NRC article: Reward for less care

Written by: Kim Bos Jeroen Wester

Hospital Bernhoven

The way in which healthcare is now financed encourages hospitals to' volume'. Bernhoven Hospital in Uden is changing its approach and is sending treatments to other hospitals.

Text Kim Bos and Jeroen Wester Photos Merlin Daleman

Surrounded by a giant parking lot, right next to the highway, is the strongest shrinking hospital in the Netherlands.

While the number of medical treatments is increasing throughout the Netherlands, the number of operations in Uden has decreased by 14% over the last two years. In Bernhoven hospital, the last two years, 29 percent fewer inguinal fractures were operated on, the number of hip replacements decreased by 19 percent. And the time spent in hospital for a new hip was reduced by 60 percent.

Bernhoven is a hospital that deliberately provides less care. And the patients are satisfied. There is plenty to save, they find in Uden. Half of all medical treatments have not been proven to be effective,"explains director Peter Bennemeer.

That's why they stopped running the volume completely. The same problem exists everywhere in the Western world. If a technological innovation takes the doctor's work out of his hands, the doctor will do other things again in the time that has become available. This is one of the reasons why the increase in healthcare expenditure is such a persistent problem.

We don't fill anymore,"says Bennemeer. This is how the amount of care declared decreases. Every new patient is extra turnover for us, but for the Netherlands BV, a patient with us means 15 percent less care costs.

American management gurus regularly come across the floor to see how this experiment is progressing. The Minister was also recently on a visit. And health insurers CZ and VGZ, the most important health insurers in the region, will also be recalling the latest developments in their experimental garden at conferences.

There was a need to do something

Bernhoven's approach was not just a simple one. Five years ago, the hospital had problems with which many Dutch regional hospitals were confronted. The merger with another hospital and the relocation to the brown-coloured new building building resulted in extra costs. The hospital's financial capacity for recovery was low, the profit poor. And the region is ageing. The only way out seemed to be hard growth. But this hard growth is at odds with government policy to moderate the growth in healthcare expenditure.

How do you break that mechanism? In Uden, they reallocated the money flows. The Dutch health care system rewards production, but health insurers and hospitals agreed to start rewarding shrinkage financially. To this end, they made special long-term agreements with the insurers. This gives peace and quiet: not every year there is no need to negotiate a percentage point more or less turnover.

The hospital has been given several years to shrink, with insurers rewarding the hospital for less care. As a result, healthcare costs fell by 12 percent. But the growth in the number of patients, the special subsidies from insurers and a few other items mean that Bernhoven is still growing in turnover and is now making a millions of profits.

Without the cooperation of the health insurance companies, it is impossible to do what we are doing now. See how important insurers are in our system,"says Bennemeer. But the fact remains that in this case, with a shrinking hospital, society is also losing more money. But perhaps it would have been even more without the' shrinkage strategy'.

How do you shrink?

But how do you make an organisation shrink in practice? At Bernhoven, they reason as follows: admissions and operations give the highest healthcare costs. They reduced them by taking more time for patients, making better conversations with patients beforehand, and scans less.

If you can keep your scalpel off a patient's face, it is always better. An operation is an attack on your body and always involves risks,"says Inge Blokzijl. She is a paediatrician and heads the Diagnosis & Indicationstelling division. Its task is to motivate doctors to take more time for the patient, to decide together on medical treatment through interviews in order to provide as much' sensible care' as possible - and therefore as little' nonsensical' as possible.

Should a very elderly patient still be given chemo? Do the benefits outweigh the side effects? Blokzijl knows that this is a conversation that doctors are increasingly entering into, as Blokzijl knows. Over the last twenty years, doctors have become much more open than they were thirty or forty years ago. The final decision can only be made properly if you know what the patient's context is.

She mentions the example of a patient from Utrecht. A young mother with a brain tumour. The automatic reaction is: we are going to irradiate and operate immediately, and we are going to do everything and everything else,"but this was a slowly growing tumour of which the question is how much complaint was there.