How Dutch Hospitals Radically Reshaped Value-Based Health Care

Value-Based Health Care, the influential management philosophy championed by Harvard Business School professor Michael Porter, promises to transform health systems by rewarding hospitals that deliver better patient outcomes for lower costs. The idea has travelled the world, embraced by policymakers and hospital boards as a way to inject competition on value into health care. But a new study from the Netherlands suggests that when a management concept crosses national borders, it does not simply arrive intact. Instead, it can be reshaped so profoundly that it becomes something quite different from what its originators intended.

Researchers Gerard R. M. Scholten and Jeroen D. H. van Wijngaarden of the Erasmus School of Health Policy and Management at Erasmus University Rotterdam examined how Value-Based Health Care, commonly abbreviated as VBHC, is implemented in Dutch hospitals. Their findings, published in BMC Health Services Research, come from a qualitative multiple-case study conducted across four Dutch hospitals, drawing on 68 semi-structured interviews with people working at every level of the hospital hierarchy, from board members to frontline clinicians. The interviews were analysed using the widely used thematic analysis approach developed by Braun and Clarke in 2006, allowing the researchers to identify recurring patterns in how the concept was understood and enacted.

The central discovery is stark: there is a fundamental mismatch between what VBHC assumes and what Dutch hospitals can actually do. The original concept, developed in the United States, presumes that hospitals can measure the total costs of care for individual patients across the full cycle of their treatment. That measurement capability is the cornerstone of the model, because only when costs per patient are known can they be linked to health outcomes and used to calculate value. Yet the Dutch researchers found that hospitals in the Netherlands largely lack both the organizational structures and the financial systems required to perform this patient-level costing. Activity-based costing, the accounting machinery that makes cost-per-patient measurement possible in the American context, is simply not in place.

Despite this structural gap, enthusiasm for the concept at the top of the organizations was remarkably strong. Hospital boards endorsed VBHC wholeheartedly and wanted to see it implemented. But rather than driving the change themselves through formal managerial programs, the boards placed doctors and nurses at the forefront of the implementation process. The expectation was that clinical professionals would act as informal leaders, bridging the traditional divide between professional and managerial logics and carrying the concept into everyday practice. This reflects a distinctive feature of Dutch health care culture, in which physicians and nurses are seen as the natural agents of change in hospitals and managerial imposition is often viewed with suspicion.

However, the professionals who were assigned this pivotal role found themselves operating under conditions that made success nearly impossible. Doctors and nurses received limited resources to support their work, unclear mandates about what exactly they were supposed to lead, and little organizational support to help them translate the abstract concept into concrete practice. The researchers describe this as a prominent but unsupported role: clinicians were expected to spearhead a demanding management transformation while being given neither the tools nor the authority to do so. The gap between expectation and support became a decisive force shaping what happened next.

What happened next was a radical adaptation. Freed from the structural anchors of cost measurement and competitive benchmarking, and led by clinicians whose primary concern is patient care rather than market positioning, VBHC in Dutch hospitals evolved into something Porter and his followers would scarcely recognize. Instead of emphasizing the relationship between health outcomes and costs, hospitals reinterpreted the concept as an approach focused on shared decision-making and improved communication between professionals and patients. The competitive logic at the heart of the original model, in which hospitals vie to demonstrate superior value, essentially evaporated.

Nowhere is this reinterpretation more visible than in the fate of patient-reported outcome measures, or PROMs. In the original VBHC framework, PROMs are instruments for systematically capturing patients’ own assessments of their health status, intended to enable benchmarking between providers and the kind of cost-outcome evaluation that fuels competition on value. In the four Dutch hospitals studied, PROMs were instead used mainly to support clinical conversations. Questionnaires about patient outcomes became conversation starters between doctors and patients, tools for understanding individual experiences and tailoring care, rather than instruments for comparing performance across institutions or driving market discipline.

The Dutch experience offers a fascinating case study in what organizational scholars call the translation or hybridization of management concepts. Ideas that circulate internationally, such as VBHC, total quality management, or lean thinking, are never simply copied. They encounter local institutional arrangements, legal frameworks, financial systems, and professional cultures that either accommodate or resist their assumptions. When the fit is poor, the concept bends. In the Netherlands, the bending was so substantial that the researchers characterize it as a radical adaptation: a management model built around outcomes, costs, and competition was transformed into a patient-centred communication approach built around dialogue and shared decision-making.

The study’s most striking conclusion concerns the role of professional expectations. The authors argue that the way Dutch hospital boards positioned doctors and nurses, as prominent leaders who were nonetheless left without resources, clear mandates, or organizational backing, played a decisive role in reshaping the imported concept. Rather than producing the intended integration of professional and managerial perspectives, this arrangement allowed the clinical perspective to dominate, steering VBHC away from its economic foundations and toward its humanistic ones. The findings suggest that when health systems import management models, the expectations placed on professional groups, especially doctors and nurses, may matter more than the design of the model itself.

For policymakers and hospital leaders internationally, the message is sobering and illuminating in equal measure. A concept that appears universally applicable may in fact be deeply dependent on context-specific structures such as patient-level cost accounting and competitive market dynamics. Transplanting it into a system with different financial architecture and a strong tradition of professional self-governance may yield not implementation but reinvention. Whether the Dutch version of VBHC, with its emphasis on shared decision-making, delivers real benefits to patients is a question the study raises but does not resolve. What is clear is that the global travel of management ideas is a story not of faithful diffusion but of continuous adaptation, and that the professionals on the front lines ultimately hold the pen.

Subject of Research: The adaptation of the Value-Based Health Care management concept in Dutch hospitals

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

Article References: Scholten, G. R. M., & van Wijngaarden, J. D. H. (2026). The radical adaptation of the Value-Based Health Care management concept in Dutch hospitals: an exploratory multiple-case study in four hospitals. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15560-5

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15560-5

Keywords: Value-Based Health Care, Dutch hospitals, management concepts, shared decision-making, patient-reported outcome measures, hospital management, health services research, implementation, hybridization, doctors and nurses, qualitative case study, health care costs