All VBHC strategies include the encapsulation of patient experiences and outcomes within the healthcare setting. — 123rf
Since the end of World War II, the global economy has grown and health expenditure has increased with it.
However, the World Health Organization’s (WHO) monitoring report for universal health coverage in 2019 reported that service coverage growth peaked in 2006 and has been decreasing since, despite increases in health expenditure.
With increasing healthcare costs, ageing populations, changing demands and technological advances, there is an urgent need to ensure that increased health expenditure is spent efficiently and effectively so that service coverage can increase, or if not, be maintained.
Recently, there has been much public discussion about healthcare expenditure in Malaysia.
Although much focus was on diagnostic-related groups (DRGs), there has also been mention about value-based healthcare (VBHC).
This concept has become an objective and strategy to ensure high-quality healthcare with simultaneous cost-efficiency in many developed economies.
Not a new concept
The roots of value in healthcare is about a century old.
The WHO stated in 2000 that there are three basic objectives for health systems globally: improvement of population health, response to patients’ expectations, and financial protection against ill-health costs.
Professor Dr Michael E. Porter and Prof Dr Elizabeth Olmstead Teisberg, in their 2006 book Redefining Health Care: Creating Value-Based Competition On Results, called for value in healthcare delivery, defining value as health outcomes per dollar spent.
They pointed out the limited impacts of what they termed “magic bullets”, i.e.:
- Turning patients into consumers – price and outcome information are lacking
- Global capitation to control spending – reduces spending, but does not improve value
- Prior authorisation – raises costs while services are rarely disapproved
- Eliminating fraud and self-dealing – does not address the root causes of low-value healthcare
- Eliminating errors – reducing errors does not itself lead to a redesign of overall care that improves value
- Evidence-based medicine/clinical effectiveness research/guidelines – fail to cover many services and individual patient circumstances
- Care coordinators – of limited impact when layered onto the existing structure
- New low-cost models of primary care – limited effect on the great majority of healthcare costs
- Electronic medical records – of limited impact on value without reorganising care, and siloed IT (information technology) systems actually work against value.
Dr Donald M. Berwick, Dr Thomas W. Nolan and Dr John Whittington of the US Institute for Healthcare Improvement (IHI) introduced the Triple Aim in 2007.
This is the simultaneous pursuit of improving the experience of care, improving the health of populations, and reducing per capita costs of healthcare.
The Triple Aim was addressed in the 2010 US Patient Protection and Affordable Care Act (also known as Obamacare).
It has since been expanded to the Quintuple Aim, which includes physician and health professional well-being and health equity.
The US IHI is collaborating with more than 100 countries/organisations globally to implement the Triple Aim, which was also adopted by New Zealand, Canada and the Nordic countries.
The wording of the Triple Aim has varied somewhat according to different countries’ health policies goals.
Different definitions
Prof Porter and Prof Teisberg defined value as the outcomes that matter to people, relative to the cost of achieving those outcomes across a whole pathway of care.
The central premise of this approach is that standardised outcomes should be measured, compared with other institutions, and rewarded through outcomes-based payments.
The US National Academy of Medicine describes high-value healthcare as safe, timely, effective, efficient, equitable and patient-centred (STEEEP) care.
Prof Dr Sir Muir Gray and his colleagues encapsulated the British National Health Service (NHS) context by describing how resources may be allocated fairly for highest value for population health.
There was less emphasis on outcome measurement or the patients’ perspective.
The Centre for Evidence-Based Medicine, in Oxford, Britain, attempted to amalgamate these two definitions, i.e. “Value-based healthcare is the equitable, sustainable and transparent use of the available resources to achieve better outcomes and experiences for every person”.
In 2019, the European Commission’s Expert Panel on effective ways of investing in health proposed a comprehensive concept built on four value-pillars to define VBHC for solidarity-based healthcare systems, i.e.:
- Personal value – meaning that an individual receives appropriate care; it is determined by how well the outcome relates to the value and goals of individual patients, considering both good and bad outcomes
- Allocative value – determined by how equitably resources are distributed to different population subgroups
- Technical value – related to achieving the best outcomes with the available resources and determined by how well the resources allocated for investment for a particular population subgroup, defined by their condition, are used for all the people in need in the population
- Societal value – related to whether the impact of the intervention in healthcare contributes to social cohesion, based on participation, solidarity, mutual respect, equity and recognition of diversity.
This comprehensive meaning of “value” provides a wider perspective than the common interpretation of “value” as purely monetary in the context of cost-effectiveness.
Making a start
Prof Porter and Prof Teisberg proposed a six-stage process, i.e.:
- Organise care into integrated practice units (IPUs) around patient medical conditions
For primary and preventive care, organise to serve distinct patient segments.
IPUs are “organised around the patient and providing the full cycle of care for a medical condition, including patient education, engagement, and follow-up and encompass in-patient, out- patient and rehabilitative care, as well as supporting services”.
- Measure outcomes and costs for every patient
- Move to bundled payments for care cycles
- Integrate care delivery systems
- Expand geographic reach
- Build an enabling IT platform.
The US IHI defined the measures of the Triple Aim in its 2012 publication A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost, as:
- Population health domains: Health outcomes of mortality (death), health and functional status, and their combination for healthy life expectancy; disease burden and behavioural; and physiological factors
- Experience of care domains: Patient experience and quality of care
- Per capita cost: Total cost per member of the population over time.
It is obvious that measurement is a sine qua non of VBHC and that data is foundational.
This was clearly stated in WHO’s 2021 Policy Brief From Value for Money to Value Based Health Services: A Twenty First Century Shift.
In Malaysia
VBHC can be used to inform decision-making and contribute to making the healthcare system more effective, accessible and resilient.
The implementation of VBHC (or for that matter, DRG) requires governmental involvement in driving change, continuous IT improvements to ensure the availability of current outcome data across the full care cycle, and institution of a VBHC culture among providers.
It should be reiterated that the “value” in VBHC is not purely monetary as many payers may perceive or interpret.
The Covid-19 pandemic exposed the chasms in Malaysia’s healthcare system.
The situation then was likened by a Health Ministry specialist to a sinking ship that was kept afloat by the resilience of healthcare professionals.
Is there a political will to act?
Or will urgently needed change be kicked down the road to the next government?
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email starhealth@thestar.com.my. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
