and thus far, journals have judged it necessary to publish only some of the details. It seems, however, that the potential ethical problem when scientists translate their research findings into the clinic in a company is not unlike that which arises when any scientist, in an academic setting is developing a theory and needs further economic funding for her/his work and may receive recognition and financial benefits for the work. The incentive is, in part, economic in this case as well and the ethical problem is similar in both cases. However, the more important incentive is the improvement of the treatment of patients with eating disorders. We are researchers working in an academic setting and like many other medical research institutes today, the Karolinska Institute encourages scientists to translate their research into the clinic in companies that aim to generate financial profits to be used for research and development (see: Strategy 2030 creating Karolinska Institutet's future together | Medarbetare (ki.se)

Mando Group AB supports the work. Please consult the competing interests statement for details.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

It was not considered necessary to obtain ethical permission because all data are publically available from Region Stockholm at: https://www.regionstockholm.se/om-regionstockholm/Information-in-English1

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All data produced in the present work are contained in the manuscript