The 3 differences between Value Based Healthcare and Triple Aim that you need to know

Both value based healthcare (VBHC) and Triple Aim claim to be the solution for the rising demand for healthcare needs and costs across the globe. Both concepts are originally from the United States and lumped together as value based care. But are we right for doing so? Are the principles of both concepts the same? That’s something we can be very brief about: no. In this blog, I’ll clarify this by zooming in on the two concepts and by highlighting the three most important differences.

Two perspectives on value based care

Future healthcare revolves around establishing multiple value creation, in which economic, clinical and psychosocial values are well balanced. There is thus no emphasis on saving costs or an excessive attention to personal experiences in future healthcare models, but there’s a balance that revolves around achieving the best care and health for the patient at the lowest possible costs. We usually speak of value based care in this context. Both VBHC and Triple Aim have their own distinctive interpretation of what value is.

What is value based healthcare?

In the book ‘Redefining Health Care’, management expert Michael Porter explains that VBHC is about realizing the best outcome for the patient at the lowest possible costs. Porter indicates that the healthcare pathway of a patient must be seen as the starting point in order to determine the added value of the different disciplines. The concept of VBHC is actually a detailed cost-effectiveness method that originated from health economics. Scientifically, however, there is still little agreement on which outcomes are most relevant to patients and what the best way is to measure these outcomes. This is thus a difficult issue. Many healthcare institutions, governments and health insurers mainly focus on budgets, instead of on the added value of a treatment. This makes it harder to establish VBHC. Michael Porter and Elisabeth Teisberg, the creators of the VBHC method, are trying to bridge this gap with an implementation model. The VBHC implementation model consists of six interrelated building blocks, see figure 1.

Point of criticism 1: Partial disease management

In the Netherlands, for example, the VBHC implementation model has been used to introduce disease management for patients with chronic illnesses, such as type 2 diabetes, cardiovascular problems and COPD. Compared to international best practices, disease management financing differs in the Netherlands, because only the primary care providers are included in the disease management contracts, see table 1. Due to the absence of medical specialists in disease management contracts, disease management in the Netherlands can also be referred to as partial disease management. Logically, the desired results in terms of quality improvements and cost savings are lagging behind. In contrast, clear positive effects have been demonstrated in countries such as the United States, England and Germany. The explanation for these findings is simple: in these countries both primary care and secondary care providers (e.g. general practitioners and medical specialists) are included in a long-term disease management contract and they work together from a single organizational network. In this case, substitution is an internal managerial question between healthcare providers, in which innovation and efficiency of the entire chain are stimulated.

Point of criticism 2: Disease-specific approach

There is also criticism on the disease-specific approach that the VBHC implementation model advocates. The risk of VBHC is that the healthcare for people with complex healthcare needs becomes further fragmented. Particularly for vulnerable groups in our society, such as people with multimorbidity or frail elderly people, it is a plausible risk that their demand for healthcare is divided into various components with the consequent stacking of treatment protocols, chain organizations and financing arrangements. Research shows that effective treatment is not achieved by the simple sum of specialized expertise or disease management programs.

Point of criticism 3: Competitive model

Another point of criticism is that the VBHC approach assumes a competitive model between providers based on health and cost outcomes. In practice, this is possible for relatively low-complex (intramural) curative care, because the entire range of care and the associated clinical and financial risks can be managed by one (hospital) organization. For the vulnerable groups in our society, a competitive model will lead to further fragmentation of care. In other words, value based cherry picking.

What is Triple Aim?

The Triple Aim approach goes one step further than VBHC and claims that a population approach and multi-stakeholder collaboration are needed to create value. Donald Berwick explains that the Triple Aim approach revolves around a threefold objective in which the individual objectives must be pursued simultaneously. The first objective is to improve the perceived quality of care. The second objective is to improve the health of a population and the third objective is to reduce healthcare costs. The organization of healthcare is aimed at the entire network of prevention, care and welfare and focuses on the need and healthcare demand of a specific (sub) population. The goal of this coordinated collaboration is to achieve an optimal outcome in terms of quality, health and costs (Triple Aim).

In practice, this means that a group of healthcare providers cooperate in a coordinated manner and are prepared to take the collective risk for the outcomes. They are thus jointly responsible for realizing the quality and costs of the healthcare they provide. Besides technological innovation and the will to cooperate, the political will to achieve improvement is also important for the Triple Aim concept to succeed. The implementation model for Triple Aim is called population management. An example is the population management model of the Care Continuum Alliance, see figure 2.

Point of criticism 1: Policy orientation

The Triple Aim approach explicitly relies on a population-based strategy. As a result, it mainly has a policy-based macro orientation. This makes this approach less relevant for everyday practice. To implement the Triple Aim effectively, the ‘how-to-question’ must also be further developed at the micro patient and meso organizational level.

Point of criticism 2: Absence of enablers

The Triple Aim approach assumes that healthcare is a complex system, consisting of various elements with mutual relationships. These elements can be people, but also departments, organizations, computer systems etc. This implies that if one cause is addressed, this could have a negative effect on another problem. A cut or cost savings within nursing and care homes for instance, could lead to a stronger increase in costs for the emergency room or GP practices. Research has shown that this is the point of failure for many initiatives. In the Netherlands for example, the required integral financing and policy framework conditions are absent across the network of prevention, care and welfare. As a result, there are no regional organizational networks that can, want and are allowed to bear the clinical and financial risks of a regional population. The absence of a positive regional business case implies that the Triple Aim approach in the Netherlands is primarily a policy ambition with its associated short-term subsidy circus. Without adjustment within the healthcare system, only elements of the Triple Aim can be applied. This has also been shown in the Living Labs Population Management in the Netherlands.

The 3 differences

Figure 3 depicts the three main differences between the VBHC and the Triple Aim approach. First, VBHC is a disease-specific chain approach, while the Triple Aim approach is a population-based approach. Second, VBHC is an example of a linear improvement approach derived from the automotive industry, while the Triple Aim approach is based on circular causality between interventions and outcomes derived from the complex adaptive systems theory. Finally, the VBHC concept assumes there’s a competitive model based on outcomes and the Triple Aim is based on a collaborative model for the exchange of products, services and knowledge.

Where do we go from here?

The Triple Aim approach is based on a broad view of health (instead of on diseases) and is based on the principles of public and primary healthcare. There is sufficient scientific evidence that a person and population based approach of this kind actually leads to better health and lower costs. The conceptual framework of the Triple Aim approach is therefore the most promising growth model to give substance to value based healthcare in many countries.

However, a joint agenda is needed to learn how to drive health. This transition requires entrepreneurship from healthcare providers, who want to run the clinical and financial risk of achieving health outcomes and cost savings together with partners in the region. In addition, contract innovation is required from governments and health insurers to realize the needed efficiency and health incentives. Policy makers must give the parties involved the freedom to organize the optimal form and scale of healthcare that fits the local population and should stop the simultaneous stimulation of competition and cooperation in the field. In short: there’s work to be done. Download the whitepaper to learn how you can break the deadlock on the road to value based healthcare in practice.

Joint Consultation within outreach clinics: What if the solution is the problem?

 

Treating complex care in hospitals and simple care in a primary care setting, that’s the ideal situation. General practitioners and medical specialists are using lots of projects to

try and refine this by offering simple specialist care at the GP’s practice. What this means is that the cardiologist, dermatologist, geriatrician or other specialist spends a few hours a week seeing patients in their GP’s practice. These so called outreach clinics are the buzzword linked to this phenomenon. At first glance, it doesn’t seem all that bad. It brings care closer to the patient and that is what we all want. But we also want better care at lower cost and unfortunately, that isn’t what the joint consultation model within a outreach clinics always delivers. It isn’t that strange; we’re not really doing what we should be doing: integrating care so we can achieve real improvements. In this blog we’re going to have a closer look at the concept outreach clinics. We will show you the pitfalls and give tips on how you actually can achieve better healthcare results, better patient experiences and lower costs – the triple aim outcomes.

What is an outreach clinic?

An outreach clinic means basically moving care from the hospital to the GP’s practice. We’re talking about care for which we don’t need advanced, expensive equipment. The idea is that the specialist might as well go to the patient to do this. An outreach clinic can be seen as a first step to letting go of the old way of thinking – secondary versus primary care. Those who support the concept of outreach clincis say that this way of working isn’t just cheaper, it’s also a lot more comfortable for patients. It doesn’t take as long for them to get the help they need, and they don’t have to make any contributions based on deductibles. But that’s theory, and practice has shown us something different, unfortunately. How come?

Outreach clinics: what’s going wrong?

We make a few mistakes when designing outreach clinics:

Unclear terminology

Outreach clinics fall into the same category as population management, network care, care coordination, managed care, disease management, substitution of care and transmural care. It’s not a synonym for these terms, but part of them. You can say that outreach clinics are part of substitution of care which in turn is part of integrated care concept care network. Outreach clinics are a small piece of a complex puzzle that could be integrated care. Because all these terms are used interchangeably, it leads to a lot of confusion.

Outreach clinics means thinking in boxes

When outreach clinics were created, this was the line of reasoning: the care system surrounding the hospital and primary care practice is too fragmented to offer good healthcare for vulnerable patient groups, so our solution is going to develop mini organisations who are going to solve this issue. Then we are going to discuss whether and to what degree that should be generalist or specialist care. What we are actually doing is adding another barrier without changing anything fundamentally. In other words, adding another box to the previously existing boxes.

Shortcommings of disease management

Disease management is still the basis for a lot of integrated care activities, when a crucial mistake was made when it was first introduced in the Netherlands. We forgot to take into account the medical specialist into the bundeld payment scheme, which has meant the desired results in terms of quality improvement and cost reduction weren’t met. Yet, there’s another way! In countries where integrated care is successful, health insures or governments make financial agreements primary and secondary care to enhance the development of integrated care networks. As long as we don’t have any integrated payment incentives, the shortcomings of integrated care will keep coming for us. The consequence is that people will continue to introduce new hypes, like outreach clinics, to try and find a model that does work.

Who is ‘in the lead’?

Is it the GP or the medical specialist (the hospital) pulling the strings? Often, there aren’t any clear agreements on this, which negatively affects the cooperation. Generally, there will also be different interests from different stakeholders, which stands in the way of a fruitful cooperation.

Data sharing

Data sharing between healthcare providers is essential to be able to work together effectively. In the Netherlands, however, data sharing between care providers is incomplete and fragmented. This makes it nearly impossible to gain insight into the current and future care demands and new care initiatives tend to miss the mark.

Process instead of outcome based guidance

When (re)designing the care process, too often we use a disease-specific perspective instead of the needs and wishes of and outcomes for the patient. In addition, measurment initiatives predominantly focus on process indicators instead of outcome indicators, when the latter should be the basis for care improvement and innovation.

What should we do?

Outreach clinics are (partially) a reaction to the failed introduction of integrated care. It was created from a policy-related paradigm instead of from the perspective of the patient. This made it doomed to fail. If we want a serious solution for the problems our current healthcare system is facing – rising and increasingly complex healthcare demands and healthcare costs that are through the roof – we need to choose an integral approach: interated care networks. But how do you go about integrated care networks? Here are four tips:

Tip 1: Are you willing to take a risk?

In an integrated care network, all those involved have their own role and jointly carry the responsibility for quality and cost outcomes . But are you willing to take this risk as a healthcare provider? Hospitals are better able to handle these risks than primary care practices. What’s really important is that all care providers that are involved in an integrated care network agree on the care, the division of responsibilities and measuring results. A number of best practices have shown us that it works for complex patient groups if you organize the care along the entire continuum of health and social care and make people collectively responsible for the outcomes. Then you will profit from taking joint risks in the end!

Tip 2: Go for results: Triple Aim outcomes

Specify the desired outcomes, use the Triple Aim philosophy as your guideline. The Triple Aim approach is about improving your outcomes in terms of quality, health and cost. To achieve the desired outcome for a specific (sub)population, you work with a group of healthcare providers in a coordinated way and you share the risks. You are all jointly responsible for whether or not you achieve the quality and cost outcomes you are aiming for.

Tip 3: Culture eats strategy for breakfast

Cooperation and shared responsibility aren’t always easy. It demands trust, openness and transparency. To make integrated care networks a success, it’s important that the individual interests are clear and there are clear agreements. Define a shared ambition together, link your goals to that ambition and make sure there is support amongst all partners. You can create this support by building trust. Map out how this joint ambition contributes to achieving the goals within a network. Make sure you have a safe culture where people are willing to stick to the agreements and aren’t afraid to speak up if something goes wrong. In short: make sure the ‘soft’ side within your care network is in order.

Tip 4: Make agreements about the top 3 pitfalls

You need clear agreements about financing, data sharing and organizational interests to increase the chances of a successful cooperation. Agree who registers which data and how it’s analyzed and with what goal. And be aware of the differences in organizational interests between medical specialists and GPs. For medical specialists, numbers are important, GPs have more to gain if they create more time in their practice. How can you meet in the middle; how can you help and reinforce each other and create a win-win situation? Start by looking at the healthcare needs in your region to increase the chances of successful cooperation within your local care network.