Is Value-Based Health Care Just the Latest Fad or can it Transform the Slovenian Health Care System?
Article Category: Invited editorial
Publicado en línea: 15 mar 2023
Páginas: 55 - 58
Recibido: 23 ene 2023
Aceptado: 28 feb 2023
DOI: https://doi.org/10.2478/sjph-2023-0008
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© 2023 Valentina PREVOLNIK RUPEL et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.
Value-based healthcare (VBHC) is a holistic, patient-centred approach to health, which came to prominence with the 2006 book Redefining Health Care: Creating Value-Based Competition on Results by Michael Porter and Elizabeth Olmsted Teisberg (1). The VBHC is a framework for redesigning healthcare with the overarching goal of value for patients, with value defined as outcomes of health treatment that are important to patients relative to the costs of the treatment. The purpose of VBHC – to achieve the best possible value of treatment for the patient – seems intuitive and so fundamental to healthcare that we need to question its rising popularity in recent years. While such value should be inherent to healthcare, creating it and overcoming considerable ambiguity concerning the very meaning of the VBHC concept (2) is extremely challenging, making the implementation of VBHC far more difficult than implied by its straightforward definition.
The idea of VBHC spread across Europe very rapidly after it was first defined. The smaller countries, such as the Netherlands and Sweden, were early adopters, together with larger ones like the UK and Germany, who introduced many aspects of VBHC, specifically the cost-benefit assessment of health technologies and evidence-based protocols for individual diseases. The other large European countries – France, Spain, and Italy – took a very fragmented approach towards the implementation of VBHC, adopting a bottom-up approach with individual institutions taking the initiative (3).
Slovenia has not been untouched by the rise of VBHC in Europe. In contrast to other small countries, the initiative to introduce elements of VBHC started with certain providers, pioneers who believed and trusted that diverse multi-tier patient-relevant health outcomes can be measured, and the results used for further treatment optimisation and efficient resource allocation. One such example is the involvement of the Community Health Centre Ljubljana in the OECD PaRIS initiative (Patient-Reported Indicator Survey), which started in 2019 and focuses on the outcomes and experiences of patients receiving care in family medicine practices. In addition to providing insights into the results and the satisfaction of patients with the care they receive, the goal is to develop a list of patient-reported outcome indicators that can be used in many countries, thereby enabling benchmarking and the exchange of good practices (4).
One such good practice is the Registry of Endoprosthetics based in Valdoltra Orthopaedic Hospital, where data on the patient-relevant health outcomes of hip and knee replacements of all the providers in Slovenia are collected. The providers use reliable, validated, and comparable patient-reported outcome measures, such as the Oxford Hip Score, Oxford Knee Score, and EQ-5D-5L to measure the treatment outcomes and health-related quality of life of the patients.
In 2023, Slovenia’s Ministry of Health prepared the National Strategy on Quality and Safety in Healthcare 2023-2031, which recommends monitoring some patient-reported outcome measures for certain procedures. While all such efforts are a step in the right direction, significant efforts will be needed to implement VBHC fully, thereby harvesting its full transformational potential. To support this process a stakeholder expert panel was set up in 2022, which prepared the guidelines for the introduction of VBHC in Slovenia (5).
The comprehensive adoption of VBHC in Slovenia has been stalled due to many factors. The extensive web-based survey (6) designed by the stakeholder expert panel and conducted among the relevant stakeholders in Slovenia between February and May 2022 revealed three main barriers to its implementation, i.e. slow and lagging adjustments of the payment models by the Health Insurance Institute of Slovenia (HIIS), insufficient resources of healthcare providers for data quality control and analysis, and inadequate IT support.
Slovenia (alongside many other European countries) uses different payment models for different levels of care, making it challenging to incentivise coordinated care across different healthcare providers. VBHC emphasises patient-centred care, focused on the patient and episode of care. The coordinated care approach thus also calls for adjustments in the payment models. In Slovenia, a combination of fee-for-service payment and capitation is used for primary care, while hospital services are paid using a combination of historic budget, prospective payments, and diagnosis-related group reimbursement. To support coordinated and integrated care, payment should be linked to a single patient-centred care pathway across providers from primary, secondary, and tertiary levels of care, that together provide a complete episode of care that addresses the comprehensive health needs of a patient. As the payment mechanisms in Slovenia remain fragmented, i.e., payment is not linked to the integrated care of a patient, but to separate services provided by individual participating providers, we are not focused on the health outcomes of the integrated care intervention, but on provider-level outcomes of individual segments of care (7). This is problematic particularly for chronic diseases with high economic burdens, such as diabetes and cardiovascular diseases, given the evidence that the episode-based or bundled payment models introduced in many countries have the potential to reduce health expenditure growth and improve the quality of care (8).
Collecting data on costs and outcomes requires digitalisation in order not to burden the medical staff and patients. If we want the data to inform decision-making and transform healthcare delivery models to actually improve the value of healthcare for the patients, we need to identify in advance the purpose of data collection, ensure effective data curation, as well as timely and rigorous data analysis. To achieve the full effect and exchange of good practices among healthcare providers, the data and its analysis must be transparent and properly benchmarked. It is important to stress that benchmarking requires the use of equal measurement instruments, an equal data collection methodology across all the units of observation, and the use of case-mix variables to ensure comparability of the health outcomes among patients or providers. In time, the volume of the data collected about the patients increases rapidly and can easily become unmanageable. The value of such data is that it can be available, analysed and linked to other relevant data in real-time, although this demands time, effort, and skills. In the UK, research has shown that there is a significant shortage of staff who can analyse data (9). In such cases, the data management and analysis are usually outsourced and not handled by the providers themselves, and the analysis and benchmarking can also be handled at the regional or national level.
Based on the opinion of the stakeholder expert panel (5), healthcare providers in Slovenia have IT support of sufficient quality as well as a good national infrastructure that allows easy integration of additional IT solutions crucial for the implementation of VBHC. Although the infrastructure differs considerably among the providers, the IT solutions that are available support the development of a patient’s lifelong electronic health record, which can have all the data stored in a structured format. New and improved practices and guidelines can easily be integrated into the existing local and national IT infrastructures. The crucial preconditions for the successful implementation of VBHC are the integration of all stakeholders in the health system, especially the patient, along with data protection, and proper data availability and transparency for all the stakeholders, to the extent required. The existing IT infrastructure represents a good foundation that allows the needed upgrades. A national information system for the collection, review, and analysis of PROMs (patient-reported outcome measures) and CROMs (clinician-reported outcome measures) should be developed. It would thus be feasible to set up the VBHC system within the existing infrastructure on the eHealth platform, by integrating it in a modular way into existing IT solutions at all levels of healthcare activity.
In Slovenia, the VBHC paradigm is receiving increasing but still scattered attention. A stakeholder expert panel has been set up to assess the challenges in moving forward with VBHC and to build a roadmap for its implementation. The web survey researching stakeholders’ opinions clearly showed that VBHC is recognised for its potential to transform the Slovenian healthcare system if some of the key challenges hindering its implementation are overcome. The three main barriers identified are slow and lagging adjustments of the payment models by the HIIS, insufficient resources among healthcare providers for data quality control and analysis, and inadequate IT support. However, these challenges are far from impossible to overcome, especially if supported by continuous education and by ensuring feedback to medical staff and other relevant stakeholders on how individual providers can contribute to the process of value creation, and how they benchmark both nationally and internationally.