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It was the waiting that drew the attention of the Stockholm County Council. In 2008, patients seeking a hip or knee replacement in Stockholm County faced wait times of up to two years of sometimes debilitating pain, intermittent missed work and income, and the trials of disability. Seeking a new model to lower wait times, but also improve patient choice of care, County Council Senior Medical Adviser, Dr. Holger Stalberg, set out to create a bundled payment system for hip and knee replacements in the County. The new model, called OrthoChoice, was set to go into operation on January 1, 2009.

By the end of 2008, all major hospitals (one of which was private) and three private specialized orthopedic centers signed OrthoChoice contracts. In 2009, hip and knee replacements in the County of Stockholm for relatively healthy patients began being reimbursed. By 2013, OrthoChoice had covered 12,531 hip and knee replacements, accounting for 59% of such operations for county residents. Total payments were SEK 704.5 million ($109.4 million). Dr. Holger Stalberg and his team at the Stockholm County Council (SLL) were reviewing the results of the new payment approach and considering how to improve the model.

In 2014, Dr. Charles D. Fraser Jr., Surgeon-in-Chief of Texas Children's Hospital in Houston, was contemplating the future direction of the congenital heart disease program. The nation's largest pediatric hospital, Texas Children's was ranked by U.S. News & World Report as #4 in the nation in 2012-2013. It was ranked #3 in pediatric heart care and heart surgery, following Boston Children's and Children's Hospital of Philadelphia (CHOP). Texas Children's had some of the highest volumes in the nation, seeing more than 20,000 congenital heart disease patients and performing over 800 cardiac surgeries annually. Fraser led the reorganization of Texas Children's care for congenital heart disease conditions beginning in 1995, and had initiated universal outcome measurement. In 2014, the challenge was to continue to improve care in a complicated patient population, and take outcome measurement to a new level. Also, Texas Children's had recently formed partnerships with pediatric hospitals in Temple, San Antonio and Mexico City, and how to structure these partnerships was under active discussion.