Value Based Healthcare perspective - Measuring and improving care pathways

Value Based Healthcare or value-driven care

Value Based Healthcare was formulated by Porter (2010) as a strategy to improve healthcare and maximize value for patients. Value is defined as the outcomes achieved relative to the costs of achieving those outcomes.

Currently, there is still too little transparency and comparability within the healthcare sector regarding the costs and quality of care provided. Therefore, this PhD research (view the doctoral thesis here) aimed to develop methodologies to measure these aspects and at the same time create a benchmark with which hospitals can compare themselves with each other.

Problem statement of this PhD research :

How do we measure healthcare costs and outcomes and how do we use that information to improve them?

Research question 1

How can we measure and use healthcare outcomes to improve outcomes?

A case study with lung cancer patients in AZ Delta was used to investigate how we can measure and use both clinical and patient-reported outcomes to improve care. While clinical outcomes are reported by the care team, patient-reported outcomes (PROMs) are measured by patients.

For this purpose, patients were sent a weekly questionnaire that assessed a number of symptoms (nausea, pain, fatigue, etc.). In addition, a number of questions regarding psychosocial and financial needs were included in the survey. (Misplon et al., 2022)

Lessons from the research:

• It is important that a multidisciplinary care team is assembled to respond to patients' clinical, psychological, palliative, financial, and family concerns.
• The reported data must be adequately followed up.
• Leadership from management and physicians is an important driver in the implementation process.
• We recommend using a digital tool instead of reporting PROMs on paper. Such a tool should (1) enable the collection of PROMs and clinical outcomes, (2) enable the visualization of these data using dashboards, and (3) provide feedback to clinical teams and patients.
  
  Furthermore, the digitally reported data can be used for further research, quality evaluation of the care process, and improvement cycles.

The PhD research did not investigate the clinical implications of  using questionnaires. These aspects were investigated on the same population in AZ Delta by Demedts et al. (2021) . They concluded that the implementation of value-driven care is beneficial in the daily clinical care of lung cancer patients.Patients in the care pathway had significantly fewer emergency department visits (3.5% vs. 4.8%, p 0.04) and shorter length of stay in the day clinic (2.5 hours vs. 4.1 hours, p < 0.05) than usual care. In patients with stage IV lung cancer, overall survival was significantly higher in the care pathway (447 days (95% CI 379-663)) compared to usual care (286 days (95% CI 191-400)) (p = 0.025).

Benchmarking of outcomes is also an important aspect in the implementation of VBHC. To enable benchmarking, clinical and patient-reported outcomes were collected for lung cancer patients in AZ Delta, and also in ZOL , another large Belgian hospital.

Research question 2

How can we measure healthcare costs?

Measuring the costs of care and making them transparent for clinical teams is another important component of value-based care. Therefore, the second research question evaluated how we can measure the costs of care.  

The aim of this research question was to select a method that allows for the allocation of costs at patient and pathology level from the perspective of healthcare providers, with a focus on hospital costs. The condition was that the method should be reproducible and automatable to allow benchmarking between hospitals. Therefore, it should make maximum use of the available information in the hospital information systems.

Conclusion

The allocation of all costs to a DRG via top-down micro-costing was selected as the most appropriate methodology to allocate costs to a patient.

The cost calculation method consisted of six steps:

Research question 3

Benchmark of processes and costs of care in Belgian hospitals

The third research question focused on the crucial role that benchmarking plays in implementing value-based care. The aim of this research question was to investigate the feasibility of setting up a benchmark between hospitals and to identify the challenges and lessons learned.

The PhD dissertation described the findings of a first pilot study, in which six Belgian hospitals participated and focused on process and cost data from 2019. This sample of hospitals consisted of two large hospitals (2019 turnover > €250 million), two medium-sized hospitals (2019 turnover between €100 and €250 million) and two small hospitals (2019 turnover < €100 million). Outcome data were not yet included in this first pilot.

The long-term goal of this study is to repeat this benchmark annually and gradually improve and expand it. This study included a full cost allocation, meaning that all hospital costs were allocated to a patient visit.

A reproducible and automatable method for calculating costs was set up to enable benchmarking between more hospitals in the future. To achieve this goal, the available accounting and activity information from the hospital information systems was used for the year 2019.

The overall methodology used in the benchmark was top-down micro-costing. Costs were calculated at detailed patient and visit level and then aggregated by patient diagnosis and severity of illness, using the Hospitalization Related Diagnosis (DRG) and Severity of Illness (SOI) classification system. This system groups patients based on their clinical characteristics and expected resource consumption. In Belgium, each hospitalization and day visit is assigned to a DRG and SOI based on the patient’s diagnoses, procedures and demographic factors.

This benchmark was further improved outside the scope of this PhD research in the Value4Health tool and expanded to 11 hospitals with data from 2021 and 13 with data from 2022. The revenues were also included in the benchmark analysis. This makes it possible on the one hand to compare more hospitals with each other and on the other hand to calculate and compare the margins associated with each service, visit and pathology.  

Research question 4

Impact of optimizations on cost and outcome of care pathways - Onco@home

The fourth research question compared the patient experience, cost and benefits of oncological home hospitalization with standard hospital care. The results of this were already extensively documented in an earlier article: Onco@home: home hospitalization, the way forward!

Other aspects of value-based care and future research

This PhD research investigated how the elements of value-based care can be applied in practice by means of detailed case studies. A number of aspects were not addressed and offer opportunities for further research.

Costs of the complete care cycle  

In this PhD research, a benchmark was set up with six hospitals that included clinical and process indicators. The costs were mapped per stay. According to the theory of value-based care, it is important to map the costs of the entire care pathway . At present, this is difficult based on the available data in Belgium, since a pathology (DRG and severity) is registered per stay and not for the entire care pathway. It is also difficult to request data from primary and secondary care at patient level and to link them to each other. This is therefore food for further research.

Benchmarking of costs and outcomes  

The benchmark that was set up focused on process and cost data. Quality indicators are not yet included in the benchmark, but the data model that was created for each hospital contains pseudonymised data on costs and processes of each visit to the hospital. Since all patient visits are included in the database, this data model can be linked to other systems and databases, such as electronic patient records, clinical or patient-reported outcomes or quality registers. This makes it possible, for example, to include outcome indicators in the data model per hospital in the future. These indicators can then be used in the benchmark at an aggregated level.

Financing model: Transition to bundled financing for care pathways

One of the components Porter and Lee (2013) describe for implementing value-based care is the transition to bundled payments for care pathways. They argue that current payment models in health care, such as global capitalization and performance-based financing, do not reward improvements in the quality of care. A single payment to cover all patient needs rewards providers for saving costs, but not specifically for improving outcomes or value. In a performance-based payment system, where providers receive payment for each service provided, providers are rewarded for increasing volume, but not for increasing value.

According to Porter and Lee (2013), a bundled payment that covers the entire care cycle for acute medical conditions or the entire care for chronic conditions over a period of time is the best way to deliver value. These bundled payments should be adjusted according to the severity of the condition to ensure that providers are accountable for preventable complications and reporting of outcomes should be mandatory. Again, further research into the implementation of such bundled financing  and the impact on quality and costs is warranted.

Appropriate care

Within value-based care, it is also important that patients receive appropriate care that is in line with standards, best practices and the specific needs of an individual patient. However, the OECD presented alarming data in their report ' Tackling Wasteful Spending on Health' . It estimated that one in ten patients experiences avoidable errors during treatment. More than 10% of hospital costs are estimated to be spent on correcting these errors. (OECD, 2017) .  

Steps are already being taken to gain insight into the appropriateness of care. In Belgium, the website 'For a healthy Belgium' provides insight into variations in the use of antibiotics, medical imaging, etc. The OECD report entitled 'Health at a Glance' (OECD, 2023b) also provides data on variations between member states. In addition, specific OECD reports, such as 'EU Country Cancer Profile: Belgium 2023' (OECD, 2023a) , provide insight into overuse and underuse compared to other OECD countries. It is important to learn from these data and to set up improvements.  

Patient participation

A major challenge in implementing value-based care is patient involvement.

This can be done at three different levels:

1. It is important to involve patients in making choices in their own care, through shared decision-making or discussing information from PROMs with their healthcare provider.
2. Patient involvement is crucial in improving the quality of the care process, because they know best what is important in delivering value-driven care.
3. Patients can be involved in developing health policy through their representation in patient organisations.

Secondary use of data

The presence of a data platform that enables data sharing is an important pillar in delivering value-driven care. This element was already included in the strategic agenda of Porter and Lee (2013). Since then, several important steps have been taken in Europe and in Belgium.

However, these initiatives are still in their early stages and outcome data to link to process and cost data are not publicly available in Belgium. It is an important policy recommendation to take the measures foreseen by the Belgian federal government for the secondary use of data in the framework of the Belgian Health Data Agency (HDA).

Conclusion

VBHC is presented as a fundamentally new strategy with the ambitious goal of transforming healthcare and delivering high-quality care while optimizing costs.

In this PhD research we have developed methodologies for a number of essential building blocks. However, the possibilities for further research make it clear that the journey to a full VBHC implementation is far from over and that many steps can still be taken to achieve value-driven care.

Bibliography

Demedts, I., Himpe, U., Bossuyt, J., Anthoons, G., Bode, H., Bouckaert, B., Carron, K., Dobbelaere, S., Mariën, H., Van Haecke, P., & Verbeke, W. (2021). Clinical implementation of value based healthcare: Impact on outcomes for lung cancer patients. Lung cancer (Amsterdam, Netherlands) , 162 , 90-95. https://doi.org/10.1016/j.lungcan.2021.10.010  

Misplon, S., Marneffe, W., Himpe, U., Hellings, J., & Demedts, I. (2022). Evaluation of the implementation of Value-Based Healthcare with a weekly digital follow-up of lung cancer patients in clinical practice. European Journal of Cancer Care , e13653-e13653. https://doi.org/10.1111/ecc.13653  

OECD. (2017). Tackling Wasteful Spending on Health . OECD Publishing, Paris. https://doi.org/10.1787/9789264266414-en

OECD. (2023a). EU Country Cancer Profile: Belgium 2023 . OECD Publishing, Paris. https://doi.org/10.1787/9a976db3-en  

OECD. (2023b). Health at a Glance 2023 . OECD Publishing.

Porter, M., & Lee, T. (2013). The Strategy That Will Fix Health Care. Harvard Business Review , 91 .

Porter, M. E. (2010). What Is Value in Healthcare? The New England Journal of Medicine , 363 (26), 2477-2481. https://doi.org/10.1056/NEJMp1011024

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