The Netherlands’ healthcare services are generally of excellent quality: according to the 2018 Future Health Index, the country has an exceptional Access score of 63.57 out of 100, one of the highest of the 16 countries surveyed. Three factors determine the FHI access score: skilled healthcare practitioner density, risk of surgical care causing impoverishing expenditure, and the number of hospital beds per 10,000 people. But even in the Netherlands’ relatively strong current state, the stress that demographic changes will place on the healthcare system poses a threat to the all-important link between family doctors and the cardiovascular specialists they refer patients to.
The Netherlands Heart Network (NHN) was set up in the Eindhoven area to tackle precisely these challenges, and has met with great success over the past few years. This year the network was awarded the fifth annual Value-Based Healthcare Prize, and is looking to expand into new regions of the country. We sat down with Dr. Lukas Dekker, co-founder and board member of the NHN, to discuss the program’s origins, its current momentum, and how it’s helping to build a working value-based healthcare model.
Why did you co-found the Netherlands Heart Network?
I work at the Catharina Hospital Eindhoven, where we’ve maintained close relationships with referring doctors and cardiologists in the local area. Over recent years we’ve become more and more focused on value-based healthcare, a healthcare delivery model where payment is based on patient health outcomes rather than the volume of healthcare services delivered.
Once we started measuring outcomes, initial conditions and other costs, we became increasingly aware that a large part of long-term outcome is determined by the performance of the cardiologists who refer patients to us (which makes up around 70% of our patient base). We realized that we needed to get a grip on the quality of care across the full patient journey, from family doctor all the way through to specialist treatment.
Three and a half years ago we decided to put more emphasis on this collaboration by founding the Netherlands Heart Network, which now spans four hospitals. We secured funding, hired a talented project manager and started defining patient care pathways that enabled us to improve quality of care not just within our own hospital, but across primary, secondary and tertiary care. We were able to improve healthcare along the whole patient journey, not just within one section of a much larger system.
How does this affect the typical patient journey?
The NHN works within four domains in cardiology – atrial fibrillation, coronary artery disease, heart failure and heart valve disease – and each has its own working group that includes family doctors, cardiologists and cardiac surgeons.
An illustrative problem we faced five years ago was that care pathways for atrial fibrillation did not match between the various care-givers. This would then impact the quality of the patient’s referral appointment, which might only last 15 or 20 minutes. This could cause stress to the patient and might even complicate the condition.
We have introduced screening tools for family doctors to aid diagnosis of atrial fibrillation, which is a leading cause of stroke among the elderly, and other conditions. This screening tool helps the family doctor understand next steps – they can easily find information regarding the best care pathways on our website and send this patient to a hospital if needed. We have developed new, protocolized outpatient clinics, where the patient will see a nurse specializing in, for example, care for atrial fibrillation or heart failure. The patient is better informed and the nurse is trained in collecting the data we would need for a quality assessment.
We’re now in the process of assessing costs before and after the establishment of these new care pathways. The preliminary data is proving that we are right in our concepts: we know that the quality of care is improving and we’ll have the final cost assessment very soon.
What is the biggest factor in ensuring these new care pathways succeed?
Change needs to be driven initially by doctors, not hospital administrators. Doctors are intrinsically motivated to provide the best care they can for patients and it’s important to make use of this. Doctors are closest to the patients, so you must involve them first and then discussions with the hospital administrators – who are also very important to making real changes – can come later. It’s always hard to drive change from the top down: winning over doctors themselves and using their intrinsic motivation to drive change will be more effective.
You also need very high levels of trust within your network. As a heart center, we needed to see other cardiologists not as competitors, but as suppliers. The NHN benefitted by having a long history with referring cardiologists on which to build this trust, but with the family doctors it was more challenging. There was a real fear of substitution of care, but we have crossed that bridge. We’re looking to further consolidate that trust by bringing more family doctors onto the board of NHN and at our next yearly convention, we have as many family doctors registered as we do cardiologists.
Is the dynamic between doctors and administrators challenging?
There are lots of competing forces at work. Administrators and the finance departments of hospitals are not impressed when we say that our work may result in fewer touchpoints with patients. Of course, it’s not fair for care providers to be financially penalized for improving patient care, and this really strikes at the heart of what value-based healthcare is all about. We are lucky that the administrators are also aware of the need to change; they will be part of the organization in the near future as well.
How can a value-based healthcare payment model be proven and implemented?
NHN collects as much data as possible to show that we’re improving value by reducing costs and improving patient outcomes. While we’re not yet trialing this with thousands of patients, over time our data will become more and more convincing and we will be able to show the insurance companies and hospitals the benefits of the model.
It’s also critical that we keep expanding. At the moment our network is centered in the Eindhoven area and comprises four hospitals and over 400 family doctors, but we want to get bigger. There are already two other regions in the Netherlands that are looking to implement something similar and the more networks exist, the more we can learn from each other.
What’s next for the NHN?
We want to create similar networks in other regions of the country and build on that to make progress on healthcare reimbursement. We’re also looking more closely at how technology can be used in preventative medicine. Early diagnosis and preventative care is the best way to relieve stress on hospitals, and in the Netherlands we have a good situation because family doctors already have quality data acquisition and analysis systems in place. Finally, our organizational structure needs to be expanded to optimally facilitate the above ambitions.