What U.S. hospitals can learn from a value-based strategy in the Netherlands

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 - Geert van den Enden ACHE 2017
Geert van den Enden, COO/CFO of Bernhoven Hospital, speaking at ACHE 2017

While healthcare costs continued to rise at other facilities, one Netherlands hospital was able to lower costs by 8 percent in a single year while improving quality. The credit goes to a value-based care strategy focusing on everything from closer coordination on cardiovascular patients to keeping more experienced physicians in the emergency department.

The 380-bed Bernhoven Hospital, located about 64 miles away from Amsterdam, does have to deal with a different regulatory structure. The Netherlands left single-payer healthcare a decade ago, for a heavily regulated private system where prices for services are set by the government, providers have to accept all insurance and being insured is compulsory.

Yet it faces the same problem as the U.S. healthcare system—unsustainable increases in costs. So Bernhoven’s strategy was to increase quality while reducing claims.

“We’re only going to do something if you’re really convinced that it has a lot of value. If not, we’ll stop it,” said PricewaterhouseCoopers consultant Sander Visser, who helped led the implementation of this strategy. “And in this way, we free up resources to invest back into the hospital to do further quality improvement.”

The hospital knew revenue would take a hit from this strategy. A key ingredient to the transition, Visser said, was entering into a multi-year agreement with insurers for a lump sum payment to help offset that drop in income. This allowed Bernhoven to focus on reducing utilization “no matter what it does to our reimbursements.”

The change in care delivery, however, was driven by the physicians. Doctors were given executive power in the hospital board and asked to come up with radical ideas for better care. More than 200 ideas were submitted, with the list then whittled down to strategies where the outcomes and costs could be estimated based on available research.

“When we say we put our physician in the lead, it’s easier said than done,” said Geert van den Enden, Bernhoven’s chief operating and chief financial officer. “You expect them to be think bigger, think wider, for the whole hospital.”

In one example, the hospital used quality data from a hospital where junior staff members went on strike, and discovered the more experienced physicians in the ER were less likely to admit patients. By introducing more veteran docs into the ER, admissions from the ER were reduced by 13 percent, along with drops in wait times, follow-up visits and length of stay. Part of the plan included having certain specialties represented in the department at all times.

“We wanted them to take shifts, senior cardiologists,” van den Enden said. “Because they’re way more experienced. They’ll see a patient and within half an hour, they’ll have a good plan, whereas the emergency doctor, a generalist normally, needs a little bit more time. I’m not saying they’re bad, but on different occasions, it’ll increase quality.”

The culture change appears to have paid off throughout the facility. Claims at Bernhoven decreased by 8 percent between 2014 and 2015, compared to a 2 percent increase in the rest of the Netherlands, and costs were down 16 percent through the first half of 2016.

Initiatives within other departments were also successful:

  • An awareness campaign for including patients in shared decision-making led to fewer surgeries. For example, after gall bladder patients discussed the pros and cons of their treatment options, “4 out of 6” decided against surgery for a “watchful waiting approach.”
  • The creation of an optometric consult center screened out more than 2,700 unnecessary visits to an eye MD (60 percent of all visits to the center). Each consultation without a referral saved $78 compared to seeing the MD.
  • Dermatologists saw patients at general practitioner offices, rather than at the hospital, with more than 80 percent of those visits not requiring a hospital referral.
  • 2,900 cardiovascular risk management (CVRM) patients were referred back to general practitioners rather than having follow-up consultations with the cardiologist at the hospital.

The individual initiatives weren’t necessarily new. What Visser felt was unique was Bernhoven implementing so many at once, with the unifying goal of a “relentless focus on eliminating overutilization.”

If other hospitals want to copy their methods, Visser said buy-in from physicians and the members of the board would be of the utmost importance. That would likely require getting the same financial commitments from the