Introducing BUNDLE: towards a roadmap for effective alternative provider payment models

Author: dr. (Frank) F. Eijkenaar

Based on in-depth evaluations of payment reform experiments in the Dutch healthcare system, the BUNDLE project aims to develop an evidence-based roadmap for effective alternative provider payment models. Why this project and what does it entail? Read all about it in this blog.

Current payment models ill-aligned with value

Concerns about the financial (un)sustainability of healthcare systems and suboptimal patient outcomes have sparked renewed interest among policymakers and other stakeholders in searching for effective ways to eliminate waste and improve quality. In order to achieve that and maximize the ‘value’ of healthcare delivery, organizing and providing value-based care must be facilitated and be rewarding for all those involved.

Surprisingly, however, current methods for paying healthcare providers do exactly the opposite: as a rule, these payment methods – which are commonly referred to as ‘fee-for-service’ – do not stimulate providers to coordinate care well, realize optimal patient outcomes, and reduce waste. In fact, because providers tend to be paid separately for each discrete service provided, it is financially more attractive to focus on ‘volume’ instead of ‘value’, while everyone would agree that it should be the other way around. Better payment models are therefore urgently needed.

Call for improved payment models

Despite broad consensus about the potential and need for provider payment reform across countries, examples of effective alternative payment models are still rare. Reform initiatives often do not even reach the implementation phase and when they do, they typically lack a rigorous evaluation. As a result, the effects on spending and quality outcomes remain largely unknown, as are the contextual factors and mechanisms driving and influencing those effects. These knowledge gaps hamper further introduction and upscaling of alternative payment models and value-based care. This must and can change if healthcare systems are to produce good quality outcomes in a financially sustainable manner.

Large-scale evaluation of payment reforms

Researchers from Erasmus School of Health Policy & Management (ESHPM) have therefore joined forces with external partners and received a grant for a multi-year research project called ‘BUNDLE’ (a Dutch acronym for ‘paying for outcomes in Dutch hospital care: doing, learning and evaluating’). The main goal of this project is to obtain in-depth insight into the black box of payment reform by answering the fundamental question of ‘What works, why, and under what conditions?’

To that end, we evaluate a broad selection of reform initiatives in the Netherlands using a combination of qualitative and quantitative research methods. The quantitative part focuses on estimating the causal impact on spending and quality outcomes, and the qualitative part on the working mechanisms (‘behavior’) and relevant contextual factors over the full development cycle of alternative payment models. The initiatives were purposively selected based on their diverse characteristics in terms of scale, scope, setting and implementation stage. For example, the initiatives pertain to seven different medical conditions (both acute and chronic), vary in in terms of maturity (some are still in the design phase while others have been running for several years), are scattered across the country, and differ in the type of alternative payment model they are testing.

Roadmap for alternative payment models

Our ultimate goal is to develop an evidence-based roadmap for effective alternative provider payment models that can broadly be used to initiate, realign or continue with payment reform. The roadmap will contain a detailed overview of different types of alternative payment models and their building blocks, hands-on tools to enable informed design choices, and concrete recommendations for sustainable implementation. To maximize impact, the roadmap will be widely disseminated and freely accessible. In the meantime, we will report our findings on a dedicated website and LinkedIn page. The first results are expected shortly, so stay tuned and contact us if you want to learn more!

About the author 

Frank Eijkenaar is an associate professor of health economics at Erasmus School of Health Policy & Management. He is co-leader of the actionline ‘Value-Based Health Care’ of the Erasmus Initiative ‘Smarter Choices for Better Health’. His main focus is on the design, implementation and effects of alternative payment models for healthcare providers, as well as on the measurement and benchmarking of quality and cost performance. You can contact Frank via

Associate professor

Dr. (Frank) F. Eijkenaar

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