Editorials

Advancing Towards ValueBased Integrated Care for Individuals and Populations

Authors: {'first_name': 'Roberto', 'last_name': 'Nu\xc3\xb1o-Solin\xc3\xads'}

Abstract

Keywords: Article has no keywords
DOI: http://doi.org/10.5334/ijic.5450
 Accepted on 13 Nov 2019            Submitted on 13 Nov 2019

Value-based health care (VBHC) is nowadays a global trend in healthcare management and policy [1]. Value is defined as the outcomes that matter to patients related to the costs required to achieve those outcomes [2]. VBHC is thus yet another strategy that promises to “fix” health care [3]. Although it is uncertain if this purpose will be achieved, it is clear that VBHC incorporates some very relevant elements that have been hitherto absent or neglected in the daily management of organizations and health systems.

To start with, a core aspect of the proposal must be highlighted here: VBHC calls for a measuring of health outcomes from a broad, plural perspective, and not merely from a health economics, primary care or other narrow scope. Not only that, but it also incorporates measuring health outcomes that matter to the patient as essential, i.e. patient-defined outcomes and patient-reported outcome measures [4]. This proposal and its instruments are not new, however it does constitute the definitive commitment to standardizing, systematizing and incorporating value-based thinking and functioning into the clinical and management routine. It involves breaking with the usual complacency of measuring activity, average stays, process indicators and resources, etc. and neglecting the true effects of healthcare interventions.

Thus, the widespread acceptance of VBHC would place us in scenarios involving organizational innovation, benchmarking and benchlearning, value-based purchasing, comparative effectiveness analysis and competition for value creation – the impact of which is not yet easy to foresee, but will lead to a disruption of the business model in health regardless of the type of health system prevailing in each country.

Following on from Porter and Teisberg’s proposals [1], other experts have also proposed their own theoretical models based on the underlying idea of value. For instance, there is the OECD’s Expert Panel on effective ways of investing in Health [5] defined in terms of value-based healthcare as a comprehensive concept founded on four value-pillars: appropriate care in order to achieve patients’ personal goals (personal value), achievement of best possible outcomes with available resources (technical value), fair resource distribution across all patient groups (allocative value) and contribution of healthcare to social participation and connectedness (societal value).

This definition can be useful at a macro level to ensure the financial sustainability of universal healthcare – a long-term strategy geared towards the reallocation of low-value and high-value care resources. However, it is not very actionable in clinical and management practice and, unlike Porter’s proposals, is not sufficiently nurtured by the advances made over the last few decades in Organization Theory, Strategy or Integrated Care.

From a care integration perspective, Porter’s proposals already incorporate a system integration vision [6] and anticipate three key changes: horizontal integration based on units of excellence that concentrate volume according to medical condition, moving non-acute care out of hospitals and multidisciplinary work into Integrated Practice Units (IPUs). The concept of IPUs was introduced in the book Redefining Health Care [1]. The term IPU was chosen to highlight the fact that whenever an organization is doing something complicated, it should organize itself around overall customer needs being met. IPUs are multidisciplinary teams organized around meeting the needs of groups of patients with a shared clinical condition.

Ultimately, at the core of VBHC there are already the seeds of a Value-Based Integrated Care vision (VBIC), but does it capture the theoretical and empirical advances of integrated care in recent decades? We believe there is a great path of conceptual and empirical progress between VBHC and integrated care that can eventually converge on a VBIC paradigm for both individuals and populations, as has been previously proposed by Valentijn and colleagues [78], although their concept of value is based on Berwick and colleagues’ Triple Aim model [9]. Therefore, Valentijn and Vrijhoef defined VBIC [8] as “patients’ achieved outcomes and experience of care in combination with the amount of money spent by providing accessible, comprehensive and coordinated services to a targeted population”.

Anyway, we can see that both proposals put forward by Porter and Berwick foster the implementation of integrated care delivery and new payment models that are key for transformation towards an era of value-based healthcare. There is also acknowledgement that successful implementation of care integration practices may provide the solutions needed to help improve patients’ care experiences and outcomes, and to minimize costs.

However, for there to be an evolution towards a VBIC paradigm, major theoretical challenges persist, such as:

At an implementation level, we can identify other methodological and operational challenges that require further research, such as the following:

To sum up, we celebrate VBHC as an important advance, but also with caution, as it has the unintended potential to boost some fragmentation trends in health systems (hyperspecialization, disease focus, hospitalocentrism, etc.). The increasing number of people living with chronic conditions and population groups with complex health and social needs (palliative care, mental health, vulnerable groups, etc.) require not only healthcare, but also social and community support [12]. This fact cannot be overlooked and needs to be considered when reformulating new organizational models.

In an attempt to respond to this challenge, for many years now integrated care models have been emerging and advocating coordination between healthcare, social and community services, so as to remove the fragmented model of organization. It will be interesting to see how leading integrated care organizations adopt VBHC in their strategies and practices [13].

Finally, proposals such as VBIC that build on the fertile seed planted by integrated care literature are needed – proposals that incorporate a systemic vision and a focus on health/well-being rather than on disease, the role of communities, the value of care, all from a fair perspective. We think that the community of practitioners and researchers that revolve around IFIC may prove to be a key agent in building that exciting new model.

Acknowledgements

I would like to express my deep gratitude to Diana Camahuali and Maider Urtaran for their valuable support and constructive suggestions on preparing this manuscript.

Competing Interests

The author has no competing interests to declare.

References

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