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

Both Value-based healthcare (VBHC) and Triple Aim claim to be the solution for the
rising demand for and costs of care in the Netherlands. Both concepts originated in the United States and are often referred to in the same breath as value-driven care. But is that right? Are the principles of both concepts the same? We can be brief about that: no. In this blog I will make this clear by zooming in on the two concepts and then highlighting the three main differences.

Two lenses on value-driven care

The care of the future is about creating multiple value, where economic, clinical and psychosocial values are in balance. So no emphasis on just saving costs or excessive attention to stories of experience, but a balance that revolves around achieving the best care and health for the patient at the lowest possible cost. In the Netherlands, this is usually referred to as value-driven care. Both VBHC and Triple Aim describe what value is, but both with a completely different focus.

What is value value based healthcare?

In the book ‘Redefining Health Care’, management expert Michael Porter describes VBHC as being about realising the best possible outcome for the patient at the lowest possible healthcare costs. Porter indicates that a patient’s care pathway should be taken as the starting point, so that the added value of the various disciplines can be determined. The concept of VBHC is actually an elaborated cost-effectiveness method from health economics. However, there is still little scientific consensus on which outcomes are most relevant to patients and how they can best be measured. So that’s a tricky point. There is also another problem in the Netherlands, namely that many healthcare institutions and health insurers focus on budgets rather than the added value of treatment. This makes the implementation of VBHC difficult to get off the ground. The founders of the VBHC method, Michael Porter and Elisabeth Teisberg, try to bridge this gap with an implementation model. The VBHC implementation model consists of six interrelated building blocks.

VBHC_implementation model

Critical point 1: Half-chain care

In the Netherlands, the VBHC implementation model has been used for the introduction of chain care for patients with chronic diseases, such as type 2 diabetes, cardiovascular problems and COPD. In comparison with international best practices, chain-based care financing in the Netherlands is different because only primary care providers are included in the chain-based care contracts. Due to the absence of second-line care providers in the integrated care contracts, integrated care in the Netherlands can also be referred to as semi-chain care. Logically, this means that the desired results in the area 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. There is a simple explanation for this: in these countries, both primary and secondary care are included in a long-term chain contract and work together from a single organisational network. Substitution is an internal management issue between healthcare providers, whereby innovation and efficiency of the entire chain are stimulated.

Critical point 2: Disease-specific approach

There are also criticisms of the disease-specific supply chain approach advocated by the VBHC implementation model. The risk of VBHC is that care for people with complex care needs will become further fragmented. Particularly for vulnerable groups in society, such as people with multimorbidity or frail elderly people, there is a real risk that their care needs will be divided into various components and a corresponding accumulation of treatment protocols, chain organisations and financing arrangements. Research shows that effective treatment is not achieved by the simple addition of specialist expertise or chains.

Criticality 3: Competition model

Another 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 a single (hospital) organisation. For the vulnerable groups in society, a competition model will lead to further fragmentation or even erosion of their care offer. In other words, value-driven cherry picking.

What is Triple Aim?

The Triple Aim approach goes a step further than VBHC, stating that a population approach and multi-stakeholder collaboration are needed to create value. Donald Berwick describes that the Triple Aim revolves around a threefold objective that must be pursued simultaneously. First, improving the perceived quality of care. Secondly, it is about improving the health of a population. The third goal is to reduce healthcare costs. The organisation of care is aimed at the entire network of prevention, care and welfare and focuses on the needs and care demands of a specific (sub) population. The aim of this integrated collaboration is to achieve an optimal outcome in terms of quality, health and costs (Triple Aim).Triple_aim_implementation model

In practice, this means that a group of care providers will coordinate and
cooperates and is prepared to bear the risk. They are therefore jointly responsible for whether or not the quality and costs of care are achieved. For the Triple Aim concept to succeed, in addition to technological innovation and the will to cooperate, the political will to improve is particularly important. The implementation model for Triple Aim is called population management. One example is the population management model of the Care Continuum Alliance.

Critical point 1: Policy orientation

The Triple Aim approach is explicitly based on a population-oriented approach and is therefore mainly macro-oriented in terms of policy. This makes this approach less relevant to everyday practice. In order to effectively implement the Triple Aim, the ‘how-to’ question must also be further elaborated at micro and meso level.

Critical point 2: Preconditions are missing

The Triple Aim assumes that healthcare is a complex system, consisting of various elements with relationships between them. These can be people but also departments, organizations, computer systems, or otherwise. This means that when one cause is addressed, it can simply have a negative effect on another problem. A cutback or cost reduction in nursing and care homes can lead to a greater increase in costs in the emergency room or GP surgery. Research shows that many initiatives already fail here. The Netherlands lacks the necessary integral financing and policy preconditions across the entire network of prevention, care and welfare. This does not create regional organizational networks that can, will, and should bear the clinical and financial risks of a regional population. The lack of a positive regional business case means that the Triple Aim in the Netherlands is primarily a policy-based ambition with the accompanying short-term subsidy fair. Without adaptation within the healthcare system, the Triple Aim can only be applied in parts in the Netherlands. This has also emerged from the population management trials.

The 3 differences in the picture

The figure below shows the three main differences between the VBHC and Triple Aim
approach is shown. First, VBHC is a disease-specific chain approach, whereas the Triple Aim assumes a population-based approach. Second, VBHC is an example of a linear improvement approach derived from the automotive industry, where the Triple Aim assumes circular causality between interventions and outcomes, derived from complex adaptive systems theory. Finally, the VBHC concept assumes an outcomes-based competition model and the Triple Aim a collaborative model for exchanging products, services and knowledge.

Difference_VBHC_and_Triple Aim

How to proceed?

The Triple Aim takes a broad view of health (rather than disease) and is based on the principles of public and primary health care. There is sufficient scientific evidence that such a people- and population-based approach actually leads to better health and lower costs. The Triple Aim framework is therefore the most promising growth model for the implementation of value-driven care in the Netherlands.

But a shared agenda is needed to learn how to manage health. This transition requires entrepreneurship on the part of care providers who, together with partners in the region, are willing to take the clinical and financial risk of whether or not health outcomes and cost savings will be achieved. In addition, contract innovation among health insurers is needed to achieve the necessary efficiency and health incentives. Policymakers should give the parties in the field the freedom to organize the optimal form and scale of care that suits the local population and stop simultaneously stimulating competition and cooperation in the field. In short: there is work to be done.

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dr. Pim Valentijn

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