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Background: To address issues related to suboptimal insight in outcomes, fragmentation, and increasing costs, stakeholders are experimenting with value-based payment (VBP) models, aiming to facilitate high-value integrated care. However, insight in how, why and under what circumstances such models can be successful is limited. Drawing upon realist evaluation principles, this study identifies context factors and associated mechanisms influencing the introduction of VBP in stroke care. Methods: Existing knowledge on context-mechanism relations impacting the introduction of VBP programs (in real-world settings) was summarized from literature. These relations were then tested, refined, and expanded based on a case study comprising interviews with representatives from organizations involved in the introduction of a VBP model for integrated stroke care in Rotterdam, the Netherlands. Results: Facilitating factors were pre-existing trust-based relations, shared dissatisfaction with the status quo, regulatory compatibility and simplicity of the payment contract, gradual introduction of down-side risk for providers, and involvement of a trusted third party for data management. Yet to be addressed barriers included friction between short- and long-term goals within and among organizations, unwillingness to forgo professional and organizational autonomy, discontinuity in resources, and limited access to real-time data for improving care delivery processes. Conclusions: Successful payment and delivery system reform require long-term commitment from all stakeholders stretching beyond the mere introduction of new models. Careful consideration of creating the 'right' contextual circumstances remains crucially important, which includes willingness among all involved providers to bear shared financial and clinical responsibility for the entire care chain, regardless of where care is provided. [ABSTRACT FROM AUTHOR]

Objective: The introduction of bundled payment for diabetes care in the Netherlands led to the origination of care groups. This study explored to what extent variation in health care costs per patient can be attributed to the performance of care groups. Furthermore, the commonly applied simple mean aggregation was compared with the more advanced generalized linear mixed model (GLMM) to benchmark health care costs per patient between care groups.Data Source: Dutch 2009 nationwide insurance claims data of diabetes type 2 patients (104,544 patients, 50 care groups).Study Design: Both a simple mean aggregation and a GLMM approach was applied to rank care groups, using two different health care costs variables: total treatment health care costs and diabetes-specific specialist care costs per diabetes patient.Principal Findings: Care groups varied slightly in the first and mainly in the second indicator. Care group variation was not explained by composition. Although the ranking methods were correlated, some care groups' rank positions differed, with consequences on the top-10 and the low-10 positions.Conclusions: Differences between care groups exist when an appropriate indicator and a sophisticated aggregation technique is used. Currently applied benchmarking may have unfair consequences for some care groups. [ABSTRACT FROM AUTHOR]

To stimulate the integration of chronic care across disciplines, the Netherlands has implemented single-disease management programmes (SDMPs) in primary care since 2010; for example, for COPD, type 2 diabetes mellitus, and cardiovascular diseases. These disease-specific chronic care programmes are funded by bundled payments. For chronically ill patients with multimorbidity or with problems in other domains of health, this approach was shown to be less fit for purpose. As a result, we are currently witnessing several initiatives to broaden the scope of these programmes, aiming to provide truly person-centred integrated care (PC-IC). This raises the question if it is possible to design a payment model that would support this transition. We present an alternative payment model that combines a person-centred bundled payment with a shared savings model and pay-for-performance elements. Based on theoretical reasoning and results of previous evaluation studies, we expect the proposed payment model to stimulate integration of person-centred care between primary healthcare providers, secondary healthcare providers, and the social care domain. We also expect it to incentivise cost-conscious provider-behaviour, while safeguarding the quality of care, provided that adequate risk-mitigating actions, such as case-mix adjustment and cost-capping, are taken.

Introduction: In the Netherlands, bundled payments were introduced as part of a strategy to redesign chronic care delivery. Under this strategy new entities of health care providers in primary care are negotiating with health insurers about the price for a bundle of services for several chronic conditions. This study evaluates the level of involvement of primary health care dietitians in these entities and the experienced advantages and disadvantages. Methods: In August 2011, a random sample of 800 Dutch dietitians were invited by email to complete an online questionnaire (net response rate 34%). Results: Two-thirds participated in a diabetes disease management programme, mostly for diabetes care, financed by bundled payments (n=130). Positive experiences of working in these programmes were an increase in: multidisciplinary collaboration (68%), efficiency of health care (40%) and transparency of health care quality (25%). Negative aspects were an increase in administrative tasks (61%), absence of payment for patients with comorbidity (38%) and concerns about substitution of care (32%). Discussion/conclusion: Attention is needed for payment of patients with co- or multi-morbidity within the bundled fee. Substitution of dietary care by other disciplines needs to be further examined since it may negatively affect the quality of treatment. Task delegation and substitution of care may require other competencies from dietitians. Further development of coaching and negotiation skills may help dietitians prepare for the future. [ABSTRACT FROM AUTHOR]

Bundled payments aim to stimulate the integration of healthcare services and ultimately reduce healthcare expenditure growth through improved quality of care. The Netherlands introduced bundled payments for chronic diseases in 2010 by reimbursing providers annually for a bundle of primary care services related to COPD, Diabetes, or Vascular Risk Management. We aimed to assess the long-term effects of these bundled payments on healthcare expenditure. We used health insurance claims data from 2008 to 2015 to compare the healthcare expenditure between everyone who was included in bundled payments and a control group. We performed a difference-in-difference analysis in combination with propensity score matching and found that bundled payments consistently increased health care expenditure over seven years. The average half-year increase was €233 (95%CI: 204-262) for DM2, €609 (95%CI: 533-686) for COPD, and €231 (95%CI: 208-254) for VRM, representing 13%, 52%, and 20% of 2008 half-year cost. The increase was higher for those with multimorbidity compared to those without multimorbidity. This suggests that the expectations of the bundled payments are yet to be fulfilled., Competing Interests: Declaration of Competing Interest The authors do not have any conflict of interest, (Copyright © 2021. Published by Elsevier B.V.)

Introduction: In the Netherlands, bundled payments were introduced gradually after 2010 to stimulate the integration of primary care services for different chronic conditions including diabetes, vascular risk management, COPD, depression, asthma, as well as for the elderly. The expectation for this reform was that integrated care could control healthcare expenditure by improving efficiency in primary care and promoting prevention. However, little is known whether this expectation is fulfilled. The aim of this study was to investigate the association between integrated care and healthcare costs in the Netherlands. Methods: Claims data from 2008 to 2017 from all Dutch health insurers was used. Enrolment of individuals in an integrated care programme was identified based on payment codes for integrated care services. Individuals entered integerated care at different points during this period. The control cohort consisted of individuals who were not enrolled in any integrated care programme and who were matched with individuals in the intervention cohort based on gender, age, socio-economic status, and type and number of chronic conditions. Cost were available on spending from basic health insurance in multiple categories e.g. GP, medication, and medical-specialist per person per half year from 2008 to 2015. Descriptive statistics and a preliminary analysis with an ordinary least squares were conducted. Preliminary Results: The intervention group consists of 2.8 million and the control group of 1 million persons. In 2008, both were of similar age median 70 and gender female 51%, and had similair costs €1600, semi-annual. More people in the intervention group used medical care, for example, for medication 87% vs. 77% and secondary care 64% vs. 53%. The largest integrated care programme in 2015 was for diabetes 675,000 people. From the people who started integrated care in 2008 over 55% stayed in the full 8 years. Patients with more than one chronic condition had higher costs €3640 vs €1236. For indivduals who had been enrolled in integrated care at the time, mean total costs remained virtually stable between the first half-year of 2008 and the first half-year of 2015 from €2558 to €2543. For those who had not been enrolled in integrated care at the time, the costs increased €1538 to €1964. Preliminary regression analysis showed that people in integrated care had increased costs of around €180 and that this amount did not reduce over time. Discussion: Preliminary results indicate that integrated care programmes were associated with higher costs. Further analysis based on type of costs needs to indicate whether cost differences were likely to be due to severity of disease for integrated care patients or due to integrated care itself. Sensitivity analysis will be performed to assess robustness of the results. Future analysis will focus on the effect of different types of financing for these programmes and whether integrated care has a different effect on people with multimorbidity. [ABSTRACT FROM AUTHOR]

Background: In recent years, various policies have been implemented in the Netherlands to improve quality of birth care and collaboration between birth care providers in order to lower the relatively high mortality rates. In 2017, the Dutch Ministry of Health, Welfare and Sport will introduce a payment reform in order to enhance the collaboration between different birth care providers. This voluntary payment reform consists of a bundled payment including all care services delivered by midwifes, gynecologists and maternity care providers. Currently, these providers are mainly based on a fee-for-services basis. Objective: To describe the key premises of the Dutch bundled payment model and to identify perceived barriers and facilitators for implementing the bundle payment model in birth care. Method: Semi-structured interviews, focus groups and document analyses were executed in the period November - June 2016. In total, 37 participants were interviewed using face-toface, audio-recorded semi-structured interviews, focused on organizational processes of the current work environment through transition of the new bundle payment, teamwork among obstetrical professionals, and perceptions of birth care quality, access, and costs. Respondents were purposively selected from all relevant stakeholders. Transcribed data were coded and analysed to generate themes relating to the study aims. In addition, four focus groups with the key stakeholders were held to confirm the findings of the individual interviews. Next to that, document analysis was applied. Results: Most providers, as they prepare for the introduction of the bundled payment model, mentioned that they see opportunities, but also threats and uncertainties. Providers are discussing how to govern a provider-led entity, which is needed as a general contractor of the bundled payment contract. This discussion appears to be complex due conflicting interest between involved providers and requires specific knowledge with respect to governance, finance and tax laws. Most providers lack this specific knowledge, which in turn leads to uncertainties among providers regarding the (financial) consequences of potential organization models. Further, uncertainties exist about the design of the bundled payment itself. The lack of a broadly agreed on health care standard for birth care, and differences in purchasing policies between insurers increase these uncertainties. Conclusion: The various topics in how to implement the bundled payment for birth care - and the difficulties providers experienced so far - make clear that implementing such a payment reform will not be smoothing sailing. As the first contracts will be signed in 2017, learning from these designs, successes and failures will be critical. [ABSTRACT FROM AUTHOR]

Introduction: In The Netherlands, disease management programs (DMPs) based on Bundled Payment (BP) for chronic diseases were initiated to, inter alia, slow down the costs growth. To date, it is unknown whether the BP model for diabetes care increased or reduced the cost growth in comparison to care-as-usual (CAU). Furthermore, BP has neither been compared to the alternative payment system (Management Fee (MF)) as to their effect on cost growth. Methods: We analyzed insurance claims of 24 different insurance agencies obtained from Vektis. In total, 64,011 diabetes type 2 patients, clustered in 3062 GPs, were analyzed in a 2-year (multilevel) design. Results: Results show an increase in curative health care costs of Euro 172 per patient from 2008 to 2009. While controlling for age, sex, comorbidity, and costs at baseline, the average costs per patient enrolled in a DMP based on bundled payment increased with Euro 287 more compared to CAU. The increase of costs of DMP based on MF did not differ significantly from CAU. The increase in costs did not vary between GPs or health insurance agencies. Conclusions: The BP model for diabetes is associated with an increasing cost growth- at least in the start-up phase of BPs.

In 2007 the Netherlands introduced bundled payments for diabetes care. Under this BP system, health insurers pay a single fee to a contracting entity - the care group - which serves as the general contractor for DMPs and which is responsible for organizing care and ensuring its delivery. Care groups subcontract care services by individual health care providers or employ providers to deliver these services themselves. Health insurers freely negotiate with care groups about the fee for the DMP in a BP contract. The care services included in the BP contracts are determined by the Dutch Diabetes Federation Health Care Standard. Principal investigator dr. Jeroen Struijs shows in the first half of the lecture the effects of this payment reform on health care delivery process, quality of care and health care expenditures. Then health economist Guus Schrijvers compares these results with the theory of Triple Aim, aiming at 1. More health 2. More quality of care and 3. Less per capita costs. At the end Schrijvers places the Theory of Triple Aim in the domain of behavioural economics. He gives suggestions for new research and demonstration projects. [ABSTRACT FROM AUTHOR]