Case 4: Value-based health systems Flashcards
What is the definition of value?
Multiple definitions:
- patient health outcomes achieved per dollar spent.
- health outcomes achieved that matter to patients relative to cost of achieving those outcomes
What is the problem with the definition of value saying “Value → patient health outcomes achieved per dollar spent”?
- limitations in context of UHC systems funded through social insurance or taxation.
- Focusing only on funds spent on each patient’s cycle of care doesn’t take account of available resources & how they are allocated across population
What are the current issues with value?
- difficult to measure & deliver value
- Providers measure only what directly control in intervention & what is easily measured, instead of what matters for outcomes
- no clear definition
Why do we need to consider value in HC?
Resources are increasingly outstripped by demand for HC. driven by:
- changing population demographics
- innovation & new technologies
- patient expectations
- increase in multi-morbidity.
How do we measure value?
- measured by outcomes achieved, NOT by # of services delivered or by process of care used.
- Health status achieved
- Nature of care cycle and recovery
- Sustainability of health
What are the 3 tiers in the 3 tiered hierarchy of outcomes?
- tier 1 - health status achieved or retained
- tier 2 - process of recovery
- tier 3 - sustainbility of health
Explain the tier 1 of the hierarchy of outcome measurement
health status achieved or retained
first level = survival of the health issue
second level = degree of health recovery → most important tier
What are the trends in health & healthcare?
- From treatable → preventable
More attention to:
- prevention relative to treatment
- QoL than extending life expectancy
- shared decision making & value for patients: patient centred care, not physician centred care
Why are HC systems so inefficient & not patient centered?
- Practice variation
- Overtreatment
- Administrative costs
→ root cause: payment NOT based on patient values
What are the reasons for practice variation & overtreatment?
- Payment is not based on what patients value
- Fee-for-service payment systems
- Rewards quantity, not quality
- Incentive to perform more interventions
What is fee-for-service (FFS)?
method where HC providers are paid for each service performed. E.g. of services include tests & office visits.
What are the advantages of FFS?
- Incentive for productivity
- Financial recognition for achievement and effort
What are the disadvantages of FFS?
- Incentive to perform as many medical interventions as possible (unnecessary interventions)
- Incentive to carry out treatment yourself and not to refer patients to medical specialist (no optimal treatment) - make more money yourself as practitioner
- Quantity is rewarded, not quality
What is VBHC?
“equitable, sustainable & transparent use of available resources to achieve better outcomes & experiences for every person”
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By focusing on health outcomes, what does VBHC do?
- helps HC providers manage cost increases
- make the best use of finite resources
- deliver improved care to patients.
What are unwarranted variaitons in HC?
Differences in… that aren’t explained by patient preference or illness:
1. resource allocation
2. resource use
3. outcomes in health
- Associated with overuse/underuse of health technologies & care
What can unwarranted variations show?
- where resources might be wasted
- underuse or overuse of care
- opportunities to increase value.
What are the types of value based payment models?
- Bundled payments
- Pay-for-performance
- shared savings
- shared risk
- Global capitation
Explain bundled payments as a value based payment model
- fee for period of care instead of paying for each individual service delivered in the care cycle
- Can be combined with shared-savings or shared-risk components
Explain pay-for-performance as a value based payment model
- often implemented together with FFS payments, to make more value-based.
- payments reward HC providers with added bonuses if they achieve specific targets set by payers for quality and costs of care.
Explain shared risk as a value based payment model
providers share financial risk with payers based on predefined quality & cost targets
Explain shared savings as a value based payment model
providers receive a share of cost savings achieved by delivering high-quality care at a lower cost
How can we transform into value-based systems?
- VBHC model requires paradigm shift from supply-driven HC system organised around what physicians do → patient-centred system organised around what patients need.
- Shift focus from volume & profitability of services provided → patient outcomes achieved
- 6 elements of patient value model from Porter
What are 5 provider behaviours that boost HC value?
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- Engage patients so they play more active role in choice & decisions that shape their health.
- Prioritise wellness & disease prevention
- Deliver high-quality, appropriate care
- Embrace continuous improvement & clinical innovation
- Do all this whilst also managing total costs of system.
What 6 elements help to support transition from volume-based to a value based system?
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- Organise into integrated practice units (IPUs)
- Measure outcomes & costs for every patient
- Move to bundled payments for care cycles
- Integrate care across separate facilities
- Expand geographic reach
- Building an enabling IT platform
Explain “organise into IPUs” as one of the 6 components of a high-value HC system
- Clearly defined patient groups since relevant outcomes differ between groups
- Organising around patient’s medical conditions rather than physician’s medical specialities
What are IPUs?
multidisciplinary team organised around medical condition/ set of closely related conditions that regularly meets to discuss care plans for patients along the full care cycle
Explain “measure outcomes & costs for every patient” as one of the 6 components of a high-value HC system
● Health outcomes are what patients find important
● Costs are the fee for all providers throughout the care cycle
Explain “move to bundled payments for care cycles” as one of the 6 components of a high-value HC system
- Efficient financing reducing costs
- “Bundled payments is the preferred payment model to increase value”
Explain “integrate care across separate facilities” as one of the 6 components of a high-value HC system
Interacting and cooperation of care providers (GP, hospital and radiologist)
Explain “expand geographic reach” as one of the 6 components of a high-value HC system
Willingness for providers to utilise new practices developed elsewhere
Explain “build an enabling IT platform” as one of the 6 components of a high-value HC system
Methods to collect, measure, report and analyse outcomes frond data
What are the 4 pillars of value?
- Technical value
- Allocative value
- Personal value
- Societal value
Explain technical value as one of the 4 pillars of value
achievement of best possible outcomes with available resources
Explain allocative value as one of the 4 pillars of value
equal distribution of resources across all patient groups
Explain personal value as one of the 4 pillars of value
appropriate care to ahcieve each patients personal goals
Explain societal value as one of the 4 pillars of value
contribution of HC to social participation & connectedness
What are the 4 domains of the adoption of VBHC?
- Enabling context of policy & institutions for value in HC
- measurement of outcomes & costs
- Integrated & patient-focused care
- Outcome-based payment approaches
What are enablers of VBHC?
● Government intervention: VBHC can’t be implemented by providers alone & should be supported/rewarded by governments
● Focus on IT improvements: improve electronic communication & integrate IT in full cycle of care
● Institute VBHC culture among providers: foster culture and behaviour within health organisation to increase willingness to adopt VBHC → also prevents top-down implementation
Explain tier 2 of the hierarchy for outcome measurement
outcomes related to the recovery process
→ first level = time required to recover r & return to normal function
→ second level = disutility of care or treatment process (discomfort, complications, ineffective care etc.)
Explain tier 3 of the hierarchy of outcome measurment
sustainability of health
→ first level = recurrence of original disease or long-term complications
→ second level = captures new health problems as a consequence of treatment
What are payment systems for physicians?
- fee for service
- capitation
- salary
What is capitation?
fixed amount per patient irrespective of amount of treatment
What are the advantages of capitation?
- Simple administration
- Beneficial for GPs
- Easier for budgeting & preferred by governments & insurers
What are the disadvantages of capitation?
Incentive to collect as many patients as possible & refer to specialists quickly to perform as little interventions possible
What is salary?
Amount per working hour
What are the advantages of salary as a payment system for physicians?
- Easiest system for administration
- Easiest system for budgeting
What are the disadvantages of salary as a payment system for physicians?
- No incentive to supply sufficient effort in work since your paid anyways
- Incentive to refer to specialists quickly
- No sense of reward
What do the payment systems for physicians have in common?
- Focus on the quantity of care instead of the quality
- Some incentives produced are not desirable for patients
Why is health spending per capita increasing?
due to ageing populations & costly medical interventions → more spending does not equate to improved health
What are consequences of VBHC?
● More patient-relevant outcome measures
● Integrated networks of care & more collaboration between different providers
● More use of data and advanced IT systems
● Embraces a shared decision making process
● Emergence of value-based payment models
Explain the domain enabling content, policy & institutions for value in HC
Countries need ecosystem of institutional & policy structures that support value-based approached → lack national-level policy makers
Explain the domain measuring outcomes & costs
● Data & measurement allows for ability to conduct costbenefit analyses & monitor outcome data
● Transparent healthcare pricing/increasing demand of electronic health records
Explain the domain integrated and patient-focused care
Integrated instead of siloed, fee-for-service care generates efficiency & reduces waste of resources but require interoperable IT systems
Explain the domain outcome-based payment approach
- Bundled payment cover end-to-end procedures
● Mechanisms for withdrawing resources from treatments, drugs and interventions that are not cost-effective
● Health expenditure is a strong indicator of VBHC
What are barriers of VBHC?
- lack of data registries
- no evidence-based approach
- multi stakeholder involvement
- no value-based culture
- risk averse nature of providers
What are the priorities of value in health systems?
- health improvement
- responsiveness
- financial protection
- efficiency
- equity
What are value based payment models?
models that reinforce VBHC, often rewarding providers with bonus when they meet predefined thresholds for quality care
What are barriers for value-based payment models?
- administration
- multistakeholder
- no data
