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.