This document discusses strategies for improving the sustainability of the Dutch healthcare system. It suggests that system innovation, rather than just process innovation, is needed. Concentrating specialized care into fewer locations while decentralizing other services could improve quality and lower costs. Case studies show relationships between higher volume and better outcomes. The document also discusses lessons from disruptive innovation theories and examines models for reorganizing the healthcare system into specialized centers, primary/chronic care, and acute care networks to make the system more affordable and accessible over the long run.

1. Driver of healthcare sustainability:
system vs. process innovation?
Jan Vos van Marken
Director UNOVATE
a holding company of
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2. Concentration and decentralization:
the ‘unravelling’
of (dutch) healthcare
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3. /wEPDwU
A combination of
the international collective thinking of…
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4. … and the local collective thinking of…
BCG, may 2010
‘chosing for quality’
KPMG Advisory, Sept. 2011
‘Health Country’
Boer & Croon, August 2010:
‘From institutes to networks’
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5. Overview:
1. Introducing Dutch healthcare
2. Exploding cost of healthcare
3. Sustainability of healthcare: do we ask the right question?
4. Lessons from Clayton Christensen’s Innovators Prescription
5. Concentration and decentralization (BCG/B&C)
6. ‘Betterland’ (healthy country): interesting model (KPMG Advisory)
7. UNOVATE: position, role and examples.
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6. Situation per region very different …
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7. … and demographics rapidly changing…
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8. … and demographics rapidly change (2)
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9. … but can healthcare keep pace?
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10. Structure of dutch healthcare
Primary General Top Clinical
care hospitals Hospitals
Duration of diagnosis/treatment
Patient
1 2 3
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11. Design of the Dutch cure sector
Insurance companies
Government
al)
Level playing field:
Co
ion
• base insurance
ntr
dit
• Pricing structure
ac
/ad
€ € • Quality institute
t
se
(qu
• Competition law
(b a
an
tity
cy
oli
/qu
.P
ali
Ins
ty)
Patients Providers
Services
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12. Overview:
1. Introducing Dutch healthcare
2. Exploding cost of healthcare
3. Sustainability of healthcare: do we ask the right question’?
4. Lessons from Clayton Christensen’s Innovators Prescription
5. Concentration and decentralization (BCG/B&C)
6. ‘Betterland’(healthy country): interesting model (KPMG Advisory)
7. UNOVATE: position, role and examples.
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13. Dutch healtcare system best in class….
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14. … but increasing costs are not sustainable
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15. …because expenditure is exploding
(KPMG Plexus)
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16. Overview:
1. Introducing Dutch healthcare
2. Exploding cost of healthcare
3. Sustainability of healthcare: do we ask the right question’?
4. Lessons from Clayton Christensen’s Innovators Prescription
5. Concentration and decentralization (BCG/B&C)
6. ‘Betterland’(healthy country): interesting model (KPMG Advisory)
7. UNOVATE: position, role and examples.
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17. Sinek’s golden circle…..
Why
How
What
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18. What is the ultimate sustainability question?
• Can we keep healthcare affordable and conveniently accesible to
everyone?
• Is that really your ‘why question’?
• Do you work in healthcare to help solve that question?
• Is that about efficiency or effectiveness?
• Or both?
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19. Meeting my daily challenges…
• How can we optimize OR occupation?
• How do we increase outpatient efficiency?
• How do I reduce length of stay in my wards?
• How do I reduce complications?
• How do I increase planning stability?
• How do I negotiate a higher price for the ever higher cost per
procedure?
• How do I prevent unnecessary/costly diagnostics?
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20. Overview:
1. Exploding cost of healthcare
2. The Dutch situation: short overview
3. Sustainability of healthcare: do we ask the right question’?
4. Lessons from Clayton Christensen’s Innovators Prescription
5. Concentration and decentralization (BCG/B&C)
6. ‘Betterland’(healthy country): interesting model (KPMG Advisory)
7. UNOVATE: position, role and examples.
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21. Lessons from Clayton Christensen
Disruptive Innovation is the only solution to sustainable healthcare:
1. Business model innovation
2. Unraveling of healthcare (pathways)
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22. Do not mingle different business models…
• Solution Shops
Fee for service model. ‘Intuitive medicine’:
All diagnostics: we search until we find. Some treatments: we try
until something works.
• Value Adding Process
Fee for outcome.
Once treatment is clear a standardized way leads to best results:
focus clinics.
• Facilitated Networks
Annual fee. Size and composition of the customer base creates
value. Chronic diseases that need behavioural changes need a
‘patient like me’ approach.
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23. … but we (are forced to) do so all the time…
• Diagnostics (CT, MRI, PET, Genetics) are intuitive medicine and
therefor Solution Shops with fee for service business model.
• Once the diagnose is conclusive, a ‘value adding process’ business
model is optimal and a fee for outcome model is used.
• In the Netherlands a model based on fee for outcome (DRG like
system) also includes the diagnostics. This does not work for top
clinical hospitals that operate in the ‘intuitive area’.
• Concentration of treatment and concentration of diagnostics should
in this theory happen in different organizations because their
business models differ.
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24. Reducing complexity and increasing volume
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25. TU Delft just found productivity surge:
2003 – 2009
• productivity per fte has
improved (34,9% nursing!!!)
• +1% revenues: + 1,23% cost
• Concentration ‘might be’
solution.
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26. Reducing complexity and increasing volume
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27. Overview:
1. Exploding cost of healthcare
2. The Dutch situation: short overview
3. Sustainability of healthcare: do we ask the right question’?
4. Lessons from Clayton Christensen’s Innovators Prescription
5. Concentration and decentralization (BCG/B&C)
6. ‘Betterland’(healthy country): interesting model (KPMG Advisory)
7. UNOVATE: position, role and examples.
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28. Concentration leads to higher quality AND
lower cost…
Lower cost through
higher quality
Better Higher
quality volume
Lower cost through
higher volume
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29. …all studies prove this
Studies (green) that prove positive correlation
between quality naar[aantal positief aantal geen verband]
Studies
andrelatie volume en kwaliteit per (orange)
volume or no relation orgaan/ziekte
8 9 23
7
7
4
6
2 4
21 20 2 6
18
15 15 4 3 7
12 12 11 0 2 0
9 9 7 1 1 3 3
6 5 5 5 5 4 4 4 0 0 4
3 3 3 3 0
1 0
1 1 1
0 0 0
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30. For example Breast Cancer (BCG study)
% patients with tumor tissue left behind % Spread in outcomes also highly correlated
Number of breast cancer patients per hospital Number of breast cancer patients per hospital
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31. …but concentration means decentralization
Mono disciplinary care • Primary Care
• “Low-tech infrastructure” • Care close to the patient
• Cheaper and small scale • Together with GP’s
• Independent locations and scattered • Functions
• Focus on process optimization • Diagnostics
• Prevention & information
• Chronic Care
• Follow-up and light rehabilitation
Current Cure
Sector that does
Concentrated Care everything Close Care
everywhere
• Thematic (multidisciplinairy) Care • Acute Care
• Heavily focussed in a small number of • Diminished to smaller number
locations per theme • Ten Trauma + 30 acute care centers
• Complex and/or multidisciplinary • Availability function
interventions; High-tech infrastructure • Seperately financed
• Research & Education
• Disconnected from other themes
• Seperately financed
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32. Current hospitals do everything for everyone….
Distribution of care in different hospital (in euro’s)
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33. … thematic focussing lowers burden rate
Top clinical / thematic Care in Euro’s
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34. ‘Next generation’ dutch healthcare
Duration of diagnosis/treatment
Primary/ Mono disciplinairy
Diagnostic/ care
Chronic Solution Shop:
Care Fee for outcome
Patient Accessibility
Facilitated network/24-7:
Annual fee / Lump sum
Value Added Process:
Fee for service / Lump sum
Simple
Acute Thematic
care Multidisciplinaire
complex/acute
care
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35. Overview:
1. Exploding cost of healthcare
2. The dutch situation: short overview
3. Sustainability of healthcare: the same and right question?
4. Lessons from Clayton Christensen’s Innovators Prescription
5. Concentration and decentralisation (BCG/B&C)
6. ‘Betterland’(healthy country): quant. approach (KPMG Advisory)
7. UNOVATE: position, role and examples.
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36. Concentration and decentralisation (cure)
KPMG Advisory developed a hypothetical ‘healthy country’:
‘Betterland’
The outcome is just a possible scenario, not
necessarily what should happen.
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37. ‘Betterland’ in revenues per region
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38. Concentration vs decentralization (acute)
Number of locations acute diagnoses
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39. Concentration vs. Decentralization (elective)
Number of locations elective diagnoses
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40. Travel time emergency, acute, elective, chronic
Traveltime patients per category
Percentage of patients
Traveltime in minutes
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41. Concentration vs decentralization
(hart faillure)
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42. Concentration study results for Breast Cancer
(BCG)
Number of locations from 97 to 23 within 30 min. drive
= 150 pat.
= 400 pat.
= 1350 pat.
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43. KPMG: revenues vs # Diagnose groups
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44. Overview:
1. Exploding cost of healthcare
2. The Dutch situation: short overview
3. Sustainability of healthcare: do we ask the right question’?
4. Lessons from Clayton Christensen’s Innovators Prescription
5. Concentration and decentralization (BCG/B&C)
6. ‘Betterland’(healthy country): interesting model (KPMG Advisory)
7. UNOVATE: position, role and examples.
UNOVATE, Hospital Management conference, 19/10/2011 44

45. UNOVATE is a 100% holding company of the UMC Utrecht
focussed on service innovation (non-IP)
UMC
Utrecht
100% 100%
UMC Utrecht
UNOVATE
Holding B.V.
≤ 100% < 100%
Alant
Comp Comp JCR
Vrouw
A Z BV
Utrecht
Product innovation service innovation
(IP- driven) (non-IP)
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46. Reducing complexity and increasing volume
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47. Most projects combine burden rate and scale
effects
UNOVATE Projects
1 Surgical (H)ear Clinic
2 Outpatient Eye Clinic
3 Clinical genetics lab
4 PCR Service lab for GP lab
5 Limb reconstruction center
6 Shared Production Pharmacy
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48. My mission: unravelling healthcare! Yours?
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