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P R O F . D R . F . V A N E E N E N N A A M
1 | THE DECISION GROUP | PROF. DR. FRED VAN EENENNAAM | JUNE 18 , 2016
Leadership and Management in Cardiovascular Medicine Forum
Value-Based Health Care in Europe.
What’s Next?
2 | THE DECISION GROUP | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
1. The fundamental challenge in health care
2. Value Based Health Care addressing the issuea. Value is …?
b. Who creates value and how?
c. How do we measure and improve Value Creation?
3. Three classic VBHC examples
4. The Dutch Meetbaar Beter in Heart Diseases
5. Wrap up and closure
PROGRAM
3 | THE DECISION GROUP | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
Value-Based Health Care Delivery
Introduction and background
Prof. Dr. Fred van Eenennaam
• Affiliated to George Washington University, Erasmus University, St. Gallen University and The Decision Institute
• Included in the Harvard Business School, Microeconomics of Competitiveness Affiliate Hall of Fame
• Managing partner of The Decision Group
• Incoming Chairman of the Value-Based Health Care Center Europe
1994 2006 2011 2013
4 | THE DECISION GROUP | V 1 | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
Michael Porter - Value-Based Health Care
The root cause of why we have difficulty in creating patient value and capturing the
value for providers and industry…
Value-Based Health Care – Healthcare Problems and Solutions
5 | THE DECISION GROUP | V 1 | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
Unexplained, unmeasured, unmanaged variations
…has led to FEE FOR SERVICE instead of FEE FOR VALUE … which has contributed
to increasing healthcare costs and over and under treatment of patients.
Doctors performing C-sections varies from 15 to
71,4% of births without case mix difference ???
Who is getting paid for or is paying for value?
Standardized death rates and charges
per admission have no correlation.
Source: NHS Confederation 2004, Brian Jarman, nhsconfed.orgSource: PBGH report: Variation in NTSV C-section rates among California hospitals (2014)
6 | THE DECISION GROUP | V 1 | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
Balance of power of stakeholders (patients vs. payer)
Are Patient(groups)/Physicians in terms of joint decision making, bargaining power,
and influence, able to drive healthcare decisions or are the payers/ insurers dominant?
Payers,
Insurers
Facilities
(Primary) Care Physicians
Patients
Patients
(Primary) Care Physicians
Facilities
Payers,
Insurers
Where will the dominant power be?
7 | THE DECISION GROUP | V 1 | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
Patient value is at the core of VBHC
Patient Value is the balance between patient relevant health outcomes and the costs of
delivering these outcomes. Patient-centered – doctor-driven.
Porter, M.E. (2013) The strategy that will fix healthcare? The New England Journal of Medicine, 363;26
“Doing the right things”
“Doing the right thingsat the right place, at the right costs”
Effectiveness
Efficiency
Value-Based Health Care is about creating value
for patients throughout the full cycle of care. It
is about maximizing the health outcome per
Euro spent (cost).
8 | THE DECISION GROUP | V 1 | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
Value-Based Health Care: Change is on its way
Value-Based Health Care increasingly becomes the norm, placing the interaction between
patient and family & physician and team at the center of care.
Patient and Family
Physician and Team
- More informed (apps, internet)- Active role decision making (palliative)- Voting by feet (go to best care&cure)
- Care around Medical Condition (e.g. diabetes, prostate cancer)
- Improvement of Outcome Measures (Meetbaar Beter, Santeon)
- Transparency (ParkinsonNet)
9 | THE DECISION GROUP | V 1 | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
Stop inflation of measurements and data
For many years, healthcare providers have been trying to measure performance in numerous
ways following different trends. Health outcomes are measured by outcome measures.
1950 1960 1970 1980 1990 2000 2005 2010 2014
Medical
Measures
Process &
Structure
Measures
Quality
Manage-
ment
(process
focus)
Followed by
Lean & Six
Sigma
Patient
Perception
Measures
(& patient
reported
outcomes)
Family
perception
Outcome
Measures
Historical development of measurement in health care over the past 60+ years
10 | THE DECISION GROUP | V 1 | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
Health Outcomes
A limited set of outcome measures and initial patient conditions provides medically relevant
and usable data for each stakeholder.
Source: Porter, M.E. &
Teisberg, E. Redefining
Health Care (2006)
11 | THE DECISION GROUP | V 1 | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
Care Delivery Value Chain
All activities over the full cycle of care are described by the Care Delivery Value Chain:
procedures, visits, treatments, communication and measures related to a patients medical
condition.
Example of a Care Delivery Value Chain for breast cancer
Source: Porter, Redefining Healthcare
12 | THE DECISION GROUP | V 1 | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
How does the CDVC translate to outcome measures?
Every outcome measure is directly related to a step in the Care Delivery Value Chain that
adds value for the patient.
Example of the Outcome Measures HierarchyExample CDVC for breast cancer
Source: Porter, Redefining Healthcare
Nausea due to
Anaesthesia
Time to functional
status
2-year survival
13 | THE DECISION GROUP | V 1 | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
VBHC: Why outcome measures?
Patient relevant outcome measures result in one common language for a transparent dialogue
plus the dissemination of best practices on four essential Value-Based Health Care topics.
14 | THE DECISION GROUP | V 1 | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
Case examples
The Martini Klinik (outcomes), Schön Klinik (cost) and Meetbaar Beter (First Dutch
Initiative) are the three most inspiring European initiatives in Value-Based Health Care.
Martini Klinik:
Prostate Cancer Care
• Application of outcome measures in
prostate cancer
• Outcome measures analysis and
continued reflection with the staff led
to:
• Higher continence rates
(96,7% as opposed to 56,7
German average)
• Adoption of multiple best
practices and new techniques
Meetbaar Beter
Measuring outcomes in Cardiology
• Implementation of outcome measures
for 10 key heart centers in The
Netherlands
• Using outcome measures for a group
of hospitals created:
• Change in patient flows
• Transparency on patient
outcomes
• Health quality improvements
Schön Klinik
Measuring Cost and Value
• Patient Value through Time Driven
Activity Based Costing (TDABC) for
total knee replacements
• TDABC over the full cycle of care
and elaborate outcome measures
resulted in:
• Reinvestment in profitable
rehabilitation facilities
• Empowerment of doctors,
nurses and hospital
15 | THE DECISION GROUP | V 1 | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
Continuous learning has led to improved health outcomes for prostate cancer
resulting in being the best prostate cancer clinic in Germany and the world.
Martini Klinik
Results - A short overview:
Source: Harvard Business Case: Martini Klinik
16 | THE DECISION GROUP | V 1 | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
Schön Klinik
De Schön Klinik is the best example for Time Driven Activity Based Costing. Insight in real
costs are a valuable source for improvement.
Health outcomes:Measured by an extensive list of outcome measures such as: • Womac scale: 23.7 points (measuring pain and functional limitation
for osteoarthritis of the knee. 0 is best status, 96 is worst)
• EQ-5D scale: 77.9 points (measuring baseline health and
functionality: 0 is the worst, 100 is best)
Cost:Measured by Time Driven Activity Based Costing:Through a combination of data-analysis and interviews with clinical and
support staff the Schön Klinik team was able to create:
• Process maps: sequence of processes the patient encounters through
the full cycle of care.
• Cost assessments: the costs and practical capacity are calculated per
resource type
Schön Klinik:
Measuring Cost and Value
Patient Value through Time Driven Activity Based
Costing (TDABC) for total knee replacements.
TDABC on the full cycle of care and elaborate
outcome measures resulted in:
• Reinvestment in profitable rehabilitation
facilities
• Empowerment of doctors, nurses and
hospital
• Cooperation between different Schön
Kliniks and other institutions are central
to the success. Based on HBS cases: Kaplan et. all, 2012, 112085-PDF-ENG
17 | THE DECISION GROUP | V 1 | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
Cost saving
Time Driven Activity Based Costing is relevant for improving the health outcomes for
patients and to secure the quality of care delivered.
Time Driven Activity BasedCosting (TDABC)
Interviews and data-analysis resulted in control over:
- Cut-to-next-cut for operation room turnover
- Labor time allocation- Costs of supplies (eg. drugs,
implants, etc.)- Indirect costs (eg. radiology)- Depreciation of instruments- Facility costs
Reassessment of real costs
Acute care:
- Costs dropped from $9300 to $8000. - Ebitda profit margins raised 6%-points (19%)
Rehabilitation:
- Costs dropped from $4600 to $3300.- Ebitda profit margins raised 13%-points (7%)
Reinvestment in rehabilitation
Restructured care process
Comparability of best practises
Schön KliniksPhysical therapy: not
individually but in groups
Internationally: US + Denmark
3 pilots to reduce coststhrough length of stay:
- 2 days Copenhagen University Hospital
- 3 days average US- 4 days Denmark- 10 days Schön Klinik
19 | THE DECISION GROUP | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
Meetbaar Beter in numbers
Source: Meetbaar Beter Outcome Book 2015.
20 | THE DECISION GROUP | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
Meetbaar Beter: Participating Centers
Source: Meetbaar Beter Outcome Book 2015.
22 | THE DECISION GROUP | V 1 | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
VBHC: The coming years
1. Value-Based Purchasing – moving from volume towards value
2. Data / IT integration and digitalization
3. Patient engagement
4. Creation of (systematic) learning loops for improvement purposes
5. Cultural and transformation change and leadership
6. Moving towards integrated practice units
7. Industry engagement
8. Primary care engagement
Various topics and challenges in Value-Based Health Care will become
increasingly important in Europe as well as internationally in the near future.
23 | THE DECISION GROUP | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016
Save the date!
May 11
VBHC Prize 2017
Pre-applications will be accepted as of September 1st, 2016
Contact us via [email protected]
@VBHCEuropeValue-Based Health Care Center Europe
VBHCPrize.com
VBHC.nl
2017 ?
Want to become the
26 | THE DECISION GROUP | VERSION 1 | PROF. DR. FRED VAN EENENNAAM | JUNE 18, 2016 |
Contact:
The Decision Group
Buitenveldertselaan 106
1081 AB Amsterdam
(t) + 31 (0) 20 40 40 111
www.thedecisiongroup.nl
www.thedecisioninstitute.org
www.vbhcprize.com
www.vbhc.nl
Thank you