Malnutrition is underestimated in the Nederlands , WHO CARES?
OUTCOME-BASED FUNDING INCREASES THE PATIENT´S QUALITY OF LIFE

The economic value of patients in the improvement of healthcare

Despite a growing awareness of patients’ crucial part in contributing to healthcare, the ways by which this can be achieved are still limited. For patients’ innovative power to be efficiently utilised, we strongly believe that patients need to be given a more equal and profitable role in the healthcare system.

By “equal,” we mean that the crucial information patients and carers can potentially provide for the transformation of healthcare must be acknowledged to be on equal terms with the information healthcare professionals are providing.

A profitable role can be either monetary or non-monetary. If patients are to have a profitable role in healthcare, an economic evaluation of the input of patients—with analysis of the positive impacts it’s had on other patients’ lives, organisations, and society—is needed. This is especially the case for those patients and carers for whom it is not their formal job: who have taken on the responsibility of collecting, reading, and reviewing information and historical data on their disease and come up with relevant insights and ideas. Whether this feedback is to skip or add steps in a care process, or commenting on experiences of additional treatments, it can contribute positively to the management of their disease and the lives of other patients.

We envision four business models that would economically value patients’ contributions to improving healthcare, and empower them to operate as active partners.

The simplest model is a realistic payment per hour system, with rates and conditions similar to freelance healthcare professionals. This could be applied for patients who are providing benefits to a wider community: by being active in focus groups, as in-depth interviewees, by acting as participants in patient panels, by speaking at conferences, by providing education for healthcare professionals, by mentoring other patients, or by working on the development and/or implementation of research and care protocols.

Another model is shared savings, which allows cost savings to be partly shared among those who have helped make the saving. In the Netherlands, the Friesland and Menzis health insurance companies recently introduced shared savings for doctors who are able to lower the costs of treatments. We suggest that often patients can contribute to more efficient care, just as doctors can, and this should be rewarded by a shared savings model. Shared savings can be applied when the valuable input of patients is utilised to improve treatment protocols, which are of enormous value for other patients and, at the same time, reduce costs. Patients can give information on major changes in, for example, food and lifestyle, additional treatments, sense giving, and sharing their own collected historical data, which supports the effective choice of a treatment.

A third model can be drawn from the recent intellectual property claim of the KWF Cancer Foundation. For newly developed medicine funded by their foundation they claim partial intellectual property rights. The revenues will be invested in new research projects. Part of these revenues could also be used for reimbursing patients for their active input into research topics on developing new medicines.

The last model is based on benefit sharing. The essence of benefit sharing is to provide a fair and equitable sharing of the benefits of an activity, and so when patients, for example, contribute to research that leads to subsequent grants for further research or the development of medical interventions, then they would be rewarded. Benefits may be monetary or non-monetary. A monetary example could be the sharing of royalties, while a non-monetary benefit could be that a patient or patient’s society is mentioned as a co-author in research papers or medical articles.

New business models that include patients as equal actors in problem solving strategies for healthcare are necessary to utilise patients’ innovative driving force. The introduction of a business model—such as benefit sharing, reimbursing payment, shared savings, payment per hour, or any other innovative concept that may be developed—can further realise the potential of patients to transform healthcare, so that it is of a high quality and affordable. We welcome all proposals that will assist organisations to implement this change, so that patients can contribute as equal partners. 

Malnutrition is underestimated in the Nederlands , WHO CARES??

Malnutrition in elderly people living at home
Recently, I visited an 87 year old single lady, who lives independently in a small village. Her memory has deteriorated and walking is becoming more difficult for her. She stays inside and gets few visitors. She is thin. Recently, home care has been arranged and her family does her shopping for her. She is waiting for a place in a nursing home. A 2 person room is available, but that is too big a step for her.

Loneliness, as well as reduced physical abilities are factors that increase the risk of malnutrition and an emergency situation. Although the doctor has visited her frequently in the past few weeks, there is no policy in place for malnutrition and preventing loneliness. I realise that this is not the only example. Newspapers regularly devote attention to this issue. The headline of an article in De STEM of April 2014, for instance, reads: "Malnutrition in the elderly is an underestimated problem." The percentage of malnourished elderly people living at home is estimated at 35%. This percentage is expected to increase enormously in the coming years.

Malnutrition not only in hospitals and healthcare institutions
But this issue concerns not only elderly people who live at home - in hospitals and care facilities, fairly high rates of malnutrition occur as well. The 2014 National Prevalence figures of the Care sector (Dutch LPZ) reported that 10% of the elderly in general hospitals and 16.7% of the elderly living in nursing homes are malnourished. Malnutrition increases as people get older, have more illnesses and are more dependent on care. In 2010, the Dutch Journal of Medicine reported that 19% of the children who visited the hospital were malnourished. On 9 September 2014, the NRC published that every day, a death caused by malnutrition occurs in the Netherlands. Malnutrition seems to occur in both the young and the old in the Netherlands. And this is not surprising, because what, how and when we eat has changed considerably the past few decades.

Economic consequences of malnutrition in the Netherlands
The effects of malnutrition, which are recognised worldwide, are significant. These include reduced resistance, the development of illnesses and a lower quality of life. This leads to an increased use of medicines, prolonged hospital stays and more complex care. The LPZ report states that an amount of 279 million in additional costs is caused by malnutrition in the WZW. The Cater with Care project mentions an estimated amount of 1.9 billion Euros per year, of which 1.5 billion is attributed to malnutrition in adults of 60 years and older.

Underexposed value of GOOD and WHOLE-FOOD BASED nutrition
In the Netherlands and Europe, the value of good and whole-food based nutrition is underestimated in mainstream care. This, in spite of the fact that Hippocrates stated: "Let food be thy medicine, thy medicine shall be thy food". Little or no attention is devoted to nutrition in medical training programmes for nurses and doctors.
Even within care organisations, there is little knowledge about the effects of good and whole-food based nutrition on people´s health. This is shown by the food choices available in kiosks, restaurants and vending machines of care organisations. This food is not appropriate for sick, old and malnourished people whose exercise is limited.

In addition, I often hear people complain about the quality of the food in hospitals and care organisations. I know people who bring home-cooked food to people who are in hospital. To me, choosing foods such as croquettes, frankfurters or pastry do not seem the best foods to recover on. Fortunately, the topic "Good care requires good nutrition" is currently receiving attention in the Second Chamber (De STEM, 3 January 2015). All in all, it is clear that in Dutch healthcare, the effect of nutrition on health has not received sufficient attention up until now.



Initiatives of care organisations in the area of nutrition
In recent years, several initiatives were started to reduce malnutrition. One of these is the Cater with Care alliance, in which Wageningen University and the hospital Gelderse Valleiziekenhuis, and the food industry are developing new, tasty, high quality products for the elderly. One of the products of Cater with Care is Carezzo bread, which is enriched with protein. Positive results are also achieved by letting patients eat what and when they want. The Cater with Care project assumes that the percentage of malnourished elderly people in hospitals and nursing homes is much higher than the LPZ 2014 figures, namely 40-50%.

The hospital Gelderse Vallei Hospital is one of the few hospitals in the Netherlands that specialises in and showcases the nutrition it provides. Currently, experiments are conducted with protein-rich diets and their effects on the recovery process. Another initiative is the innovation network Foodsquad of Hutten. The purpose of this network is to achieve food innovations that really matter. The network focuses on three pillars; sustainable chains, an active lifestyle and specialty foods.

In 2007, several hospitals launched an initiative to detect and address malnutrition at an early stage through the "Faster Better" programme. However, besides these good initiatives, more attention is needed for the growing problem of malnutrition. The LPZ report of 2014 reports a slight increase in malnutrition. Interventions to prevent malnutrition are still not used often enough.

Who Cares?
The main questions that remain are: who and where is malnutrition identified, and has action been taken? "Malnutrition in nursing homes due to high workload” is a headline in Skipr on 29 November 2014. GPs do not have enough time. People with vague symptoms are told such things as: "We all feel a bit poorly sometimes, you eat healthy don´t you?". In my opinion, malnutrition in the Netherlands is a much bigger problem than might be thought. People with a low BMI or spontaneous weight loss who come into contact with a hospital or healthcare institution are the tip of the iceberg. When malnutrition is established because people have a low BMI or have inexplicably lost a lot of weight in a short time, the malnutrition process is already at an advanced stage. Possibly the result of years of poor nutrition.

In recent years, I have studied the diagnostics, personalised diets and lifestyle, and the  monitoring of these. Every day, a life can be saved in the Netherlands by a timely screening and a well-balanced, personalised approach which is monitored properly. I support the prevention of malnutrition. Would you like to know how, please contact me via info@carlapeeters.nl or +31 (0)6 543.115.07

©  dr.ir. Carla Peeters

OUTCOME-BASED FUNDING INCREASES THE PATIENT´S QUALITY OF LIFE

More and more medical professionals, policy makers and financiers are aware that the current healthcare system is no longer sustainable. Health care costs rise every year due to an increasing number of chronically ill people, and 2-3% in costs that are unaccounted for. According to Michael Porter, healthcare should increasingly focus on providing added value for the patient. A transition in the funding system from volume and price based, to quality and efficiency based funding can significantly contribute to this process.

External pressure to change the system
In spite of the efforts of many hard-working care professionals who want the best for their patients, as shown by several reports on cure and care, all too often potentially attainable results are not achieved, leading to the unnecessary suffering or even death of many patients. The care provided appears to be too little, too much or even wrong. From the patient's perspective, care is fragmented and poorly coordinated and many opportunities for improvement are overlooked. Currently, there is no direct relationship between funding and the quality and efficiency of the care. In the current funding system, an increase in volume results in more income, regardless of the appropriateness of the care provided. In general, quality and safety improvements lead to fewer complications and cases of care that could have been avoided, which leads to reduced costs.

Outcome-based funding in the Netherlands
Outcome-based funding can be an important tool to improve the quality of care at lower costs. This can be achieved by funding care on the basis of concrete results and maximum added value for the patient, rather than volume and price. In the Netherlands, outcome-based funding is currently being introduced to a limited extent. Often, contracts are based on volume and price, with, in some instances a bonus-malus system for an HKZ certificate, innovation and suchlike. Health insurers Friesland and Menzis have started introducing a shared savings model for specialists and general practitioners. If the costs are less than the standard price, the costs saved are shared or made available for other purposes to improve the care at the location concerned. An experiment in population funding was recently launched by health insurer CZ in Zeeuws Vlaanderen. What this change will mean in terms of funding for the quality of the care for the patient is still unclear. In America, Canada and England they are also conducting quality and efficiency based funding pilots. I am awaiting publications about these pilots with interest.

Preconditions for the implementation of outcome-based funding
Obviously, conditions need to be in place to implement an outcome-based funding system like this on a wider scale.
Examples of these conditions include :
• A well-developed plan on the part of the financier
• Passion and commitment of healthcare providers regarding the quality and improvement of care
• The translation of quality and added value for the patient by the healthcare provider
• A pragmatic set of indicators based on which outcome-based funding will set up
• A multi-year contract between the financier and the healthcare provider incorporating a process of continuous improvement.

Risks associated with implementing outcome-based funding
Each system has advantages and disadvantages, and no change is without risk. The introduction of outcome-based funding may entail the following risks, which can be anticipated during the implementation
• Reliable data; correct and complete data (relevance for the patient group, quality of the measurement instrument and quality of the data used)
• Financial risks; insufficient available resources on the part of the financier to fully transition to outcome-based funding
• Selection of patients the healthcare provider can make a significant profit from.

Transition routes to added value for the patient
Several routes can be opted for to implement outcome-based funding.
This means:
• a preparatory phase of data collection and determining indicators
• an outcome-based funding pilot
• full transition to outcome-based funding Which transition route is most suitable depends on the capabilities of the financier and the care provider.

Future
Fortunately, more data has been collected in both the cure and the care areas in recent years. A growing number of healthcare facilities publish this data, such as the Santeongroep, which publishes data in the field of oncology. Patient organisations are also increasingly taking responsibility by indicating which results they consider important. Therefore, the move to outcome-based funding does not need to be a complicated and lengthy process.

Outcome monitoring after hip surgery can improve the quality and reduce the costs of the care
Recently, I saw the impact of hip surgery after a hip fracture on an 88 year old woman who suffered from dementia and atrial fibrillation and whose physical and mental condition was still rather good, given the circumstances. The hospital where the surgery took place has friendly and knowledgeable staff and is known as a quality local hospital. Because there was no adjustable bed available at the care facility, and a leaking wound developed on the 4th day, she was kept in hospital for 5 days.

Structurally and process-wise, the operation went very well. Adequate action was taken as far as the hip replacement, thrombosis prophylaxis, antibiotic prophylaxis and physiotherapy treatment were concerned. After a few days, she was able to take short walks using a walker, and she did not develop an infection or thrombosis. When taking into account the patient experience and looking at effectiveness and safety, however, the assessment is different. Because of a prophylactic antibiotics treatment, the patient grew weaker as a consequence of diarrhoea and impaired digestion, and deteriorated physically, mentally and emotionally. In addition, she was discharged from the hospital with left category 4 heel pressure ulcers, and tailbone category 1 ulcers, which had developed in the hospital on day 3. During the two weeks after she was discharged, she was taken to the emergency room of the hospital once as a consequence of weakness and once as a consequence of a serious allergic reaction.

The amount of care required for this patient in addition to the usual care for dementia and rehabilitation after hip surgery increased significantly. Immediately after she was discharged from the hospital, a pressure sore mattress with alternating pressure was used. In consultation with the wound nurse of the hospital a foam dressing was used to treat her wounds. Five weeks after the surgery, the cut has closed and the category 1 pressure ulcers have healed. The care of the stage 4 heel pressure ulcers is expected to require several more months. Treatment with alginates has been started to promote the healing of the wounds.

The question that arises is "Could both the diarrhoea and the ulcers have been prevented if different measures had been taken?". For example, by using a different antibiotic that has less risk of diarrhoea and using a pressure sore mattress immediately after the surgery. An interview with the attending specialist led to the conclusion that the prophylactic use of a pressure sore mattress for all patients who have had hip surgery is too expensive for the hospital. Deciding whether or not to use antibiotics, and what type of antibiotics, is not always easy.

What choices would have been made if the hospital had outcome-based funding of, for example, <1% decubitus ulcers? Calculating the cost of preventing pressure ulcers and comparing this with the follow-up care of pressure ulcers shows that overall, prevention saves money and improves the quality of life of the patient. Currently, however, we are dealing with separate funding systems, as a consequence of which pressure ulcers generate funds for the hospital, while for the care organisation, when ZZP5 is maintained, they cost money, and lead to additional health insurance costs. .

Imagine that your organisation is decubitus ulcer free.
Aiming for care organisations that are free of decubitus ulcers by taking timely measures is possible. This improves the quality of life of the patient, it reduces the workload of staff and it significantly reduces healthcare costs. Call me on +31 (0)6 543.115.07 if you would like to take up the challenge to develop a course of action together to achieve this.

Photo of patient´s heel 5 weeks after discharge from hospital and after 1 week of alginates treatment

Resources:

1. Contracting values; shifting paradigms, healthcare. KPMG International 2012
2. 2. Paying for quality, starting with outcome-based funding, KPMG 2014
3. 3. Oral Communication Doove Care Groep Waddinxveen

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