VBHC Center Europe – VBHC Thinkers Magazine, winter 2022 edition

How did your interest in VBHC arise, and why do you think it is so important?

It is 2021 and we have taken a very hard blow from the outside to wake up and realize that things must change in healthcare. This hard blow (read: the corona crisis) has opened our eyes, but I already had that feeling of discomfort that is needed for true innovation 1 before. I was aware that our current healthcare system cannot keep up with the challenges of the future – there are still too many inefficiencies in it.

For me, this sense of discomfort started in 2015, when my former boss and general manager at Amgen, asked me to think about how we could add value to healthcare in other ways than just through our portfolio of medicines. Due to the aging population, more diseases becoming chronic, and more and more treatment options, healthcare was already under pressure at that time. In addition, the labor market problem has only become more acute since then.

If we continue as we are now, by 2040 1 in 4 people should be working in healthcare 2 . Those people simply don’t exist! All this means a dangerous cocktail for the sustainability of our system and access to high-quality care for everyone now and in the future.

So back to that question, which actually consisted of two questions: find out what value means for healthcare and think about how we can contribute to this so that healthcare remains accessible?

My musings took me back to 2007, when I first came across the theory of Value Based Healthcare, and the book by Michael Porter and Elisabeth Teisberg 3 . I was on maternity leave at the time and was reading “Redefining Healthcare”. How well this book described how things can be done differently in healthcare! But it took until 2015 before I really started working on this matter. The great thing about VBHC is that you improve the quality and efficiency of care while at the same time reducing costs. Of course, no one can argue against that! And brilliant VBHC examples exists, that show that reduction in healthcare costs can certainly be achieved 4 . Unfortunately, this is not yet commonplace in the Netherlands. There are several reasons for this, but the most important is that “outcomes” have still not been given a leading role in our healthcare system.

There is no clarity about which outcomes of care are really important. And important to whom? People tend to think that quality of care consists of good clinical outcomes, but quality means something different to everyone. With an identical knee problem, some require surgery because they may want to be able to play hockey again, and for others, physiotherapy is the best approach so that she/he does not experience pain during the short, daily walk to the local supermarket - the only exercise she/he gets per day. In other words, quality is different for every patient. Currently there is still too little attention for that, for a good conversation about what is important for this one patient in his or her treatment.

I have a distressing example from my private life in which a friend was terminally ill, but still received chemotherapy. Simply because this treatment option still existed. But this left him confined to a hospital bed, when all he wanted was to spend his last weeks at home with friends and family. In this example, not treating suddenly became a very valuable option that contributes enormously to the quality for this one patient. Talking about the most important outcome for the patient, and treating and managing on that outcome, makes care more personal. And gives both clinical outcomes and PROMs an equal value in treatment. It also paves the way for measuring outcomes, eliminating inefficiencies in healthcare, and ultimately being paid based on outcomes achieved.

How do you see the role of the various parties in outcome-oriented care?

We are used to thinking of healthcare as if it were between 3 players; the patient, the care provider and the care payor, regulated by the government.

However, providing good care is more complicated than that. Pharmaceutical companies and providers of medical technology and eHealth solutions all make an indispensable contribution to healthcare. Each party contributing to a treatment is therefore partly responsible for the outcome of that treatment.

So, if you want to take joint responsibility for the outcome of a treatment process, it is important that you maximize the chance of the best outcome.

In the “patient journey”, however, there are countless moments when value for the patient can leak out, or if you turn it around, where there is risk of not achieving the desired outcome. Jointly parties can develop solutions for those moments in the “patient journey” to ensure that the value is preserved. You can think of a solution for one single moment, such as a care program that influences therapy adherence, but also a solution across the entire ‘patient journey’ such as digitizing the care path, which can lead to enormous efficiency.

eHealth solutions in which questions can be asked or disturbing signals can be picked up early also provide patient value at times when the patient is home alone and is uncertain about her or his situation 5 . In an ideal situation, you can, risk stratification based, direct patients to the right care path from the moment of first symptoms and ensure everyone receives the care that best suits their situation and needs.

Digital or physical, in the hospital or at home. Also, check-up visits do not have to take place if everything goes well, but only with those patients where extra help is needed. We must collaboratively strive for this ideal situation, because it is the joint responsibility of every party in healthcare.

And what’s next?

At the moment this question is the subject of several reports. We also discuss this in the Nza steering group “Passende Zorg”, of which I recently became a member. In this steering group, together with the Dutch Care Institute (ZiNL), we are looking at other ways to pay for healthcare, creating room for important solutions like early diagnosis, prevention and digitization. Also, in Porter’s “Value Agenda” (figure 2) you find 6 important themes that need attention in order to transform to a valuebased system. What is officially not included is a crucial 7th theme; the medical team, culture and leadership. It goes without saying that without leadership of medical teams and their firm belief that we need to rethink the quality and organization of care, no transformation will ever be successful!

Since 2017 I have had the opportunity to partner with the Decision Group and others, to create and constantly refine the Value Agenda for the Netherlands. Together with 25 influential healthcare stakeholders, we define important next step that must be taken to further implement value-based care in the Netherlands. We have seen the themes shift from medical leadership, to data-sharing and last year to paying for outcomes and paying for innovation. What I remember most from last year was the sense of urgency, and the collective strong statement: “Don’t wait for others, start the change now.”

At the moment, 3 of the elements of the value agenda are crucial if we want to take the next step in the Netherlands.

Firstly, it is important that the value of a pilot is conclusively demonstrated, both in terms of the effect on treatment outcomes and the consequences for the costs (Theme 2: Measure outcomes & Costs for very patient). Only with this information pilots can be scaled and this transformation can accelerate. Secondly, it is very important to share data transparently, not only so patients know where to get the best care, but also so that much more efficiency can be achieved in care and a learning system is created (Theme 6: Build an enabling information technology platform).

We are used to thinking of healthcare as if it were between 3 players; the patient, the care provider and the care payor, regulated by the government (figure 1).

However, providing good care is more complicated than that. Pharmaceutical companies and providers of medical technology and eHealth solutions all make an indispensable contribution to healthcare. Each party contributing to a treatment is therefore partly responsible for the outcome of that treatment.

So, if you want to take joint responsibility for the outcome of a treatment process, it is important that you maximize the chance of the best outcome.

In the “patient journey”, however, there are countless moments when value for the patient can leak out, or if you turn it around, where there is risk of not achieving the desired outcome. Jointly parties can develop solutions for those moments in the “patient journey” to ensure that the value is preserved. You can think of a solution for one single moment, such as a care program that influences therapy adherence, but also a solution across the entire ‘patient journey’ such as digitizing the care path, which can lead to enormous efficiency.

eHealth solutions in which questions can be asked or disturbing signals can be picked up early also provide patient value at times when the patient is home alone and is uncertain about her or his situation 5 . In an ideal situation, you can, risk stratification based, direct patients to the right care path from the moment of first symptoms and ensure everyone receives the care that best suits their situation and needs.

Digital or physical, in the hospital or at home. Also, check-up visits do not have to take place if everything goes well, but only with those patients where extra help is needed. We must collaboratively strive for this ideal situation, because it is the joint responsibility of every party in healthcare.

Finally, organizing care in Integrated Practice Units (IPUs) is an important step towards more efficient care. In an IPU you manage the entire care path for an indication in 1 team, where extensive expertise is built up and economies of scale arise. This will not be very likely to happen in the very short term because Dutch hospitals are organized per specialism, not per “patient journey”, but it is important for future acceleration. (Theme 1: Organize into integrated practice units).