Santeon, a Dutch network of seven leading teaching hospitals, has achieved reductions of nearly 30% in unnecessary inpatient stays and up to 74% in the rate of reoperation due to complications in breast cancer patients. Santeon achieved these results in a year and a half, not merely by meeting protocols or guidelines—its member hospitals have been doing that for a long time—but by emphasizing transparency and making value delivered to patients the core of its strategy.
The key to Santeon’s success was the implementation of a structured, value-based health care (VBHC) approach. In 2015, BCG started working with Santeon to make VBHC a reality at its hospitals. After an initial design phase, Santeon began implementing VBHC in March 2016 among five patient groups: breast cancer, prostate cancer, lung cancer, cerebrovascular accident (CVA), and hip arthrosis. Implementation in each group consists of four stages:
The breast cancer group was the first to reach the third stage. After defining a short list of key metrics for outcomes, costs, and process indicators (stage 1), Santeon began sharing data within and among its seven hospitals to foster internal learning in a safe environment (stage 2). Now, following the completion of three improvement cycles, the results are being shared with the outside world on a hospital-by-hospital basis (stage 3). Those results are very impressive indeed. In addition to the figures noted above, Santeon achieved, on average, a reduction of more than 15% in lumpectomy reoperation rates after positive margins, with one hospital achieving a reduction of about 60% (from 11% to 4%).
Other Santeon patient groups show similar signs of improvement, although they are not yet at a sufficiently advanced stage for the results to be published externally. Still, the variation observed in the metrics data among the hospitals for the other patient groups is comparable to that seen in the breast cancer group and clearly indicates the potential for improvement (for 30% of the metrics, Santeon found that the highest and lowest scores varied by a factor of between two and five, indicating significant improvement potential in those domains).1 Notes: 1 Based on international BCG experience, this level of variance is not uncommon; it is often much higher. (Elsewhere in this report we cite variance factors of four to thirty-six.) What is uncommon is for such variance to be made visible like-for-like for complete sets per patient group, and to be acted upon as Santeon does.
In this report, we share Santeon’s successes in implementing VBHC, describe how the hospital group has made the transformation work, and offer a number of key lessons for other providers whose ambition is to put value for patients at the center of their approach to health care.
Santeon is a cooperative of seven top-performing Dutch hospitals that together account for 11% of the nation’s hospital care volume, employ approximately 29,000 people, and generate €2.9 billion in annual revenues. Santeon represents a unique effort by hospitals that have joined forces to increase the quality and efficiency of patient care. The hospitals are widely dispersed across the Netherlands and do not directly compete with one another. (See Exhibit 1.)
Santeon embraced the VBHC concept in 2012 and between 2015 and 2017 worked with BCG on various projects to put VBHC at the core of its collaboration model. Santeon is now widely recognized in the Netherlands and beyond as a VBHC pioneer and a driving force and partner in the movement toward a more value-based health care system. (See “The Promise of Value-Based Health Care.”)
Value-based health care aims for the best patient outcomes for every euro spent. Many articles have described the concept since Michael E. Porter and Elizabeth Olmsted Teisberg introduced it in Redefining Health Care: Creating Value-Based Competition on Results (2006). VBHC makes the delivery of improved health outcomes for the same or lower cost the primary objective of global health systems. The potential for improvement in health care value is enormous, given the large variations that exist among providers in treatment decisions, cost of care, and patient outcomes. The exhibit below shows the differences in outcomes among hospitals at the national level. Similar variations among hospitals are found across treatment areas and geographies.
In many industries, a difference in costs or quality of 5% to 10% between competing organizations typically triggers major improvement programs by the trailing organization. Among hospitals worldwide, the differences in cost and quality can range from 400% to 3600%! The failure to act on such large disparities reflects what Porter calls the “pre-industrial nature of health care.”
The VBHC approach emphasizes the systematic measurement of health outcomes and of the costs involved in delivering them to specific subpopulations—for example, to all patients who suffer from a particular disease or condition, such as colon cancer, or who share a similar risk profile, such as the multimorbid elderly. Teams composed of clinical specialists use this data on outcomes and costs to devise customized interventions that, over time, will improve the ratio of positive outcomes to costs for each patient group.
Focusing on the objective of improving health care value, VBHC has the potential to deliver better health outcomes at lower costs than are currently achievable by most health care systems around the world. VBHC also improves patients’ access to suitable care, identifies significant innovations in treatment and care delivery, and offers major new public- and private-sector business opportunities for health care organizations. VBHC promises to be a solution for hospitals that aim to deliver the best possible care for their patients while facing ever-increasing pressure from rising costs and a high registration burden around process metrics, guideline adherence, and reimbursement administration.
More and more health care organizations recognize the potential of VBHC and are moving toward a value-based way of working. Implementing VBHC is not merely a project; it transforms hospitals into learning organizations that provide care around patient groups, based on transparency in their outcomes and costs per medical condition.
Santeon’s success is based on three imperatives that it established before it began implementing VBHC around patient groups:
Prepared with a shared ambition, a working model, and the necessary infrastructure, Santeon began rolling out VBHC for the first patient groups early in 2016. The VBHC team for each patient group has a clear path to follow, consisting of four stages:
The International Consortium for Health Outcomes Measurement (ICHOM) is a nonprofit organization cofounded in 2012 by Michael Porter of the Harvard Business School, Martin Ingvar of the Karolinska Institute, and The Boston Consulting Group. The consortium’s mission is to transform health care systems worldwide by measuring and reporting patient outcomes in a standardized way.
ICHOM convenes global teams of physician leaders, outcomes researchers, and patient advocates to publish standard sets, which define the outcome measures that matter most to patients. The organization also supports health care providers worldwide in implementing and measuring these outcomes in practice, which ultimately places patients at the center of health care delivery, and in the process drives up the quality of care and reduces costs.
As of May 2018, ICHOM had collaborated with 658 working group members representing 44 countries and had published 23 standard sets (9 more are in the pipeline). The exhibit below illustrates ICHOM’s standard set for breast cancer.
Evidence that Santeon’s VBHC approach is working is emerging from the breast cancer group, which has already reached the external transparency stage, as well as from the other four patient groups (hip arthrosis, lung cancer, prostate cancer, and CVA), which have not yet reached that stage.
Santeon’s multidisciplinary breast cancer teams, the first to complete three improvement cycles, recently revealed their first results externally.3 Notes: 3 For more details about the breast cancer results, see Santeon’s report at https://issuu.com/santeon/docs/breast_cancer_2017_care_for_outcome. Exhibit 5 shows a selection of the improvements that Santeon achieved within about a year and a half. The breast cancer teams will closely monitor these results in future improvement cycles to ensure lasting impact. They will also continue to identify and implement new improvement initiatives to increase the value of care for breast cancer patients. Each of the seven hospitals discovered practice areas where it could learn from others—as well as teach others—to improve patient outcomes. Here are just a few examples:
The VBHC teams in Santeon’s other four initial patient groups are now either finalizing the second improvement cycle or have started the third. (Santeon also recently started the first improvement cycle for patient groups focused on kidney disease, colorectal cancer, and childbirth.) Consistent with VBHC principles to protect a safe and open learning environment, data sharing at these early stages is restricted to internal teams and cannot yet be disclosed in this report. Nevertheless, some anonymized examples offer a preliminary view of select initiatives launched to improve outcomes, costs, and processes.
Member hospitals are making changes to improve outcomes for patients.
Member hospitals are reducing costs by eliminating practices that do not contribute to better outcomes:
Member hospitals are changing processes to improve the patient experience:
In light of the proven benefits for both patients and clinicians, Santeon plans to roll out value-based health care to 20 to 25 additional patient groups by 2020.
Santeon’s experiences with VBHC already offer a number of valuable lessons for any hospital that is trying to improve health care quality while maintaining or lowering overall costs:
VBHC teams engage directly with patients in order to understand the outcomes that matter most to them. In many cases, patients’ suggestions for improvement can be adopted quickly.
“Awaiting the results of mammography, at home, is a most horrible period filled with insecurity. Sharing this in the VBHC team led to tangible impact: mammography results are now communicated on the same day.” — patient of breast cancer VBHC team
“All patients are now actively encouraged to bring a second person to consultations at the prostate outpatient clinic. This change was implemented based on my recommendation.” — patient of prostate cancer VBHC team
“Breast cancer patients now find soft facial tissues to dry their tears in the waiting room of the breast cancer outpatient clinic. This is the first impact I saw after sharing my experiences with the value-based health care team.” — patient of breast cancer VBHC team
VBHC allows doctors to share best practices and learn from one another in a safe and supportive environment. The focus is always on delivering better quality for patients while maintaining or lowering overall costs.
“This is an unbelievably good concept. Although it takes time, it is much more motivating than the other ways we have to look at data and deal with quality indicators. By learning from each other, we can really improve care for our patients. That gives me a lot of energy and I definitely recommend working like this to my colleagues.” — Yvonne van Riet, breast surgeon, Catharina Hospital
“For me, the power of collaboration is in directly getting feedback if something’s working or not. More contact about the content. A practical way to mold our profession together. Looking at the numbers more often and making plans for a new process. And adjusting the process faster.” — Ron Koelemij, oncological surgeon, St. Antonius Hospital
“This way of working stimulates us to improve ourselves. We discuss recognizable practical situations, and you have a conversation partner you know well. It helps; it makes it easier to talk to each other. You have the feeling of forming some kind of a club that is less anonymous, which makes talking easier.” — Luc Strobbe, surgeon, Canisius-Wilhelmina Hospital
Value-based health care is poised to transform the health care industry, improve patient outcomes, lower health care costs, and dramatically improve the patient experience. By creating transparency around differing approaches to care, comparing outcomes, and changing protocols accordingly, providers are gaining new insights into the ways specific treatments improve the health of patients. As the data on outcomes continues to grow and national registries become richer and more robust, the VBHC model will only become more compelling.