Abstract Lectures Value Based Health Care
Week 1
College 1.1A: Value Based Health Care
What is Value Based Health Care?
There are quite some definitions. The Erasmus MC uses the definition: “The optimal balance between
the gain in health, costs and societal value in light of characteristics of the individual patient
(personality, preferences, socio-economic status, comorbidity, grade of the disease, etc.).“
Gain in health Gain in health is first and foremost. That is what we aim in health care: prolong life
en improve the quality of life. But is not the only thing!
- In health care we cannot permit ourselves to rely on intuition
- However: that is exactly what we did last 2000 years
- We used to call that “Fingerspitzengefuhl”, “klinische blik” or craftmanship
- For a quality leap in (value based) health care we need reliable real life (“big”) data
Changes
The big changes that allow us to change health care radically:
- EPF
- ICT
- validated questionnaires / PROMS
- PREMS
- (public) databases
Big data and VBHC: a perfect match
‘Value’ is very personal
- Age, gender
- Ethnicity
- Personality
- Values
- Spiritual
- Expectations
- Education and profession
- SES
- Previous medical history
- Intoxications
- Medication
- Comorbidity
How is value measured?
- Medical outcome (survival, restoration of function, etc.)
- PROM’s
- Societal outcome (revalidation, return to work)
Why is VBHC so hard to implement?
VBHC is disruptive!
- Cultural change
1
, o Doctor’s need to develop a broader view
o Willingness to use data for continuous improvement
o Patients must be ready for shared decision making
- Logistics: the right questionnaire on the right time
- ICT
o Questionnaires in EPF (at intake and during FU)
o Dashboards
o Analytics
o Decision aids
Current status
- At intake: an in depth analysis of the individual
- For each condition a validated (set of) validated questionnaires is obtained at set intervals
- The questionnaires are sent out digitally, or filled in at the hospital (with help of a buddy)
prior to the consultation
- Results are discussed during the consultation
Patient and doctor are better informed
Loneliness, sexuality, depression, etc, are usually not addressed during a regular oncologic
consultation
History taking is more complete, holistic
The doctor is already informed before the patient enters the room and is better prepared
Value Based Health Care 2.0
Take home messages
- The human memory and intuition are unreliable and we have question their role in clinical
decision making
- Logistics of VBHC is demanding
- Patients have to be willing to use questionnaires repeatedly
- The doctor must be willing to use AND discuss questionnaires
- ICT is crucial
- Continuous improvement needs to be implemented
- Costs and benefits are not (always) clear
College 1.1B -Theoretical Principles
Value-based health care (VBHC) used to be called value-based competition.
The origins of VBHC
2
,Redefining Health care (2006)
- Michael Porter
o “Founding father”
o Harvard Business School Professor
o Famous for his work on competition
o Competition drives improvement
- Elizabeth Teisberg
Michael Porter
- Value chain:
o All the activities a business organization performs, which together create a valuable
product or service.
- Central premise:
o In any industry, a successful and sustainable enterprise needs to create value for its
clients – particularly in a competitive market.
- This is the framework from which he looks at competition
Porter & Health Care
- Value as the single goal (unifying all participants in the system).
- In healthcare delivery, clients = patients.
- Goal = Patient Value
Patient value
outcomes
- Why conclude that value= ?
costs
- The reason is that “Value is that what matters most to patients”
- What do patients want to achieve when they need health care?
o A patient has issues related to their health
o You want to get better, but if that is not possible, you want the best next option
What do patients want?
- To get better
- Best possible treatment outcomes
o Outcomes are really important
o Outcome is one element of value
- Treatments come at a price, we pay our healthcare professionals
o Some treatments are more expensive than others
o Some providers charge higher prices
- If two providers/treatments have the exact same outcome, we should go for the less costly
one.
What do patients value?
- The health status they achieve (outcomes) and the price they have to pay for it (costs)
outcomes
- value=
costs
- Optimizing this equation becomes the central goal the best outcomes, as efficiently as
possible
Key principle
3
, Value in health care is created at the level of medical conditions, over the full cycle of care.
a. Value is created at the level of medical conditions
i. Patients seek health care to address health related issues/disturbances.
ii. Those issues, complaints, symptoms are caused by a certain condition
iii. Ergo: professionals create value by addressing specific conditions!
iv. “Value in health care can only be understood by focusing on the level at which it is
actually created, which is in addressing particular medical conditions” (Porter &
Teisberg 2006: 99)
b. Value is created over the full cycle of care
1. Value is generated through the full set of activities (i.e. value chain)
2. Full care cycle: from start to end (diagnosis to rehabilitation).
3. Surgery for example, is only one element of the full cycle.
Remember
- Value should be the goal
- Value is created at the level of medical conditions over full care cycles
Implications for measurement
Value (outcomes & costs) to be measured at that level, over full cycles
- Different conditions cause different effects/outcomes.
- Measuring and reporting outcomes is crucial; it will enable effective comparisons.
o This should be the same in every clinic so they can be compared
Implications for organizing care delivery
(Re)organizing care around medical conditions & full cycles
(where value is created)
- Healthcare delivery commonly structured around separate specialties (fragmented, not
integrated around value creation)
o For example, you have to go through a MRI, then someone has to give a diagnosis,
then there has to be a surgery
o For value, you want these to all work together
Integrated Practice Unit (IPU)
multidisciplinary team, coordinating all the services necessary to address a medical condition
Implications for payment
Value-based payment covers the full care cycle of a certain condition.
- Bundled payments that cover all the necessary activities
o This way you don’t have to send your bill to the insurer every time you see a
different department
- For chronic conditions, bundled payments covering episodes of care
Value-based payment
- Removing adverse incentives (e.g. overtreatment)
- Alternative to fee-for-service
o (Providers are rewarded for volume)
- Instead: rewarding good outcomes & efficiency
4
Week 1
College 1.1A: Value Based Health Care
What is Value Based Health Care?
There are quite some definitions. The Erasmus MC uses the definition: “The optimal balance between
the gain in health, costs and societal value in light of characteristics of the individual patient
(personality, preferences, socio-economic status, comorbidity, grade of the disease, etc.).“
Gain in health Gain in health is first and foremost. That is what we aim in health care: prolong life
en improve the quality of life. But is not the only thing!
- In health care we cannot permit ourselves to rely on intuition
- However: that is exactly what we did last 2000 years
- We used to call that “Fingerspitzengefuhl”, “klinische blik” or craftmanship
- For a quality leap in (value based) health care we need reliable real life (“big”) data
Changes
The big changes that allow us to change health care radically:
- EPF
- ICT
- validated questionnaires / PROMS
- PREMS
- (public) databases
Big data and VBHC: a perfect match
‘Value’ is very personal
- Age, gender
- Ethnicity
- Personality
- Values
- Spiritual
- Expectations
- Education and profession
- SES
- Previous medical history
- Intoxications
- Medication
- Comorbidity
How is value measured?
- Medical outcome (survival, restoration of function, etc.)
- PROM’s
- Societal outcome (revalidation, return to work)
Why is VBHC so hard to implement?
VBHC is disruptive!
- Cultural change
1
, o Doctor’s need to develop a broader view
o Willingness to use data for continuous improvement
o Patients must be ready for shared decision making
- Logistics: the right questionnaire on the right time
- ICT
o Questionnaires in EPF (at intake and during FU)
o Dashboards
o Analytics
o Decision aids
Current status
- At intake: an in depth analysis of the individual
- For each condition a validated (set of) validated questionnaires is obtained at set intervals
- The questionnaires are sent out digitally, or filled in at the hospital (with help of a buddy)
prior to the consultation
- Results are discussed during the consultation
Patient and doctor are better informed
Loneliness, sexuality, depression, etc, are usually not addressed during a regular oncologic
consultation
History taking is more complete, holistic
The doctor is already informed before the patient enters the room and is better prepared
Value Based Health Care 2.0
Take home messages
- The human memory and intuition are unreliable and we have question their role in clinical
decision making
- Logistics of VBHC is demanding
- Patients have to be willing to use questionnaires repeatedly
- The doctor must be willing to use AND discuss questionnaires
- ICT is crucial
- Continuous improvement needs to be implemented
- Costs and benefits are not (always) clear
College 1.1B -Theoretical Principles
Value-based health care (VBHC) used to be called value-based competition.
The origins of VBHC
2
,Redefining Health care (2006)
- Michael Porter
o “Founding father”
o Harvard Business School Professor
o Famous for his work on competition
o Competition drives improvement
- Elizabeth Teisberg
Michael Porter
- Value chain:
o All the activities a business organization performs, which together create a valuable
product or service.
- Central premise:
o In any industry, a successful and sustainable enterprise needs to create value for its
clients – particularly in a competitive market.
- This is the framework from which he looks at competition
Porter & Health Care
- Value as the single goal (unifying all participants in the system).
- In healthcare delivery, clients = patients.
- Goal = Patient Value
Patient value
outcomes
- Why conclude that value= ?
costs
- The reason is that “Value is that what matters most to patients”
- What do patients want to achieve when they need health care?
o A patient has issues related to their health
o You want to get better, but if that is not possible, you want the best next option
What do patients want?
- To get better
- Best possible treatment outcomes
o Outcomes are really important
o Outcome is one element of value
- Treatments come at a price, we pay our healthcare professionals
o Some treatments are more expensive than others
o Some providers charge higher prices
- If two providers/treatments have the exact same outcome, we should go for the less costly
one.
What do patients value?
- The health status they achieve (outcomes) and the price they have to pay for it (costs)
outcomes
- value=
costs
- Optimizing this equation becomes the central goal the best outcomes, as efficiently as
possible
Key principle
3
, Value in health care is created at the level of medical conditions, over the full cycle of care.
a. Value is created at the level of medical conditions
i. Patients seek health care to address health related issues/disturbances.
ii. Those issues, complaints, symptoms are caused by a certain condition
iii. Ergo: professionals create value by addressing specific conditions!
iv. “Value in health care can only be understood by focusing on the level at which it is
actually created, which is in addressing particular medical conditions” (Porter &
Teisberg 2006: 99)
b. Value is created over the full cycle of care
1. Value is generated through the full set of activities (i.e. value chain)
2. Full care cycle: from start to end (diagnosis to rehabilitation).
3. Surgery for example, is only one element of the full cycle.
Remember
- Value should be the goal
- Value is created at the level of medical conditions over full care cycles
Implications for measurement
Value (outcomes & costs) to be measured at that level, over full cycles
- Different conditions cause different effects/outcomes.
- Measuring and reporting outcomes is crucial; it will enable effective comparisons.
o This should be the same in every clinic so they can be compared
Implications for organizing care delivery
(Re)organizing care around medical conditions & full cycles
(where value is created)
- Healthcare delivery commonly structured around separate specialties (fragmented, not
integrated around value creation)
o For example, you have to go through a MRI, then someone has to give a diagnosis,
then there has to be a surgery
o For value, you want these to all work together
Integrated Practice Unit (IPU)
multidisciplinary team, coordinating all the services necessary to address a medical condition
Implications for payment
Value-based payment covers the full care cycle of a certain condition.
- Bundled payments that cover all the necessary activities
o This way you don’t have to send your bill to the insurer every time you see a
different department
- For chronic conditions, bundled payments covering episodes of care
Value-based payment
- Removing adverse incentives (e.g. overtreatment)
- Alternative to fee-for-service
o (Providers are rewarded for volume)
- Instead: rewarding good outcomes & efficiency
4
