The radical adaptation of the Value-Based Health Care management concept in Dutch hospitals: an exploratory multiple-case study in four hospitals

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Abstract
Background: Value-Based Health Care (VBHC) was developed to improve patient outcomes relative to costs and has been promoted internationally as a strategy to enhance quality and efficiency by stimulating competition on value between hospitals. However, the concept was originally designed for the United States and assumes organizational structures, financial incentives, and competitive dynamics that differ across health systems. This study examines how VBHC is implemented in Dutch hospitals, considering the expectation in The Netherlands that doctors and nurses should lead the process to integrate professional and managerial logics, and explores the conditions that influence the adaptation of the concept when introduced into a different institutional and local context. Methods: A qualitative multi-case study was conducted in four Dutch hospitals. Data were collected through 68 semi-structured interviews. Data were analyzed using a thematic analysis approach as described by Braun & Clarke (2006). Results: A mismatch emerged between the assumptions of VBHC and the Dutch hospital context. Dutch hospitals especially lack the structures and financial systems needed to measure costs per patient, a cornerstone of VBHC. Although hospital boards strongly endorse the concept, they place doctors and nurses at the forefront of the implementation process, expecting them to act as informal leaders. Doctors and nurses, however, receive limited resources, unclear mandates, and little organizational support. This seems to contribute to a significant adaptation of the concept. Instead of emphasizing the relationship between outcomes and costs, hospitals reinterpret VBHC as an approach focused on shared decision-making and improved communication between professionals and patients. Patient-reported outcome measures are used mainly to support clinical conversations rather than for benchmarking or cost-outcome evaluation to improve competition, as VBHC assumes. Conclusion: The Dutch experience indicates how transferring management concepts like VBHC across national borders can lead to substantial reinterpretation when local structures and professional dynamics differ from those assumed in the original model. The prominent but unsupported role assigned to doctors and nurses strongly shaped this adaptation: rather than integrating professional and managerial perspectives, VBHC evolved into a patient-centered communication approach focused on shared decision-making. This suggests how expectations placed on professional groups—especially doctors and nurses—play a decisive role in reshaping international management concepts in practice.