2023-2024, Block 4 GW4014MV. Value Based Services
VBS Lectures
Inhoud
Lecture 1. VBHC & Integrated Practice Units (16-2-2024) .................................................................... 3
Introduction Value & Value-based healthcare............................................................................................... 3
The issue in HC........................................................................................................................................... 3
4 types of value.......................................................................................................................................... 4
Value from a patient perspective .............................................................................................................. 5
Porter’s 3 tiers............................................................................................................................................ 6
PROMs, PREMs, NPS .................................................................................................................................. 6
VBHC framework: the 4 values .................................................................................................................. 7
VBHC implementation ................................................................................................................................... 9
The Implementation Matrix....................................................................................................................... 9
The Value Agenda ...................................................................................................................................... 9
Challenges for VBHC ................................................................................................................................ 12
Concept of Integrated Practice Units........................................................................................................... 12
Interesting tools ........................................................................................................................................... 14
Quality dashboard ................................................................................................................................... 14
Importance/Performance matrix ............................................................................................................. 15
Care Process Self-Evaluation tool (CPSET) ............................................................................................... 15
Lecture 2. Decision analysis & Decision-making (23-2-2024) ............................................................... 16
Why? ............................................................................................................................................................ 17
Applying decision analysis ........................................................................................................................... 19
Direct rating procedure ........................................................................................................................... 19
Set priority weights.................................................................................................................................. 20
Normalize values ..................................................................................................................................... 20
Calculate weighted value scores .............................................................................................................. 21
Calculate benefit-cost ratios .................................................................................................................... 21
How do people actually make decisions? .................................................................................................... 22
Prospect theory (Kahneman & Tversky, 1979) ....................................................................................... 23
Lecture 3. Shared Decision-Making (SDM) (1-3-2024) ....................................................................... 24
History of SDM............................................................................................................................................. 24
Ethics, since 1960s: patient autonomy .................................................................................................... 24
Doctor–patient models ........................................................................................................................ 24
The 4 ethical principles ........................................................................................................................ 25
Practice variation 1990s: “preference sensitive decisions” ..................................................................... 26
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,2023-2024, Block 4 GW4014MV. Value Based Services
VBHC: 2015-’20: “SDM with PROMS” ...................................................................................................... 27
Shared decision-making .............................................................................................................................. 29
SDM in practice........................................................................................................................................ 29
Role of the patient in SDM (→ patient readiness) .............................................................................. 30
Barriers .................................................................................................................................................... 31
Re-design care paths.................................................................................................................................... 33
1) Metro mapping ................................................................................................................................... 33
2) Patient Decision Aids .......................................................................................................................... 36
Clinical practice guidelines (CPGs) ............................................................................................................... 37
Implementation of SDM in the western world............................................................................................. 38
Lecture 4. Zooming in on outcomes: PROMs, PREMs and beyond (8-3-2024) .................................. 39
Healthcare quality dimensions .................................................................................................................... 39
Value based (personalized) healthcare.................................................................................................... 41
Patient Reported Outcomes ........................................................................................................................ 42
PROM types: generic, domain, disease ................................................................................................... 43
Patient Reported Experience Measures ...................................................................................................... 48
‘Patient values’ vs. ‘Value for patients’ .................................................................................................... 49
Patient centered care → Person centered care........................................................................................... 50
Integrated care ............................................................................................................................................ 53
Healthcare as a service ................................................................................................................................ 54
Lecture 5. Cost measurement in VBHC (15-3-2024) ................................................................................ 60
Relevance to VBHC ....................................................................................................................................... 60
Different meanings of the word ‘cost’ ...................................................................................................... 61
Why is measuring costs so important and so complicated? ..................................................................... 62
Common cost-estimation methods .............................................................................................................. 62
Trade-offs ................................................................................................................................................. 63
Assumptions ......................................................................................................................................... 64
Emerging methods ....................................................................................................................................... 64
TDABC = time-driven activity based costing ............................................................................................. 64
Case: Application to fertility care ......................................................................................................... 65
Some of the results .......................................................................................................................... 68
Current challenges ....................................................................................................................................... 70
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,2023-2024, Block 4 GW4014MV. Value Based Services
Lecture 1. VBHC & Integrated Practice Units (16-2-2024)
Content overview:
Porter's definition of value is well known: "value is the health outcome achieved per dollar spent" (Porter,
2010, p.2477). In this lecture, we will provide a broader conceptualization of value. We will discuss our own
research into a framework for value-based healthcare. The first category involves introducing PROMs and
PREMs into the consultation room and using this data in shared decision-making. The second category is
about organizing a care pathway by an Integrated Practice Unit (IPU), applying data-driven improvement
and involving patients in the development of the care pathway and indicators (beyond participation in
tuning their care needs). The third category is about costs and the right financial incentives in healthcare.
Finally, there is a fourth category on visualizing performance using a dashboard to monitor, benchmark,
improve and learn. This comprehensive framework helps to implement VBHC, and can uncover what is
present in practice and what needs further exploration. We explore the approach of forerunners (Erasmus
MC, Amsterdam MC and Santeon hospitals). In the remainder of the lecture, we will delve into the care
pathway and integration concept and the leadership role of the IPU leader.
Preparation before the lecture:
- Read the paper of Steinmann et al. (2021). (→ see literature)
- Watch the Youtube video from Ahaus. (→ see literature)
https://www.youtube.com/watch?v=_zDdbUO4xVk&feature=youtu.be
- Watch the Youtube video on how value-based healthcare has been applied in 2 best practices:
https://youtu.be/hMoRd4xg1zc (→ see lecture notes: slide 14)
o The focused prostate cancer Martiniklinik (starts 1.50-8.04)
o The Cleft and Cranofacial Center of Boston's Children's hospital (starts 10.43-13.57)
Contribution to course learning objective:
• 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.
Introduction Value & Value-based healthcare
The issue in HC
Slide 3. What’s the issue?
• How can the fragmented, siloed health system be redesigned?
The healthcare system is very siloed, both on the provider’s side as on the purchaser’s side.
o On the provider’s side, we deliver primary care (GPs), secondary care (hospitals) and tertiary care
(very complex care in UMCs).
o On the purchaser’s side: e.g. health insurance companies contract the care in a single relationship
of insurer and provider. So within a health insurer, there are different (siloed) departments for
primary, secondary and tertiary care.
In this course, we will show you that it is very beneficial to think from the perspective of the patient.
The patient has a journey that is across primary, secondary and tertiary care (and what is the right place
for the right care?), and also across departments on as well the provider’s as the purchaser’s side.
• The way we pay for healthcare incentivizes volume instead of value (Porter, 2010)
Porter said that the current way of paying for healthcare is primarily based on ‘volume’, so more
delivery of care means more income. This is not helpful in containing the healthcare costs.
Therefore, Porter said that we need incentives for value in the payment model.
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, 2023-2024, Block 4 GW4014MV. Value Based Services
• We measure quality mainly with process indicators instead of outcome indicators (Porter et al., 2016)
Porter also said that we should use more outcome indicators to measure quality.
• There is a call for balance between measuring for accountability and measuring for improvement
(Meyer et al., 2012; Elg et al., 2013)
So we have an emphasis on measuring for accountability, and there is hardly any time left to measure
for improvement reasons. VBHC changes that.
• We need ‘orchestrated teams’ that take responsibility for the ‘full cycle of care’ (Bohmer, 2016, p.710;
Porter, 2010, p. 2478)
Bohmer said that we need ‘orchestrated teams’ with clinical lead (e.g. a lung specialist in COPD care, a
specialized lung nurse, physical therapist, etc.). And these teams then take responsibility for the full
cycle of care for the patients.
These teams could or should be across organisations (e.g. by including a GP).
So this is the issue: a siloed system, without the right financial incentives, with an over-emphasis on process
indicators and on measuring for accountability, and we miss orchestrated teams where a clinical lead takes
the responsibility with the team to improve a full cycle of care.
Value-based healthcare is kind of a solution. It is a way of working that might help and might lead to the
right direction.
Slide 4. 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, moral, and scientific values’ (Frederiksson et al., 2015)’
‘ Doctors know about the illness, patients know about the impact’
4 types of value
Slide 5
There was an expert panel on effective ways of investing in health (EXPH) and they distinguished 4 types of
value. The previous slide is more on the level of 1 and 2.
1. Personal value: the care should fit the goal
of the patient.
2. Technical value: deliver the best outcomes
possible with not too many costs or
resources.
Most of this course will focus on 1 & 2.
3. Allocative value: the resources should be
fairly distributed.
4. Societal value: by treating patients, they can
be very productive in/have contribution to
society again.
It’s always good to know that this discussion is a bit relative. I’ve drawn a matrix with 4 quadrants:
A: this is of course always fine. A better outcome at lower costs is always preferred.
D: this will never be made standard care, because you both don’t want a worse outcome and a higher
spend.
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