May 2017 TOWARDS EXCELLENT PATIENT VALUE HAS NEVER …€¦ · healthcare professional and the society p. 22 From measuring to knowledge to value p. 24 Putting VBHC into practice:

WORKING

TOWARDS

EXCELLENT

PATIENT VALUE

HAS NEVER BEEN

MORE PROMISING

THAN IT IS TODAY A DISTINCT APPROACH TO VBHC IMPLEMENTATION

VBHC

THINKERS

MAGAZINE

VBHC Prize 2017

Edition

May 2017

@VBHCEurope Value-Based Health Care Center Europe

CONNECT CREATE SHARE

“One of the innovative things happening in The Netherlands, that we don’t see in many

places around the world, is the existence of VBHC Center Europe.”

– Prof. Michael E. Porter –

www.vbhc.eu

Join the community!

The European platform for VBHC implementation

Become a member of VBHC Center Europe & Expand your VBHC network

Membership benefits: • Unlimited access to breakthrough VBHC articles; • Free personal advice on the best suitable education;

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FEATURES

4 VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION | MAY 2017

Interview

p. 12 Michèle van der Kemp

p. 26 Prof. Dr. Jan Hazelzet

Expert Blog

p. 14 Competition based on quality

makes good sense

p. 20 Value for the patient, the

healthcare professional and the

society

p. 22 From measuring to knowledge

to value

p. 24 Putting VBHC into practice: CZ

Group moving towards value-

based health care procurement

Perspective

p. 6 Ten years of VBHC

implementation

p. 8 A new skill set for value-based

health care

p. 16 Five reasons why value-based

health care is beneficial

VBHC Prize

p. 28 Meet the nominees

p. 32 VBHC Prize winner 2016

p. 19 VBHC Prize applications 2017

VBHC Thinkers Magazine

is now available in the following versions:

Print: Get acces to a print copy via

[email protected]

Digital: www.vbhc.eu

Editors

Fred van Eenennaam

Tahita Ringers

Publisher

Value-Based Health Care Center Europe

Designed by

Tahita Ringers

VBHC Thinkers Magazine serves a

catalyst for the VBHC community in

collaboratively working towards excellent

patient value. Through sharing best practices

and the latest insights in VBHC

implementation, VBHC Thinkers Magazine

aims to inspire the VBHC community to push

VBHC implementation to the next level.

VBHC Center Europe is the European

platform for VBHC implementation. Sharing

implementation experiences, connecting the

VBHC community and creating new

collaborations are the goals of the VBHC

Center Europe.

#VBHCPrize2017

mailto:[email protected]



http://www.vbhc.eu/

http://www.vbhc.eu/

http://www.vbhc.eu/

http://www.vbhc.eu/

http://www.vbhc.eu/

MAY 2017 | VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION 5

CONTENT

Ten years of VBHC implementation

Prof. Dr. F. van Eenennaam – Chairman of VBHC Center Europe

A new skill set for Value-Based Health Care

Prof. Sir M. Gray – Better Value Health Care

The 360° health care manager – Michèle van der Kemp

T. Ringers – VBHC Center Europe

Competition based on quality makes good sense – Dr. R. Dillmann

Bianke Buursma – Isala

Five Reasons why Value-Based Health Care is beneficial

M. Fakkert, Prof. Dr. F. Van Eenennaam & V. Wiersma

Value for the patient, the healthcare professional and society

Dr. B. Geerdes – Zilveren Kruis

From measuring to knowledge to value

L. van der Tang - VitalHealth Software

Putting VBHC into practice: CZ Group moving towards Value-Based Health Care Procurement

R. Soffers & J. Verlind – CZ Group

Value-based patient involvement – Prof. Dr. Jan Hazelzet

T. Ringers – VBHC Center Europe

Meet the Nominees - VBHC Prize 2017

L. Oudt – VBHC Center Europe

VBHC Prize Winner 2016: One year later, what did the VBHC Prize bring?

L. Kuijten-Slegers & A. Lenssen – Catharina Hospital & CZ Group

6

8

12

14

16

20

22

24

26

28

32

.


EDITOR’S LETTER

In 2006, Harvard Professor Michael E. Porter and Prof. Elizabeth Olmsted Teisberg first introduced the concept of

Value-Based Health Care (VBHC). During the following ten years, VBHC has provided fundamental insights into

creating excellent patient value.

Europe has its own unique way of providing health care, which has led to a distinct approach to VBHC

implementation. Doctors and medical teams are in the lead in the transition toward value-based care. Working

towards excellent patient value has never been more promising than it is today!

Ten years ago, the Value-Based Health Care Center Europe began pioneering VBHC implementation in Europe.

With a network of more than 5,000 practitioners in Europe and worldwide, the VBHC Center Europe facilitates

people with an interest in VBHC to connect, create and share VBHC best practices: from hip and knee

replacements, oncology and cardiology to chronic and internal care.

To mark the 10th anniversary of VBHC, the Value-Based Health Care Center Europe is excited to announce the

VBHC Prize Edition of the ‘Value-Based Health Care Thinkers’ Magazine 2017. We are excited to bring together

leaders in VBHC to give an up-to-date view of this exciting and rapidly moving field. In this edition, you can expect

to read about the latest developments, best practices and experiences in the field of VBHC implementation. The

goal of this magazine is to serve as a catalyst for new ideas and future growth as VBHC enters its second decade.

As we move to a next phase of VBHC we must consider the challenges ahead, such as horizontal implementation of

VBHC and creating subpopulation based payments. Thank you for being a friend in implementing VBHC in the

past decade. I look forward to continuing this journey together with you.

10 Years of VBHC Implementation By Prof. Dr. Fred van Eenennaam

Prof. Dr. F. van Eenennaam

Chairman VBHC Center Europe Non-voting Chairman VBHC Prize


VBHC EDUCATION

Seminar: Redesign healthcare delivery processes

according to the value-based model

Cerismas | Rome, Italy

May 15, 2017

You will have the chance to listen to distinguished

international speakers (Richard Siegrist, Harvard University

and Pamela Mazzocato, Karolinska Institute) and to

understand the different perspectives involved.

Summer School: VBHC – Learn from the best

The Decision Institute | Amsterdam, the Netherlands

July 14, 2017

During this Summer School several best practices in VBHC

implementation, such as the Cleveland Clinic (USA) and the

Martini Klinik (Germany), will be discussed. These

organizations are worldwide renowned for their superior

outcomes on healthcare delivery. Detlef Loppow, CEO of the

Martini Klinik, will be guest speaker. He will speak about the

way the Martini Klinik has implemented VBHC.

Summer School: VBHC – Advanced Strategies

The Decision Institute | Amsterdam, the Netherlands

August 25, 2017

VBHC implementation is much more than measuring

outcomes for a certain medical condition. How do you

incorporate VBHC in your healthcare organization’s strategy?

How do you implement VBHC in your organization? During

this Summer School, the most recent Harvard Business cases

‘Oak Street Health: Value-Based Primary Care’ and

‘Vanderbilt: Transforming a Health Care Delivery System’

will be the base of for discussing various strategies for VBHC

implementation.

6th World Congress of Clinical Safety

IARMM | Rome, Italy

September 6-8, 2017

Rome Congress is organized by IARMM to develop highly-

advanced, safe and clean science and technology. The

congress covers a wide range of safety topics, such as clinical

safety (patient safety, medication safety, medical device

safety), infectious disease outbreak, disaster health care,

clinical crisis governance, environmental health & safety, food

safety, and other related safety subjects.

2017 ICHOM Conference – Global Progress on the

Value Agenda

ICHOM | Washington DC, USA

October 25-26, 2017

Globally, Value-Based Health Care (VBHC) is transforming

practice and informing both payment and policy. As

innovative organizations from across the health sector unite

around a common aim of optimizing outcomes for patients,

each has come to understand the respective role they must

play in driving the value agenda.

With this in mind, we invite you to join health system leaders

from around the world for the 2017 ICHOM Conference,

where we will discuss progress and perspectives on value,

with overarching plenaries from international experts and

breakout sessions targeting topics critical to enabling and

accelerating the shift to Value-Based Health Care.

Value-Based Health Care Delivery: An Intensive

Seminar for Students & Practitioners

Harvard Business School | Boston, USA

January 8-12, 2018

There is growing recognition that true healthcare reform will

require major strategic and organizational changes in the way

health care is actually delivered, measured, and reimbursed.

As described in the book Redefining Health Care, by Michael

Porter and Elizabeth Teisberg, value for patients can be

measured by the health outcomes achieved per dollar spent.

Value-based, health care delivery concepts start with

providers but encompass new strategies for health plans,

employers, and government. Prof. Porter and the institute

have developed a weeklong, intensive seminar focused on

frameworks, application tools, and case studies highlighting

real-life examples of organizations moving toward value-

based care delivery models.


PERSPECTIVE

The core training of clinicians focuses on clinical

practice. More recently research has been added to the

curriculum and, for a small proportion of clinicians,

management skills, but the sharp distinction between

‘managers’ and ‘clinicians’ is unhelpful. It is

increasingly recognised that it is better to speak about

’people who manage health care’ many of whom are

clinicians with both clinically and non-clinically trained

people involved in management learning, a set of skills

that focuses on evidence-based decision making,

quality improvement and cost reduction as well as the

principles of general management, because ideas and

insights from other industries are very relevant to

people working in the Health Service.

It is also important to distinguish between leadership

and management with most people now agreed that the

basis of distinction is that leadership creates the culture

of the organisation, whereas managers work within that

culture so people involved in leadership, and many

people who manage health care are part of the

leadership and need to be thinking about how they

promote the culture of Value-Based Health Care as well

as helping the services work in a different way.

The Value Transformation

Tremendous progress has been made over the last forty

years due to the second healthcare revolution, with the

first healthcare revolution having been the public

health revolution of the nineteenth century. Hip

replacement, transplantation, and chemotherapy are

examples of the high tech revolution funded by

increased investment and, in the last twenty years,

optimised by improvements in prevention, quality,

safety and evidence-based decision making.

However, there are still three outstanding problems

that are found in every health service no matter how

they are structured and funded. One of these problems

is huge and unwarranted variation in access, quality,

cost and outcome, and this reveals the other two:

Underuse which always results in:

● Failure to prevent the diseases that health care can

prevent and may also aggravate

● Inequity

Overuse which always results in:

● waste, that is anything that does not add value to

the outcome for patients or uses resources that

could give greater value if used for another group of

patients and may also result in

● patient harm, even when the quality of care is high.

In addition, services will have to cope with the rising

need and demand without additional resources. What is

needed is a focus on value which has three aspects, one

of which focuses on the individual, with two relating to

the population’s health:

1. Personalised value, determined by how well the

outcome relates to the values of each individual.

2. Allocative value, determined by how well the assets

are distributed to different sub groups in the

population;

3. Technical or utilisation value, determined by how

well resources are used for outcomes for all people

in need in the population.

A New Skill Set for Value-Based Health Care By Prof. Sir M. Gray – Founder of Better Value Health Care


PERSPECTIVE

What is needed to increase value is to continue with the

processes that have increased effectiveness and value in

previous decades namely prevention, evidence-based

decision making, quality improvement and cost

reduction. But more of the same, even better, quality,

safer care is not the answer. The focus has to be on

value, on better value for individuals and populations.

To achieve this we need three new activities:

I. Increasing personal value by ensuring that by

providing people with full information about the

risks and benefits of the intervention being

offered.

II. Increasing value for the population by increasing

investment in budgets for populations in which

there is evidence of underuse and inequity by

shifting resource from budgets where there is

evidence of overuse or lower value interventions.

III. Developing population based systems that:

Address the needs of all the people in need,

with the specialist service seeing those who

would benefit most;

Increase rates of higher value intervention

(underuse) funded by reduced spending on

lower value intervention (overuse) e.g.;

shift resources from treatment to

prevention or polypharmacy to district

nursing;

Implement high value innovation

(underuse) funded by reduced spending on

lower value intervention (overuse).

This also requires new skills and concepts and training

is needed to help people answer questions such as:

● What do you understand by the term complexity?

● What is meant by the term system and how does it

differ from a network?

● What is meant by population-based health care

rather than bureaucracy-based care?

● What are the three meanings of the term value in

21st century health care? Not ‘values’ as in ‘we value

diversity’ but the economic meanings.

● What is the relationship between value and

efficiency?

Value-Based Health Care embraces evidence based

decision making and quality improvement but is a

broader concept. It is the future and the future is

already here but just not evenly distributed.

A new skill set is needed to tackle the problems of

overuse and underuse and to deal with all three

dimensions of value. The new skill set, and the actions

that it facilitates are *:


PERSPECTIVE

A. Understanding and increasing value

Those who pay for and manage health care need to

understand the transition from the quality era to the

value era and understand the new priorities, new

concepts and new skills required.

B. Designing and building systems of care

Systems of care, provided by dynamic and adaptable

networks of individuals and organisations are able to

deliver improved value and better outcomes without

requiring extra funding.

C. Creating the right health care culture

Structural change has been the norm in health care but

is rarely effective due to health care’s great complexity.

Culture is more difficult to change but brings about

more effective transformation.

D. Delivering population-based medicine

Clinicians of the future must also consider their

responsibilities to those outside their referred group

who may benefit most from the service. No extra

funding is available so we need new ways of thinking

and new skills.

E. Designing and delivering patient-centred and

personalised decision making

Personalised health care, including the impending

impact of stratified (genomic) medicine is the other

side of the coin of population health care.

F. Realizing the potential of he internet and digital

services to create knowledge-based health care

Internet and the smartphone allow not only the

delivery of best quality knowledge ‘just in time.’ They

also allow the personalization of decision making and

facilitate patient-centered care.

Perhaps the most important distinction of this set of

skills from the skill set currently required for the

management of health care is that most people who

manage health care focus primarily on the quality,

safety, effectiveness and outcome for the patients

treated whereas those involved in Value-Based Health

Care have to think not only about the outcomes for the

patients treated but also about two other important

issues for the population they serve:

The first of these is the need to consider the underuse

of high value health care by people who do not reach

the relevant service and this is sometimes complicated

by inequity and of course linked to this is the challenge

of overuse because the resources currently involved in

overuse will have to be switched to allow the unmet

need for high value interventions to be met.

The second is allocative value, namely looking at the

distribution of resources between different

programmes, for example between the programme with

cancer and the programme for people with respiratory

disease and then within each programme between

different systems. Within the respiratory programme

for example there are separate systems for people with

asthma, for people with COPD and for people with

sleep apnoea.

Neither of these issues are particularly relevant in the

United States from where many of the articles on value

based payments have emanated.

Transformation through training

Value-Based Health Care is the new paradigm.(1) To

achieve it, a new culture and new systems are required

and this will not be brought about by structural change

- training is key to change how people how think.

REFERENCES

Gray J.A.M., Cripps M. and Bevan R.G. How To Get Better Value Healthcare 3rd edition Offox Press 2017 *The new skill set that we developed in Oxford is also available online

For more information, please visit the website: www.thedecisioninstitute.org/vbhc-green-belt-track or

send an e-mail to: [email protected].

Follow the VBHC Green Belt Track and become a VBHC Certified Green Belt!

VBHC GREEN BELT TRACK

The Decision Institute offers, amongst other VBHC education, the Value-Based Health Care Green Belt

Track!

Gain insight into the essentials of VBHC;

Bring your conversations with colleagues and customers to the next level;

Prepare for the VBHC Green Belt exam;

Acquire the VBHC Green Belt certificate to become a VBHC Green Belt!

In four sessions you will be immersed in the most up-to-date knowledge on VBHC. The sessions take place

throughout the year, so you can enter the track at any time.

Become a VBHC Certified Green Belt!

The European platform for VBHC implementation

Are you passionate about Value-Based Health Care (VBHC) and creating excellent patient value?

Gain recognition for your VBHC expertise with the VBHC Certified Green Belt certificate.

The VBHC Certified Green Belt certificate proves:

You are an expert on VBHC;

Your VBHC knowledge is up-to-date;

Your dedication towards creating excellent patient value to patients, insurers, industry,

your clients and the VBHC community.

For more information visit VBHC.nl/vbhc-certified-green-belt


INTERVIEW

Michèle van der Kemp, founder of VDKMP, has

many years of experience in creating business strategies

for both private and public companies. In 2010, she

shifted her focus to Value-Based Health Care and,

wherever possible, helps hospitals to transform health

care into the valuable and sustainable success it

deserves to be.

How would you describe Integrated Practice

Units (IPU)?

A multidisciplinary clinical team that organizes itself

around a disease or medical condition forms an IPU. It

is of the utmost importance that key stakeholders are

together responsible for the full cycle of care and share

accountability for their patient group. To facilitate care

around a specific disease or condition, we thus need to

bring the full range of care providers and supporting

staff from different specialties together. In many cases

this involves leaving ‘specialty islands’ and merging

into new IPU teams. Furthermore, we should not forget

that the patient is a vital member of this

multidisciplinary team and the IPU is responsible for

incorporating their voice, needs and wishes.

What are the key elements for successful IPU

implementation?

The first real driver is Clinical Leadership. Key players

from different specialties and disciplines should feel

full ownership of their IPU. It is up to these key players

to get everyone on the same page and motivate the

entire team. Together with patient advocates, they have

to decide what their standard of care should be and in

what way and by whom this care can be delivered.

The approach and professional poise of these key

players will greatly influence the success of the IPU.

Secondly, as said, it is essential that each member of

the team, no matter what specialty, feels a Shared

Responsibility. There is one common goal: to deliver

the best care and best outcomes for the entire patient

group, through and across specialties.

In many cases this is the most difficult part of creating a

successful IPU. The vertical way in which clinicians are

educated and hospitals are organized makes it complex

to start organizing horizontally, along the actual care

paths and patient journeys. Working together as a value

driven team, we need to start looking at the complete

picture: processes, experiences and outcomes, in order

to succeed. For most patients, their condition is

monitored by a multitude of clinicians, and the

outcomes influence not just one single aspect of life.

Thus, in a way an IPU is a patient’s 360° disease

manager taking all these aspects into consideration. A

clinical team should therefore, together with patients,

decide which care can be best delivered within the IPU,

but also has a responsibility to refer patients outside of

the IPU to, for example, primary care. In this way a

patient is able to convey the total impact of their

disease, and trust the IPU to take care and co-own

results.

Another aspect that can be quite helpful when creating

or organizing an IPU is proximity. Not only in goals,

hearts and minds but actual physical proximity of the

clinical teams - in outpatient clinics for example. The

more you see each other, the easier it is to actually

share and benefit day-to-day from each other: a great

way to becoming members of a team and its culture.

The 360° Healthcare Manager

Michèle van der Kemp By T. Ringers – VBHC Center Europe


INTERVIEW

To finalize the list, which actually goes on and on, it

would be in the best interest of the IPU to approach the

IPU as a stand alone company and for instance plan

regular management meetings. The purpose of these

meetings should be to discuss specific IPU matters.

For example, what have we learned this month from

our outcome data? What went wrong or what went

right in our care processes? How do we raise the bar on

both patient outcomes and experiences? What about

our team culture and internal communications? This is

completely different from our multidisciplinary

discussions on patient cases. We should run an IPU like

a business, and thus also talk about efficiency, results

and opportunities for innovation on a regular basis.

What are the major challenges when creating

an IPU?

Every new corporate strategy has its own challenges. In

the case of creating an IPU Michèle defines two

common major issues. First, culture can be a major

constraint in the process of organizing into an IPU.

Moving towards a horizontal organization of care,

leaving behind the systems and governance structures

we have learned to work in, does not change overnight.

For example, it is a challenge to start a new team with

multidisciplinary specialists instead of your good old

co-workers whom you’ve grown to know over the years

and who ‘speak the same language’. It is also a

challenge to actually feel shared responsibility for the

outcomes of the total care process. A cultural mind

shift, showing guts instead of fear, and taking

ownership as a team is necessary to aim for this actual

shared responsibility.

Financial structures and incentives are a second major

challenge. Ideally an IPU should be financed

horizontally, through the full cycle of care, from

diagnose to follow up. In the Netherlands however,

there are not many examples yet of complete financially

independent IPU’s. In-hospital IPU’s are taking small

steps in financing according to patient paths. We could

take bigger steps by starting to calculate whether it is

possible to finance the entire care delivery within an

IPU instead of our current fee-for services or, relatively

specialist minded, current chunks of the care path.

Knowing upfront what the financial opportunities or

challenges could be before actually changing the entire

system will lower fear and skepticism to move on.

“Ideally an IPU should be able to be financed

horizontally, through the full cycle of care”

What is your advice to healthcare

professionals?

We can endlessly talk about protocols and outcome

measurement, but we need to start implementing

today. Take a look at Karolinska University Hospital

and learn from the challenges they have taken upon

themselves. Of course it’s a bumpy road, but it is the

fastest road to team innovation and actually creating

better patient outcomes.

Key elements

for successful

IPU

implementation


EXPERT BLOG

Somewhere in his office there must also be a signed

copy of the book Redefining Healthcare by Michael

Porter. As soon as that book was published, Rob

Dillmann, chairman of the Executive Board of Isala

Hospital in Zwolle, was enthusiastic. ‘I did indeed

think, this is the direction health care should be going

in the Netherlands as well.’

Later, Dillmann took a masterclass at Harvard Business

School led by Prof. Michael Porter where he really got

to know the principles of Value-Based Health Care

(VBHC). VBHC makes the medical perspective more

exact’, says Dillmann. ‘Using VBHC we place the

emphasis on outcomes and on the added value we can

have, as care professionals, for our patients. We have

represented our hospital's strategy for the next few

years in a pyramid, with patient value at the top,

followed closely by safety, experience and lastly, care

outcomes. Safety is inextricably linked to VBHC. If you

do not offer safe care, you destroy value for patients

and, clearly, that is the last thing you would want.’

“The way we organize our specialisms should

never get in the way of optimum patient care”

Adjusting the hospital's structure

Working according to the principles of VBHC is not

actually new at Isala. Dillmann: ‘Medicine has always

been about improving health and avoiding damage. A

clear trend is the example of our multidisciplinary

center for cases of Osteogenesis Imperfecta (OI).

Doctors and nurse specialists are focusing on this

disorder. They are building a center of expertise around

it, where the focus really is on patients, for instance, by

ensuring that all examinations and

outpatient appointments can take place on the same

day. They are also doing research and sharing the

results within this country and abroad as well. As a

consequence, patients from the whole of the

Netherlands are coming to Isala.’ Apart from the center

for OI, the chairman of the board also cites the Isala

Oncology Centre, the Heart Centre, and the Mother-

Child Centre as examples of centers of expertise where

care providers work in multidisciplinary teams and

organize care around patients as far as possible.

Dillmann: ‘In addition, Isala recently opened a center

for physical mobility, where Orthopaedics,

Rehabilitative Medicine and Sports Medicine

collaborate. Adjusting the structure of your hospital is

an important condition for making a success of VBHC.

The way we organize our specialisms should never get

in the way of optimum patient care’.

Education

Apart from changes in the organizational structure,

Isala has also started on an extensive educative

pathway. Dillmann: ‘We train everyone in our hospital

according to the Lean principles . We offer various

courses, from a white belt training for all employees, to

a green belt training for supervisors and managers. By

the end of this year we will have trained 2000

employees. Lean looks very closely at processes. Does

what you are doing have no added value for the

patients? Then it is wasted energy. In my opinion,

working according to the principles of lean is in keeping

with the ambition of wanting to be a VBHC Center.’ A

special VBHC day was held recently for the hospital's

operational management.

Competition Based on Quality Makes Good Sense

Dr. Rob Dillmann By Bianke Buursma – Isala


EXPERT BLOG

This will be followed by master classes on VBHC for

higher management and doctors. Dillmann: ‘We are

also bringing in external expertise, namely, patient

experts from IKONE. This foundation advises care

institutions based on the experience of patients. We

have asked them to help us to re-design health care.’

“I want to move with VBHC towards a system

that is held accountable based on results”

Paying for healthcare outcomes

Value-driven health care has become an indispensable

concept. It includes the question of how we will fund

this new method of providing care. Dillmann: ‘Porter

argues in favor of paying for healthcare outcomes. This

is a good solution in my opinion. A hospital can

compete in terms of quality. And our own experience

proves that you can make proper agreements about this

with health insurers. At the moment, if someone is re-

admitted after a complication, we must submit a new

invoice. That doesn't make sense, does it?

I want to move with VBHC towards a system that is

held accountable based on results. For instance, we

could agree with the health insurer that our heart

patients will be able to do certain things again after six

months, e.g. work, and that quality of life is given

positive value. I think this will provide plenty of

opportunities for every hospital.’

There is no crystal ball in Dillmann's office, but if asked

to predict where health care in his hospital will be in

five years, he says: ‘Fifty percent of our care will be

organized around the care chain. And twenty percent of

health care will be funded based on outcomes, not on

volume. I also expect to see that we will be supervising

patients at home more frequently, just as Isala is

already doing for patients with heart failure. We will

also be providing more connected care. In other words,

not going to hospital for every consultation, but staying

at home, using an e-health connection. This too will

have a lot of added value for our patients.’


PERSPECTIVE

Patient-centered care is becoming a major topic in

healthcare. Many initiatives have begun focusing their

care around patients and their medical conditions. This

requires focusing on patient value (Porter and Teisberg

2006). When focusing on value for patients, a few

challenges may arise. Firstly, the meaning of value for

patients varies widely among stakeholders in

healthcare. Secondly, not all patients receive the same

treatment for the same illness. Patients (and their

families) want to be treated differently based on their

preferences. Thirdly, the quality of care delivery in

terms of patient relevant outcomes differs among

hospitals. The diversity in measurements makes it

difficult to compare.

I. Patient Value: A Common Definition

Doctors would base the meaning of patient value on the

skills of a doctor, an improved medical lab result, or a

well-performed surgery. These measurements are

mainly based on the treatment or intervention

perspective. On the other hand, a patient may base

patient value on aspects such as the length of waiting

lists, how kind the doctor was or perhaps how good the

coffee or breakfast tasted. "Most people would agree

that both sets of measurements do not truly reflect the

quality of care from a medical perspective. Patients'

perception: "They were so kind to me when performing

the surgery seven times.

II. A Singular Language

Value-Based Health Care provides a singular language

that is comprehended by doctors, medical teams,

patients and their families. Patient value is defined by

an equation whereby patient-relevant outcome

measurements are the numerator, and costs per patient

in delivering those outcomes are the denominator.

Patient value is defined for a specific medical condition

over the full cycle of care (Figure 1).

Meetbaar Beter (winner of the VBHC Prize 2014) is a

great example that transparently reports patient

relevant outcome measurements for specific medical

conditions. They include coronary artery disease, atrial

fibrillation, aortic valve disease and combined aortic

valve disease and coronary artery disease (Meetbaar

Beter 2012-2016). It is important to note that outcome

measurements should be defined around a medical

condition and should be manageable and actionable.

Doctors and their teams are then intrinsically

motivated to improve the quality of care they deliver to

patients. All they need are the tools to measure and the

ability to visualize accurate and valuable outcomes.

III. Focused on Measurable Health Outcomes to

Facilitate Improvement

Measuring outcomes in health care began in the 1950s

(Figure 3), followed by a strong trend towards process

and structure measurements. Some of the

measurements focused on at that time were the length

of waiting lists and the number of (certified) staff. This

led to quality management based on the optimization of

processes, including Lean.

Five Reasons why Value-Based Health Care is beneficial By M. Fakkert, Prof. Dr. F. Van Eenennaam, V. Wiersma

Figure 1. Patient value deteremnied by the ratio of patient relevant outcome measurements to the costs per patient over the full cycle of care (Porter 2010)


PERSPECTIVE

All of these measurements are important in improving

the internal process of care delivery. Patient and family

perception only became important from a measurement

perspective in the 1990s. Surprisingly, the healthcare

sector took quite some time in realizing the significance

of patients in healthcare delivery. Luckily, healthcare

providers are now able to present true patient-relevant

outcome measurements to their colleagues and

patients.

One of the most inspiring examples of improving

measurable health outcomes is the Martini Klinik at the

University Hospital Hamburg-Eppendorf (UKE) in

Germany. Since the founding of the clinic in 2005, the

Martini Klinik has focused on improving long-term

health outcomes for patients with prostate cancer. The

Martini Klinik massively improved their care by

measuring patient-relevant outcomes

(Table 1).

The improved outcomes led to growth in volume and

the Martini Klinik became the world’s largest prostate

cancer care clinic by 2013. It later received the VBHC

European Inspiration.

A second example is Meetbaar Beter. Meetbaar Beter

has helped doctors learn from one another and improve

care delivery based on reported outcomes. Over the last

few years, impressive effects on patient-relevant

outcomes have been achieved by looking at and

learning from fellow cardiologists and cardiovascular

surgeons.al Award in 2016 based on these inspiring

results.

IV. Protocols Do Not Fit Every Patient, But Patients

Benefit From Protocols

Every patient is unique but they each walk a different

path through the cycle of care. Protocols are very useful

as they provide care delivery guidelines for patients

with common medical conditions.

Figure 2. The Care Delivery for Breast Cancer provides an overview of the care activities around breast cancer patients (Porter 2006). Reproduced by permission.


PERSPECTIVE

REFERENCES

In the St. Antonius hospital (winner of ‘VBHC Cost-

Effectiveness Award’ 2016), elderly patients with end-

stage renal failure are guided towards their choice of

treatment. Previously, protocols stated that patients

with this medical condition should primarily be treated

with dialysis. Dialysis is highly invasive (and costly) for

elderly patients and it requires them to remain in

hospital for long periods of time. Research made by Dr.

Willem Jan Bos and his team found that conservative

treatment is much better than dialysis (Verberne et al.

2016). By having discussions with patients, protocols

can be changed and care delivery can be optimized and

adjusted to fit every individual.

V. Become a Patient-Centered, Fast-Learning Team

Value-Based Health Care is centered around learning.

Doctors who have a drive to show medical leadership

and create a learning culture are key for the

implementation of VBHC. Learning to improve value

for patients provides satisfaction. This motivates

doctors and their teams and also cuts costs. VBHC

empowers doctors and their teams to do what they do

best—provide excellent patient-value by using clinically

relevant and evidence based insights.

1 Definition of fully continent: inconcentinence pads are unnecessary or are only

used for safety

2 more than 5 incontinecne pads per day

3 including patients suffering from erectile dysfunction previous to operation

Creating Excellent Patient Value

— Patient-centered care is on the rise;

— VBHC provides a common definition for patient-

value and a common language for all

stakeholders in healthcare;

— VBHC puts the patients, their families, doctors

and their teams at focus;

— Patients with similar medical conditions have

different preferences and they each follow

roughly similar care-paths;

— Care quality improves by measuring the right

patient relevant outcome measures. This creates

compelling learning cycles for the medical team.

Martini Klinik (2014) Facts count: unique data on the success of our therapies. [Accessed: 24 January 2017] Available from martini-klinik.de/en/results

Meetbaar Beter Boek (2012-2016) [Accessed: 6 February 2017] Available from:meetbaarbeter.com/documents/meetbaar-beter-boeken

Porter ME, Teisberg EO (2006) Redefining health care, 2006. Boston, MA: Harvard Business School Press.

Porter ME (2006) Value based competition in health care [presentation]. [Accessed 24 January 2017] Available from

hbs.edu/faculty/Publication%20Files/20061020_MayoPresentation_e10acf3c-846b-4d39-9c8b-88f01c1be0f1.pdf

Porter ME (2010) What is value in health care? N Engl J Med, 363(26): 2477-81.

Value-Based Health Care Europe (2016) Harvard Prof. Porter on value-based health care in the Netherlands. [Accessed: 10 February 2017] Available from youtube.com/watch?v=36ZH1gxq8XQ

Van Eenennaam F (2016) Value-based health care in Europe. What’s next? [presentation]. Leadership and Management in Cardiovascular Medicine Forum, 16-18 June, Vienna. [Accessed: 6 February 2017] Available from lmcforum.org/wp-content/uploads/2016/09/VanEenennaam-Fred_Value_based-healthcare-in-europe_what-is-next.pdf

Verberne WR, Geers AB, Jellema WT et al. (2016) Comparative survival among older adults with advanced kidney disease managed conservatively versus with dialysis, Clin J Am Soc Nephrol, 11(4): 633-40.

Figure 3. Historical development of measurement in healthcare (Van Eenennaam, 2016).

Table 1. Patient relvenat outcome measurements of prostate cancer care in the Martini Klinik versus German average. Source: Martini Klinik martini-klinik.de/en/results

First published in: Health Management, Volume 17 - Issue 1, 2017.


*The international collaborations were extrapolated, taking into consideration the amount of international connects within initiatives and are likely underestimated.


EXPERT BLOG

The patient journey, the entire path the patient has to

travel when confronted with disease, is the central

entity delivering value to the patient. This chain is only

as strong as its weakest link. Improving the quality of

each individual link is just as important as improving

the quality of and the cooperation in the whole chain.

In Value-Based Health Care chains are created through

the procurement of bundles. Each disease has its own

optimal bundle which is designed by healthcare

professionals, patients and health insurers together.

Value can be defined as appropriateness x outcomes /

integral costs of care. We will explain what this means

from the health insurer perspective.

Appropriateness deals, from a medical perspective,

with the evidence and practice based diagnostics and

therapy for the indicated patient at the right time and

place. From a patient perspective, it must be aligned

with preferences and needs of the individual patient.

Choices will be medical but can also include housing,

education, food and may concern social, mental or

spiritual wellbeing. From a payer perspective this

means that the interfaces within health (ZVW) and

between health (ZVW) and wellbeing (WMO, WLZ)

become more and more important.

“ Each disease has its own optimal bundle

which is designed by healthcare professionals,

patients and health insurers together”

Outcomes deal with what is important to the patient.

ICHOM has published so far 21 sets for various diseases

which can nicely be used in value based purchasing. If

for a certain condition ICHOM sets are not available

dedicated sets can be made by professionals and

patients. In addition to that, analyses of declaration

data can reveal potentially avoidable complications

(pac’s).

Integral costs for the individual institution can be

calculated by time driven activity based costing

(TDABC) considering all staff and means involved in

each step of the internal process(es). But this is only a

part of costs: real value means taking the total integral

costs of care into consideration. For chronic care this

means looking at primary care and hospital care. For

elective care this means, readmissions, rehabilitation

cost, mental support to cope with life treating disease

etc. When we design bundles, the whole cost structure

of a diseases is taken into account and this approach

makes shared savings possible. It promotes the

development of the healthcare infrastructure and the

way healthcare organisations work together.

Value for the Patient, the Healthcare Professional and the Society By Dr. B. Geerdes – Senior Medical Advisor at Zilveren Kruis


EXPERT BLOG

Value-Based Health Care delivering and purchasing

demands a change in culture for all partners in the

bundle. Designing and deciding all together what the

bundle should look like and how it should be paid for is

a great challenge. We believe that mutual respect and

trust are the determining factors for success.

For Zilveren Kruis it means changing the way we

purchase care, make and monitor contracts. We have

started by making a toolbox containing all the

instruments necessary to help us and our partners in

each step of the value based purchasing process.

These steps are about: the condition,

inclusion/exclusion, the bundle, the outcome, the sort

of contract, the attribution etc. etc.

This toolbox is filled with the help of scientific

literature, extensive experience from projects all over

the world and all the information that comes from the

pilots we are carrying out. These pilots are: with

general practitioners in Nijkerk (COPD) and

Nieuwegein (CVRM) and with hospitals like ISALA

(myocardial infarction), OLVG (HIV) and ErasmusMC

(Stroke). All conditions have their particularities and

implications for the bundle which generate a lot of

useful information.

“Real value means taking the total integral

costs of care into consideration”

Zilveren Kruis believes that the only sustainable way

forward to maintain high quality care accessible for

everyone, is to focus on health care as a chain that

creates values for our members. Care bundles are a

promising way to work together with patients and

health care providers to realize this goal. By doing it in

a structured way and adjusting the process while

delivering it we are confident that it will allow us to

apply value based purchasing on a much larger scale in

the nearest future.


EXPERT BLOG

The basic principle of Value-Based Health Care is both

simple and timeless. The value of care is determined by

care outcomes in relation to costs. It starts by

measuring outcomes and costs: measuring patient

reported outcomes on the one hand and related

healthcare costs on the other.

The practice can be rather complicated. Consider only

measuring health care costs. How can this actually be

done? Well-known ‘gurus’ such as Prof. Robert Kaplan

propose to determine costs through Activity Based

Costing (ABC) – or variants thereof. This analyzes

which activities are necessary for which care paths, and

the costs of these activities. It also provides insight into

actual treatment costs.

Measuring is no Small Feat

Measuring sounds easier than it is. How are overhead

costs allocated? How do we deal with the costs of

complications that may arise, or readmission costs? Do

you calculate only institutional costs, or do you

calculate total costs in the process, or even the total

social costs?

Suppose a care provider knows the exact cost of a

treatment, and suppose they will use this information

actively to determine which treatments are provided to

which patient. Will this actually lead to a better

financial result for the care provider? Not necessarily.

Savings on paper are not the same as savings in the

wallet. In practice, actual cost are determined by

organizational revenue. Many costs are fixed. Only

when measuring cost is no small feat.

While measuring may help us to understand costs vs.

outcomes, the path to knowledge can be complicated.

revenue is decreased at the organizational level, are

measures taken to reduce ‘real’ costs, e.g., reducing the

number of beds.

Meaningful Results

Does this mean that Value-Based Health Care is a

theory that does not work in practice because it is too

complex? Definitely not. The interesting thing about

Value-Based Health Care is that you can start relatively

small, and still realize meaningful results. This can be

done by measuring patient reported outcomes.

Implementation does not necessarily have to be

complicated, especially when good IT tools are being

used.

Begin with patient reported outcomes and use them as

a starting point for continuous improvement. This can

lead to surprising insights and will eventually lead to

better quality while controlling costs.

The basic principle of Value-Based Health Care is both

simple and timeless. Implementing a Value-Based

Health Care model may be inevitable, but sometimes

complex. Therefore, start simple. Start with measuring

patient reported outcomes.

From Measuring to Knowledge to Value By L. van der Tang - CEO VitalHealth Software

@VBHCEurope Value-Based Health Care Center Europe www.vbhcprize.nl

5th VBHC Prize Event

April 26, 2018

Applications will be accepted as of September 1st, 2017

“The VBHC Prize 2015 has helped us tremendously in

shaping our ambitions.”

Prof. Dr. B. Bloem (ParkinsonNet, winner VBHC Prize 2015)

Why should you apply?

• Boost your initiative through exposure to >200,000 healthcare

professionals;

• Be recognized as a leading initiative in patient- centered care and

inspire others;

• Network with VBHC pioneers;

• Be at the center of healthcare innovation;

• Push your initiative to the next level.

Subscribe to the newsletter for more information:

www.vbhcprize.com


EXPERT BLOG

Hip and knee osteoarthritis: a common

condition with major treatment differences

Osteoarthritis is a common joint disorder — in 2015, an

estimated 1.2 million people in the Netherlands

suffered from this condition (Dutch National Institute

for Public Health and the Environment [RIVM], 2017).

The high prevalence of osteoarthritis leads to extensive

healthcare costs. Roughly 1.2% of total healthcare

spending in the Netherlands goes towards treatment of

this condition. The condition is most likely to occur in

hips and knees — roughly two thirds of osteoarthritis

sufferers have hip osteoarthritis, knee osteoarthritis, or

both. When it comes to treatment of this condition,

there are major differences between healthcare

providers. The ratio of revision procedures performed

within one year of a primary total hip replacement

differs greatly between healthcare providers. Where

this figure stands at only 0.5% at some healthcare

providers, it is as high as 5.5% at others (Dutch

National Register for Orthopaedic Implants [LROI],

2016). The percentage of patients who undergo surgery

also varies by a factor of 2.5 between providers (Vektis,

2017).

Value-Based Health Care Procurement: health

care in line with the patient’s needs

The nature and impact of hip and knee osteoarthritis,

together with the differences between healthcare

providers when it comes to treatment of this disorder,

have prompted us to seek to increase the value of

health care for patients with hip and knee

osteoarthritis. In the following paragraphs, we will

outline how we are working towards Value-Based

Health Care Procurement for hip and knee

osteoarthritis, as we put the VBHC model into practice

in our healthcare procurement. By this, we mean that

our healthcare procurement practices will be targeted

at ensuring that health care matches the patient’s

needs, is delivered at the right place, is of good quality

and is provided at an acceptable cost.

Step 1: Mapping out the healthcare chain

The first step in our Value-Based Health Care

Procurement is to map out the entire healthcare chain

for a patient with a certain condition. In doing so, we

look at things such as data, guidelines, reports and

treatment option grids. The healthcare chain for hip

and knee osteoarthritis is depicted in the figure below*.

*For a detailed description of our Value-Based Health Care Procurement for hip and knee osteoarthritis, please visit our website

https://www.cz.nl/zorgaanbieder/zorginkoopbeleid/zo-koopt-cz-waardegedreven-zorg-in (in Dutch).

Putting VBHC into Practice: CZ Group moving towards Value-Based Health Care Procurement By R. Soffers & J. Verlind – CZ Group


EXPERT BLOG

Step 2: Identifying bottlenecks and

opportunities

Based on documents, data analyses and input from

healthcare providers and patients, we identify

bottlenecks and opportunities in the healthcare chain

for a certain condition. The basic aim is always to

secure health care that is in line with the patient’s

needs. When it comes to hip and knee osteoarthritis,

for example, we have found that stepped care prior to a

potential hip or knee replacement could be organised

much better. As it turns out, 81% of patients referred to

an orthopaedic surgeon were offered insufficient or no

conservative treatment options (Snijders, 2011). This is

an undesirable situation, as surgery is risky and will not

always alleviate all the symptoms, while a replacement

joint also only has a limited lifespan. For many patients,

conservative treatment is a way to put off surgery for a

long time or even prevent it altogether. Although

treatment outcomes and costs are nowhere near

transparent yet across the entire healthcare chain, they

are in the specific area of specialist medical health care.

In our view, this provides a key opportunity.

Step 3: Launching improvement actions

After we have identified bottlenecks and opportunities,

we select the best approach for each subject. To

improve stepped care for hip and knee

osteoarthritis, we will be working together with

stakeholders from across the field to improve

collaboration between general practitioners and

orthopaedic surgeons over the coming years, we will

target standardisation of care needs assessments

for surgery and we will promote the Samen Beslissen

[Decide together] initiative in first-line and second-line

care. Furthermore, we will take advantage of the

existing transparency on the quality and effectiveness

of specialist medical health care for hip and knee

osteoarthritis: we are going to take stock of the

differences between healthcare providers in greater

detail in 2017 and reward the well-performing ones. In

areas where there is little information on the quality

delivered by healthcare providers, we will seek

transparency, such as in the area of physiotherapy.

As a health insurer, our primary pursuit is to push for

content-based change processes in the healthcare

chain. We leave the organisation of health care to the

providers themselves wherever possible. A funding

model is, in our view, a secondary concern, not a

leading one. Where necessary to further promote good

outcomes, we will experiment with innovative funding

arrangements.

Onwards to other conditions

Besides hip and knee osteoarthritis, we are also

working towards Value-Based Health Care

Procurement for dementia, intestinal cancer and

complex wounds for 2018. Going value-based for only a

select number of conditions first will allow us to go

through a rapid and intensive process that will see us

gain vital experience. Any lessons learned will benefit

us in procuring health care for 2019. It goes without

saying that patients will be closely involved in these

processes.

REFERENCES

Dutch National Register for Orthopaedic Implants [LROI] (2016). LROI-rapportage heup. Retrieved from http://www.lroi-rapportage.nl/heup-overleving-1-jaarsrevisie-per-zorgaanbieder

Dutch National Institute for Public Health and the Environment [RIVM] (2017). Artrose. Retrieved from https://www.volksgezondheidenzorg.info/onderwerp/artrose/

Snijders (2011). Improving conservative treatment of knee and hip osteoarthritis (Doctoral Dissertation). Retrieved from http://repository.ubn.ru.nl/bitstream/handle/2066/93631/93631.pdf?sequence=1

Vektis (2017). Vektis-rapportage praktijkvariatie electieve zorg. Retrieved from https://www.zorgprisma.nl/CookieAuth.dll?GetLogon?curl=Z2F&reason=0&formdir=10


INTERVIEW

Jan Hazelzet, MD PhD, Erasmus MC, Rotterdam,

the Netherlands has a long clinical experience as

Pediatric Intensivist, and Associate-Professor in

Pediatrics. He gradually moved to the field of

information and quality, first in the position of chief

medical information officer of Erasmus MC, later as

professor in Health Care Quality & Outcome. He is the

clinical lead of the Value-Based Health Care Program

in Erasmus MC and the shift towards a more Patient-

Centered Care.

How can patients be involved in health care

from the VBHC perspective?

When you consider that VBHC means that you are

aiming for the best outcomes for patients, it is very

natural to involve them in the selection of those

outcome measures. The patient can be involved in

different ways; he/she can be involved either in

defining outcomes or setting up a project to improve

healthcare delivery. But they can also participate in the

healthcare delivery, discussing it with the individual

patient and the individual care process, actually.

When we, at Erasmus MC, develop an outcome set or

outcome measures, we include the patients in the

developing teams. Of course it depends on the disease

whether they can really contribute but normally they

can. Either the patients themselves are present during

the development process or a patient advocate, patient

representative or a representative of a patient

organization. Involvement includes a survey amongst

patients. In which we ask what is important to you,

what matters to you? The survey process is part of the

care process, which mean that the results are

communicated to the patients as a vital part of the

care process. So the way we work is we send out an e-

mail two weeks before they come to the outpatient

consultation. In the email there is a web link that

allows you to fill in the questionnaire. When they come

to the consultation facility either the physicians or a

nurse specialist discusses the results with the

individual patients. There even are groups who use a

patient panel to discuss the workflow changes.

What is also interesting is that the response rate from

the questionnaires at Erasmus MC is already at 95%.

Patients have expressed that the questionnaires benefit

themselves and not just research purposes. Discussing

the results of the surveys during the consultation is the

greatest benefit to patients. Moreover, the way patients

fill in the surveys gives physicians insight into how

patients value their outcome. Those results are also

used for other patients. The way that patients are asked

to fill in the forms can make a big difference. Thus

future possibilities such as creating apps can improve

the response rates and give more insight into patient

outcome measures.

What are the major challenges with patient

involvement in VBHC implementation?

The first major challenge in patient involvement is

health literacy. Not every patient is able to read a bar

graph or spider diagram for example. Physicians are

dependent on health literacy and the intellectual level

of the patient, thus it is important to think about how to

visualize and discuss the results. Including the patient

in this development process is key. This can be done by

videotaping consultations and let patients review the

visuals they receive.

Value-Based Patient Involvement

Prof. Dr. Jan Hazelzet By T. Ringers – VBHC Center Europe


INTERVIEW

Secondly, some physicians are naturally born

communicators but most are not. Difficulties arise

because not every physician is used to or trained to

discuss all results transparently. It can be difficult for

physicians to explain the meaning of certain results.

Adding reference values can partly resolve this

problem, because this makes it comparable. However,

not all outcomes have reference values which

sometimes lead to challenging discussions in the

consultation room. Finally, in most cases, especially in

elderly patients, we deal with more than one disease.

The problem that arises then is that patients are

approached by different teams, with different

questionnaires and different QoL scores. The burden of

registration is in a way shifting from physician towards

patient. The challenge is to harmonize this process and

create generic outcome sets that can be used for

multiple diseases. Which means that as a physician you

are not treating solely breast cancer, on the contrary

you are treating an individual with, amongst other

diseases, breast cancer.

What is the most inspiring example of patient

involvement from the VBHC perspective?

There are many inspiring examples of multidisciplinary

collaboration where the collaboration is very important

and with the right input of the patient care is improved.

For example, a team that takes care of patients with

Turner Syndrome. This genetic disease involves many

different physicians ranging from pediatricians,

gynecologist, cardiologists etc. Including and

interacting with the patients has been very beneficial to

this disease team, who now collaboratively treat these

patients.

This collaboration and interaction with the patients has

led to new insights from the patients. Physicians found

that patients are now reporting problems with energy

and chronic fatigue, which can lead to physical

problems. Because patients started reporting this,

physicians are now able to act upon it. The clinical team

changed the way they do their outpatient clinic and

discuss outcomes with a patient panel; both patients

and physicians are very enthusiastic about this

development. Another example is breast cancer.

Specialist teams have managed to merge two

operations into one. Just by sitting down as a real team

they changed the care path in such a significant way,

that breast cancer patients are now operated by an

oncological and a plastic surgeon in one procedure. Just

by discussing the care path, by analyzing why one

should wait for another and it was possible to improve

the care path by making it more coordinated.

What is your advice to healthcare professionals

that want to increase patient involvement?

One of the things we forget in VBHC is that it is not just

about measuring outcomes and costs. Team-based

work is another thing, Prof. Porter is calling it IPU’s,

I’m calling it team-based approach. Integrated care and

especially in the Netherlands is organized around silos

of care next to each other instead of horizontally

integrated care.

Aiming for horizontal integration means cooperation,

collaboration and changing our reimbursement

policies. If we are able to align these key factors it might

work, otherwise VBHC is just a luxury and more

window dressing instead of real change.


NOMINEES

Benchmarking Mental Health Care 'ROM and Benchmarking aims to enhance quality of mental health care by providing transparency about outcomes and costs to all stakeholders: patients, providers, and financiers.'

Closing the Loop Our initiative aims to improve patient empowerment, shared decision making, transparency and continuous learning during healthcare delivery.

MyIBDcoach The aim of this project was to validate the effects of the telemedicine tool myIBDcoach compared to standard care on healthcare utilisation and patient-reported quality of care (PRQoC) in a pragmatic randomised trial.

Netherlands Heart Network 'The NHN aims to continuously improve outcomes that matter most to cardiac patients. Subsequently, those patient relevant outcomes are delivered at the lowest costs. '

FAMOUS Famous triage aims to achieve a worldwide accessible, efficient and safe, triage method in chest pain patients to improve patient service and reduce emergency crowding with considerable less cost.

Value-based healthcare in pulmonary sarcoidosis Participating hospitals collect, exchange and discuss their outcomes with the aim to identify best practices in order to improve value for pulmonary sarcoidosis patients.

Desired care during the last phase of life Our pathway improves the quality of dying, prevents health care misuse and overuse, and prevents informal caregivers from becoming overburdened.

The Dutch Surgical Colorectal Audit The nationwide DSCA was initiated by the Association of Surgeons of the Netherlands to monitor, evaluate and improve care for colorectal cancer patients.

VBHC@Santeon We aim to continuously improve value to our patients by improving outcome and cost over the full cycle of care for 20-25 conditions in 2020. Transparency on outcomes and costs, including patients, health insurers and professionals from all relevant disciplines, are key parts of the initiative.

Diabeter We aim to decrease the burden of type 1 diabetes for patients by helping them to achieve outstanding outcomes, providing individualized care and supporting self-care, focusing on digital care and measuring outcomes for every patient.

Value-Based HIV Care To increase value of HIV care, OLVG has developed a selected set of HIV care indicators, made data to these indicators easily accessible to multidisciplinary teams which are supported towards ongoing improvement of care. Patients and insurers are included in this doctor-led initiative.

G-Watch The aim of G-Watch is to reduce Emergency Department-presentations and hospital admissions and increase Quality of Life for elderly with Heart Disease by enabling them to self-manage via a telerehabilitation program that connects them 24/7 to cardiac and elderly experts.

A virtual asthma clinic for children A virtual asthma clinic for children: improving asthma control in children while reducing visits to the outpatient clinic by 50%.

Meet the Nominees By L. Oudt – VBHC Center Europe

Meet the nominees of the VBHC Prize 2017:


NOMINEES

Of all the formal applications that were received for

the Value-Based Health Care (VBHC) Prize 2017,

thirteen have been nominated to win the prestigious

VBHC Prize 2017. What do these initiatives aim to

achieve? How do the nominated initiatives pursue

superior patient value?

Since the book Redefining Healthcare was published in

2006, many organizations have embraced the Value-

Based Health Care (VBHC) methodology. This is

reflected by the numerous applications of high-quality

VBHC initiatives. They vary from small e-health

solutions that create a large impact to VBHC

implementation within large institutions. The

international jury has had the difficult task of selecting

the winners for the various awards from this rich pool

of high-quality initiatives. One thing all nominated and

runner-up initiatives have in common is a mutual

passion for improving patient value.

Value-Based Health Care and Cure

There is a great diversity amongst the nominated

initiatives, ranging from care in the last phase of life to

hand and wrist care curing everyday injuries. The

examples show the importance of improving patient

value: VBHC in both care and cure.

The care-initiative 'Desired Care in the Last Phase of

Life' implements a transmural multidisciplinary

palliative care pathway, collaborating with many

institutions. The focus is on improving the quality of

dying rather than the quality of life, through early

detection of the last phase of life by measuring

outcomes, among others.

Preliminary results show patients, as preferred, are

more often able to pass away at their place of residence

instead of in a hospital and are more at peace with

dying.

On the other hand, cure-initiative 'Closing the Loop'

focuses on improving patient value in hand and wrist

injury treatments.

The entire care cycle can be followed by Pulse, an

outcome measurement system facilitating transparency

into outcomes for both the doctor & team and the

patient & family.

Patient relevant outcome measures

One of the first steps in improving patient value is to

measure and identify patient relevant outcome

measures for a specific medical condition. This is

exactly what is being done in, for example, the

nominated initiatives 'Benchmarking Mental Health

Care', 'Value-Based Healthcare in Pulmonary

Sarcoidosis', and 'The Dutch Surgical Colorectal Audit

(DSCA)'.

Facts about the applicants of 2017


NOMINEES

Stichting Benchmark GGZ stimulates the collection of

outcome measures in mental health care to enable the

assessment of quality of care in institutions. This

transparency makes the exchange of experiences and

best practices possible in order to further improve

outcomes.

St. Antonius Hospital has designed an international

outcome set for patients with pulmonary sarcoidosis, a

disease with a highly heterogeneous manifestation of

symptoms. Due to the inclusion of patients in the

research team, this set represents the outcomes that are

most important to patients.

By making the variation between providers and

treatment transparent and giving insights in best

practices, colorectal cancer care is improved by the

outcome registry of the ‘The Dutch Surgical Colorectal

Audit (DSCA)’. These insights have resulted in a

prevention of colorectal cancer deaths and significant

cost reductions.

E-Health to facilitate VBHC

As technology slowly facilitates every step one takes, it

has also emerged as a tool in health care: E-health.

Radboud UMC has been nominated with their 'virtual

asthma clinic for children', that decreases how often

children need to visit the hospital. The virtual platform

‘Luchtbrug’ facilitates outcome measurements by which

physicians as well as patients and their families can

monitor their condition.

Another great example of e-health is telemedicine

'myIBDcoach', which enables continuous monitoring of

relevant PROMs and PREMs. Patients with

inflammatory bowel disease using myIBDcoach have a

36% reduction in outpatient visits, a 31% reduction in

telephone consultations and a 50% reduction in

hospitalization.

E-health is also being used in 'G-Watch', by connecting

elderly patients with heart disease with cardiac and

geriatric experts in a telerehabilitation program 24/7.

Elderly patients are hereby able to stay in their own

homes with potentially higher quality of life. E-health

solutions are used to monitor outcome measures

enabling learning about and improving patient

outcomes.

Collaboration

In the Netherlands, care is divided into primary,

secondary and tertiary care, respectively general

practitioners, specialists and highly specialized

physicians in academic medical centers. What makes

the initiative 'Netherlands Heart Network' unique is

that this division has faded through multidisciplinary

collaboration of all health care professionals.

Collaboration facilitates the achievement of the best

outcomes for patients with heart disease.

The strength of collaboration is also present in

'FAMOUS', a pre-hospital triaging system for chest pain

patients. In this initiative, paramedics, general

practitioners, cardiologists and clinical chemists work

together for risk stratifications of chest pain patients,

potentially preventing overcrowding of the emergency

department and reducing costs.


NOMINEES

Between the nominated initiatives, many integrated

practice units have been identified, such as 'Value-

Based HIV Care' at OLVG, 'VBHC@Santeon', and

'Diabeter'. The OLVG has the largest HIV care center in

the Netherlands and has a multidisciplinary team

responsible for achieving the best patient relevant

outcomes. In collaboration with HIV patients, relevant

outcome measures that are most important to them

have been defined. 'VBHC@Santeon' represents an

innovative integrated practice unit with shared

responsibility across seven different hospitals that

collaborates in ensuring patients are treated at the

hospital with the best patient outcomes for five

prevalent conditions. Outcome measures are compared

and learning cycles are implemented to stimulate

improving outcomes.

Shared responsibility is also key in 'Diabeter‘, a patient

-centric clinic with a multidisciplinary team focused on

on diabetes care. Diabeter focuses on improving value

for diabetes patients over the full cycle of care,

including comorbidities such as kidney disease and

myocardial infarction.

The high quality of the nominated initiatives reflects

the sophistication in which Europe approaches a

healthcare system based on the methodology of Value-

Based Health Care. Each VBHC initiative has a unique

strength with which it enables excellent patient care.

Recognition of these initiatives and celebrating the

success of VBHC implementation is key to inspiring the

initiatives of tomorrow.

VBHC in the Netherlands

*Locations of the nominated initiatives are pointed out.


VBHC WINNER 2016

It seems only yesterday that we received the VBHC

Prize 2016. We are so busy with our day to day routines

that we tend to forget to take a step back and see where

we are headed. So let’s take a step back and see what

has happened since we won the prize on April 7th, 2016.

In our project we established a Value-Based Health

Care contract between Catharina Hospital and

insurance company CZ. This contract rewards value

instead of volume. With a growing number of initiatives

in Value-Based Health Care there is a growing need for

contracts that follow these principles allowing all

stakeholders in health care to focus on the same goal:

value for the patient. We managed to establish this

innovative contract within the complex playing field in

which hospitals and insurance companies find

themselves, with regulations and roles that change

annually, political discussions and rising costs.

The VBHC Prize brought us recognition of our hard

work and good collaboration. It helped us remember

the great steps we have taken and it helps us to

continue focusing on the goal of Value-Based Health

Care. The VBHC Prize gave our project a huge boost on

several levels.

Firstly, it gave us great exposure in the field. We came

in contact with many different people working on

similar ideas or wanting to start initiatives related to

ours. We have presented our ideas to hospitals, policy

makers and other parties. The discussions that followed

inspired us to further develop our project.

The VBHC Prize and the inspiration it brought us gave

us an extra drive to continue making improvements on

the contracting model.

Many ideas for improving and expanding the model

have arisen. As the Prize jury stated in the its report,

the initiative has potential for application to other

medical conditions. Secondly, the model could be rolled

out on a national level, involving more hospitals and

more insurance companies. Finally, the contracting

model itself could be improved by adding more

outcome measures, improving statistical relevance and

broadening the scope.

“The VBHC Prize brought us recognition of our

hard work and good collaboration”

At the same time we have learned that the success of

our project lies in the fact that we kept it simple and

practical. And this is the way to move forward.

One Year Later, what did the VBHC Prize bring? By L. Kuijten-Slegers & A. Lenssen – Catharina Hospital & CZ Group


VBHC WINNER 2016

Thus, we sat down with the team and discussed what

matters most to us. For the cardiologists it was clear

that to improve the measurements of quality of life for

patients was most important. This is also considered to

be one of the most important outcome measures, but

we find it difficult to measure. We have decided to use

the incentive from the project to improve this measure.

And we therefore decided to implement it in our

contracting model.

Furthermore, we have included the TAVI procedure

into the model. This relatively new procedure is finding

its place in the healthcare system and has received a lot

of attention from the cost point of view. It seemed

logical to add this procedure to our contracting model,

thus covering monitoring value (and not only cost).

We often feel that we are not moving fast enough. Then

again, one can only do so much per year. We improve

and expand step by step in the complex field that we

find ourselves, and we are proud to be part of the

Value-Based Health Care movement – a movement that

we wholeheartedly believe in!

The Project – Value-Based Purchasing

Contracts

Catharina Hospital Eindhoven and healthcare

insurance company CZ developed the first model for

Value-Based Health Care contracts based on robust

patient relevant outcomes. The crucial principles of

Value-Based Health Care as described by Porter (2010)

are integrated in the model. The contracts relate to

heart patients with coronary artery disease and atrial

fibrillation. The related outcome measures (defined by

Meetbaar Beter) are compared and when the hospital

has improved, it is rewarded. The outcome measures

hierarchy is applied by determining success. With this

contract all stakeholders in health care focus on the

same goal: value for the patient.

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Y O U R P A R T N E R I N V B H C I M P L E M E N T A T I O N

“Focus on patient value and continuous learning while enjoy doing it”

- Prof. Dr. Fred van Eenennaam

“I appreciate your work and your recognition of the

work of people implementing value-based strategies”

- Prof. E.O. Teisberg, PhD -

“I want to congratulate Prof. Dr. Van Eenennaam

for his pioneering work in this area”

- Prof. M.E. Porter, PhD -

VBHC implementation

It is all about coaching the team

VBHC culture change

Creating an Integrated Practice Unit

VBHC patient involvement

VBHC reviews: outcomes, costs,

organization, learning cycles, etc.

Academic & methodology councils

VBHC

implementation

pioneer since 2006

Over 100 unique

VBHC

implementation

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implementation

partners

Implementation

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over

75 medical

conditions

www.vbhcprize.nl @VBHCEurope Value-Based Health Care Center Europe

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Documents

May 2017 TOWARDS EXCELLENT PATIENT VALUE HAS NEVER …€¦ · healthcare professional and the society p. 22 From measuring to knowledge to value p. 24 Putting VBHC into practice: