The consortium members are working on a variety of projects applying TDABC to support value-based health-care programs or to make the healthcare system more effective.

The proposition of a bundled reimbursement strategy for the COVID-19 treatment in Brazil

Principal researchers: Carisi Anne Polanczyk, Ana Paula Beck da Silva Etges, Milena Soriano Marcolino, Karen Brasil Ruschel, Richard Urman.

The resources are finite and, therefore, the health system needs to operate with efficiency to deliver care to the population without causing a collapse. The disease caused by SARS-COV-2 (COVID-19) evidenced the constant relationship between health and economy and so that, over time, health care remains sustainably, it is necessary to comprehend the cost that hospital treatment represents for institutions. The disease caused by SARS-COV-2 (COVID-19) evidenced the constant relationship between health and economy and so that, over time, health care remains sustainably, it is necessary to comprehend the cost that hospital treatment represents to the system. Based on that information, reimbursement strategies that reflect the Brazilian reality can be introduced with better precision.   As a continuation of the project “Hospital register of patients with the disease caused by SARS-COV-2 (COVID-19)”, this study aims to generate real hospital cost information of patients with COVID-19 to scientifically subsidize reimbursement strategies in a bundled format from the perspective of public and supplementary health systems in Brazil. The study contemplates the analysis of real costs by microcosting technique to create a reference ​​for cost information considering the comorbidities and clinical complexity of the patients. Resource consumption data will be analyzed by patients hospitalized with COVID-19 in hospitals participating in the hospital registry project. Data from clinical registers and administrative systems will be extracted from each institution guided by a standard form to sustain the future data analysis. Financial and institutional data will also be collected through a standard questionnaire to the institutions. The union of the databases of the clinical, financial, and resource consumption records per patient will form the datasheet for the real hospital costs analysis in Brazil. Descriptive statistical analyzes and comparisons between groups using multivariate data analysis will be used to identify hospital cost reference information. Additionally, the Diagnosis-related groups (DRG) established for the treatment of SARS will be used to classify patients in terms of risk and resource consumption for proposing a reimbursement bundled for COVID-19 in Brazil. The definition of bundles by DRG classification will contemplate the expectation of clinical and process outcomes. Remuneration bands will be assigned for each level of patient classification and expected performance in clinical and process outcomes. At the same time, the literature proposing reimbursement models for the treatment of COVID-19 will be continuously monitored, so that the Brazilian model resembles that of other countries. A Business Intelligence platform will be developed to provide accessibility of information to the population and health managers, and the data collection guidance protocol for cost analysis will be made available online for use in multiple centers in the country. In addition to the products delivered, the information generated by the study will be documented in scientific articles, allowing Brazilian COVID-19 cost and reimbursement information to be consulted internationally, guiding sustainable economic management strategies for the treatment of COVID-19 in multiple countries.

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A Microcosting analysis for two technologies hip arthroplasty and use of alteplase in the treatment of ischemic stroke

Principal researchers: Ana Flávia barros da Silva Lima, Luciane Nascimento Cruz, Ricardo Bertoglio Cardoso, Ana Paula Beck da Silva Etges e Bruna Stella Zanotto

A research funded by the Brazilian Ministry of Health through the PROADI/Hospital Moinhos de Vento

The use of different costing methodologies and the absence of an automated cost system in public health institutions generate difficulties in the use of real cost data in economic analyzes and limit the capability to identify benchmarks of care among health services. By the use of the time-driven Activity-based Costing, this study aims to estimate the real cost of a surgical procedure (hip prosthesis surgery) and a clinical pathway protocol (clinical pathway of the use of alteplase for stroke) from the perspective of the Brazilian Public Health System (SUS) and the Brazilian Supplementary Health System. A total of 9 hospitals compose the group of institutions that will have patients included in the sample, which was defined by an observation period (2 months). In each institution, all patients submitted to the surgery or to the ischemic stroke clinical treatment protocol will be included in the study. A group of researchers is responsible for joining the databases from all the hospitals and perform the cost analysis, which will explore the data granularity that the TDABC provides. Cost per activity and per resource will be performed, and the differences in time and costs identified by the pathway flow from each institution will guide the final discussion to suggest cost-saving opportunities. All the results will be delivered to the Brazilian Ministry of Health.

Advances in evaluation methods to support the decision making process of surgical pathways redesign

Principal researchers: Ana Paula Beck da Silva Etges and Richard D. Urman

The redesign of surgical pathways has been used as a compelling manner to contribute to greater assurance of quality when providing a patient-centered service. The Enhanced Recovery After Surgery (ERAS) society has published a list of recent recommendation guidelines orienting good practices that may be adopted by hospitals to increase the quality of care. Regarding the evaluation of the impact that an internal redesign may achieve, the literature usually reports clinical outcomes results. However, the decision making to invest in an internal culture change may consider multiples variables, including the economic impact.
Usually, the recommendation guides include a list of process of care suggestions, such as: multi-professional consulting routines, patient and family education, exclusive diet analysis, exams that may be monitored (before and after), post-surgery care, use of telemedicine services, and others. Length of time of hospitalization after surgery, consumption of specific medications, pain, and rehospitalizations are frequently used as outcomes to evaluate the pathway impact.
The health technology assessment research area is continually advancing in economic models to orient the right decisions in health-care. However, the evaluation of the implementation or changing of a new pathway is innovative and scarce from economic models’ recommendation to support the decision-making process.
As a tendency in recent studies, the method Time-driven Activity-based Costing (TDABC) has been used as a powerful technique that can evaluate costs by the comprehension of the patient’s entire episode of care. In its principle, the method evaluates the processes of care by the identification of all activities that patients are submitted. Considering the patient cycle care change that happens in a pathway redesign project, we have studied how those advanced cost management methods could be applied to support the decision making process associated with the development of surgical pathways redesign projects. This project aims to develop a recommendation guide including economic, clinical, and patient reported outcomes to support health-care managers to decide about the adoption of surgical pathways redesign and innovative projects.

Proposition of a value-based health care program for public and supplementary health systems in Brazil

Principal researchers: Carisi Anne Polanczyk and Ana Paula Beck da Silva Etges

Researchers: Sheila Cristina Ouriques Martins, Bruna Stella Zanotto, Ana Claudia de Souza, Leonardo Alves Ogliari, Luciane Nascimento Cruz, Eduardo Gabriel Cortes, Avner Dal Bosco e Ricardo Cardoso

A research funded by the Brazilian Health Institute for Technology Assessment, IATS/CNPq


This research is unprecedented in Brazil in discussing the feasibility of making value-oriented priority care lines and has the potential to contribute, on a national scale, to value-based health-care management programs. It aims to propose a value-based health care model for supplementary and public health systems that could support management and health reimbursement practices.

The study is fragmented in the stages: development of a method for assessing the quality of delivery of the health service and outcomes; development of a real cost monitoring tool based on time-driven activity-based costing; and proposing the operationalization of a value-based management model for supplementary and public health systems. 

The ischemic stroke clinical pathway was defined as an object of study, and hospitals that operate in the public and supplementary systems and are members of the national stroke network (Rede AVC Brasil) were invited to compose the sample of institutions that will have their financial data and patient outcomes analyzed retrospectively. 

The patient sample will consist of all patients undergoing treatment for ischemic stroke over six months between the years 2018 and 2019 in each of the hospitals, with a total of 950 patients estimated. The outcome identification step was based on a literature review, including ICHOM standard stroke set and specific studies discussing stroke outcomes, followed by discussion with experts. The outcomes identified were classified into three categories of variables: structure (safe and effective service), process (clinical management and treatment process), and clinical (Rankin, self-care, communication, and cognitive capability) and a total of 25 outcomes variable was already identified. A spreadsheet was built for the Python algorithms training process, and a multidisciplinary team is working on extracting structured information from EMR using supervised machine learning approaches. The final outcome will be measured in a number between 0 and 1 which represent a unique consolidated result from the performance achieved in each outcome variable. The Time-driven Activity-based Costing was defined for the micro-costing studies, and a math rule will be applied to normalize cost data and achieve a number between 0 and 1 that represents high or lower costs.

The division of outcomes and costs will measure the value achieved in each institution. The benchmark will be identified as the highest value identified, and the incremental value between institutions will be evaluated by dividing the value of each institution by the benchmark. This result will be used to orient reimbursement policies and to apply regression models that can identify the outcome variable or cost activity where the hospital may focus improvement actions on increasing value.

The union of the first steps will allow the proposition of the value-based health management model, which will be documented in 2 value frameworks, one for the public health system and the other for supplementary. The proposal of the model accompanied by the intelligence of data collection and analysis is understood as a way to make it possible to implement value-based health management practices in scale in Brazil.

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A master thesis on the opportunities for more efficient TDABC implementation

Researcher: Isabelle Saberi-Far
Supervisor: Prof. Fred van Eenennaam
Supported by Value-Based Health Care Center Europe

Currently, a study is being conducted for a master thesis at The Decision Group in collaboration with Vrije Universiteit Amsterdam on exploring the opportunities for automated Time-Driven Activity-Based Costing  (TDABC) calculations and how the efficiency of the TDABC process can be improved. The study is supervised by Prof. Fred van Eenennaam and supported by Value-Based Health Care Center Europe. As most TDABC measurements and calculations are done manually, the process is time-consuming and labor-intensive. Potential technologies such as software, apps, and process mining in hospital’s data systems could facilitate the TDABC process. The Decision Group is interested in these potential solutions to implement TDABC in the most successful way. The aim of the study is to make recommendations on implementing TDABC more efficiently by analyzing VBHC implementors' barriers, facilitators, and potential strategies and needs towards more advanced TDABC implementation.

Therefore, it is necessary to interview relevant experts that have an important role in these processes. The interview questions will be about the implementation process of TDABC, how the time and costs are measured in practice and the opportunities and needs for more efficient (automated) TDABC measurements and calculations (e.g., software). Other questions will be about the obtained insights from the calculations, how the insights help with process optimization and improved care delivery. The interview will take approximately 45-60 min. 

If you are interested in participating in this research, please contact Isabelle Saberi-Far via

For any further information and questions, please do not hesitate to contact.