A scramble for value:On the interpretation and application of value-based health care in the Netherlands

In many health care systems across the globe, value-based health care has quickly become a remarkably popular concept. Yet, despite its global popularity, the meaning of the concept remains shrouded in ambiguity, and efforts to put value-based health care into practice are characterized by a high degree of local variability. This makes it rather challenging to grasp the essence of this seemingly influential concept, let alone evaluate its effects within health care systems. A Scramble for Value addresses that challenge.The thesis traces the journey of value-based health care from its original conception by Harvard business scholar Michael Porter to its global popularity, and zooms in on its interpretation and application in the Netherlands. As the original set of ideas runs into the historically rooted institutions of the Dutch health care system, the meaning of value-based health care gets moderated, and its application conforms to the very structures it once so boldly set out to reform. It is by overlaying rather than overthrowing those traditional structures that value-based health care has ignited a renewed focus on outcomes that matter to patients, and amplified multidisciplinary efforts to improve those outcomes. All in all, this can be seen as quite an accomplishment..<br/

Redefining value: a discourse analysis on value-based health care

__Background__ Today’s remarkable popularity of value-based health care (VBHC) is accompanied by considerable ambiguity concerning the very meaning of the concept. This is evident within academic publications, and mirrored in fragmented and diversified implementation efforts, both within and across countries. __Method__ This article builds on discourse analysis in order to map the ambiguity surrounding VBHC. We conducted a document analysis of publicly accessible, official publications (n = 22) by actors and organizations that monitor and influence the quality of care in the Netherlands. Additionally, between March and July 2019, we conducted a series of semi-structured interviews (n = 23) with national stakeholders. __Results__ Our research revealed four discourses, each with their own perception regarding the main purpose of VBHC. Firstly, we identified a Patient Empowerment discourse in which VBHC is a framework for strengthening the position of patients regarding their medical decisions. Secondly, in the Governance discourse, VBHC is a toolkit to incentivize providers. Thirdly, within the Professionalism discourse, VBHC is a methodology for healthcare delivery. Fourthly, in the Critique discourse, VBHC is rebuked as a dogma of manufacturability. We also show, however, that these diverging lines of reasoning find common ground: they perceive shared decision-making to be a key component of VBHC. Strikingly, this common perception contrasts with the pioneering literature on VBHC. __Conclusions__ The four discourses will profoundly shape the diverse manners in which VBHC moves from an abstract concept to the practical provision and administration of health care. Moreover, our study reveals that VBHC’s conceptual ambiguity largely arises from differing and often deeply rooted presuppositions, which underlie these discourses, and which frame different perceptions on value in health care. The meaning of VBHC – including its perceived implications for action – thus depends greatly on the frame of reference an actor or organization brings to bear as they aim for more value for patients. Recognizing this is a vital concern when studying, implementing and evaluating VBHC

Expert consensus on moving towards a value-based healthcare system in the Netherlands

Objectives: While the uptake of value-based health care (VBHC) is remarkable, uncertainty prevails regarding the most important actions and practices in establishing a value-based healthcare system. In this paper, we generate expert consensus on the most important aspects of VBHC. Design: The Delphi technique was used to reach consensus on the most important practices in moving towards a value-based healthcare system. Setting and participants: A Dutch expert panel consisting of nine members participated in a two-round survey. Primary and secondary outcome measures: We developed 39 initial items based on the pioneering literature on VBHC and recent health policies in the Netherlands. Experts rated the importance of each item on a 4-point Likert scale. Experts could change items or add new ones as they saw fit. We retained items that were rated (very) important by ≥80% of the panel. Results: After two survey rounds, 32 items (72%) were included through expert consensus. Experts unanimously agree on the importance of shared decision-making, with this item uniquely obtaining the maximum score. Experts also reached consensus on the importance of outcome measurements, a focus on medical conditions, and full cycles of care. No consensus was reached on the importance of benchmarking. Conclusion: This paper provides new insight into the most important actions and practices for establishing a value-based healthcare system in the Netherlands. Interestingly, several of our findings contrast with the pioneering literature on VBHC. This raises the question whether VBHC’s widespread international uptake indicates its actual implementation, or rather that the original concept primaril

Insect pectinate antennae maximize odor capture efficiency at intermediate flight speeds

Flying insects are known to orient themselves over large distances using minute amounts of odors. Some bear pectinate antennae of remarkable architecture thought to improve olfactory per- formance. The semiporous, multiscale nature of these antennae influences how odor molecules reach their surface. We focus here on the repeating structural building blocks of these antennae in Saturniid moths. This microstructure consists of one ramus or branch and its many hair-like sensilla, responsible for chemical detection. We experimentally determined leakiness, defined as the proportion of air going through the microstructure rather than flowing around it, by particle image velocimetry visualization of the flow around three-dimensional printed scaled-up mock-ups. The combination of these results with a model of mass transfer showed that most pheromone molecules are deflected around the microstructure at low flow velocities, keeping them out of reach. Capture is thus determined by leakiness. By contrast, at high velocities, molecular diffusion is too slow to be effective, and the molecules pass through the structure without being captured. The sensory structure displays maximal odor capture efficiency at intermediate flow speeds, as encountered by the animal during flight. These findings also provide a rationale for the previously described “olfactory lens,” an increase in pheromone reception at the proximal end of the sensors. We posit that it is based on passive mass transfer rather than on physicochemical surface processes