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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;
• Exclusive two for the price of one VBHC masterclasses*;
• Initiate, participate and have access to the work in Chapters.
*one time offer
Become a member via: vbhc.eu/become-a-member
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
info@vbhc.nl
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
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
.
6 VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION | MAY 2017
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
MAY 2017 | VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION 7
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.
8 VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION | MAY 2017
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
MAY 2017 | VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION 9
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 *:
10 VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION | MAY 2017
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: s.nonnekes@thedecisioninstitute.org.
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
12 VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION | MAY 2017
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
MAY 2017 | VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION 13
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
14 VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION | MAY 2017
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
MAY 2017 | VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION 15
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.’
16 VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION | MAY 2017
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)
MAY 2017 | VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION 17
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.
18 VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION | MAY 2017
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.
MAY 2017 | VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION 19
*The international collaborations were extrapolated, taking into consideration the amount of international connects within initiatives and are likely underestimated.
20 VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION | MAY 2017
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
MAY 2017 | VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION 21
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.
22 VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION | MAY 2017
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
24 VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION | MAY 2017
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
MAY 2017 | VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION 25
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
26 VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION | MAY 2017
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
MAY 2017 | VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION 27
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.
28 VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION | MAY 2017
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:
MAY 2017 | VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION 29
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
30 VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION | MAY 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.
MAY 2017 | VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION 31
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.
32 VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION | MAY 2017
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
MAY 2017 | VBHC THINKERS MAGAZINE – VBHC PRIZE EDITION 33
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
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