IMPROVING THE UNDERSTANDING OF INTEGRATION OF CARE IN THE CONTEXT OF VALUE-BASED HEALTH CARE
Master’s Thesis, MSc Supply Chain Management University of Groningen, Faculty of Economics & Business
13 August 2018
MARLEEN TUTEIN NOLTHENIUS Student number: S2331233 E-mail: marleen.tutein@gmail.com
Supervisor/university prof. dr. ir. C.T.B. Ahaus
Co-assessor/university A.C. Noort, MSc, promovendus
Second examiner Prof. dr. J.T. van der Vaart
Abstract
Purpose: Value-Based Health Care (VBHC) has become a concept of interest. The main goal of VBHC is maximizing the patient value. The value can be increased by improving the health comes with lower or equal costs for the full cycle of care. In order to increase the value, health care needs to be rearranged by developing Integrated Practice Units (IPUs). Integrative practices have been adopted from the field of supply chain. However, more research is needed to gain deeper understanding of VBHC and how integration of care can be achieved. This study aimed to research the perceptions of professionals of VBHC and how to achieve integration of care to improve our understanding.
Design: a multiple case study has been done to explore the perceptions of professionals. Semi-structured interviews were held with two multidisciplinary teams operating around a medical condition, which are involved in VBHC. A framework of VBHC has been retrieved from previous research, which consists of four categories: patient value, costs, organization of care and steering. Integration of care has been researched inductively, by creating new coding trees. Findings: this study found additions and adjustments to the framework of VBHC. Patient value is the centre and main focus of VBHC by focussing on the health outcomes and shared decision making. Providing care in a care pathway for the full cycle of care with a multidisciplinary team is already in practice in The Netherlands, where alignment and trust are needed between the involved professionals. This increases the sharing of information, knowledge and data. Collaboration with health insurers is necessary to reduce costs and increase patient value. This study found seven conditions to achieve integration of care in the context of VBHC, which are: professional and organizational alignment, division of care between organizations and delivery of care in transparent care pathway, multidisciplinary collaboration, focus on trust, sharing of information, knowledge and data to improve learning, health professional involvement, and patient involvement. In addition, there must be awareness of the difficulties of integration of care.
Table of Content
Abstract 2
1. Introduction 4
2. Theoretical background 6
2.1. Value-Based Health Care 6
2.2. Integrated Practice Units 7
2.3. Integration of care 8 2.4. Care pathways 10 2.5. Illustrative framework 11 3. Research methodology 12 3.1. Research design 12 3.2. Case description 12 3.3. Data collection 13
3.4. Data collection instruments 15
3.5. Data analysis 16
4. Results 17
4.1. Value-Based Health Care 17
4.2. Integration of care 24
4.3. Cross-case analysis 27
5. Discussion 29
5.1. Value-Based Health Care 29
5.2. Integration of care 31
6. Conclusion 34
6.1. Limitations and future research 35
References 36
Appendix A 40
Interview guide Dutch 40
Interview guide English 42
Appendix B 44
Lysanne Douma: Interview-protocol in English 44
Appendix C 45
Coding tree of VBHC (retrieved from the thesis written by Lysanne Douma) 45
Appendix D: Results VBHC 48
Appendix E: Results integration of care 55
Case 7 55
1. Introduction
The costs of health care are rising rapidly due to the aging population and improved technology (Porter, Pabo, & Lee, 2013). According to Porter et al. (2013), former approaches to manage the costs were not paying attention to the core business of the health care delivery system, namely: delivering and improving care (Porter, Larsson, & Lee, 2016). The focus must be on increasing the value for the patient. Value is defined as “the patient’s health outcomes per dollar spent” (Porter, 2009, p. 109). This idea forms the principle of Value-Based Health Care (VBHC). By measuring health outcomes, comparison is possible between organizations, which can lead to improvements in health care (Porter, 2010).
However, the measurement of outcomes in order to improve patient value is still in its infancy. VBHC has gained interest in different countries, because of its comprehensiveness for health professionals (Fakkert, Eenennaam, & Wiersma, 2017; Keswani, Koenig, & Bozic, 2016). The objective of the creation of more value for patients is hard to disagree with, therefore more evidence is needed (Seicean & Neuhauser, 2007). Knowledge and understanding can be increased in health care by learning from other organizations in an explorative way (Holloway & Galvin, 2016).
The population who suffer from co- and multi-morbidities is rising. This leads to an increased involvement of different disciplines and organizations to deliver the complex care needed (Minkman, 2012b). To deliver adequate care, the health care system needs to act as a unified whole instead of operating as functional silos (Barki & Pinsonneault, 2005). However, health care is a highly differentiated field, because of various stakeholders with different mind-sets, activities, and ways of organizing. The higher this degree of differentiation, the higher the need for integration (Glouberman & Mintzberg, 2001).
Therefore, rearrangement of health care is inevitable in the eyes of Porter (2006). Health care should be organized around one medical condition for the full cycle of care with the right kind of services (Porter et al., 2013). In order to deliver the total care of one medical condition, Integrated Practice Units (IPUs) need to be created (Porter et al., 2013). In an IPU, a dedicated team of professionals with different backgrounds work together in one practice area. IPUs are expected to improve the health outcomes and reduce the costs (Bleser et al., 2006; Porter & Lee, 2013). Porter describes the ideal situation for reorganizing the health care delivery system, but with limited empirical justification (Kievit, 2017).
the health supply chain (de Vries & Huijsman, 2011). De Vries and Huijsman (2011) created more clarity about what can be integrated in health supply chains, namely: processes, information flows, planning processes, and intra- and inter-organizational processes. Although the importance of this integration of care is obvious and is seen as a critical strategy (de Vries & Huijsman, 2011), the question of how to achieve the integration of care has not yet been fully addressed and needs more research (Drupsteen, van der Vaart, & van Donk, 2016; Minkman, 2012b), especially in the context of VBHC.
In previous research, a framework has been developed with four important main categories of VBHC (Ahaus, 2018) based on the perceptions of professionals. These four categories are: patient value, costs, organization of care and steering. The added value of the underlying research is to gain more empirical evidence on VBHC by capturing the perceptions of professionals, who apply VBHC in practice (Koeijer & Hazelzet, 2017). The framework will be adjusted and/or complemented. In addition, this research is studying how integration of care can be achieved in the context of VBHC, as this is under-researched in the current literature. Semi-structured interviews are held in two hospitals in The Netherlands, which are both familiar with VBHC and integration of care.
Therefore, the two main questions of this research are:
- What are perceptions of professionals of Value-Based Health Care? - How can integration of care be achieved in the context of VBHC?
This research contributes by gaining new insights on VBHC and IPUs through the perceptions of professionals and incorporate them in the framework of VBHC (Porter & Lee, 2013; Ahaus, 2018). Furthermore, it aims to contribute by creating more empirical evidence of achieving integration of care in the context of VBHC. (Drupsteen et al., 2016). Professionals in health care can learn from organizations who already apply VBHC and integrative practices, to gain more value.
2. Theoretical background
In this chapter, more in-depth definitions and insights will be given on Value-Based Health Care and Integrated Practice Units, to find out what is already known and what not. Thereafter, integration in health care and care pathways and the importance will be explained, to research which differences and similarities exists between the organization of IPUs and integration of care.
2.1. Value-Based Health Care
With the phenomena of an aging population and rising health costs, the health care system needs a change. Porter (2009) describes the strategy and path of getting there. Most literature existing on Value-Based Health Care has been written by Porter, without much empirical evidence yet. Since this subject has gained a lot of interest for the past years, more empirical evidence is needed to support the current literature (Koeijer & Hazelzet, 2017) and research the value-adding elements.
As explained before, Porter (2009) focuses on the value for patients, which can be achieved by better health outcomes per dollar spent. By improving the value, automatically the efficiency should increase. This can be done by cost reduction without reducing the health outcomes, or vice versa. Cost reduction without looking to the health outcomes, is self-defeating (Porter, 2010). Porter (2013) further emphasizes that organizations who fail to improve their value, will feel more pressure by health insurers particularly to reduce costs. A bottom-up approach and pressure are both needed to change in health care.
Figure 2.1. Patient value determined by the ratio of patient relevant outcome measurements to the costs per patient over the full cycle of care (Porter, 2010 in Fakkert et al., 2017, p. 115)
The second principle is the measurement of outcomes and costs at patient level. Data and information is needed to be able to make choices, guide improvement, and motivate change and collaboration (Porter, Pabo, & Lee, 2013), to reduce costs in return. Without this information, it is more difficult to know what improves value (Porter, 2009). Porter (2010) argues that quality was mostly about process compliance to guidelines, instead of increasing value. Outcomes must be measured according to what matters to the patient during the full cycle of care. Health outcomes can be measured by focussing on the clinical outcomes and Patient Recorded Outcome/Experience Measures (PROMs/PREMs). The PROMs/PREMs are questionnaires for patients which could provide more insights in the effectiveness of care (Zwartkruis, 2018). The third principle is applying bundled payment. Reimbursement should cover the full cycle of care per medical condition and not the quantity but the quality. This includes managing common co-morbidities and related complications (Porter, 2009). The bundled payment also supports the formation of Integrated Practice Units (Porter & Kaplan, 2016), because of the overall responsibility that providers will get by introducing this payment system. This will motivate the coordination and integration of all professionals, needed to deliver the best care possible (Porter & Kaplan, 2016).
However, there exist risks and criticism on his approach, as Porter does not use empirical justification for his theory (Kievit, 2017; Dol, 2018). Porter does not describe how this should be exactly achieved (Kievit, 2017). Next to this, the term VBHC is used a lot, but people do not know the literal meaning (Kievit, 2017). This makes VBHC as a term sensitive for misuse and inflation. Therefore, it is important to develop more insights in what the perceptions are of professionals in The Netherlands on VBHC in order to improve our understanding.
Developing integrated and coordinated care is important to improve value, without overlooking the competition (Putera, 2017), to deliver health in a more efficient and effective way (de Vries & Huijsman, 2011).
2.2. Integrated Practice Units
communication, collaboration and efficiency for patients (Low et al., 2017). To increase the value as efficiently as possible, the feeling of responsibility for outcomes and value of professionals should increase. The professionals working in the IPU become experts in the medical condition, because of the treatment volume. Therefore, the professionals should trust each other to coordinate the patient’s chain of care as efficient as possible, by minimizing waste and resources (Porter & Lee, 2013). Their knowledge must be shared during formal and informal (virtual) meetings to review their performance.
Value can be increased when the different components of an integrated system work well together (Crosson & Shortell, 2007). An organization should not be fragmented in functional silos. For example, in an IPU for lower back pain, collaboration is needed between a neurologist, an orthopaedist, a rheumatologist, and a physical therapist (Putera, 2017).
However, to organize the care around a certain medical condition into a unified whole, first the mind-set of professionals should change, second, the structures of care, and third the processes of care (Dunbar-Rees, Panch, & Dancy, 2014). The mind-set of professionals should change into a value-based mindset: “thinking about the problems people want to solve when they require care” (Dunbar-Rees, Panch, & Dancy, 2014, p. 828). This could be an obstacle in implementing changes in health care. As multiple specialties are involved in delivering care for a particular condition, the benefits of one will depend on the effectiveness of all involved (Porter, 2010).
Perceptions of professionals will provide us with the state of current integrative practices which are applied in the context of VBHC. With the gained knowledge about the perceptions of professionals on how integration can be achieved, our understanding of integration of care can be improved, and may be helpful in future implications.
2.3. Integration of care
coordinated set of services is needed to cover the full range of client demands” (Minkman, 2012a, p. 1).
Integration stems from the manufacturing industry, but also became popular in health care, as they faced similar problems (Brennan, 1998 in de Vries & Huijsman, 2011). The need to decrease costs, while also decreasing health errors and increasing patients’ satisfaction, led to an increase of integration of the health supply chains (Hyer, Wemmerlöv, & Morris, 2009). Integration is needed to improve the performance (Vanhaecht, 2007), in particular quality and financial performance (Thrasher, Craighead, & Byrd, 2010).
De Vries and Huijsman (2011) defined the integration of care by the modes from the manufacturing industry, as shortly named in the introduction. These modes are:
- Integration and coordination of processes
- Integration and coordination of information flows - Integration and coordination of planning processes - Integration of intra- and inter-organizational processes.
First, the integration and coordination of processes can be related to the flow of patients, and the operational processes of physical products (medical devices and pharmaceuticals). Intensive coordination and integration would lead to better supply chain performance (de Vries & Huijsman, 2011). Second, the integration and coordination of information flows, by, for example, deployment of information technology, support the improvement and smoothening of integration and coordination of processes. Third, the integration and coordination of planning processes can contribute significantly to smoothing the processes. Fourth, there are many different stakeholders (providers, managers and consumers) operating in a health supply chain, which relates to the integration of intra- and inter-organizational processes, and goes paired with building relationships, and allocating authorities and responsibilities (De Vries & Huijsman, 2011).
the full continuum of care (Nolte & McKee, 2008). The process of integration is divided in “structural integration (the alignment of tasks, functions and activities of organizations and healthcare professionals), cultural integration (convergence of values, norms, working methods, approaches and symbols adopted by the (various) actors), social integration (the intensification of social relationships between the (various) actors) and integration of objectives, interests, power and resources of the (various) actors” (Nolte & McKee, 2008). To achieve a high level of integration, organizations in general, need the capability and willingness to integrate (Zhao et al., 2011). The capability is defined by the level of internal integration (break down functional silos, share information and deploy cross-functional teams). The willingness is defined as the relationship commitment to its partners (trust and commitment). Therefore, integration is closely linked to collaboration, trust, and the atmosphere of the relationship (de Vries & Huijsman, 2011).
There exists a lot of literature which defines integration of care, describes what can be integrated and on which different levels and dimensions (breadth, degree and process). There exists a lot of knowledge on what integration of care is. However, there has not been described how integration of care can be achieved (de Vries & Huijsman, 2011). Especially now integration is necessary in the context of Value-Based Health Care, it needs more research.
2.4. Care pathways
The most common form of integration in health care found in literature is the development of care pathways (Minkman, 2012b), which are applied to a high level in The Netherlands as well. The European Pathway Association accepted the following definition of care pathways in 2005: “a care pathway is a complex intervention for the mutual decision making and organization of care processes for a well-defined group of patients during a well-defined period. Defining characteristics of care pathways include:
- An explicit statement of the goals and key elements of care based on evidence, best practice and patients’ expectations and their characteristics.
- The facilitation of the communication among the team members and with patients and families.
- The coordination of the care processes by coordinating the roles and sequencing the activities of the multidisciplinary care team, patients and their relatives.
The aim of a care pathway is to enhance the quality of care across the continuum by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources”. Care pathways are focused on structuring processes to improve quality and efficiency of care (Vanhaecht, 2007). Care pathways reduce unnecessary complexity and variation of care processes in and between organizations. Furthermore, they improve patient outcomes, team outcomes, and better organization (Seys et al., 2013).
Porter (2006) mentioned that keep doing incremental changes, such as developing care pathways, will not make the big change for health care. However, care pathways are the most common form of integration of care in The Netherlands. IPUs and care pathways have similarities such as the integrated and coordinated manner of collaboration around one medical condition with a multi-disciplinary team. It is useful to understand the concept of care pathways in order to improve our understanding of the state of current integrative practices.
2.5. Illustrative framework
The following framework can be developed after the explanation of all the concepts to give a clear overview. Value-Based Health Care is the overarching concept in this research. It is stated that integration is important to create more value for patients. Therefore, Integrated Practice Units should be developed, which are a part of VBHC. This research will not give actual prove of the increased value.
Value of care Integration
of care
VBHC IPU
3. Research methodology
In this chapter, the chosen research method will be discussed. Further, the cases selected to carry out the research will be described. The data collection of the different concepts will be set out. Last, the data analysis will be explained.
3.1. Research design
One of the aims of this research is to study the unexplored phenomenon Value-Based Health Care. This research will complement the research of Lysanne Douma with two cases: case 7 and 8. The other aim is to improve our understanding of how integration of care can be achieved in the context of VBHC, by capturing the perceptions of health professionals.
Value-Based Health Care has gained a lot of interest in The Netherlands recently, and many hospitals apply elements of VBHC. However, as addressed in the theoretical background, the exact meaning and appliance of VBHC is not clear, which makes it interesting to research the different perceptions of professionals who are involved in VBHC (Kievit, 2017). Furthermore, perceptions of health professionals on integration need to be researched to improve the understanding on how health professionals apply integrative practices.
The explorative characteristic of this research leads us to the chosen research method: a multiple case study (Karlsson, 2009; Yin, 1981). A case study is the fitting research design to find the answer by collecting qualitative data on how professionals perceive VBHC and how integration of care can be achieved (Yin, 1994).
This research has been done in two Dutch hospitals, which apply VBHC and integrative practices. Two cases made it possible to make analyse the data within-case and cross-case, and increase the reliability of this research (Karlsson, 2009).
3.2. Case description
The following criteria were used to select the cases: experience with VBHC and usage of integrated practices (multidisciplinary teams/collaboration and focus on one medical condition (Porter, 2010). These selection criteria were discussed with the teams beforehand. Both teams operate around a medical condition in a care pathway and focus on VBHC, so the same results are expected in this research. This refers to the literal replication logic (Yin, 1981). The characteristics and description of both cases is given in table 3.1.
Case 7 is the leading case, because this team is familiar with VBHC and integration of care for a longer time. This case is a multidisciplinary team working together in a general hospital, which focuses around Cerebro Vascular Accident (CVA). Ten professionals participate in this team since 2003. Different organizations outside the hospital are involved in the care pathway to provide care to the patients for the full cycle of care. CVA is an acute condition, where fast treatment is necessary. A few years ago, the CVA care pathway already started with several improvement projects (f.e. development of chain protocol, implementation of a practice guide), and a year ago the hospital started with projects around VBHC.
The second case is a multidisciplinary team working in a big University hospital, which focuses around atrial fibrillation. They participate in a VBHC-program since January 2018, but already participated in a program “Meetbaar Beter”, which focuses on patient and professional outcome indicators, and could be seen as precursor of VBHC. In the context of VBHC, is it a more novel case, as they are involved for a shorter time than case 7. 10 professionals work together in the care pathway, and 4 additional professionals work around the pathway for VBHC in particular.
Table 3.1. Case descriptive
3.3. Data collection
3.3.1. Primary data/interview protocol
The primary data of this research is obtained by semi-structured interviews with 9 health professionals and managers/advisors in April, May and June 2018. The interview guide can be found in Appendix A.
Table 3.2. Interview summary
Beforehand, an appointment of 45 minutes was made with the interviewees. The interviews were taken in a private room, to avoid any disruptions. The interviewees were asked to fill in a consent form that they approved that the interview would be recorded with a phone and noted. The privacy and anonymity of the interviewees were assured. Further, the skills list for a good interviewer was considered (Yin, 1989), such as: be a good listener, be adaptable and flexible, and be unbiased. A short introduction about the aim of the research and the subjects of the questions were given at the beginning of the interview.
After the interviews were taken, the recorded files were transcribed in Word. This needed to be done to analyse the interviews in Atlas.ti.
3.3.2. Secondary data
3.4. Data collection instruments 3.4.1. Value-Based Health Care
To collect the perceptions of professionals of VBHC, a semi-structured interview with open questions about VBHC has been created, to avoid biased answers. The interview guide of Lysanne Douma (see Appendix B) and current literature on VBHC have been used to develop the interview questions. A first draft was handed to the supervisor of this research and thereafter to the contact person of case 7, who complemented and adjusted the questions.
We started with general questions about VBHC and its characteristics: focus on outcomes and multidisciplinary collaboration (Porter et al., 2013) (Question 2 & 3). Starting this way gave the interviewee the room and possibility to discuss everything he/she wanted. Thereafter, more specific questions were asked about the role of patients in the process (Question 4 & 5), because the goal of VBHC is to increase the value for the patient, but their role is not clear from current literature.
The perceptions of professionals can complement the coding tree retrieved from previous research (see Appendix C). The framework (Ahaus, 2018) consists of four categories, namely: patient value, costs, organization of care and steering. We expect that new insights can be gained by complementing this framework with additional meaning. The new developed coding trees will be compared with the second-order concepts from the framework to find out if they match or not. If not, the new second-order concepts need to be added to the framework. This way of research refers to deductive research as an already existing framework has been used (Eisenhardt & Graebner, 2016).
The first reason for this deductive research is adding more cases to previous research on VBHC, by researching additional perceptions of VBHC. The second reason is to find out if new second-order concepts were found.
3.4.2. Integration of care
The first general question was: “What would your description be of integration in health care?” (Question 6). In addition, questions were asked about potential and existing barriers of achieving integration (Question 7). Further, the current status on the integration of care (Question 8), if the interviewee thought the current integration was successful (Question 9), and when integration is successful (Question 10) were asked. These answers will be compared with the literature on integration, to find out what the similarities and differences are for achieving integration in the context of VBHC.
3.5. Data analysis
First, VBHC needed a deductive kind of analysis. To start, the within-case analysis was done. The transcribed interviews were deeply analysed according to the framework retrieved from Ahaus (2018) and by the characteristics retrieved from literature. The perceptions of professionals on VBHC are captured in a new coding tree, but with the existing second-order concepts and aggregate dimension (see Appendix D). 234 first-order concepts were defined for both cases together. Thereafter, the first-order concepts were assigned to the existing order concepts. Two existing order concepts have been adjusted and 3 new second-order concepts have been developed. Finally, the second-second-order concepts were again assigned to the four existing aggregate dimensions.
After the within-case analysis, a cross-case analysis was done between the two cases researched for VBHC (Eisenhardt, 2016). Comparison of the two cases made it possible to find out if there were any differences in the perceptions of professionals in both cases.
Second, to analyse the achievement of integration of care, the open coding process according to Gioia, Corley, & Hamilton (2013) has been used, because this concept needed an inductive research approach. The first-order analysis was done by labelling important quotations with codes. The second-order analysis looked for differences and similarities between the first-order concepts. The second-order concepts needed to be distilled in aggregate dimensions. For case 7: 60 first-order concepts, 25 second-order concepts, and 7 aggregate dimensions were defined. For case 8: 50 first-order concepts, 27 second-order concepts, and 7 aggregate dimensions were defined. The complete coding tree can be found in Appendix E. The aggregate dimensions were overall similar, so both cases have been merged in the results section.
4. Results
The results found for the perceptions of professionals of VBHC and how integration of care can be achieved will be described in this section.
4.1. Value-Based Health Care
The framework of Ahaus (2018) is the starting point to incorporate the perceptions on VBHC (see figure 4.1.). Four categories (aggregate dimensions) have been found in previous research, which are substantiated by key-elements (second-order concepts). The found second-order concepts (see Appendix D) will be described per category for each case supported by quotations (see table 3.1.).
Figure 4.1. Value-Based Health Care categories (Ahaus, 2018).
4.1.1. Patient value
The most important category of VBHC is “patient value” in the framework. Patient value is accomplished by: focus on outcomes, focus on PROMs and PREMs, use PROM data in the medical consultation, reach a shared decision, and chose systematically, i.e. based on criteria. Case 7: The main focus of the professionals of VBHC in this case is increasing the value for patients by making the health outcomes visible, which is a value-adding element of VBHC. All interviewees mentioned “focus on outcomes”. When registering health outcomes, hospitals will be able to compare their outcomes and possibly learn from each other to improve care processes and eventually increase the actual value.
7-4: “VBHC is about looking to the health outcomes, the satisfaction of patients with the
PROMs (and PREMs) are meaningful methods to capture the patient’s perceptions of quality and experiences of care. “Focus on PROMs and PREMs”, is emphasized by three out of five interviewees. The organization of collecting the data of PROMs must be explicit and clear. An extended form of measuring PROMs are ICHOM scores1. This scoreboard is a method to collect data on patient and professional recorded outcome indicators.
7-2: “It would be very good to have PROMs. But you need to define responsibilities in the care
pathway, who is responsible to make sure the patients fill it in, how/when are the PROMs processed”.
“Reach a shared decision” is an important form of patient involvement in the full cycle of care, with both the patient and his/her relatives. This was mentioned by all interviewees to increase patient value, but in terms of “shared decision making”. It is suggested to change the second-order concept in figure 4.1. to: shared decision making.
7-1: “We try to involve the patients as much as possible, e.g. by family-patient conversations
with the therapist, but it can be improved. Shared decision making can be done better.
“Use PROM data in medical consultation” and “chose systematically, i.e. based on criteria” were not named explicitly in this research. No new second-order concepts were found for this aggregate dimension.
Case 8: Increasing patient value is the main focus of VBHC in this case. Improvement of care is based on what the patients want and need.
8-1/8-3/8-4: “Right care for the right patient, in the right place, against the right costs”. “Focus on outcomes” is mentioned by all. Measuring outcomes based on patient’s opinions is a value-adding element of VBHC and can improve the quality of life (8-2). However, 8-2 mentioned that it must be clear what is measured and who measures it. Outcomes provide awareness of your medical acting (8-2).
“Focus on PROMs and PREMs” and “use PROM data in medical consultation” are both given attention to. Case 8 is aware that PROMs and PREMs could deliver interesting insights. Until now, experiences of patients with the care pathway are not clear. 8-4 mentioned the usefulness of PROM data in medical consultations to be up-to-date about the daily outcomes/feelings of patients. Good organization is needed for the follow-up of the questionnaires, as previous experience with shared questionnaires was a 50% answer-ratio from the patients.
8-4: “If patient fill in how they are doing in daily life, and if doctors can see this information
during medical consultation, deviations can be noticed and discussed. In this way not only the person will be better based on care, but also as a person in life”.
In addition, case 8 is also aware of ICHOM indicators, and are valuable because they are scientifically proved.
8-4: “ICHOM questionnaires have not been developed here, but are scientifically validated.
We want to check whether the patient thinks that the questions are relevant in this region. Maybe we should delete some items”.
“Reach a shared decision” was mentioned by all interviewees from case 8. Patients’ relatives involvement in shared decision making can increase patient value. Good information is important. The second-order concept is suggested to be changed into: shared decision making. 8-1: “We have a flyer with information for the patient about the medical condition, where
different treatments are compared, with advantages and disadvantages. […] With this in mind, the patient can discuss with the doctor what the best situation is”.
“Chose systematically, i.e. based on criteria” was not named and no new second-order concepts were found for “patient value”.
4.1.2. Costs aspect
The category “costs” in the framework is supported by the following second-order concepts: reduce costs with unchanged or improved outcomes, apply financial incentives that encourage the delivery of value instead of volume, and pay for value-adding activities.
Case 7: “Reduce costs with improved or unchanged outcomes” was mentioned. Important is to compare costs with other hospitals in order to develop room for improvement.
7-5: “The interesting part is: how can you keep the costs low? That is a subject that always
recurs, not only measuring the outcomes, but also the costs. You can compare the costs with others to see if you do it cheaper”.
“Apply financial incentives that encourage the delivery of value instead of volume” was named by 7-4. If a care pathway shares a budget in order to collectively practice VBHC, it would stimulate all organizations involved. However, the partnerships2 in The Netherlands, which still reward based on volume-production, are not supportive for VBHC.
A new second-order concept was found: “health insurers’ support”. 7-4 noticed that insurers are interested in VBHC and will support development of VBHC in hospitals.
7-4: “Health insurers pay hospitals often P x Q, with a certain maximum. We agreed that the
payment for basic care stays the same, but for integrated care it will be P x Q without a maximum. Insurers agreed with this, but asked us to work with VBHC”.
The second-order concept “pay for value-adding activities” was not repeated in this research. Case 8: “Reduce costs with unchanged or improved outcomes” came forward. 8-2 emphasized that financial resources can be spend more effectively by carrying out care procedures only when they are meaningful and lead to better health outcomes.
8-2: “We should look for manners to work more effectively, with the obtained financial
resources, and still deliver qualitative-good care”.
“Apply financial incentives that encourage the delivery of value instead of volume” is important in health care, because the way health care is paid for needs to change. The current payment system rewards production-based health care, instead of value.
Case 8 also supports the new second-order concept “health insurers’ support”, in order to stimulate the collaboration between health care organizations and health insurers.
8-4: “You can imagine that you need the health insurers as a partner in the development of
care. They need to contract care, also when care changes. […] It is important to have the insurers on board”.
The second-order concept “pay for value-adding activities” was not found in this research. 4.1.3. Organization of care
The category “organization of care” consists of the second-order concepts: provide care in a care pathway, ensure patient involvement in the care pathway and indicator development, organize intensive multidisciplinary collaboration in an Integrated Practice Unit, other data/BI support and change support, and strengthen an open and safe culture of collaboration with “the professional in the lead”.
Case 7: “Provide care in a care pathway” is essential. Emphasized by 7-1 was the alignment of the care pathway. By aligning the organizations and professionals, efficiency can be increased. Therefore, it is suggested to adjust the second-order concept into: provide care in an aligned care pathway.
“Ensure patient involvement in care pathway and indicator development” was emphasized. Involving patients can help to improve the efficiency and alignment of care pathways. Further, health professional involvement (especially the doctors) is necessary, as they are the executors of care. Their enthusiasm and motivation can be challenging, due to limited time of the professionals (7-3). It is suggested to change the second-order concept (see figure 4.1) in: ensure patient and professional involvement in care pathway and indicator development. 7-2: “We had discussions with former patients and an interviewer about their care pathway. A
lot of information can be gained from these discussions.”
“Organize intensive multidisciplinary collaboration in an IPU” is important in this case according to all respondents, except not in terms of IPUs, but in term of care pathways. Further development is mentioned by 7-2: multidisciplinary should become more interdisciplinary, which means that professionals know more about what other disciplines do.
7-2: “You need to work interdisciplinary. Create a lot of knowledge of other discipline’s
possibilities, and not only your own discipline. […] You can improve care for the patients and decrease the risks”.
A new second-order concept found is “focus on trust”. Multidisciplinary collaboration is based on trust between professionals. Two interviewees mentioned that trust develops over time by sharing knowledge and experiences between the different disciplines. Trust can be vulnerable due to a feeling of competition between different hospitals and/or other organizations in the care pathway.
7-4: “Trust is created by sharing experiences and knowledge. It starts with communication.
This will contribute to the feeling of doing something together and get to know each other, networking”.
Another new second-order concept found is “focus on sharing information and knowledge to learn in the care pathway. Information and knowledge sharing between professionals supports integration and collaboration. Notable is that everybody mentioned that by sharing, professionals and organizations can learn from each other.
7-1: “Education and knowledge sharing is important. How do you do that, can we learn from
you? […] In theory, we want to offer integrated care”.
7-1: “Every CVA-care pathway has a care pathway coordinator, just a figure who connects the
chain. If something happens, he/she facilitates the collaboration, what are the bottlenecks, what needs to be improved”.
The second-order concepts “other data/BI support and change support” and “strengthen an open and safe culture of collaboration with the professional in the lead” were not reconfirmed in this research.
Case 8: “Provide care in a care pathway” is reconfirmed in this case. An important step when developing a care pathway, mentioned by 8-1, is: making sure the care pathway is aligned. To create a care pathway for the full cycle of care, care needs to be divided between the secondary and tertiary care organizations (who is going to do what?). It is suggested to change the current second-order concept (see figure 4.1) in: divide and provide care in an aligned care pathway. 8-2: “I think that the awareness of VBHC is regional. We need to do this together for us and
the patient. We need to divide care between hospitals, define responsibilities and agreements”.
“Ensure patient involvement in care pathway and indicator development” is also in this case suggested to be changed into: ensure patient and health professional involvement in care pathway and indicator development. The development of VBHC and care pathways needs common effort from health professionals (8-3).
“Organize intensive multidisciplinary collaboration in an IPU” is mentioned by all in this case, but not in terms of an IPU, but in terms of care pathways.
The new second-order concept “focus on trust” between professionals and organizations came also forward as important in this case to improve collaboration. To achieve trust, meetings, listening and information sharing have to be ensured.
8-3: “Trust is created based on the feeling of equality. That is, I think, the most important, that
everybody has their own place in the care pathway”.
The new second-order concept: “focus on sharing information and knowledge to learn in the care pathway”, is again named in this case. Especially sharing of the outcome data is seen critical for VBHC (8-1) in order to compare.
The last new second-order concept “appoint a care pathway coordinator”, is also reconfirmed in this case. It is important to have a contact person in general (8-4).
4.1.4. Steering (information)
The category “steering” exists out of the second-order concepts: apply evidence-based practice3, formulate in addition to outcome and cost indicators a few process indicators, implement PDCA4 based on standardized outcome and cost indicators (measure, monitor, benchmark, improve, learn), and visualize performance using a dashboard.
Case 7: “Apply evidence-based practice” is reconfirmed. In previous research (Appendix C) guidelines and protocols are a part of evidence-based practice. Guidelines and protocols are the basis of care, mentioned by 7-5. Moreover, there exists a care pathway protocol since the beginning of 2018 (secondary data 7-6), where the care pathway has been written down, complete with goals and missions.
“Formulate in addition to outcome and cost indicators a few process indicators” is important to make numbers more visible, which in turn can be negotiable with other organizations. 7-4 mentioned three different types of indicators which need focus: process, structure and outcome indicators
“Implement PDCA based on standardized outcome and cost indicators (measure, monitor, benchmark, improve, learn)” was mentioned by the fact that that processes need to be improved in order to improve the organization of care. By working more efficient, with less variation, the processes could become smoother.
The utility of indicators increases when several organizations use the same indicators, so organizations speak the same language and comparison is possible, which was emphasized by all respondents.
7-1: “We are not used to be open about our results of care. […] To share and compare your
results, you first need trust. […] If your results are worse, than you have some explaining to do”.
“Visualize performance using a dashboard” was not named and no new second-order concepts were found.
Case 8: “Apply evidence-based practice” was not explicitly named in this case, but two of the four respondents mentioned the use of guidelines and protocols in the care pathway.
“Formulate in addition to outcome and cost indicators a few process indicators” is reconfirmed. Not only outcomes and costs can be improved by measuring, but also processes.
8-2: “One side of VBHC is looking to your own results. Measuring and comparing outcomes
and results makes it possible to improve your processes”.
Elements from “implement PDCA based on standardized outcome and cost indicators (measure, monitor, benchmark, improve, learn)” were named. Clarity is needed what organizations in the care pathway are going to do with the registered outcomes. A risk of focus on outcomes is too much focus, according to the cardiologist (8-3). This leads to avoidance of registering bad data to not achieve bad results by having bad outcomes.
“Visualize performance using a dashboard” was not named and no new second-order concepts were found.
4.2. Integration of care
A new coding tree has been developed for the analysis of integration of care (see Appendix E). Noteworthy is that all found aggregate dimensions, which will be called conditions, are similar between case 7 and 8, so both cases are merged to present the results.
Case 7 is organized around CVA care, which is complex, transmural and multidisciplinary. This requires integration of care to treat the patient as best as possible, mentioned 7-3.
There is a change going on in heart care delivery, which plays a role for Case 8. The care will be divided between primary, secondary and tertiary care. Case 8 is responsible for the more complex (tertiary) care. This change leads to more need for integration (8-3).
The first condition for integration of care found in both cases is professional and organizational
alignment. More than half of the interviewees from both cases mentioned that alignment
between professionals will support faster achievement of integration.
7-3: “If professionals discuss with each other about what is important in care, they are quickly
motivated and trust each other, because they think the same way. They can be quickly aligned”.
In addition, there exist different cultures and working methods in hospitals, which can hinder integration. Therefore, an aligned working method is necessary. The steps of the change process need to be clear for all involved, which can be done by describing the current situation, bottlenecks and priorities in a multi-year plan (secondary data 7-7).
8-4: “You work with different hospitals in the care pathway in a totally different manner. A
The second condition is the division of care between organizations and delivery of care in a
transparent care pathway. A care pathway makes sure to provide equal care in the region, that
it does not matter to which hospital patients go (7-3). Moreover, transparency is important in the care pathway, which can be done by clearly defining the stakeholders and responsibilities (7-2).
8-1: “The patient needs to go fluently from one organization to another. We make agreements
with all organization in the pathway”.
All respondents in both cases mentioned the importance of having a care pathway protocol, which gives a clear overview of the pathway, and a care pathway coordinator to provide insightfulness, structure and connection between the organizations.
Especially in case 8 the division of care between primary, secondary and tertiary care was discussed. Meetings and discussion are needed to agree on the exact division of care between organizations in the care pathway (8-3).
8-1: “Dividing care is a process of “giving and taking”, which needs collaboration”.
The third condition for integration of care is multidisciplinary collaboration. Multidisciplinary collaboration contributes to complete the focus on the full cycle of care, which can be challenging due to involvement of different disciplines. Multidisciplinary discussions support the collaboration between professionals, by creating moments of contact. In general, professionals are open and enthusiastic to collaborate.
7-2: “With the help of multidisciplinary discussions, you get to know other professionals, from
other hospitals. This increases your approachableness. You understand each other’s questions, offer each other possibilities, and increase efficiency”.
The fourth condition is focus on trust. Trust supports collaboration and sharing of information, which is emphasized by all respondents. Further, trust supports and stimulates the openness and sense of equality of the partners in the care pathway. Trust can be created by sharing of experiences and knowledge through listening, hearing and collaborating (7-1 and 8-3).
8-2: “Trust is created by a lot of conversations, what is our/their vision on the patient?
Everybody wants the best care. Yes, trust, making agreements is important”.
the website (7-1 and 7-4). Sharing of knowledge between professionals in the care pathway increases their overall knowledge of other disciplines, which can decrease the risks for patients (7-2). Furthermore, sharing of data (for example health outcomes) makes comparison possible between different organizations in order to keep improving and learning (7-1 and 7-3).
7-3: “Collaboration is making agreements about information sharing. Information transferring
has to be a smooth and continuous process”.
8-1: “I see integration as the development of the care pathway. We hope that there will be no
barriers anymore in the region. That the sharing of education, knowledge, experiences, and personnel will exist. There should be one care system in heart care in this region”.
The sixth condition is health professional involvement. Especially the doctors can be challenging to involve, but even more important (7-3). Professional involvement is needed in order to create agreements for the care pathway. (8-3).
7-3: " What are bottlenecks of the care pathway? […] We started with problems, from
professionals’ perspective, who have experience. If they experience it as a bottleneck, they probably want it to be solved”.
The seventh condition is patient and relatives involvement. Patient experiences are valuable to help improving and achieving integration (8-1). Emphasized was their involvement in improvement projects (7-3 and 8-1). Moreover, involvement of the patient leads to shared-decision making, which is an important concept in the care pathway. If necessary relatives can be included (7-1).
7-3: “Most important from integration is that the patient notices the collaboration, that it is a
continuous process, that the moments of contact are obvious”.
8-1: “I think we can learn a lot from patients, because it is new for them to hop from one hospital
to another in the care pathway. We think we developed a smooth care pathway, but I am curious how the patient experiences this”.
7-5: “To evaluate care you need outcome indicators, but every profession in health care has its
own outcome indicators. If we are registering too much, which costs a lot of time, it is disadvantageous for the patients”.
Third, noticeable was the fear of professionals of spending too much time on registering data, which could hinder integration (8-3).
7-5: “Time is an important factor in our job. Less time means less time for the patient”. Fourth, the unclarity about the usefulness of registering data is not motivating for integration (8-4). Fifth, integration can be complex due to different ICT systems, cultures and working methods between organizations, because this causes inefficiency. The systems and working methods still need to be aligned (8-1).
8-1: “ICT systems do not connect with each other in the care pathway. How can you ease the
transfer of information then?”
Sixth, division of care between different hospitals in the pathway can hinder integration, because it is complex to set boundaries of which hospital will do which part of the cycle (8-3). Seventh, typical for The Netherlands is that some professionals get paid based on volume, which is still an incentive to treat as many patients as possible, and hinders multidisciplinary collaboration and thus integration.
4.3. Cross-case analysis
The cross-case analysis has been done for Value-Based Health Care, because for integration of care the cases are merged.
4.3.1. Value-Based Health Care
Table 4.1. Cross-case analysis VBHC.
5. Discussion
This study researched the perceptions of professionals on VBHC and investigated how integration of care can be achieved in the context of VBHC. The results of this research will be discussed and compared to previous literature, through which similarities and differences will be evaluated.
5.1. Value-Based Health Care
This research aimed to extend previous research by exploring two more cases to complement and adjust the framework (Ahaus, 2018), which categorizes the perceptions of professionals into four categories. This discussion will follow the categories of the framework. New and adjusted second-order concepts are incorporated in the framework (see figure 5.1).
Figure 5.1. The complemented framework of Ahaus (2018).
2017). The patient involvement by shared decision making needs to be extended by involvement of their relatives. Bleser et al. (2006) already stated that the involvement of relatives is underreported in literature.
Second, the category "costs" was partially reconfirmed in this research. Costs must be reduced with unchanged or improved outcomes, by comparing costs of medical actions between different organizations, which is not named in literature. “Apply financial incentives that encourage the delivery of value instead of volume” came forward in this research. Especially the partnerships in The Netherlands, who are still rewarded according to treatment volumes, hinder the practice of integration (Porter, 2010). A very important finding is the health insurers’ support. Effective collaboration between hospitals and health insurers is helpful, because insurers are very interested in VBHC projects. Porter (2013) acknowledged that organizations need to improve value, otherwise the insurers will exercise pressure. “Pay for value-adding activities” was not reconfirmed.
knowledge between professionals and/or organizations (Panahifar, 2018; Zhao et al., 2011). Porter (2006) did mention trust between professionals, because of their expertise. He emphasized the importance of information and knowledge sharing. Information must be shared both with the patient as with the partners of the care pathway. The importance of information sharing is acknowledged in previous literature to ensure the patient centeredness and improve performance (Schneider et al., 2011). Another finding is “appoint a care pathway coordinator”, which is not found in current literature. However, the coordination of activities and roles is frequently stated (Vanhaecht, 2007; Minkman, 2012b).
Fourth, in the category “steering”, “apply evidence-based practice” and “formulate in addition to outcome and costs indicators a few process indicators” were confirmed. Elements of the Plan-Do-Check-Act cycle were in line with previous research. Outcome indicators in different organizations are only useful when standardized, otherwise they could hinder comparison of data and information sharing, where Porter et al. (2016) also warned for. A consequence of the professionals spending considerable amount of time on registering, is that a fear for spending too much time prevails. This time can be better used for patient care. Moreover, clarity about the follow-up of registering of the outcomes has to be created. The risk of focusing on outcomes too much is the avoidance of registering patients with possible bad outcomes to keep the organization’s results high. For example, avoiding patients with a lot of co-morbidities, which was also emphasized in a recent article of Kleyne (2018).
5.2. Integration of care
preserved their own structures, which refers to a low degree of integration (Nolte & McKee, 2008).
This research provides possible conditions on how to achieve integration of care, which were lacking, according to previous research (Drupsteen et al., 2016; Minkman, 2012b). The found conditions for integration are: professional and organizational alignment, division of care between organizations and delivery of care in a transparent care pathway, multidisciplinary collaboration, focus on trust, sharing information, knowledge and data to improve learning, health professional involvement, and patient and relatives’ involvement. These conditions will be discussed according to previous research.
First, professionals and organizations need to be on the same page in order to achieve integration. There exist different cultures and working methods between organizations, which need alignment as much as possible. The alignment of professionals and working methods fits within “cultural integration” (Nolte & McKee, 2008). To align, the responsibilities between professionals and organizations need to be allocated, which agrees with the mode “integration of intra- and inter-organizational processes” of De Vries and Huijsman (2011).
Second, the delivery of care in a care pathway is the most common form of integration and is reconfirmed (Bleser et al., 2006; Minkman, 2012b). Developing care pathways is a process of giving and taking and of repetition and overlap (Minkman, 2012b), because care needs to be divided between primary, secondary and tertiary care. Transparency of the care pathway is important to create sufficient clarity for all involved. This corresponds with the finding of Vanhaecht (2007), which stated that transparency increases the understanding of the processes in the pathway.
Third, multidisciplinary collaboration is needed to deliver the best care to the patient, which corroborates previous literature (de Vries & Huijsman, 2011; Minkman, 2012b). This was also found important for VBHC.
and data support trust and the opportunity to learn from each other. A care pathway stimulates the facilitation of sharing.
Sixth, the involvement of health professionals (especially doctors) in both the improvement of integration, as the involvement in the development of care pathways, is found to be important. Zhao et al. (2011) have shown that integration could be hindered by their unwillingness to integrate.
Seventh, the patient involvement is found to be as important for VBHC as for achieving integration. Patients’ experiences are valuable to include in improvement projects, which is not found in current literature.
6. Conclusion
The objective of this research was to improve our understanding of VBHC and how integration of care can be achieved by researching the perceptions of professionals. The perceptions of professionals contain valuable knowledge and other organizations/professionals can learn from these perceptions.
To conclude, the health care delivery system in The Netherlands is changing. Despite the fact that Porter (2006) emphasized the importance of radical change in health care, The Netherlands maintained more incremental changes. Integration of care was already in practice, before VBHC was introduced. The added value of VBHC is that it provides professionals a focus to increase patient value by measuring both health outcomes and costs, which makes problems more visible. Therefore, indicators for measurement should be standardized in order to compare the results of care between different organizations. Patient involvement can contribute to increase value by shared decision making and care pathway and indicator development. PROMs (and PREMs) could provide valuable insights from the patient’s perspective, but are still in the developmental phase. If VBHC can help to improve quality of care and life, it is value-adding concept.
This research showed new second-order concepts in addition to the four categories of the VBHC framework (Ahaus, 2018): patient value, costs, organization of care and steering. The new second-order concepts found are: focus on trust, sharing of information, knowledge and data to improve learning, health insurers’ support, and appoint a care pathway coordinator. Health insurers support VBHC, because patient value is important in their eyes. Good collaboration between organizations and insurers is therefore necessary. The adjusted second-order concepts found are: “divide care between organizations and provide care in an aligned care pathway” and "ensure patient and professional involvement (in indicator and care pathway development)”. These findings are preliminary and need to be further attested in quantitative research (see 6.3). The second-order adjustments and additions are suggested for a better alignment of the model with the practices and perceptions of health care professionals in The Netherlands.
collaboration, focus on trust, sharing of information, knowledge and data to improve learning, health professional involvement, and patient and relatives' involvement.
According to the interviewees, successful integration is achieved when: “all involved have the same goal for the patient, the care pathway is insightful and all bottlenecks are solved, the patient knows where he/she is up to and feels the continuity in the pathway, and all involved know who to turn to”. VBHC can increase patient, if health outcomes show that integration of care contributes to quality of care and life.
6.1. Limitations and future research
One of the limitations of this study is that only the side of professionals has been analysed. No empirical evidence has been gained from the patient perspective. PROMs/PREMs as outcome indicators are still in development. Also shared decision making was named frequently from the professionals’ perspective, but no evidence was gained from the patient’s perspective. Further research is necessary. A case study could be done by interviewing multiple patients who have experience with a care pathway, filling in PROM questionnaires and shared decision making.
Health insurers are interested in VBHC, as it gives them an approach to measure health outcomes and costs. The development of care pathways requires the support of health insurers. Interviewing the health insurers’ side in a case study could provide valuable insights.
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