- ‘Value’ for the patient as the core purpose of care
- A responsible, well-balanced Multidisciplinary Team
- A Vision and a Plan
- Good understanding of the Medical Condition and Outcomes set
- VBHC as a change process
- Involved stakeholders
- Good contracts on Financing – Reimbursement
- An Improve Culture
Healthcare is under pressure in many ways. In a recent study, the main problems in healthcare that greatly contribute to the pressure were outlined (Hanselaar and van der Linde 2020). The same study pointed out that many of these problems could be solved by wide value-based healthcare (VBHC) implementation. Since 2018, the Linnean initiative and the Dutch government programme, Outcome-Based Healthcare, try to accelerate the transition to a VBHC system in the Netherlands (Linnean initiatief). Given the great amount of resources that have been invested since, it seems relevant to know what factors are considered to be the most important for successful VBHC implementation. Dutch VBHC expert give their insights and opinions in this paper.
The research question is: “Which success factors help to implement the VBHC concept in practice?” With the answers we want to create a best practice for healthcare providers, innovators and policymakers who want to start, have started, or plan to invest in a VBHC initiative, and inform those who have not (yet) come into contact with VBHC.
In 2019, a series of semi-structured interviews was conducted with 21 Dutch experts. The interviewees were approached by email (n = 3) and by telephone (n = 18) by one of the authors (TH). Each interview was summarised and sent to the interviewee for approval and/or supplementation. The interviewees were healthcare administrators, patients, doctors, healthcare insurers, business people working in healthcare, researchers, advisers and winners of the VBHC Prize. All were well-acquainted with the VBHC concept. Some interviewees appreciated remaining anonymous. Hence, no list with the interviewees’ full names has been included in this paper.
The answers to the questions were compiled afterwards and divided into a number of overarching categories. The categorisation was based on common denominators considered relevant by the authors. No breakdown is made by background (director, advisor, etc.) of the interviewees.
137 unique, distinctive answers were provided, which were categorised in 26 categories in 8 clusters. An overview of the clusters and subcategories is presented below.
What are the reported success factors for VBHC implementation?
1. To create ‘value’ for the patient is at the core of care
•Organise care around the patient
•Make sure the patient is informed
2. A responsible Multidisciplinary Team
•The multidisciplinary team is well-balanced
•The multidisciplinary team is task-mature
•Team members are enthusiastic, confident and engaged
3. Start with a Vision and a plan
•There is a well-thought-out, recognisable Future Vision with feasible planning
•IT Vision is ready
4. Choose and promote the Medical Condition, Outcomes, and IT Dashboard
•Good understanding of the Medical Condition
•Motivational, Reliable Outcomes set
•An outcomes Thermometer has been developed
5. Behaviour and Culture deserve much attention
•To put VBHC in practice is a change process
•Agree on how you want to work together
•Do what you are good at
6. Involve stakeholders
•Board, management and medical staff are positively involved
•Involve healthcare insurers
•Engage regional partners
•Involve expertise of pharma and tech companies
•Simplified accountability to society
7. Good agreements and knowledge about Financing – Reimbursement
•Financial stability of Institution and Team
•Risk assessment made and Contracts concluded
8. Improving is crucial
•Good quality registration
•Provide proper training
•Innovations will help
1) To create ‘value’ for the patient is the core purpose of care
Organise care around the patient
VBHC is doctor-driven and patient-centred. Patients must be an integral part of the multidisciplinary team and be involved in the entire development process of the VBHC process, starting with the development of an outcomes set. An outcomes set that has been developed by both care providers and patients better addresses the outcomes that are most important and relevant to patients. The patient’s score on jointly developed outcomes set need to be discussed in the consultation room and patients need to be guided by their care providers to make informed health decision (shared decision-making) that matches their needs (both medically and quality of life). Sometimes several ingrained cultural and organisational barriers have to be overcome. For example, the care path to be followed for patients runs both inside and outside the hospital, something that healthcare providers in hospitals are often only slightly aware of.
“Really involve the patients, take them seriously. Don’t talk about them, talk to them! This can be structured in specific patient panels or focus groups per condition. It increases patient participation.”
“Not all patients will be able to do this immediately. Build a network of patients who understand this. Involvement of patient associations can be helpful. A patient advisory board can also be deployed to increase participation.”
Make sure the patient is informed
Get clear insight of what really matters to patients (medical, psychological and quality of life aspects). Patients must and can indicate themselves what they consider important; they are the experts of their own lives. Focus on patients as being both users and suppliers of information leads to involvement and strengthens patient loyalty to care. Communication with patients benefits greatly from common language. This also applies to communication with fellow care providers. Conversation with patients about quality of life during the entire treatment process often provides direct feedback and valuable suggestions about the care provision and care providers.
“Questions from patients may arise such as: What does the effect of chemotherapy do with my wish to die with dignity? What will it do to me if a large neck muscle is removed for oncological reasons but I have a high chance of not being able to move my head properly afterwards? etc.”
“Provide the information that is relevant to the patients. Information about mortality is important, but information about quality of life is firmly number 1 for them!”
2) A responsible Multidisciplinary Team
The Multidisciplinary team is well-balanced
Right at the start of a VBHC process, the composition of the multidisciplinary team and leadership must receive much attention (Porter and Lee 2021). The role of doctors is quite significant; putting doctors in the lead is seen as an important success factor, and top-quality expertise in the teams can contribute to a more result-driven healthcare system. If, in addition to medical disciplines, patients, paramedics and nurses are present and motivated, the chance is greater that the implementation will be successful. In the eyes of patients, nurses and paramedics are often at least as important as the physician in achieving patient value. And, just like doctors, many nurses and paramedics want to work with outcomes data and are motivated to measure (meaningful) outcomes. The team must be adequately supported in business and analytical terms and be of sufficient size (8-13 people).
“Involve doctors from different disciplines in the team and in the selection of the outcomes. This way, you get less discussion about procedures and more about outcomes. They get to know each other better, also outside their own specialism, and often enjoy and find it valuable at the same time to communicate with each other, increasing mutual trust.”
“Make sure that enthusiastic, renowned, dedicated doctors are involved; this is not necessary in a formal position, they can also play an informal, guiding role.”
The Multidisciplinary team is task-mature
Teams must build on the necessary (para)medical and nursing competences with a good knowledge of the effectiveness of treatments and forms of communication with patients. Good knowledge of the VBHC care process with well-established roles, powers and responsibilities contribute to the best care. Functioning like small companies, competent teams can act fairly independently. Frequent checking of outcomes, costs and improvement initiatives, by means of the Plan-Do-Check-Act (PDCA) cycle, is appropriate. In addition, a good connection with the care institution’s Planning and Control system is important.
“A PDCA circle generates attention for improvement potential and can thus form a continuous systematic approach for planning, executing, analysing, learning and improving.”
Team members are enthusiastic, confident and engaged
Enthusiasm and motivation about the goal to be achieved is a precondition for the success of VBHC implementation; this applies to everyone, be it a doctor, nurse, director, data analyst, or desk clerk. This is the case for mutual trust, sticking to the set course, and loyalty. Multidisciplinary collaboration means learning to build on each other and looking for solutions, also if these solutions are outside your area of expertise or even outside your organisation.
“Cross-discipline projects often provide insights into each other’s working methods and thus increase mutual trust with a positive impact on motivation, cooperation and employee satisfaction.”
“The team must be a safe environment so that healthcare providers dare to speak with confidence about their own competences.”
Most often, leadership in VBHC is associated with medical leadership. In practice, however, the medical leader is often part of a small leadership team together with a nurse (practitioner) and/or manager. The leadership team is supported by an experienced, dedicated project manager with good understanding of the care process and the internal organisation. This team is responsible for day-to-day management; accountable for the results; prevents that the initiative fades into the background, delayed, or not finished at all; and maintains a good connection with the director who bears responsibility for the institution. The leader(s) must have good substantive knowledge and natural authority.
“Professional support of team and team management works well and promotes mutual cooperation. A Project Manager has to have good knowledge of VBHC and project-based work and have a relevant network to which questions can be submitted.”
“Don’t be penny-wise pound-foolish; rather bring in someone from outside than muddle through.”
“Good leadership is leadership by example and inspiring; it is not bossing around. A leader keeps team members focused by asking questions like: what did we agree? what is the goal? how do we get the right data at our disposal? how do we want to continuously improve? can you solve it yourself?”
3) Start with a Vision and a plan
There is a well-thought-out, recognisable Future Vision with feasible planning
The actual choice of the hospital or care institution to engage in VBHC implementation is an important success factor for all VBHC projects within the organisation. Therefore, this must be communicated in a recognisable way. Thinking in cohesive connections (not being limited to your own department – hospital, but involving the entire system) can help the ambition. Also, it is important to immediately formulate a clear goal and a well-thought-out feasible plan.
“A success factor is the recognition that VBHC ultimately benefits patients through better diagnostics and treatment; the health of the population is increasing; caregivers become better at their job, with greater job satisfaction and positive well-being; improving costs in relation to quality (decreasing costs, financially and of people and resources).”
IT Vision is ready
Value-based healthcare is data-driven healthcare. The choice to engage in VBHC also means the choice to adjust/improve the IT system. The necessary IT systems, business intelligence and data analysis to measure, analyse and present care outcomes in an accessible manner are important and must be anchored in the daily practice of the organisation. An appropriate IT vision includes attention to storage, availability of data and seamless connection with the design of the process. There must be sufficient competent people and resources to implement the IT plan.
“Avoid having to enter data on multiple computers in practices; a known source of great frustration among doctors”.
4) Select and promote the Medical Condition, Outcomes and IT Dashboard
Good understanding of the Medical Condition
The entire medical condition must be coherent and clearly defined by the multidisciplinary team. Immediately at the start, the care process for the medical condition must be mapped, whereby the various interests are also established, especially if multiple departments/organisations are involved in the care process.
Motivating, reliable Outcome set and cost knowledge
A well-selected, standardised, hierarchical outcome set, with relevant medical outcomes and PROMs is crucial for VBHC implementation (Porter and Teisberg 2006). Patients must and can indicate themselves what they consider important (medical, psychological, quality of life). The set should be motivating to discuss together in the consultation room. The outcome set must be adequately supported by IT, periodically analysed and discussed in the Multidisciplinary Team.
After the care process and the outcome set are established, the cost price needs to be calculated. The Time-Driven-Activity-Based-Costing (TDABC) system can be helpful (Kaplan and Anderson 2004). The results are used to optimise the care process, for risk assessment and for value-based contracts with insurers.
“Limit the administrative burden to a manageable set and explain the necessity and method well. Low registration pressure is a precondition for avoiding frustration.”
“Starting the cost-price calculation too early can demotivate healthcare professionals and not bring solutions closer” (Steinmann etal. 2020).
An Outcome Thermometer
A reliable thermometer is an important tool. Such a dashboard with the set of outcome indicators is useful for sharing in the consultation room and discussing options. A tailor-made dashboard for patients in the consultation room (near-real time) that is understandable is often rewarded with a high response rate of completed PROM questionnaires. For practitioners, the management dashboard provides (weekly/monthly) insight into the care process, outcomes and costs and their progress, and can be used in team meetings to initiate improvement initiatives.
“Invest in a culture of transparency and benchmarking for (double) loop learning and improvement.”
5) Behaviour and Culture deserve much attention
VBHC is a change process
You have to learn to provide value-driven care, invest energy and pay attention to doing the right things well. A well-thought-out project-based approach is required throughout the entire process of VBHC. Experiences argue against a Big Bang; small initiatives have higher success rates than big shows. By not starting big, using what has been proven elsewhere, and positive social interaction, team members can learn with and from one another and from others who have already started implementing VBHC.
“Approach VBHC as a long-term change process instead of a (small) project that you do on the side or that ends after the project deadline has passed.”
“Don’t make it too difficult; it is not rocket science! Strive for perfection, but don’t wait for it! After setting up the team and the results, get started with the other domains of Porter to create progress, and do so ambitiously, but realistically.”
“In a medical/nursing environment it is necessary to keep the pressure on and keep the pace up. Good project supervision is in line with the systematic approach to VBHC initiatives. Healthcare providers often have more difficulty with this than, for example, engineers.”
Agree on how you want to work together
By discussing how you want to work together to achieve the best possible outcomes for the patient at acceptable costs, the team must get information on what is important to all involved. On the one hand, such a working method focusses on the patient; on the other hand, also on the wishes and interests of the members of the MDT and, by extension, their care organisation. The guiding principle here must be that the interests must first of all be in line with what adds value for the patient.
“Put the whole system in the room. Sit around the table with patient, doctor, assistant, nurse and manager, and examine the care path together. In the discussion that will arise, the best evidence-based treatment can be connected, the best nursing care practice added, etc.”
“Start with defining costs as the energy expended by the multidisciplinary team instead of costs in euro. This is a better source of motivation for the multidisciplinary team.”
Do what you are good at
Multidisciplinary collaboration gives joint responsibility and can facilitate more efficient task differentiation; let people do what they do best. Work redistribution can be stimulating for everyone, be they doctors, nurses, or outpatient staff.
“Have the questioning and discussion of the results done in the consultation room by the person who is best equipped for it.”
“Pride is a great inspiration for team and individuals. All team members own the initiative and co-own the success. Experience also shows that top-down implementation and financial incentives do not work sufficiently without this intrinsic motivation.”
“Limit administrative burden to a manageable set; explain necessity and method well. Healthcare providers should be concerned with patient care, not filling out lists.”
6) Involve Stakeholders
Board, management and medical staff positively involved
Visible, positive and strong support from the Board of Directors is a great success factor. Also, positive involvement of the medical staff Board and/or highly valued nurses benefit the probability of allocation of resources (time and money) to the VBHC project. This also applies to opinion leaders.
“A good relationship between care professionals in the workplace with the Board and well-informed and committed managers can result in a safe working and innovation environment.”
Involve healthcare insurers
Health insurers and government traditionally look at healthcare from a macroeconomic perspective. In order for the macroeconomic effects to occur, several successful VBHC initiatives are needed. At local level, insurers can help move towards desired outcomes and costs control, sharing experiences and asking what they can do to help realise these types of VBHC initiatives. Budget negotiations between healthcare providers and healthcare insurers will then shift from fee-for-service towards fee-for-value, multiyear contracts. These contracts will need to cover, for example, (temporary) loss of income and/or extra costs.
“From a value perspective of the patient and the insurer, reduction of under- and overtreatment saves a lot of wasted care efforts, complications and side effects. On the other hand, a relatively expensive drug or aid can also prove to be a ‘cheap’ solution when viewed from the perspective of the entire care cycle.”
“Health insurers must absolutely be involved; but don’t wait for their early commitment if everything is ready internally to get started!”
Engage regional partners
Looking further down the line of what matters to the patients often sheds a different light on a VBHC initiative than primarily from the perspective of the own clinical environment. For example, it could highlight the need to expand the scope of the medical condition that may be limited to the own organisation to involving other institutions in the region. It can also mean not starting a VBHC initiative on a stand-alone basis if a neighbouring institution happens to be a world-class institution in the same area. At the start of a VBHC process, it may be useful to primarily limit the medical condition to hospital care, but it quickly pays off to think more broadly towards primary care and home care. Conversely, regional primary care practices can independently take VBHC initiatives that have an impact on hospital care (Lee and Myers 2018). Scale size and perceived urgency (e.g. new construction or another major adjustment) can provide a good opportunity to work together.
“Health benefits can be achieved in, for example, frail elderly people, through a targeted collaborative partnership between hospital, primary care and home care. Everyone recognises bottlenecks in the workplace, even if this is from various points of view.”
“Health gains through such partnerships can be achieved by using remote monitoring to prevent readmissions in, for example, heart failure. This has already been addressed in several places” (Hartwacht).
Involve expertise of pharma and tech companies
A larger role for pharma and tech companies is not (yet) an obvious success factor. They often have workers who have much knowledge of goal-oriented organisation of activities, and there are many dedicated employees who are willing to cooperate in the field of VBHC.
“Match the choice of involving an external company in a VBHC process with the expertise and choices that already exist there”.
Simplified accountability to society
Good quality registration based on standardised outcome sets simplifies accountability to society, such as to the Healthcare Inspection, government and health insurers. Regional healthcare insurers can also use this quality information when purchasing healthcare.
7) Good knowledge and agreements about Financing – Reimbursement
Financial stability of Institution and Team
There must be financial stability at the care organisation. The importance of stability applies to the organisation as a whole, to the intended multidisciplinary team and to other involved parts of an organisation. A movement towards promoting health instead of disease with a focus on appropriate care at the right place will help transform to more sustainable financing.
“Ensure transparent (financial) relationships between medical specialist groups and hospitals, with sufficient investment capacity.”
Risk assessment made and Contracts concluded
A contract team, with good (internal) organisational connections, and aligned with the VBHC and organisational goals, assesses the scope of the agreements, determines risk profiles, defines gradual profit and loss to minimise risk and monitors them (Porter et al. 2015). In good coordination with the multidisciplinary team, financial incentives are now placed at the MDT level. Contracting means that the team no longer only feels responsible but can also be held accountable for the value achieved.
“Also include risk protection in the contracts (stop – loss/termination provision). In this way there is always a solution available.”
“Include incentives for learning, improving and sharing in the team.”
If the care chain wants to take the VBHC steps, the reimbursement for the organisational units involved and the care professionals involved must also be appropriate.
“The financial reimbursement should be a reward for creating patient value.”
8) Improving is crucial
A culture needs to be created in which improvement initiatives are made attractive and are rewarded. By organising feedback on the actions of the team and individual professionals, knowledge is gained about what is effective to create value for the patients. Quality improvements can arise in conversations between healthcare providers and patients, and between healthcare providers themselves. Learning from one’s own experiences and best practices (benchmarking) makes work more enjoyable and helps create an improvement culture, whether or not including appropriate remuneration. Other organisational units and structures, such as financial and IT systems, can also grow and be adapted and improved in this way.
“Learn from each other, from the best, e.g. by studying previous VBHC Prize winners, and from fellow institutions with experience, such as Santeon” (VBHC Prize 2020).
“An example of a consultation structure is the one used at the Martini Klinik, with daily work consultation, weekly and monthly multidisciplinary team discussion with interdisciplinary discussions about complications, morbidity and mortality, and discussion of new data from the professional literature. And an annual Quality Review of outcome results at team level with benchmarking and recent research results” (Martini Klinik).
Good quality registration
Good quality registration of an outcome set paves the way for improvement initiatives. The core is good accessible quality registration, transparent reporting, appreciating criticism and rewarding feedback.
“Make quality agreements about outcomes a standard part of the PDCA cycle and the Planning & Control cycle. Frequent standardised review of the results achieved creates structural attention for the improvement potential.”
Provide proper training
Training in the field of VBHC and project-based working ensures, especially at the start of a VBHC process, that care professionals are informed about (what, when to expect during) the VBHC process. This also applies to the Board, managers and department heads. Supervised learning within a care institution can be done through structured meetings and agreement- and decision-making procedures.
“On the one hand, the role of the Board is important in the choice of VBHC training, on the other hand, administrators and opinion leaders often need help to be really involved.”
“It is important that everyone ‘speaks the same language’ and interprets VBHC in the same way. This includes the language used with patients. Training is essential here.”
Innovations will help
Innovations can help to further improve healthcare. Predicting health effects based on the use of wearables and artificial intelligence can help doctors and patients make better decisions (Tana et al. 2017; Van der Meulen 2019). Research data on, for example, clinical trials of comparable patients that until recently were reserved for researchers are more widely available. These kinds of data, brought together per patient group, may predict health effects for an individual and can help patients and their doctors make better decisions. These are illustrations of developments that are going on and that are (will be) available to the patient and the doctor.
“An adequate (R&D) budget is required; in healthcare institutions this is now often no more than 1-2%.”
With the answers to the question “Which success factors help to implement the VBHC concept in practice?” we want to offer a best practice for those who want to start or have started a VBHC initiative and inform those who have not (yet) come into contact with VBHC about this. Divided point-by-point into three perspectives, patient, care providers, and costs and IT, we conclude as follows.
• The organisation of healthcare must be set up in such a way that a) the agreed outcomes can jointly be discussed in the consultation room between patients and caregivers, both from a medical perspective and from the perspective of the personal life of the patients, and b) personalised decisions can be weighed and be taken together.
• Patients must be included in the multidisciplinary team, right from the start. Really involve them, don’t talk about them, but to them! Not all patients will be able to do this immediately, so build (upon) a network of patients who are already engaged, and provide education for the others.
• Focus on patients as both users and information providers. Get clear what is really of value to patients (medical, psychological, quality of life). Patients are the experts of their own lives. Tailor the information to what really matters to them.
• Communication with patients benefits greatly from the same language. This also applies to fellow care providers!
Directors and opinion leaders:
• Focus on VBHC initiatives that can really lead to improvements. Allocate resources and guidance. Commitment of the Board and opinion leaders are beneficial to the VBHC initiative. Provide training/coaching for all involved.
• Board and opinion leaders should not want to solve everything themselves, but rather put responsibility back to the teams. They must, however, safeguard the desired culture.
• Adjust the organisational structure, give direction and support innovation with the patient care cycle as point of view. Take your time; it might take five years before you are well on the way.
The Multidisciplinary Team:
• First find out who should be involved; make a good team composition with the right people, who can and must bear the consequences of the team’s actions.
• Keep in mind that the care path for patients runs within and outside the care institution.
• Arrange support from competent external parties, and training. Make time (not ‘just add’ VBHC to the already too busy schedule).
• Start with a step-by-step, thoughtful approach and only start if you can do it well, not if, for example, there are not enough patients, or if your team is simply not distinctive enough.
• Define the key outcome measures that matter to patients and caregivers and are motivating for patients to discuss in the consultation room with their practitioner. Make use of well-thought-out, standardised sets of outcomes and stick to them.
• Start measuring outcomes in a standardised way, but proceed pragmatically and limit the administrative burden.
• Be transparent; collect, analyse and share the results (often first internally); make the implications visible and open to discussion for parties and individuals.
• Learn from the outcomes; it is not a tool for assessing people, but for improving outcomes for patients.
• Innovate and improve in areas where there is room for improvement, e.g. communication with patients, unwanted variation, treatment-related changes, and measure the quality improvement and costs results.
Costs and IT:
• The care delivery value chain is about the range of activities that add value. All (clinical and supportive) activities that do not add value to the patients must be identified and removed from the care pathways.
• Provide cost price calculations and appropriate IT and data analysis setup. They will really be needed in different phases of the VBHC process. Hiring top expertise in these areas can help enormously.
• Change the money flow accordingly and link VBHC care to payments through contracts with external parties such as healthcare insurers.
In this way, doctors and other healthcare providers can increasingly become the guides that are badly needed in today’s healthcare. The difficulty lies not in the appropriateness of the VBHC concept, but in breaking free from our old ideas.
Conflict of Interest
Responsibility: The opinions expressed in this paper represent those of the authors/interviewees and do not necessarily reflect those of their employers.