VALUE-BASED HEALTH CARE L E S S O N S F R O M E U R O P E _ V I N C E N T W I E R S M A, MSC. 1 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
The Decision Group The Decision Group has been a pioneer in Value-Based Health Care and its methodology and is implementing and educating VBHC in the Netherlands since 2006. 1. Over 100 unique VBHC-projects in The Netherlands since 2006 (in the field of e.g. oncology, diabetes, elderly care, neurology, cardiology, nephrology, haematology and many more); 2. Education in VBHC to: Over 14.600 Dutch professionals in healthcare Over 6.060 International professionals in healthcare 3. Developer of the Value of Medical Products methodology; 4. Annual awarding of the Value-Based Health Care Prize With Honorary Chairman Prof. M.E. Porter Auspiciën 2 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE Partner
Health care challenges Restructuring of health care is necessary to avoid rising costs while preserving quality of care by creating a healthcare system that is sustainable. 1. Medical innovation 2. Aging population 3. More chronic care: Higher life expectancy Multi comorbidity Health Expenditures % of BBP Source: WHO HO 3 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE Source: OECD
Michael Porter - Value-Based Health Care The root cause of why we have difficulty in creating patient value and capturing the value for providers and industry Value-Based Health Care Healthcare Problems and Solutions 4 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Unexplained, unmeasured, unmanaged variations has led to FEE FOR SERVICE instead of FEE FOR VALUE which has contributed to increasing healthcare costs and over and under treatment of patients. Doctors performing C-sections varies from 15 to 71,4% of births without case mix difference??? Standardized death rates and charges per admission have no correlation. Source: PBGH report: Variation in NTSV C-section rates among California hospitals (2014) Source: NHS Confederation 2004, Brian Jarman, nhsconfed.org Who is getting paid for or is paying for value? 5 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Balance of power of stakeholders (patients vs. payer) Are Patient(groups)/Physicians in terms of joint decision making, bargaining power, and influence, able to drive healthcare decisions or are the payers/ insurers dominant? Where will the dominant power be? Payers, Insurers Facilities (Primary) Care Physicians Patients Patients (Primary) Care Physicians Facilities Payers, Insurers 6 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Healthcare is changing The patient is acting more and more like a consumer of delivered care and claims a position in health care. 1. The patient wants to be as healthy as possible; 2. The patient has access to a huge source of information (internet/apps); 3. The patient wants to have a say; 4. The patient thinks along and ahead. This demands a great change of care providers and all stakeholders in health care. Leading will become: What is the value for the patient / consumer? 7 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Value-Based Health Care The theoretical concept of Value Based Health Care was developed at Harvard by Michael Porter providing a framework focusing on patient value with the medical condition as unit of measure. Prof. M. Porter (Harvard Business School) has set up a clear framework that centers patient value as the critical driver of quality and performance improvement, while minimizing costs. This concept is embraced worldwide by several leading medical centers. 2006 2010 2011 8 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Essence of Value-Based Health Care The interaction between the patient and his/her family & the physician and his/her team... - Better informed (apps, internet) - Active role decision making (palliative) - Voting by feet (go to best care&cure) Patient and Family Physician and Team - Care around Medical Condition (e.g. diabetes, prostate cancer) - Improvement of Outcome Measures (Meetbaar Beter, Santeon) - Transparancy (ParkinsonNet) 9 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Patient value is at the core of VBHC creates patient value in a patient-centered and doctor-driven way. Value-Based Health Care is about creating value for patients throughout the full cycle of care. It is about maximizing the health outcome per Euro spent (cost). Effectiveness Doing the right things Doing the right things at the right place, at the right costs Efficiency Porter, M.E. (2013) The strategy that will fix healthcare? The New England Journal of Medicine, 363;26 10 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Why health outcomes? Patient relevant outcome measures results in one common language for a transparent dialogue plus the dissemination of best practices on four essential Value Based Health Care topics. 11 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Outcome Measures Examples of Outcome Measures, divided in the Outcome Measures Hierarchy. 12 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE Source: Porter, Redefining Healthcare
UCLA Medical Center UCLA started measuring outcomes for medical conditions in 1987 13 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
UCLA Medical Center and shows that measuring outcomes leads to improved health outcomes for patients. 14 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Examples Three leading examples of successful VBHC implementation in Europe. 1. Martini-Klinik 2. Schön Klinik 3. Meetbaar Beter 15 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Martini Klinik Continuous learning has led to improved health outcomes for prostate cancer resulting in being the best prostate cancer clinic in Germany and the world. Results - A short overview: Source: Harvard Business Case: Martini Klinik 16 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Schön Klinik The Schön Klinik is the best example for Time Driven Activity Based Costing. Insight in real costs are a valuable source for improvement. Schön Klinik: Measuring Cost and Value Patient Value through Time Driven Activity Based Costing (TDABC) for total knee replacements. TDABC on the full cycle of care and elaborate outcome measures resulted in: Reinvestment in profitable rehabilitation facilities Empowerment of doctors, nurses and hospital Cooperation between different Schön Kliniks and other institutions are central to the success. Health outcomes: Measured by an extensive list of outcome measures such as: Womac scale: 23.7 points (measuring pain and functional limitation for osteoarthritis of the knee. 0 is best status, 96 is worst) EQ-5D scale: 77.9 points (measuring baseline health and functionality: 0 is the worst, 100 is best) Cost: Measured by Time Driven Activity Based Costing: Through a combination of data-analysis and interviews with clinical and support staff the Schön Klinik team was able to create: Process maps: sequence of processes the patient encounters through the full cycle of care. Cost assessments: the costs and practical capacity are calculated per resource type Based on HBS cases: Kaplan et. all, 2012, 112085-PDF-ENG 17 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Cost saving Time Driven Activity Based Costing is relevant for improving the health outcomes for patients and to secure the quality of care delivered. Time Driven Activity Based Costing (TDABC) Interviews and data-analysis resulted in control over: - Cut-to-next-cut for operation room turnover - Labor time allocation - Costs of supplies (eg. drugs, implants, etc.) - Indirect costs (eg. radiology) - Depreciation of instruments - Facility costs Reassessment of real costs Acute care: - Costs dropped from $9300 to $8000. - Ebitda profit margins raised 6%-points (19%) Rehabilitation: - Costs dropped from $4600 to $3300. - Ebitda profit margins raised 13%-points (7%) Comparability of best practises Schön Kliniks Internationally: US + Denmark Reinvestment in rehabilitation Restructured care process Physical therapy: not individually but in groups 3 pilots to reduce costs through length of stay: - 2 days Copenhagen University Hospital - 3 days average US - 4 days Denmark - 10 days Schön Klinik 18 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Measurably Better Moving away from volume-driven permission whether or not being allowed to perform heart surgery by showing delivered value in health outcomes. 19 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Measurably Better in numbers Transparent reporting of health outcomes in a yearly outcome book has lead to national expansion and benchmarking of outcome measurement in cardiology. Source: Meetbaar Beter Outcome Book 2015. 20 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Measurably Better: The Program Doctor-driven establishment of intra- & inter organizational learning as starting point for improving value in cardiology and health care. 21 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Wrap-up What can we learn from leading VBHC initiatives in Europe to improve quality and effectiveness of care delivery? 1. Start measuring outcomes that are relevant for patients, and costs to achieve those outcomes a. For a medical condition b. Over the full cycle of care 2. Start with the medical team and involve patients 3. Organize care towards Integrated Practice Units, IPUs (& shared responsibility) 4. Collaborate & learn 22 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
VBHC: The coming years Various topics and challenges in Value-Based Health Care will become increasingly important in Europe in the near future. 1. Value-Based Purchasing moving from volume towards value 7. Cultural and transformation change and leadership 2. Bundled payments 3. Patient reported outcomes 4. Data / IT integration and digitalization 5. Patient engagement 8. Moving towards integrated practice units 9. Industry engagement 10. Primary care engagement 11. Stakeholder collaboration 6. Creation of (systematic) learning loops for improvement purposes 23 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
How to start? The fundamental change starts with the people who create value in health care: the doctor and medical team & the patient and his / her family. 1. Search for key players (frontrunners in care organizations) 2. Get / define outcomes and start measuring 3. Create a learning culture a. Stimulate inter- and intra-organizational improvements b. Avoid a judgemental culture 24 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
VBHC Prize The aims to: Impression of the Inspire Impression of the Celebrate Recognize Inspire, Celebrate and Recognize initiatives that focus on improving patient value in the Netherlands 25 VALUE-BASED HEALTH CARE CENTER EUROPE 1 WIERSMA 14-12-2016 LESSONS FROM EUROPE
Save the date! VBHC Prize 2017 May 11 Pre-applications will be accepted as of September 1st, 2016 Want to become the 2017? Contact us via application@vbhcprize.com VBHCPrize.com VBHC.nl Value-Based Health Care Center Europe @VBHCEurope 26
Some well-known projects The Decision Group Meetbaar Beter is a scientifically based program that uses patient relevant outcome indicators to work on improving the quality and transparency of care in participating heartcenters in a docter driven and patient centered way. Santeon developed so called outcome indicators for treatment of lung cancer and prostate cancer. What is the risk of complications, how long does a patient live after treatment and what is the quality of life? The goal of the FAMOUS project is improving and optimizing the diagnostic process (the triage) of (NSTEMI) patients. A cooperation between St. Antonius Ziekenhuis, Isala, The Decision Group, RAVU, RAV Ijsselland en Meander Medisch Centrum, UMC Utrecht en het Julius Centrum 27 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Thank You Contact: The Decision Group Vincent Wiersma, MSc. v.wiersma@thedecisiongroup.nl +31 (0)20-40 40 111 +31 (0)6-27 31 98 55 More information, please visit: www.thedecisiongroup.nl www.thedecisioninstitute.org www.vbhc.eu www.vbhcprize.nl 28 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Greek health care system The health care system in Greece is financed by a mix of public and private resources. Central government Social insurance funds Private insurance companies Financial flows Service flows Population ¹ Care providers Patients Source: Greece Health System Review Health Systems in Transition ¹Private Payments 29 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Alexander Monro Alexander Monro is the first specialized center for breast cancer in the world for the patient s full cycle of care. Why Alexander Monro is a frontrunner: 1. Medical conditions & the full cycle of care: Delivering all activities in the full cycle of care. From preventive (familiar high risk program), diagnostics, treatment and aftercare (to palliative care). 2. Organization: Organizing different specialties as a part of the breastcancer team. No individualistic approach with separate specialists. 3. Standardization: Protocols in the diagnostic phase and for treatment options create chances for improving healthcare.. 30 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE
Alternative reimbursement models Moving from Fee-for-Service towards Fee-for-Value requires a purchasing model in which the core principles of Value-Based Health Care are incorporated. The Decision Group Free to McClellan et al. (2015). 31 THE DECISION GROUP I WIERSMA 14-12-2016 LESSONS FROM EUROPE