Does More Value Naturally Lead to Better Care?

Value-based healthcare (VBHC) starts with the patient and uses patient-oriented outcomes to improve care. Not everything can be expressed in figures: psychological and sociological factors play a role as well. The medical-industrial complex does not always benefit from VBHC, which is the reason why the different interests are not always advantageous to the patient. With an approach that starts with the patient and with the help of patient advocates it will be possible to change care into a direction that benefits the patient. VBHC is an important means with huge added value.

Once I asked an economist if he thinks that an economic model can predict tomorrow morning’s economy better than the meteorologist tomorrow’s weather. In the discussion that followed it became clear to me that we have allowed mathematics and its figures to become too dominant. In reality there is more than only digits. There are citizens with their behaviour, events that influence those same citizens and so on. We should consider all this and then we are in the weatherman’s neighborhood. We do not do this, for in our model we have created a reality and in that reality we are right. That feels safe.

Thinking of Michael Porter's article on value in healthcare and the discussion with the economist I will try in this article to show the importance of value-based healthcare (VBHC) from the patient’s perspective. To come straight to the point: VBHC is good, has value for the patient and deserves our attention and effort, with due regard for the resistance against it. The largest opponents of VBHC come from the medical-industrial complex, the joint effort of patient organisations, doctors, scientists, industry, government and healthcare insurers. And strangely enough there is no evil intent. If this were the case, we could do something about it more easily. Fortunately there is a solution and it lies with the patient. The solution is difficult and requires stamina. But it has to be done, for the benefit is worth it.

VBHC we can do it well.

In short VBHC means that:

• In consultation with the patient one illness is chosen (to start with). Transferring a complete hospital into VBHC all at once does not work. As an example: “prostate cancer and the manner of operating (prostatectomy)”
  
• A team is built consisting of the right combination of knowledge, involvement and experience required to get the best result
  
• It is researched well how this can and must be done and the patient’s wish and interest gets priority. It is required to discuss with the patients how they see it and want it to be done
  
• You start as soon as you have the feeling that the first steps can be taken and not when everything has been worked out up to three decimal positions
  
• You use ‘patient- and medical-reported outcomes’ and improve all this in recurring cycles. There is continuous improvement and this also means that the team can or has to be adjusted.
  

Patient-Centred Value-Based Healthcare in Practice

At the Martini-Klinik, a private clinic of the University Hospital Hamburg-Eppendorf in Hamburg, Germany (martini-klinik. de/en/for-patients), they prove that patients with prostate cancer become impotent and incontinent less often as a result of the operation technique they use, with fewer complications that cause a large decrease in quality of life. The consequences of the operation technique in the Martini-Klinik are dozens of percentages less impotence and incontinence. This is the result of continuous improvement of the procedures and techniques. It is a pity that opponents of specialisation of healthcare immediately question the improvement figures to postpone the solution for the patient and to safeguard their own interest, which is that the treatment has to stay within their own clinic. The specialist has to be able to carry out his work in the same way and the money has to keep flowing into the same direction. The Martini-Klinik procedure is an example of VBHC, and from a patient’s point of view it deserves powerful support. Patient advocates need to take the initiative to spread this further than Hamburg.

A Dutch example of VBHC is ParkinsonNet (parkinsonnet.info). Neurologists Bas Bloem and Marten Munneke have talked to patients and have noted down how the latter want to be treated: by specialists in diagnostics and treatment of Parkinson patients and not by a random neurologist. Caregiving also proves to be important here. After that they made an inventory of more demands and wishes of patients and have realised ParkinsonNet in cooperation with healthcare insurers. Better care, satisfied patients and working cost-efficiently were the result. ParkinsonNet and the Martini-Klinik are good examples of the fact that costs decrease when you focus on quality. That is by the way a result of VBHC and not the starting point. VBHC is not primarily about money and profit. That is a secondary aspect. Patient care and quality are number one. And then we see that costs decrease. This approach differs from the current procedure, where costs are diminished and quality decreases (at least the service to the patient).

Cardiologist Eric Topol from San Diego, USA, has a special view on the relationship between the patient and a doctor. In his book The patient will see you now he comes to the conclusion that we are on our way to an implementation of VBHC led by the patient and with modern techniques. Already patients enter the doctor’s room better informed (through the internet and smartphones), and they indicate what they know and want. In the not too distant future they will make appointments via video for consultation with each other. Topol compares the patient’s new tools with the invention of printing. Because of this the clergy lost its monopoly on reading and writing. That is happening to the doctor’s primacy on health, shown symbolically as “from god to guide” (to quote Bas Bloem in his Tedx talk) (https:// iii.hm/7s9). The changing relationship between physicians and patients changes healthcare. This is a good and positive development, which is not without resistance, but brings us what we wish: healthcare attuned to the patient and agreed upon.

My conclusion, based on quite some literature and a few powerful examples from practice, is that VBHC works. But not always?

Why Aren’t Figures Always Reality?
 

Patients prefer not to become a patient and, if they become one, they do not want to be a patient any longer than needed. Patients have hope and they want friendly doctors and nurses who pay attention. Patients want certainty. However, everything they are involved in contains psychological and sociological aspects and these cannot be expressed in figures. As a patient you live with this uncertainty and at the same time with the certainty that the best doctors, nurses, hospitals and treatments are available. That certainty is what VBHC can mean for patients. That is why it is necessary and important to come to an agreement with the patient about what care has to be offered and in what form.

Medical-Industrial Complex as Obstacle to VBHC

Care is about interest. According to all stakeholders, however, the patient is in the forefront. Worldwide, healthcare involves hundreds of billions of dollars and euros and together we are working hard for the patient, but also earning money. The unintentional consequence is that healthcare as a sector benefits from a situation with as many patients as possible, who remain patients as long as possible. We pay for the provision of services and that is exactly the outcome: providing many services. We know this, but many of us avoid the subject or look away, because the responsibility we have for this does not feel comfortable. This is what I call the immoral result of the medical industrial complex, namely the teamwork of the healthcare stakeholders, who together have allowed a form of cooperation that doesn’t necessarily serve the patient best. In my book Hoe heeft het zover kunnen komen I have written about this extensively, remarking that all this is not caused by evil intent, but by the ambition to get more money, power and influence. This amoral behavior leads to an immoral result that is undesirable and that we cannot and do not want to live with. The only solution is walking away from our responsibility and looking away from the damage we cause. Or is it?

Gerd Gigerenzer, managing director of Max Planck Institut in Berlin, investigated the pursuit of maximizing profits and the consequences of this for the patient. In his book Risk savvy, but also in Better doctors, better patients, better decisions, he shows that in radiology there is strong pressure to carry out as many MRI scans as possible in spite of the fact that it can be demonstrated that an experienced doctor can determine some diseases in less time and with greater accuracy. As an example Gigerenzer mentions the MRI that is carried out with illnesses of the organ of balance, the ‘acute vestibular syndrome’. With knowledge and experience a doctor can determine faster, cheaper and with more accuracy if there was a brain hemorrhage. Another example that Gigerenzer mentions is the choice of the harmful CT scan (because of radiation consequences), where the MRI scan would be a better option. A thing that many doctors do not know, but the hospital accountant does. The real costs of a CT scan are lower than those of an MRI scan, but the compensation of the healthcare insurer is the same. Thus more money remains in the hospital cash box.

What to Do?

Now I have said this, the question is of course how we can change this and how we can implement VBHC. It is essential that there are enthusiastic sponsors, people in influential positions that believe in it, such as Detlef Loppow, the CEO of Martini-Klinik in Hamburg. But he cannot do this alone. He needs the management of the Academic Hospital in Hamburg that supports him and also believes in it. Besides, it requires teamwork of four components that mutually reinforce each other, but lose their power

separately:

• Put different people in a room: The solution comes from people from different backgrounds who share the conviction that it’s all about the patient. When you ask the same people to solve a problem they have not been able to solve in the past ten years, you know that it will not be successful in the next five years either. Change does not come from the inside.
  
• Go for the root cause: Remain polite and strict when the search for truth is at stake. Keep asking questions until you have the certainty and the feeling that you are at the bottom. Only then you can start. And that is why you should:
  
• Scale fast: Think big, start small and scale fast.  When you and your team have found out what the situation is like, you have to speed up. Keep approaching each other critically, give feedback about the results and adjust actions when circumstances change or the result is different from what you expected. Holding on to your original plan does not serve the patient. And finally:
  
• Be independent: The most difficult component, for everyone has a job, a family and a boss. And you want to keep those. Fortunately, the first two ingredients help to minimise independence.
  

Conclusion: ‘Central position of the patient is not enough’

It sounds nice to put the patient in a central position and take him/her as the starting point in everything we do in healthcare. However, it is not sufficient for a successful implementation of VBHC. The medical-industrial complex does not surrender just like that. And that is not because it wants to do evil. On the contrary, people involved in healthcare want to do well. What it is all about is that the system is moving into a direction that seems irreversible. Inevitability seems to have arisen that reinforces this irreversibility. Yet it is possible to turn the tide by letting the change come from the patient. Bizarre, for the patient comes from outside healthcare. Up to now he/she has not had a say in healthcare and has had to undergo what others have decided. But it is all about us, the patient: “If about us, not without us”. It is necessary that patients stand up and defend their interests, force them with arguments and express them in clear language. The arguments are supplied by VBHC. Combine emotion (“I want to get well again”) with facts and continue working harshly at the solution you have devised and worked out with the various stakeholders. Through cooperation, placing the patient in the central position and the patient taking the leading role and with the help of patient advocates an excellent way out of the existing situation has become possible. Isn’t that beautiful? Those who benefit from excellent care are the ones that give direction to the solution and fulfill an essential role in this. Patient advocates are independent patients with a lot of knowledge; they are well informed and eloquent. In every discussion with any stakeholder they are capable of saying: “Do your work well, then we will all benefit.”

We know how it must be done. We also want this and we can do it, for we have done it before. What remains is doing it for all patients. And do it now

Key Points

• Value-based healthcare, looking at healthcare from the perspective of adding value to patients
  
• Medical-industrial complex, the cooperation of patient organisations, doctors, researchers, industry, government and health insurance companies
  
• Patient advocacy, an activist way of taking care of the interests of patients by patients
  
• Change management, changing healthcare is like moving a cemetery