Value Based Services
Week 1; Value-based Health Care and Integrated Practice Units
Introduction Value and Value-based health care
What’s the issue?
- How can the fragmented, siloed health system be redesigned?
We delivery primary care, secondary and tertiary care, these are siloed. But also, for the
purchaser, the care that is contracted between health insurer and organization. This is also
done separately.
- The way we pay for healthcare incentivizes volume instead of value.
- We measure quality mainly with process indicators instead of outcome indicators.
- There is a call for balance between measuring for accountability and measuring for
improvement.
- We need ‘orchestrated teams’ that take responsibility for the ‘full cycle of care’
> Value Based Health Care can improve this.
What is value?
‘Value is health outcomes achieved per dollar spent’
‘Value is in the eye of the beholder’
‘Focus: What matters to you?’
‘The different meanings of value: economic value (outcomes and costs), moral values (treat me
respectfully), scientific values ’
‘Doctors know about the illness, patients know about the impact’
Expert Panel on effective ways of investing in Health
Four types of value: micro and macro -> previous slide is more based on number 1 and 2. Whole
course will be mostly based on these two.
1. Personal value: deliver care based on the individual patient
2. Technical value: deliver the best outcomes possible with not too many costs/ resources.
3. Allocative value: resources should be fairly distributed, there are big debates about this
4. Societal value: the doctor cures you, which causes that you can contribute to society
A: this is always fine
D: you will never do this
What about B&C?
,What would be your advice in situations like C or B?
Focus on C is interesting, also has to do with allocative value, C asks for a lot of focus on improvement
of outcomes.
With B, it is even more complex. You can try to lower the spend. Also, you can accept it as it is, trying
to lower the spend is the easy way. But better outcomes in health can be so good, that you accept the
higher spend.
What matters to the patient with a replaced hip:
Experience or Outcome?
We are not only interested in clinical outcomes, also patient reported experiences, and outcomes.
Is this an experience or an outcome?
> Patient with hip replacement, all clinical characteristics are important outcomes. But what about:
‘The surgeon said I could go home. The nurse said the physiotherapist had to give permission. I got
confused?’
> Experience
‘I had to have more painkillers, I never had enough. I didn’t want to take too big of dose, it made me
gloomy’
> Outcome, since it says something about the health outcome of the patient.
‘Hopefully I will start walking better again and be able to do more’
> Outcome, because it says something about the health status
‘It’s strange that I almost did not speak to the doctor after the operation, it was no more than two
minutes’
> Experience
‘I have not been able to sleep all night and now feel very tired’
> Outcome, it’s a health status
These are more moral outcomes you could say.
Video: Human Empathy: very interesting and important to deliver patient centered care, take into
account the personal stories.
More aims are at stake;
- Triple aim: (1) improving the experience of care, (2) improving the health of populations, and
(3) reducing per capita costs of healthcare
- Quadruple aim: (4) healthcare team well-being
- Quintuple aim: (5) health equity
- And how about the planet?
,Focus on outcomes: Porter’s three tiers and ICHOM
Lower tiers are contingent on the higher tiers.
Tier 1: for example, survival rate of cancer. Having breast-saving surgery is also important
information, next to removing breasts.
Tier 2: the process towards survival. Time to return to… More societal value. No discomfort for
example, like infections.
Tier 3: more long-term perspective. If disease returns, long-term consequences of treatment. How it
helps you to survive.
PROMs, PREMs, NPS
• PROMs
- Any report of the status of a patient’s health conditions that comes directly from the patient,
without interpretation of the patient’s response by a clinician or anyone else
- 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? (disease specific)
• PREMs, 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.
• NPS:
- What is the likelihood that you would recommend this hospital to a friend or colleague? NPS
= % prospectors (give 7, 8, 9 or 10) - % detractors (give 1-6)
Question;
Proposition 1 PREMs report on the patient satisfaction and experience, PROMs report on the
patient’s health condition.
Proposition 2 In value-based healthcare, 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
b. You agree with proposition 1, you disagree with proposition 2
c. You disagree with proposition 1, you agree with proposition 2
d. You disagree with both proposition
A
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 groep with ‘Digitable’ tool
• Delphi study with 10 experts
> All research within the Value Based Healthcare field.
Based on that research, this model is made.
Costs: they would like to introduce new ways of payment that incentive outcome, so for example pay-
for-performance, bundled payment, or extra’s that incentive value. Insurers should only pay for value,
not for waste.
Organization of care: ensure patient involvement, in improving the care pathway, not only in their
own care path. What you need is data, to improve.
Steering of quality: VBHC is also working on a learning community, related to the care pathway. For
example, by using dashboards.
This comprises VBHC, derived from interviews.
VBHC at the Martini Klinik and Boston’s Children
What can be learned from the Martini Klinik and Boston’s Children, what are the key messages?
> Reimbursement system is important
> Patient perspective / value is important -> main message
> Very important to know the cost drivers / mapping the care pathway
Top 5 Delphi study
‘VBHC became intertwined with shared decision-making.’
This is not in the definition of Porter, but is it seen as very important in multiple studies.
