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Summary VBS: lectures, workgroups and literature
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Summary VBS: lectures, workgroups and literature
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Value based servicesWeek 1
Lecture 1 – Value based health care and integrated practice units
Objectives:
The student can generate suggestions for improving value-based services by relying on
relevant theories, models and/or concepts.
The student can critically reflect on the different aspects behind value-based healthcare and
the trade-offs involved.
The student has understanding of state-of-the-art value-based healthcare approaches of
forerunners.
Preparation:
VBHC:
- Value for the patient
o Patient journey for showing patient care procedure
o Health status, recovery process, sustainability
o Clinical outcomes, PROMs, PREMs SDM
- Organization of care
o Treatment plan
o Creating care path
o Indicators that are important for patient/care and for improvement
o Multidisciplinary teams with clinical leader that secures for an open and safe
environment
- Costs
o Including all costs of the care traject but also sick leave from work, also those of the
informal carers if they cannot work fulltime anymore
o Only costs for value adding processes, avoiding other costs, creating incentives for
this. So not focus on volume.
- Quality of care
o Care based on protocols and guidelines evidence-based medicine and practice
o Monitoring care to see whether improvement is desirable/required
o Plan, do, check, act cycles/creating dashboards to visualize the care process
What’s the issue?
• How can the fragmented, siloed health system (from provider/purchaser side) be
redesigned? (meso level)
• The way we pay for healthcare incentivizes volume instead of value (Porter, 2010) We
need incentives for creating value
• We measure quality mainly with process indicators instead of outcome indicators (Porter et
al., 2016) should use more outcome indicators)
• There is a call for balance between measuring for accountability and measuring for
improvement (Meyer et al., 2012; Elg et al., 2013)
• We need ‘orchestrated teams’ with clinical lead that take responsibility for the ‘full cycle of
care’ (Bohmer, 2016, p.710; Porter, 2010, p. 2478)
What is value?
‘Value is health outcomes achieved per dollar spent’ (Porter, 2010, p. 2477)
‘Value is in the eye of the beholder’ (Prada, 2016, p. 162)
‘Focus: What matters to you?’ (Bisognano, 2012)
, ‘The different meanings of value: economic values, moral values, scientific values’ (Frederiksson et
What is value from a patient perspective? Process and Relationship
(Bastemeijer, Voogt, Van Ewijk, Hazelzet, 2017)
Uniqueness Respected as a person rather than as a patient with a health problem Patient
Autonomy Respecting the patient’s capacity for making his/her own decisions about treatment and care
Partnership Interaction based on equality Interaction
Empowerment Enabling patients to keep control of their own situation
Compassion Attitude of being truly concerned and ability/willingness to emphatize Professional
Professionalism With knowledge, skill and attitude in treatment and in communication with the patient and
colleagues
Responsiveness Responsible execution of treatment and care
al., 2015)’
‘Doctors know about the illness, patients know about the impact’
Expert Panel on effective ways of investing in Health (EXPH, 2019; Gray, 2017)
Four types of value: micro and macro
1. Personal value (the care should fit the goal of the
patient)
1. Technical value (deliver the best possible outcome
With not too many costs/resources)
-------------------
3. Allocative value (are resources distributed fairly?)
4. Societal value (contribution to society)
What would be your advice in situations like C or B?
B: trying to lower the spend
C: focus on improving the outcome
What matters to the patient with a replaced hip:
Difference between experience or outcome:
1. The surgeon said I could go home. The nurse said the physiotherapist had to give permission.
I got confused: Experience
2. After the operation, I had to have more painkillers, I never had enough. I didn't want to take
too big a dose, it made me gloomy: Outcome painkillers (says something about health
status of a patient) and made them feel a certain way
3. Hopefully I will start walking better again and be able to do more: Outcome
4. It's strange that I almost did not speak to the doctor after the operation, it was no more than
two minutes: Experience
5. I have not been able to sleep all night and now feel very tired: Outcome (says something
about health status of patient)
YouTube Human Empathy
Movie about empathy in relation to patients, carers and other people involved
“Everybody has their own story, to deliver personalized care you need to take these into account”.
,More aims are at stake
• Triple aim (Berwick et al., 2008): (1) improving the experience of care, (2) improving the
health of populations, and (3) reducing per capita costs of health care
• Quadruple aim (Bodenheimer and Sinsky, 2014): (4) healthcare team well-being
• Quintuple aim (Nundy et al., 2022): (5) health equity
• And how about the planet?
Focus on outcomes: Porter’s three tiers and ICHOM
PROMs, PREMs, NPS
• PROMs: Patient Reported Outcome Measures
• Any report of the status of a patient’s health condition that comes directly from the
patient, without interpretation of the patient’s response by a clinician or anyone
else (Rothrock et al., 2011)
• Generic: EQ-5D; Domain specific: Pain, Anxiety; Disease specific: Oxford Hip Score,
Oxford Knee Score, before and after measurement
• For example: Have you had any trouble with washing and drying yourself (all over)
because of your hip?
• PREMs, Patient Reported Experience Measures so about patient satisfaction, CQ index, e.g.
factor Communication with doctors:
• Doctors treat me with respect, take me seriously, listened carefully, explained things
clearly, spent enough time, kept their appointments (Stubbe, et al., 2007)
• NPS:
• What is the likelihood that you would recommend this hospital to a friend or
colleague?, NPS= % prospectors- % detractors
Question:
Proposition 1: PREMs report on the patient satisfaction and experience, PROMs report on the
patient’s health condition.
Proposition 2: In value-based health care, outcome indicators and costs are by definition important
in measuring value. However, process indicators need to be included in a disease-specific dashboard
as well, as these are actionable determinants of outcome.
a. You agree with both propositions
The essence of value-based healthcare
• Multiple case study
• 30 interviews, eight teams/vanguard sites, five
Dutch hospitals and one American
, • Gioia methodology for identifying second-order concepts and aggregated
dimensions
• Focus group with ‘Digitable’ tool
• Delphi study with 10 experts (Steinmann et al, 2021)
• The Delphi technique was used to reach consensus on the most important practices
in moving towards a value-based healthcare system.
Costs: pay-for-performance
VBHC at the Martini Klinik and Boston’s Children
https://www.youtube.com/watch?v=hMoRd4xg1zc
1:50-8:04: Martini Klinik Hamburg
All carers are paid the same and their opinions are taken into account. Goal of clinic is to improve
prostate cancer treatment and create higher quality of life for patients, therefore they want the
personnel to be motivated to engage in research/care procedures that may take years. They use
PROMs to analyze their care and really talk with patients about their experiences. 98% of patients
recommend the clinic to friends/family.
10.43- 13.57: Cleft and Cranofacial Center of Boston's Children's hospital
Biggest center for facial care for children of the world, providing specialized care. Want to change
processes based on outcomes and experiences. They want the processes to be in favor of the
patients, providing better care in a more efficient and effective way. Really looking from patient
perspectives and being able to look in the mirror of the patient to see their perspective.
What can be learned from the Martini Klinik and Boston’s Children, what are the key messages?
Healthcare and patient outcomes are both important, looking from patient perspective makes you
look in the mirror.
Top 5 Delphi study
‘VBHC became intertwined with shared decision-making’
(Engels et al., 2024)
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