Closing the gap between health care systems and community services has become an important goal in Western countries as they aim to improve population health by addressing health-related social needs, improving quality of care and health outcomes, and reducing costs. In the U.S., for example, the Centers for Medicare and Medicaid Services (CMS) pursues this goal with its Accountable Health Community (AHC) model, as Germany does with the Gesundes Kinzigtal and the United Kingdom in its Torbay region. We wish to discuss recent efforts in the Netherlands, with an eye toward helping policymakers from the U.S. and elsewhere learn from our Dutch experience.
In 2013, the Dutch Ministry of Health, Welfare, and Sport designated nine pioneer sites — serving more than 2 million people and representing partnerships among providers, insurers, and other stakeholders — to participate in an effort to provide better care at lower costs. Specifically, the effort focused on integrating clinical and community services, with monitoring by the Dutch National Institute for Public Health and the Environment. From January 2014 to July 2016, we interviewed 63 stakeholders (insurers, primary care groups, hospitals, municipalities, and community-based organizations, mostly representing patient organizations) and 9 program managers on a quarterly basis. Our initial observations from these interviews focus primarily on the importance of fostering relationships among organizations, reconciling conflicting organizational interests, and navigating information-related needs.
Three Key Lessons
1. Build trust by bridging gaps in organizational culture. So far, the Dutch pioneer sites have pursued small-scale interventions that foster collaboration among insurers, health care providers, community services, and community representatives. Interventions have ranged widely — from developing starter kits, to initiating dialogue between patients and health professionals about end-of-life care (similar to the U.S. Conversation Project), to redesigning health services for specific patient subgroups to enhance the Triple Aim. These small-scale interventions, though concrete, are used primarily to improve underlying relationships among the participating organizations. Implementing the interventions put stakeholders in constant contact, thereby creating a common language, a shared vision, and channels of communication. As one representative from a health insurance company put it, “What really helped in the early stages was to discuss . . . big-picture questions such as ‘What is important for you and your organization?’ and ‘How do you think about this topic?’, as well as granular ones such as ‘What do you mean when you use this term?’”
Despite this progress, important sociocultural differences persist. For instance, some health care providers and representatives of insurers were frustrated by the slow decision-making process within municipalities, particularly when municipal officials were not authorized to approve previously agreed-upon decisions without going through a protracted democratic process. This cultural gap regarding procedures led to distrust among stakeholders at some pioneer sites. In many cases, health insurers also struggled to disentangle the purchasing process for pioneer-related interventions from the regular purchasing process. At times, provider–payer contracts were even misaligned with the agreed-upon goals, which further damaged trust among all parties. With the benefit of such lessons, most of the pioneer sites now understand that overcoming sociocultural differences requires the continuous effort of every stakeholder.
2. Current fee-for-service payment and funding models inhibit integration. Fragmented payment systems that focus on the short term tend to put organizations’ interests in conflict with the Triple Aim. For example, Dutch specialists get reimbursed only if they actually treat a patient, and Dutch general practitioners (GPs) get more reimbursement if they refer patients to specialists. In addition, long-term investments in helping patients develop a healthful lifestyle are not appealing if an insurer focuses primarily on 1- or 2-year returns.
New payment methods and governance structures are taking root at the Dutch pioneer sites. However, change is incremental so as not to overwhelm providers (with sudden increases in their risk burden) and insurers (with new payment methods). For instance, shared-savings contracts reward pharmacists, providers, and insurers for raising prescription rates of lower-cost generic drugs; long-term (3-year) contracts between insurers and hospitals reduce income uncertainty when more patients are shifted from hospital-based to primary care; and new bundled-payment models (e.g., for mental health) provide a single payment for a range of related services, thereby encouraging integration.
Nevertheless, separate funding for providers of health care, social services, and public health still leads to major conflicts of interest. For example, hospitals’ efforts to reduce patients’ length of stay increase pressure on municipalities’ homecare budgets and require GPs to deliver more-complex, time-intensive care. In part because of this fragmented approach, implementation of larger-scale, population-wide shared-savings contracts aligned with the Triple Aim has failed so far. Therefore, some pioneer sites are working to integrate budgets and thereby eliminate funding silos between municipalities (which provide community services) and health insurers.
3. Muster the political courage to increase transparency. Consider the issue of data management. The Dutch experience with bundled payments for diabetes care, for example, has improved transparency by introducing care groups — fully accountable legal entities that serve as the main contractors for primary-care patients with diabetes. However, unlike a disease-specific care group, pioneer sites must tailor social and health services to the needs of a whole population. Their consequently greater information needs require the reorganization of governance structures in addition to financing and payment reform.
In the Netherlands, as in other countries, progress in this area is influenced more by political concerns (related to privacy, resources, and antitrust regulations) than by technological challenges. Within this political context, the “Healthy Care, Healthy Region” pioneer site (in the area around Leiden) has developed a business-intelligence tool that links selected data from primary-care, pharmacy, and laboratory registries in order to track and reduce the use of low-value services for specific chronic diseases. The plan is to expand the tool’s use to encouraging high-value services and, eventually, to helping patients manage their own care and their social and economic needs.
Two Next Steps
Our early observations on nine pioneer sites in the Netherlands highlight important successes and pitfalls in the effort to make all stakeholders collectively accountable for the health of the people in a particular community. Further progress in closing cultural gaps among organizations, developing payment and funding models that foster integration, and encouraging transparency depends on two larger reforms:
Community engagement. Increasingly, the Dutch pioneer sites recognize that direct engagement with communities is crucial for empowering them to take charge of their own population’s health, for tailoring interventions to communities’ needs and preferences, and for helping all stakeholder organizations look beyond their own interests to shared goals. Several community-engagement strategies are underway.
First, in six of the nine pioneer sites, communities are represented in steering groups so that they can always ask questions about whether policies align with their needs and preferences. Second, communities are being asked directly for their preferences using questionnaires and discussions (e.g., in the “Friesland Ahead” pioneer site in the state of Friesland) and online communities (e.g., in the “Good Living” site in the Zeeuws Vlaanderen region). And in the “Vital Vechtvalley” pioneer site, a new legal entity owned by the citizens of the Vechtdal region empowers the citizenry to promote local health and influence system redesign. Specifically, the entity has negotiated a supplementary insurance package (including additional preventive services) with the dominant insurers.
Regionalization of financial risks and benefits. Given the inherent tension between community interests and those of individual organizations and other stakeholders, how do you ensure that cost savings derived from an intervention flow back to the investor? The aforementioned Dutch experience with care groups in a bundled-payment model for diabetes is a disease-specific example. Just as the care group assumes clinical and financial accountability for all primary-care diabetes patients assigned to its care program, so might accountability be extended to primary-care organizations that assume broader-based financial risk. Currently, some pioneer sites gradually scale up the number of bundled-payment contracts for specific subpopulations (e.g., the frail elderly and pregnant women) rather than immediately introducing more-disruptive, riskier payment models. The Dutch bundled-payment care-group experience has shown that in order to shift accountability in a way that advances the Triple Aim, strengthening primary care itself is not enough. Primary care must be reorganized on a larger scale so that solo GPs and independent group practices can assume financial risk collectively.
The various ways that the Dutch pioneer sites have been operationalized — and the difficulties they have experienced so far — make clear that integrating health and community services will not be smooth sailing for payers and providers. As health-accountable communities continue to take root in multiple countries, learning from their successes and failures will be critical.
We thank Richard Heijink and Simone de Bruin for their valuable and helpful comments on an earlier version of this article. In addition, we thank all of the pioneer sites and interviewees for their valuable time, experiences, and insights.
This article originally appeared in NEJM Catalyst on October 12, 2016.