10 YEARS OF VALUE-BASED HEALTH CARE: A SCOPING STUDY OF
EMPIRICAL EVIDENCE ON CARE PROVIDERS’ IMPLEMENTATION
20th of July, 2020
Eekelina Hendrika Nutma Student number: s2720760
e.h.nutma@student.rug.nl
Master Thesis
MSc Business Administration – Change Management Faculty of Economics and Business
University of Groningen
Supervisor RUG N. Renting
Co-assessor RUG I. Maris-de Bresser
2
ABSTRACT
The concept of Value-Based Health Care (VBHC) with the goal of efficiently creating patient-centric value was introduced by Porter about a decade ago. Although the concept has gained popularity in both practice and literature, VBHC is still far from being the status quo. The implementation of VBHC is a complex endeavour. Consequently, the reason (why), content (what), and process (how) of the change to VBHC needs to be well-developed. While the goal and content of VBHC are clearly articulated, no advice is given on how to change to VBHC. In addition, little is known about the implementation of VBHC from a change management perspective. Establishing a clear overview on what we know about the implementation of VBHC in the past decade will help shape future VBHC change processes to be more effective and efficient. By conducting a scoping study, this research aims to systematically investigate the concept of VBHC implementation and to provide guidelines on how VBHC can be successfully implemented from a change management perspective. The findings confirm the complexity of the implementation of VBHC. While the key conceptual papers on VBHC are cited often, few studies seem to implement VBHC by improving value. No change initiative attempted to implement the complete VBHC concept and few accomplished to measure both costs and patient-centric outcomes. Moreover, important factors for the implementation of VBHC were found, although the question on whether the change to VBHC is sufficiently managed remains unanswered. Using change management literature, the study’s findings, and the ideas from Porter, clear guidelines were developed to successfully implement VBHC. The likelihood that VBHC implementation succeeds can be increased by establishing the need and vision for change throughout the organisation, managing of stakeholders’ responses to change, combining a supportive top-down and participative approach to change, and using data on patient-centric outcomes and costs. In any respect, knowledge of change management can be a valuable resource for the implementation of VBHC.
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INTRODUCTION 5
METHODOLOGY 7
Identifying the Research Question 7
Search for Relevant Studies 7
Selecting Studies 8
Charting the Data 9
Collating, Summarising and Reporting the Results 9
RESULTS 10
Search and Selection of Scoping Review 10
General Characteristics of Included Studies 10
Why VBHC is Implemented 18
What is Implemented 19
Outcome measures 19
How it is, or Should be, Implemented 21
Communication 21 Create incentive 21 Involvement 22 Support 23 Team alignment 24 Execution 24
Outcomes of VBHC Implementation Efforts 25
Adherence to protocols 25
Partial implementation 25
Impression of VBHC 25
Improved outcome measures 26
4
DISCUSSION & CONCLUSION 29
Principal Findings and Theoretical Interpretation 29
The content of the VBHC initiatives 30
How the VBHC change initiatives are managed 33
Guidelines to Successfully Implement VBHC 34
Awakening phase 34
Mobilisation phase 36
Acceleration phase 38
Institutionalisation phase 39
Limitations and Suggestions for Future Research 41
Practical Implications 42
Conclusion 42
ACKNOWLEDGEMENTS 44
REFERENCES 45
APPENDIX A: CODEBOOK 51
5 About a decade ago, Porter (2009) had a novel vision for how health care should be organised, called Value-Based Health Care (VBHC). Porter (2010) pleads that the focus in health care has to be on efficiently creating value, defined around patients. Value refers to the outcomes achieved per unit of cost (Porter, 2008; 2010). Accordingly, the ultimate goal of VBHC is efficiently achieving good outcomes (Porter, 2009; Porter & Lee, 2013). While this vision has been around for over a decade, VBHC is still far from being the status quo. The implementation of VBHC is a complex endeavour. Consequently, the reason (why), content (what), and process (how) of the change to VBHC need to be well-developed. The goal of VBHC and the content of VBHC are clearly articulated, namely creating value (Porter, 2008) and the “value agenda” (Porter & Lee, 2013). However, no advice is given on how to change to VBHC. Nonetheless, the process of change requires careful thought and planning (Deszca, Ingols, & Cawsey, 2019). Although the concept has received a continuously growing interest in both literature (Fredriksson, Ebbevi, & Savage, 2015) and practice (Moriates & Valencia, 2019), little is known about the implementation of VBHC from a change management perspective. Establishing a clear overview on what we know about the implementation of VBHC in the past decade will help shape future VBHC change processes to be more effective and efficient.
Addressing what needs to change to ensure VBHC, Porter and Lee (2013) proposed a strategic agenda for the implementation of VBHC, the “value agenda”, consisting of six interdependent yet mutually reinforcing components. When advancing these six components together, change progress towards VBHC will be “easiest and fastest” (Porter & Lee, 2013, p. 53). Firstly, care should be organised into integrated practice units (IPUs) (Porter & Lee, 2013), which are multidisciplinary teams with all the necessary skills and specialties for a medical condition (Porter, 2008). “Care should be organized
around the way value is actually created” (Porter, 2008, p. 504), demanding IPUs that provide the total
6 Ever since VBHC was introduced by Porter, it has received growingly scholarly interests (Fredriksson et al., 2015). Consequently, previous studies have reviewed literature on VBHC, or elements thereof. For example, multiple review studies have focused on the development or the use of Patient-Reported Outcome Measures (PROMs) (e.g. Faraj et al, 2017; Kim et al., 2018; Lagendijk et al., 2019; Younossi, 2018). Furthermore, specific financial incentives and payment systems connected to VBHC have been reviewed (e.g. Cattel & Eijkenaar, 2019; Keel, Savage, Rafiq, & Mazzocato, 2017; Lansky, Nwachukwu, & Bozic, 2011; Scott, Liu, & Yong, 2018), as well as the impact of certain strategies that could be a method for VBHC, such as the centralisation of cancer care (Williams et al., 2019). Other reviews have attempted to develop frameworks for the implementation of VBHC or for value measurement in a specific discipline (Hamid, Nwachukwu, & Ellis, 2014; Teckie, McCloskey, & Steinberg, 2014), or have focused on the role of specific stakeholders, for example patients (Kamal, Lindsay, & Eppler, 2018) or anaesthesiologists (Leissner, Shanahan, Bekker, & Amirfarzan, 2017). Lastly, reviewing the understanding of the VBHC concept in literature, Fredriksson et al. (2015) conclude that the VBHC concept is not understood at the required level, inferring that VBHC might be undergoing a process of dilution. All in all, a significant amount of research has been conducted to provide reviews related to the concept of VBHC, divided over different disciplines or different elements of the VBHC concept.
Simultaneously, the idea of VBHC has also been affecting health care practice during the past decade, as more and more hospitals start focusing on improving value (Moriates & Valencia, 2019). However, no comprehensive literature review on the implementation of VBHC from a change management perspective is available yet. While the theoretical idea might be well-argued, implementation is needed to reap the benefits of this idea. As no change approach is given by Porter, it is important to map what lessons can be learned from previous implementation efforts. Accordingly, this knowledge about the implementation can be used in continuing and initiating efforts of care providers to successfully change towards VBHC. Therefore, this research addresses the following research question: What is known about the implementation of Value-Based Health Care?
By conducting a scoping study, this research aims to systematically investigate the concept of VBHC implementation in the literature from a change management perspective by identifying and mapping the available empirical evidence on care providers’ implementation of VBHC. Moreover, the study aims to provide guidelines on how VBHC can be successfully implemented from a change management perspective. This study contributes to the growing field on VBHC by clearly exhibiting what is known about its implementation. Moreover, it contributes to the field of change management by gathering evidence on the change of a large economic sector based on a prominent theory without clear change management guidelines.
7 section will compare the results with Porter’s idea of VBHC and recent change literature, provide guidelines on how VBHC can be successfully implemented, reflect on this study’s limitations, discuss the practical limitations, and wrap up with the conclusion.
METHODOLOGY
In order to systematically investigate the practice of VBHC implementation in the literature, a scoping study is conducted. In this research the available empirical evidence on care providers’ implementation of VBHC is identified and mapped. As scoping studies are particularly useful when there is no comprehensive review on the body of literature yet (Peters et al., 2015), it fits to the emerging field of VBHC. Additionally, a scoping study is especially relevant in the field of patient care (Peterson et al., 2017), thus for the concept of VBHC. This study addresses three purposes of scoping studies, namely to identify the available evidence, to identify related key characteristics or factors, and to identify and analyse knowledge gaps (Munn et al., 2018).
To conduct the scoping study, the framework of Arksey and O’Malley (2005) was followed. This framework consists of five necessary steps, namely:
1. Identifying the Research Question
As the research question needs to be broad in order to address it with a scoping study (Arksey & O’Malley, 2005), this research was guided by the research question ‘What is known about the
implementation of VBHC?’. In addition to the research question, a clearly articulated scope of inquiry
was developed as advised by Levac, Colquhoun, and O’Brien (2010), namely empirical research on the implementation of VBHC by care providers.
2. Search for Relevant Studies
As a first step in the search for relevant studies, a database was created with all papers that cited one or more of the seminal papers of Porter about VBHC:
1. Porter, M. E. (2008). Value-based health care delivery. Annals of surgery, 248(4), 503-509; 2. Porter, M. E. (2009). A strategy for health care reform—toward a value-based system. New
England Journal of Medicine, 361(2), 109-112;
3. Porter, M. E. (2010). What is value in health care. New England Journal of Medicine, 363(26), 2477-2481;
4. Porter, M. E., & Lee, T. H. (2013). The strategy that will fix health care. Harvard business review, 91(10), 1-19.
8 and 2009 were chosen to ensure that implementation efforts before the trendsetting articles would also be included.
For all four studies, the cited-by list was collected on the 22nd of April 2020 from two databases: Scopus and Web of Science. These databases are comprehensive and have a broad coverage of disciplines, containing both medical and managerial journals relevant for this study. This resulted in an excessive number (n = 3512) of articles which were not feasible to screen one by one. Therefore, the choice was made to conduct a “search within results” on the word “implementation”. This search contained a search within the topic of the articles. As the focus of this scoping study is the implementation of VBHC, this was a logical choice. The list of search results was filtered on the language “English” and type of document “article”, (n = 877).
Each list of cited-by articles was exported to the web-based bibliographic manager RefWorks Legacy. Within RefWorks Legacy, the exact duplicates were searched and deleted after which the close duplicates were also targeted. For the close duplicates, each proposed duplicate was double checked and consequently deleted when it was indeed a match with another reference. The remaining articles (n = 596) were retained for the selection phase.
To investigate whether surely relevant articles on the implementation of VBHC were included in the sample, an additional search was conducted on Scopus and Web of Science for the concepts "value-based healthcare" or "value-"value-based health care", combined with "implementation" or "initiative". Sorting the results by the most recent and by the most cited articles, the articles on the first page that were deemed relevant were selected. Comparing with the sample, each of these was included in the current list, indicating that the sample included the most relevant articles.
3. Selecting Studies
The list of references was exported to Microsoft Excel for screening. To select the relevant studies, all found articles (n = 596) were screened on title and abstract. To be deemed relevant for this research, the literature needed to address the concept of VBHC implementation and needed to consist of empirical research. Consequently, the articles were first screened on the type of study, excluding all studies that were not empirical. When a study was empirical, attention was paid to whether the study reported on the implementation of VBHC.
9 VBHC-related element, for example the development of outcome measures, was not deemed relevant for this study about the implementation of VBHC more broadly.
4. Charting the Data
A list of study characteristics to extract was developed before the charting of the data. The included articles were imported to a new Microsoft Excel spreadsheet, after which the following characteristics were extracted from the full-text articles: author(s), year of publication, title, journal, aim or purpose, concept studied, number of studies included, types of study design or approach, country where the study is conducted, discipline in which the study is conducted, and key findings.
5. Collating, Summarising and Reporting the Results
Considering the descriptive numerical summary, the spreadsheet with study characteristics was copied into an overview table. For the thematic content analysis, the full-text PDFs of the articles were imported to the software program for data analysis ATLAS.ti, in order to enable a structured coding process.
The coding process started by in vivo coding of text fragments that were deemed relevant in the first ten documents, in order to get an idea on what data would arise in the articles. Consecutively, the coded text fragments were revisited and inductive and deductive coding was applied. Each text fragment was attributed to a code consisting of two parts. These started with “why”, “what”, “how”, or “outcomes”, followed by a more precise description of the situation. The why, what, and how were chosen in a deductive manner following change management literature. In addition, when a text fragment related to one of Porter & Lee (2013)’s six components, these were deductively coded in the second part of the code accordingly. As implementing one of the six components can be seen as the “what” of change, all except one were labelled as “what”. The component of an enabling IT system corresponds more with how a change is implemented, hence, text fragments on enabling IT were coded for the first part as “how”. Furthermore, the code-start “outcomes” and the other more precise descriptions were coded in an inductive manner. As multiple barriers to changing to VBHC became visible throughout the coding process, a separate inductive code for this category was created.
After all the interesting fragments were coded, reflection took place on which code a fragment belonged to. Fragments were relocated to codes they fitted most, resulting in 48 codes. Subsequently, codes were grouped in new “why”, “what”, “how”, “outcome”, and “barriers” categories, to sort for the thematical elaboration. The codebook in appendix A gives an overview of the categories and code groups, in which the underlying codes are also included when this distinction is of importance.
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RESULTS
The following paragraphs will outline the findings of this scoping study. First off, the search and selection of the scoping study is elaborated upon with the numbers of articles considered in each step of the process. Thereafter, the general characteristics of the included studies are discussed, exhibiting, amongst others, the time frame in which the studies were conducted. Following the aim of this study, an objective overview is provided on what is discovered about the implementation of VBHC in the included articles. The findings are thematically grouped following the why, what, how, outcomes, and barriers of the change to VBHC.
Search and Selection of Scoping Review
The search conducted in April 2020 with the filter on “implementation” yielded a total of 1297 articles, of which 978 came from the Scopus database and 319 from Web of Science database. After filtering the articles for the language “English” and document type “article”, 616 articles remained from the Scopus list and 261 remained from the Web of Science list. After deduplication of the combined sets of articles 569 articles sustained. Succeeding both screening rounds, 26 articles remained for full-text assessment. Two articles could not be procured through institutional credentials. A request was sent to the authors to provide the article. However, no response came within the timeframe of this study, leading to the exclusion of these two articles from this research. Consequently, 24 articles remained for qualitative synthesis. An overview on the search and selection process can be found in figure 1.
General Characteristics of Included Studies
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Table 1.
Overview of included studies and their general characteristics.
Authors Year of
publication
Title Journal Discipline Country of
study conduct
Types of study design/ approach
Concept studied Aim/purpose Key findings
Bernstein et al. 2018 Evaluation of a Preoperative Optimization Protocol for Primary Hip and Knee Arthroplasty Patients
Journal of Arthroplasty
Orthopaedics USA Retrospective
study
Implementation of a TJA preoperative optimisation protocol
To evaluate the implementation of the optimization protocol developed for patients undergoing primary lower extremity TJA in an urban acute care hospital, and its effect on clinical and financial outcomes.
Evidence-based preoperative optimization program resulted in higher value care (similar outcomes with lower resource utilisation).
Chatfield, Longenecker, Fink, & Gold
2017 Ten CEO
Imperatives for Healthcare Transformation: Lessons from Top-Performing Academic Medical Centers Journal of Healthcare Management Health care management
USA Data envelopment
analysis, on-site semi-structured interviews Key imperatives in achieving system-wide healthcare transformations To identify top-performing healthcare institutions and ask the CEOs about their imperatives for achieving system-wide transformation.
10 clear imperatives essential for achieving system-wide healthcare transformation.
Colldén & Hellström 2018 Value-based healthcare translated: A complementary view of implementation BMC Health Services Research Health care management | Psychiatry
Sweden Longitudinal case
study
Two-year implementation of the Management Innovation Value-Based Health Care (VBHC) to a psychiatric department in a large Swedish hospital
To investigate how a translation theory perspective can inform the Consolidated Framework of Implementation Research (CFIR) to increase understanding of the complex process of putting MIs into practice.
2 themes for which CFIR did not explain the findings: intervention characteristics were modified along the process, and the process did not follow predefined plans. Also, translation theory can complement research on implementation and the CFIR framework.
Dundon et al. 2016 Improvement in
Total Joint Replacement Quality Metrics Year One Versus Year Three of the Bundled Payments for Care Improvement Initiative Journal of Bone and Joint Surgery-American Volume
Orthopaedics USA Comparison of
quality and cost metrics
Effects of Bundled Payments for Care Improvement initiative after 1 vs. 3 years
To compare year-1 and year-3 results of the BPCI program with respect to hospital LOS; discharge to inpatient facilities; 30, 60, and 90-day readmission rates; and the cost of the episode of care.
The institution improved the overall quality of care, lowered readmission rates, and decreased episode-of-care costs by year 3 of
implementation of the BPCI program. Value-based alternative payment models can be successful in reducing cost while maintaining or even improving quality for total joint
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publication study conduct design/ approach
Ebinger et al. 2018 Value-based
ST-segment-elevation myocardial infarction care using risk-guided triage and early discharge
Circulation: Cardiovascula r Quality and Outcomes
Cardiology USA Retrospective
application; Prospective application; quantitative analysis Impact of STEMI risk score, implemented to increase value
1. To determine the impact of risk-guided STEMI care on value through a retrospective comparison of actual costs with estimated costs. 2. To evaluate the impact of an electronic medical record–integrated risk calculator for the identification and standardised care of low-risk patients after successful treatment prospectively.
Lower costs and reduced length-of-stay for both retrospective and prospective cohorts. Applying risk-guided care safely reduces costs (improved clinical efficiency and low complication rate), improving the value of STEMI care.
Glotzbach et al. 2018 Value-driven cardiac surgery: Achieving "perfect care" after coronary artery bypass grafting Journal of Thoracic and Cardiovascula r Surgery
Cardiology USA Retrospective
observational analysis; Linear regression analysis; Multivariate analysis The implementation of a value-driven outcomes tool in post-operative care.
To determine if the implementation of a value-driven outcomes tool comprising modifiable quality and utilisation metrics lowers cost and improves value of coronary artery bypass grafting (CABG) post-operative care.
"Perfect care" achieved in 65.1% of the patients. Negative relationship between costs and percent compliance with "perfect care". Quality and utilisation metrics can help promote quality and decrease costs, thus increase value.
Goretti, Marinari, Vanni, & Ferrari 2020 Value-Based Healthcare and Enhanced Recovery After Surgery Implementation in a High-Volume Bariatric Center in Italy Obesity Surgery
Bariatrics Italy Observational
study Implementation of Value-Based Model in ERAS to increase patients' engagement and adherence.
To demonstrate the feasibility of applying a Value-Based Healthcare (VBHC) strategy associated with ERAS to increase patients’ engagement and outcomes.
Building a caring relationship by a
multidisciplinary team, adding patient wellness in a VBHC framework on top of ERAS as a patient-centered approach, increases patients’ engagement and adherence to the pathway of care, resulting in better health outcomes (clinical and PROMs). The Value-Based Model is sustainable and replicable.
Gorman et al. 2019 Does Value Matter
in Orthopaedic Trauma?: A Survey of Orthopaedic Trauma Association Members Journal of orthopaedic trauma Orthopaedic trauma USA Systems-based survey study Perceptions of VBHC
To examine the perceptions of value-based care among orthopaedic traumatologists and how they influence their practice.
14
Authors Year of
publication
Title Journal Discipline Country of
study conduct
Types of study design/ approach
Concept studied Aim/purpose Key findings
Low et al. 2017 Transitional home
care program utilizing the integrated practice unit concept (THC-IPU): Effectiveness in improving acute hospital utilization International Journal of Integrated Care Transitional care Singapore Retrospective cohort study Implementation of IPUs in transitional care
To evaluate the effectiveness of a Transitional Home Care program that applied the IPU concept in reducing readmission and in improving acute hospital utilisation. Also, to identify patient subgroups that will benefit maximally from the THC-IPU program.
Patients within the THC-ICU program were less likely to be readmitted within 30 days, and had lower Emergency Department attendance rates within 30 until 90 days after discharge. The program was especially effective for patients with a higher risk of readmission.
Makari-Judson, Hubbard, & Wrenn 2013 Use of survivorship care plans to re-engineer breast cancer follow-up Open Breast Cancer Journal
Oncology USA Observational
study
Impact of Survivorship Care Program
To demonstrate the use of Survivorship Care Plans (SCPs) to coordinate follow-up in a multidisciplinary practice and improve access to breast surgeons.
SCPs were useful in re-engineering follow-up habits of clinicians, adding value to each visit and gaining acceptance from established patients regarding recommended surveillance. SCPs contributed to reduced wait times and increase in volume of new patients seen by breast surgeons. McCray, Grobmyer, & Pederson 2017 Impact of valuebased breast cancer care pathway implementation on pre-operative breast magnetic resonance imaging utilization Gland Surgery
Oncology USA Retrospective
review
Effect of BC care paths on pre-operative MRI utilisation
Determine the impact of BC care paths on pre-operative MRI utilisation.
Implementation of online BC care paths was associated with a decreased use of pre-operative MRI overall and in patients without a BC care path indication, driving value based care through the reduction of pre-operative breast MRIs.
McLaughlin, Buxey, Chaw, & Martin 2014 Value-based neurosurgery: The example of microvascular decompression surgery Journal of neurosurgery
Neurology USA Retrospective
review
Impact of coordinated implementation of processes across the episode of surgical care on value of neurosurgical care
To assess the impact of implementing a comprehensive bundle of perioperative and intraoperative care improvement processes on the overall clinical value of Microvascular decompression.
Comprehensive implementation of improvement processes throughout the continuum of care resulted in improved global outcome and greater value of delivered care.
Mittal et al. 2018 ValuedCare
program: A population health model for the delivery of
Journal of Orthopaedic Surgery and Research
Orthopaedics Singapore Non-randomised
historical controlled study
Impact of
ValuedCare program
To test a population health program which could implement multiple evidence-based practices across the continuum of care.
15
publication study conduct design/ approach
evidence-based care across care continuum for hip fracture patients in Eastern Singapore Nabhani et al. 2016 Cost Analysis of
the Enhanced Recovery After Surgery Protocol in Patients Undergoing Radical Cystectomy for Bladder Cancer European Urology Focus
Urology USA Resource-based
cost analysis
Implementation of the ERAS protocol
To evaluate the ERAS protocol for 30-day global costs relative to standard management in the era immediately preceding the initiation of ERAS for RC.
Implementation of ERAS protocol leads to reduced costs. Nilsson, Bääthe, Andersson, & Sandoff 2017a Value-based healthcare as a trigger for improvement initiatives Leadership in Health Services Health Care Management Sweden Explorative interview study Experiences of improvements resulting from VBHC implementation
To gain a deeper understanding of VBHC when used as a management strategy to improve patients’ health outcomes.
VBHC worked as a trigger for initiating processes, measurements, and patients' health outcomes improvements. To implement and sustain improvements, it is important to establish awareness of the need for improvements and to motivate changes not just among managers and clinical leaders directly involved in VBHC projects but also engage all other staff providing care. Nilsson, Bääthe, Andersson, Wikström, & Sandoff 2017b Experiences from implementing value-based healthcare at a Swedish University Hospital - a longitudinal interview study Bmc Health Services Research Health Care Management Sweden Explorative interview study Experiences from implementing VBHC
To explore how representatives of four pilot project teams experienced implementing VBHC over a period of 2 years
Value for the patients is the fundamental drive for implementing VBHC. However, there were multiple understandings of the value concept. Coordination, cooperation and inter-departmental teamwork was critical.
Nilsson, Bääthe,
2018 The need to
succeed: learning experiences resulting from the
Leadership in Health Services Health Care Management Sweden Explorative interview study Learning
experiences from the
To explore learning experiences from the two first years of the implementation of VBHC
16
Authors Year of
publication
Title Journal Discipline Country of
study conduct
Types of study design/ approach
Concept studied Aim/purpose Key findings
Andersson, & Sandoff implementation of value-based healthcare implementation of VBHC
development-oriented leadership with power of decision.
Nuti, Noto, Vola, & Vainieri
2018 Let's play the
patients music: A new generation of performance measurement systems in healthcare Management Decision Health Care Management
Italy Longitudinal case
study The re-framing process of a new performance measurement system.
To investigate the development of performance measurement systems that can assess the population-based value creation process across multiple healthcare organizations while adopting a patient-based perspective.
Re-framing PMSs contributes to re-focusing stakeholders’ perspective toward value creation; legitimizes organizational units specifically aimed at managing transversal communication, cooperation and coordination; supports the alignment of professionals’ and organizations’ goals and behaviours; and fosters shared accountability among providers. Pelt, Erickson, Gililland, & Peters 2018 Adding Value to Total Joint Arthroplasty Care in an Academic Environment: The Utah Experience Journal of Arthroplasty
Orthopaedics USA Care pathway
redesign
To describe the experience in adding value to joint arthroplasty care at the University of Utah.
Real-time data and knowledgeable personnel, engaged physicians, investment in money and resources, and alignment of providers, payers, and hospital administration can help lead to improvements and the successful implementation of value creation and care pathway redesign. Robinson et al. 2017 Measuring the Value of a Clinical Practice Guideline for Children with Perforated Appendicitis Annals of Surgery Paediatric Surgery USA Retrospective review Clinical outcomes and costs of clinical practice guideline
To determine the incremental cost-effectiveness of a clinical practice guideline (CPG) compared with ‘‘usual care’’ for treatment of perforated appendicitis in children.
An evidence-based CPG increased the value of surgical care for children with perforated appendicitis by improving outcomes and lowering costs.
Russell et al. 2014 Optimal utilization of a breast care advanced practice clinician American Journal of Surgery
Oncology USA Incorporation of
"lean" business philosophy to role of APCs.
To broaden the Advance Practice Clinician (APC) scope of practice.
Using a lean philosophy in the APC breast clinic leads to added value in patient care.
Van Den Berg, Dijksman, Keus, Scheele, & Van Pampus 2020 Value-based health care in obstetrics Journal of evaluation in clinical practice Obstetrics The Netherlands
Comparison study Development and impact of a practical outcome set
To demonstrate a practical approach to VBHC for obstetrics and demonstrate what is necessary to learn through benchmarking.
17
publication study conduct design/ approach
Continuous monitoring of outcomes and expanding the set of outcomes that is readily available are key in the process towards value‐ based care provision.
van Veghel et al. 2020 Organization of outcome-based quality improvement in Dutch heart centres European Heart Journal - Quality of Care and Clinical Outcomes Cardiology The Netherlands Mixed-methods (interviews and surveys) Implementation of patient-relevant outcome measures.
To evaluate the current state of outcome-based quality improvement within six Dutch heart centres.
The predominant focus of the heart centres is on the actual monitoring of outcomes. A systematic approach for the identification of improvement potential and the selection and implementation of improvement initiatives is lacking. The organizational context for outcome-based quality improvement is similar in the six heart centres.
Zipfel et al. 2019 The
implementation of change model adds value to value-based healthcare: A qualitative study BMC Health Services Research Cardiology The Netherlands
Case study Implementing
VBHC with versus without a systematic implementation method.
1. To investigate the implementation of improvement initiatives in the context of VBHC. 2. To explore how implementation science could be of added value for VBHC and vice versa.
Outcome measures were seen as an important starting point for the implementation and for monitoring change. Several themes were identified as most important: support, personal importance, involvement, leadership, climate and continuous monitoring. Success factors included intrinsic motivation for the change, speed of implementation, complexity and continuous evaluation.
Why VBHC is Implemented
Concerning why a VBHC-related initiative is implemented, arguments for the goal of the change, the reasons for the change, and the need for a shared vision have been found in 21 of the studies. An overview of which factors are addressed in each of the studies can be found in table 2.
For the goal of the change, the general idea to improve care was mentioned the most. Most of the other mentioned goals were related to increasing cost efficiency, such as to improve utilisation rates or reduce costs of care. Two articles expressed different goals, namely relating to identification of improvement areas (Van Den Berg et al., 2019) and the standardisation of care (Bernstein et al., 2018).
Three main forces were identified as reasons for change. In some articles, implementing VBHC seemed to be mostly a top-management decision. In other articles, it became clear that the studied organisation followed in the footpaths of other organisations who were focussing on VBHC. In the last group of articles, institutional pressures were the predominant force for change, for instance when a bundled payment system was implemented (Dundon et al., 2016) or when regulatory requirements were demanding change (Robinson et al., 2017).
The goal and reason for change should not only be acknowledged by top-management, instead, a shared vision should be dispersed throughout the organisation. This need for a shared vision is addressed in four of the included articles. The change initiative’s project team members should have a shared vision, together with a common language and shared toolkit for change (Chatfield et al., 2017). Having the common goal of creating value increases the willingness of working according to VBHC (Nilsson et al, 2017b). Leadership and the modelling of behaviour, which will be further elaborated upon in the how-section, can help establish this needed shared vision (Chatfield et al., 2017).
19
Overview studies addressing why-factors.
What is Implemented
In regard to what was changed relating to VBHC, six types of changes were found in 21 of the articles (table 3). The majority of the articles implemented some type of IPU, explaining that care is organised by multidisciplinary teams in their case. Moreover, half of the articles expressed that new outcome measures were established. Another frequently mentioned element was the coordination of care. The institutionalisation of the last three contents of change were mentioned to a lower degree, being bundled payment, risk assessment, and the spread of services across geography.
Outcome measures. Of the five different types of outcome measures that were applied (table 4), the implementation of costs outcome measures and general outcome measures were mentioned the most. In the cases of general outcome measures, it was not made explicit what the outcome measures would exactly entail at that point. Furthermore, only six articles specified that (a part of) the measures that were implemented were patient-centric.
All in all, the content of the change was focused on different components of VBHC (bundled payment, IPU, services across geography, and outcome measures) as well as care coordination and risk assessment. The implementation of care coordination or risk management were viewed as a possible strategy to enhance value, as both were in most cases associated with improved outcome measures. Even though different components of VBHC were implemented, one can question the extent to which VBHC is truly implemented in the included studies. While the content of change often focused on the implementation of outcome measures and multidisciplinary teams, other components of VBHC such as
Goal: Improve care Goal: Increase cost efficiency Goal: Other Reason: Follow others Reason: Institutional pressures Reason: Top-management decision Need for a shared vision Bernstein et al. (2018) x x x Chatfield et al. (2017) x x
Colldén & Hellström (2018) x x
Dundon et al. (2016) x x x Glotzback et al. (2018) x Goretti et al. (2020) x Gorman et al. (2019) x Low et al. (2017) x x Makari-Judson et al. (2013) x McCray et al. (2017) x McLaughlin et al. (2014) x x Mittal et al. (2018) x Nilsson et al. (2018) x
Nilsson et al. (2017a) x x
Nilsson et al. (2017b) x x
Nuti et al. (2018) x x
Pelt et al. (2018) x x x
Robinson et al. (2017) x
Russell et al. (2014) x
Van Den Berg et al. (2019) x
Zipfel et al. (2019) x x x
20 the bundled payment or services across geography were often forsaken. Moreover, while the outcomes element of value is supposed to be patient-centric, most studies only addressed costs or clinical outcomes. As not one VBHC initiative implemented all six components, one could conclude that none of the initiatives implemented the complete concept of VBHC.
Table 3.
Overview studies addressing what-factors. Bundled payment Care coordination IPU Risk assessment Services across geography Outcome measures Bernstein et al. (2018) x x
Colldén & Hellström (2018) x x
Dundon et al. (2016) x x x Ebinger et al. (2018) x Glotzback et al. (2018) x Goretti et al. (2020) x x Low et al. (2017) x x Makari-Judson et al. (2013) x x McCray et al. (2017) x x McLaughlin et al. (2014) x x x Mittal et al. (2018) x x x x Nilsson et al. (2018) x
Nilsson et al. (2017a) x x
Nilsson et al. (2017b) x x
Nuti et al. (2018) x x
Pelt et al. (2018) x x x x
Robinson et al. (2017) x x
Russell et al. (2014) x x
Van Den Berg et al. (2019) x
van Veghel et al. (2020) x x
Zipfel et al. (2019) x
Total: 2 10 13 3 3 12
Table 4.
Overview studies addressing implementation of outcome measures. General outcome measures Clinical outcome measures Costs outcome measures Patient-centric outcome measures
Quality & utilisation outcome measures
Colldén & Hellström (2018) x x x
Glotzback et al. (2018) x x
Goretti et al. (2020) x x
McLaughlin et al. (2014) x
Mittal et al. (2018) x x
Nilsson et al. (2017a) x x
Nilsson et al. (2017b) x x
Nuti et al. (2018) x x x x x
Pelt et al. (2018) x x
Robinson et al. (2017) x x
Van Den Berg et al. (2019) x
van Veghel et al. (2020) x
21 When implementing a VBHC-related initiative, there are several areas that deserve attention while deciding on how to implement it. Six areas of attention are identified in the studies, namely communication, creating incentive, involvement, support, team alignment, and execution (table 5).
Table 5.
Overview studies addressing how-factors.
Communication Create
incentive
Involvement Support Team
alignment
Execution
Bernstein et al. (2018) x x x
Chatfield et al. (2017) x x x x x
Colldén & Hellström
(2018) x x Ebinger et al. (2018) x x Glotzback et al. (2018) x x Goretti et al. (2020) x x x x x Gorman et al. (2019) x Low et al. (2017) x x x Makari-Judson et al. (2013) x McCray et al. (2017) x McLaughlin et al. (2014) x x x x x Mittal et al. (2018) x x x x x x Nabhani et al. (2015) x Nilsson et al. (2018) x x x x x
Nilsson et al. (2017a) x x x x x
Nilsson et al. (2017b) x x x x x x
Nuti et al. (2018) x x
Pelt et al. (2018) x x
Robinson et al. (2017) x
Russell et al. (2014) x x x
Van Den Berg et al.
(2019) x
van Veghel et al. (2020) x x x
Zipfel et al. (2019) x x x x x x
Total: 10 18 11 16 9 7
Communication. To successfully transform a health care organisation, continuous and effective communication is crucial. Frequent (multidisciplinary) team meetings can be used to communicate about the change, for example to visualise the goals (Chatfield et al., 2017) or reflect on results (Mittal et al., 2018). Communication and cooperation are needed between employees (Nilsson et al., 2017a), departments (Nilsson et al., 2017b), different levels in the organisation, and with the patients (Goretti et al., 2020). Effective communication is the underlying factor for successful change.
22 extrinsic motivation (e.g., through making physicians’ adherence to protocols an item of their salary (Ebinger et al., 2018) or gainsharing through funds to divisions (Pelt et al., 2018)) could be powerful, intrinsic motivation should not be underestimated either. The study from Zipfel et al. (2019) shows that when individuals have the intrinsic motivation to change through a feeling of personal relevance of the change, the implementation process improves. In addition, when a change is implemented because another health care institution implemented it, this could actually have a negative influence on the success of the change through social pressure (Zipfel et al., 2019). Therefore, it is important to make a well-thought decision regarding how to motivate the employees.
Incentive could be created through monitoring. In reporting the results, transparency is key. Results should be shared with everyone involved and progress needs to be discussed in dedicated meetings (Goretti et al., 2020) to enable the change process to move forward (Nilsson et al., 2018). By reflecting on the outcomes areas of improvement can be identified (Van Den Berg et al., 2019) and the visualisation of undesired outcomes can create willingness to change through people’s pride and morale (Chatfield et al., 2017).
Five studies showed another way to increase compliance to change, namely through protocols (Bernstein et al., 2018; Ebinger et al., 2018, Glotzback et al., 2018; Nabhani et al., 2015; Robinson et al, 2017). Protocols enable compliance with new metrics (Glotzback et al., 2018) and the standardisation of risk assessment (Bernstein et al., 2018). However, compliance to protocols is still subordinate to improved outcomes (Ebinger et al., 2018). Therefore, while protocols can be used to increase compliance or incentive to change, they should not be the main goal.
Lastly, it is essential that success and goals are translated frequently. “Employees need to be able
to visualize the connection between each of their everyday activities and one or more of the organizational goals” (Chatfield et al., 2017, p. 379). When participants are unable to see results of their
efforts to change, engagement for VBHC decreases (Nilsson et al., 2017b). Moreover, before the change implementation, staff already needs to be engaged (Nilsson et al., 2018). Clearly formulating goals and translating success can thus aid in the successful implementation of VBHC.
Involvement. The involvement of all levels of the organisation is a recurrent theme in the studies. Chatfield et al. (2017) argue that strategy development and the planning process should include as many stakeholders as possible, crossing multiple levels. Similarly, Nilsson et al. (2017a) argue that change initiatives could be ineffective when not involving staff from multiple levels right from the start of the change to VBHC. Nilsson et al. (2018) show that when staff is engaged later in the process, this can result in difficulties. Employees had had to learn what VBHC was about at the same time as they were implementing it. Correspondingly, when involvement is lacking, this could lead to frustration and a less engagement with the initiative (Zipfel et al., 2019). Therefore, the entire workforce should be involved from the start of the change to VBHC.
23 uninvolved. Discrepancies between the providers’ perceptions of value delivered and the value experienced by patients (Nilsson et al., 2017b) show that patients have a role to play in determining what value is about. Hence, patient representatives should be invited to the discussion, in which questions relevant to the representatives should be discussed (Nilsson et al., 2017b). Yet, the engagement of patients can be difficult. Patients are not a homogeneous group and representatives talk from their own point of view (Nilsson et al., 2018). In addition, often the voice of medicine is stronger than the voice of the patient representatives (Nilsson et al., 2017b). Even though patient involvement can be challenging, it can be valuable for implementation of VBHC.
Support. Support for the change can be shown and materialised through multiple means. Support should be made visible through leadership, the modelling of behaviour, a supportive culture. Furthermore, it can to be materialised through empowering the front line and making resources available, especially an enabling IT system.
Leadership and the leader’s commitment to VBHC are key factors in successful change to VBHC. Success of a change is “a product of how the organization is led” (Chatfield et al., 2017, p. 380). Leadership should be dedicated, development-oriented, have the power to make decisions (Nilsson et al., 2018), and be clearly appointed, as ambiguity on who is responsible for the outcomes could result in a lack of uptake of the initiative (Zipfel et al., 2019). Furthermore, leaders should model the desired behaviour while managing the department (Chatfield et al., 2017), being the most enthusiastic about the VBHC initiative (Nilsson et al., 2018). Thus, the commitment to VBHC needs to be evidently expressed by leaders in the health care organisation.
Alongside committed leadership, having a culture supportive of change will also contribute to the success of the organisational change. A high-reliability learning culture is an imperative for organisational transformation (Chatfield et al., 2017). Creating trust through transparency, this no-blame culture propagates continuous learning, critical thinking, and sharing knowledge throughout the organisation (Chatfield et al., 2017). Similarly, a positive climate was found to be important for successful change (Zipfel et al., 2019). However, van Veghel et al. (2020) observed that such a culture existed within specialties, but not across specialties. Accordingly, constant efforts should be invested in the development and maintenance of a supportive culture throughout the entire care organisation.
24 accessible at all times (e.g. Ebinger et al., 2018; Low et al., 2017; McCray et al., 2017; Pelt et al., 2018). To conclude, sufficient resources should be provided to implement VBHC, with special attention to an enabling IT system.
Team alignment. It is essential to ensure that the efforts to change to VBHC are made in teams. Health care is “the ultimate team sport” (Chatfield et al., 2017, p. 376). Multiple studies expressed that the implementation of VBHC was targeted by project teams (e.g. McLaughlin et al., 2014; Mittal et al., 2018; Nilsson et al., 2018). Nonetheless, ensuring that the change is considered to be teamwork is not enough. Van Veghel et al. (2020) expressed issues arising from ambiguities in roles and responsibilities. Hence, the roles and responsibilities of each team member should be clearly communicated. Changing to VBHC should be targeted in teams which are in unison regarding the vision for change, as discussed earlier, and the roles and responsibilities.
Execution. Concerning the actual execution of the change to VBHC, two main themes emerged: the use of consultancy and the development or absence of a change plan.
Consultancy was used to start the implementation of VBHC in four studies (Colldén & Hellström, 2018; Nilsson et al, 2017a; 2017b; 2018). However, inconveniences can be experienced in working with consultants. The study by Nilsson et al. (2017b) showed that care providers perceived working together with consultants as time pressuring. Accordingly, consultancy can be used to aid the start of changing to VBHC, although enough resources should be provided to reap the benefits.
While a change plan is important, very few studies elaborated on a plan concerning the implementation of VBHC. In most cases, authors just mentioned that the initiative was rolled out in phases (e.g. Colldén & Hellström, 2018; Mittal et al., 2018). Analysing the effects of absence or presence of an implementation model, Zipfel et al. (2019) observed that the use of an implementation model resulted in a better uptake of and more positive experience on the change and developed the Integrated Implementation Model to be used for quality improvement interventions, such as VBHC. Nonetheless, the presence of a change plan does not ensure success either. In one case, the plan was actually adapted throughout the change process, ending up with only a partial implementation of VBHC (Nilsson et al, 2017b). Meanwhile, in another case, management’s plan failed in its execution phase (Colldén & Hellström). Furthermore, although planning and preparation before the launch of the implementation process are important (Pelt et al., 2018), Colldén and Hellström (2018) argue that an instrumental view of a pre-planned process does not always reap benefits. Clearly, a change execution plan should not be overlooked, or be considered unchangeable, yet it is barely discussed within the included studies.
25 on how implementation of VBHC can be approached the most successfully.
Outcomes of VBHC Implementation Efforts
Discussed elements relevant to the outcomes of the implementation efforts were classified along four categories: improved adherence to protocols, partial implementation, impression of VBHC, and improved outcome measures. Table 6 provides an overview of which studies discussed elements relevant to each category.
Adherence to protocols. When protocols are used as a means to change, the adherence to these protocols can be seen as a measure of the outcome of the change, as addressed in four included articles. Increased adherence was linked to reduced costs (Glotzback et al., 2018; Bernstein et al., 2018) and to a shorter length-of-stay of patients in the hospital (Goretti et al., 2020). Implementing VBHC can also affect adherence to protocols of existing programs. The study by Pelt et al. (2018) showed that implementation of VBHC in an enhanced recovery after surgery (ERAS) program increased the patients’ adherence to the ERAS program.
Partial implementation. Four analysed studies explicitly stressed themselves that only a part of the original change plan, or only a part of the VBHC concept, was implemented. Colldén and Hellström (2018) argue that there was a lack of faithfulness to the original VBHC concept in their case. The VBHC initiative that was implemented was adapted throughout the change process, leaving as end product only improved measurements and a future vision to benchmark these against other health care centres. Similarly, in another study, in the end little attention was paid to measuring costs, making it debatable whether VBHC was actually implemented (Nilsson et al, 2017b). In addition, the VBHC initiative in one case studied by Zipfel et al. (2019) ended up being perceived as not value-adding and was consequently broken off. Lastly, Van Den Berg et al. (2019) disclose that they were unable to collect data on patient-centric outcomes, viewing this as a future target. The remaining twenty studies do not by any means comment on the extent to which the VBHC concept is implemented. Nonetheless, the four studies show that implementing VBHC is not always clear-cut.
26 care was about, value for the patient (Nilsson et al, 2017b), and was thus perceived very positively. Hence, perceptions on VBHC differ among cases.
Improved outcome measures. Improved outcomes were a common result of the change initiatives. Eighteen studies used the improvement of outcome measures as a means to determine the success of the change. What exactly was measured varied among articles (table 7). Four studies reported an improvement in outcomes and two reported improved performance, without specifying what kind of outcomes this pertains. Most of the studies reported reduced costs, which is linked to a reduced length-of-stay (LOS) (without an increase in mortality rate) in seven cases. Three other reported outcomes are also connected to lower costs, namely a lower rate of discharge, lower rate of readmission, and lower resource utilisation. More importantly, only four studies report some improvement in patient-centric outcomes. All in all, most studies reported improved outcomes, concluding that the change was successful.
Table 6.
Overview studies addressing outcome-factors. Adherence to protocols Partial implementation Impression of VBHC Improved outcome measures Bernstein et al. (2018) x x Chatfield et al. (2017)
Colldén & Hellström (2018) x x x
Dundon et al. (2016) x Ebinger et al. (2018) x x Glotzback et al. (2018) x x Goretti et al. (2020) x x Gorman et al. (2019) x Low et al. (2017) x Makari-Judson et al. (2013) x McCray et al. (2017) x McLaughlin et al. (2014) x Mittal et al. (2018) x x Nabhani et al. (2015) x Nilsson et al. (2018)
Nilsson et al. (2017a) x
Nilsson et al. (2017b) x x x
Nuti et al. (2018)
Pelt et al. (2018) x
Robinson et al. (2017) x
Russell et al. (2014) x
Van Den Berg et al. (2019) x
van Veghel et al. (2020)
Zipfel et al. (2019) x x
27
Overview studies addressing outcome measurements. Improved patient-centric outcomes Lower resource utilisation Improved performance Lower rate of discharge Lower rate of readmission Reduced costs Reduced LOS Improved general outcomes Bernstein et al. (2018) x x x
Colldén & Hellström
(2018) x Dundon et al. (2016) x x x x Ebinger et al. (2018) x Glotzback et al. (2018) x x Goretti et al. (2020) x x x Low et al. (2017) x x x Makari-Judson et al. (2013) x x McCray et al. (2017) x x McLaughlin et al. (2014) x x x x Mittal et al. (2018) x x Nabhani et al. (2015) x x
Nilsson et al. (2017a) x x x
Nilsson et al. (2017b) x Pelt et al. (2018) x x x x Robinson et al. (2017) x x x Russell et al. (2014) x Zipfel et al. (2019) x Total: 4 3 2 1 6 12 10 4
In sum, the dominant result of the change initiatives was improved outcomes, which could be expected since outcome measurement is one of the six core elements of VBHC. However, while over half of the articles that reported an improvement in their outcome measures showed a decrease in costs, only four reported improved patient-centric outcomes. Although outcomes show perceived success of change through adherence to protocols or reduced costs, it is questionable whether value was truly increased in the cases. In general, the conclusion that value was increased was drawn quickly when the established outcome measures improved, while either the cost or patient-centric outcomes were not adequately measured, barely knowing the total effect on value. Moreover, changes were not always found to be fully successful, as some studies reported a partial implementation.
Barriers to VBHC Implementation
28 addition, a lack of change management in general was also found to influence the successfulness of the change. Factors that could lead to poor change implementation are a lack of change management knowledge and practice (Nilsson et al., 2017a; van Veghel et al., 2020), of governance regarding roles and responsibilities (van Veghel et al., 2020), of a shared vision for change (Chatfield et al., 2017; Low et al., 2017), and of a change in behaviour (Makari-Judson et al., 2013).
All in all, the identified barriers show the importance of good change management when implementing VBHC. With a lack of general change management, a lack of shared vision, or a lack in support through resources it becomes difficult to successfully implement the VBHC concept. The importance of the enabling IT component of VBHC is certainly evident. In addition, the change to VBHC needs to be well-managed from developing a clear and shared need for change up to the anchoring of the change into the organisation’s everyday practice. A clear change approach with a shared vision should be developed and implementation should be supported through provision of the needed resources.
Table 8.
Overview studies addressing barriers to change to VBHC. Change management Lack of collection of patient-centric outcomes Lack of enabling IT Lack of shared need for change Lack of time Lack of transparency Lack of under-standing Chatfield et al. (2017) x x
Colldén & Hellström (2018) x Gorman et al. (2019) x x x Low et al. (2017) x x Makari-Judson et al. (2013) x Nilsson et al. (2018) x
Nilsson et al. (2017a) x
Nilsson et al. (2017b) x x
van Veghel et al. (2020)
x x
Total: 2 1 4 2 1 1 1
29 concept. This raises the question whether the VBHC idea from Porter is not too complicated for real-life care practice. Similarly, while important factors for the implementation of VBHC were found, the question on whether the change to VBHC is sufficiently managed in the included studies remains unanswered. Nevertheless, these findings give a comprehensive overview on what is known about the implementation of VBHC.
DISCUSSION & CONCLUSION
In this last section, the study’s results will be discussed, elaborating and reflecting on the main findings from a change management perspective. Moreover, guidelines are provided on how VBHC can be successfully implemented by applying the same perspective to the context of the healthcare transformation to VBHC. Subsequently, the practical implications specify this study’s contributions to practice. Lastly, this section will be wrapped-up with this study’s limitations, future research recommendations, and conclusion.
Principal Findings and Theoretical Interpretation
In accordance to the first aim of this scoping study, the results provide a comprehensive overview on what is known about the implementation of VBHC. Overall, 24 articles were identified through the search that focus on the implementation of VBHC, no study attempted to implement the complete VBHC concept, and the knowledge on how the VBHC change initiatives are managed is limited.
Number of identified articles. After screening almost 600 articles, only 24 articles were found to focus on the implementation of VBHC. While the key conceptual papers on VBHC are cited often, few studies seem to implement VBHC by improving value. There are two factors that might have contributed to this limited amount of studies on the implementation of this popular concept.
Firstly, a publication bias could play a role in the relatively limited publication on the implementation of VBHC. This bias assert that a role is played by the chance of getting published (Dickersin & Min, 1993). Hence, research on the implementation of VBHC that resulted in insignificant results might not have been presented to journals, leading to fewer papers in total.
30 of VBHC is still scarce. The findings support this explanation, as four years passed between the trendsetting article and the publication date of the primal published article included in this research. Not to mention that on average the included articles were published over eight years after the trendsetting article. Therefore, the short period of time that passed since the introduction of VBHC probably contributes to the limited amount of relevant studies included.
The content of the VBHC initiatives. While this study’s search was conducted to find studies focussing on the implementation of VBHC, no single study seemed to truly succeed in implementing the concept how Porter has intended it. Porter’s (2008; 2009) foremost argument is that the goal in health care practice should be completely focused on increasing value for the patient. Porter (2009) argues that the “only way to truly contain costs in health care is to improve outcomes” (p. 109), because “achieving
and maintaining good health is inherently less costly than dealing with poor health” (p. 109). Hence, to
increase value, good outcomes have to be efficiently achieved (Porter, 2009). While value is defined as the patient-centric outcomes per unit of cost spent (Porter, 2008), and thus incorporates efficiency (Porter, 2010), pursuing cost reduction should not be the objective (Porter, 2008; Porter & Lee, 2013). Porter (2008) argues that a focus on cost reduction creates a trap leading to increased costs in the end. In addition, without regard to outcomes, cost reduction is precarious and could lead to so-called “false savings” and limit the ability to reach effective care (Porter, 2010). Consequently, while costs are an inherent aspect of value, these should always be targeted or measured in combination with outcomes.
However, this study shows that the two are rarely combined. While most articles observed a reduction in costs, only two articles showed a combination of improved patient-centric outcomes and reduced costs. In addition, two other studies showed a combination of reduced costs with improved general outcomes. Only when the outcomes are combined, one can conclude whether there is an increase in value. Moreover, the outcome measures have to be patient-centric. Porter (2008) stresses that these measures should include three tiers of patient-centric outcomes, namely the attained health status, care-related outcomes, and the sustainability of the patient’s health. Although eight studies reported an improve in outcomes, only four studies show an improvement in patient-centric outcomes relating to Porter’s (2008) three tiers. As the outcome measurements of most studies do not include the three-tier elements of patient-centric outcomes and the outcome and cost measures are rarely measured both, drawing the conclusion that value is increased in these studies is relatively premature. Correspondingly, Nilsson et al. (2017b) already raise the question whether VBHC is really implemented in the initiative that they analysed, as cost measurements was more or less neglected. In sum, one can question the extent to which value is achieved in the included studies.
31 implementing VBHC, a great deal remains to be changed. Hence, the care providers in these initiatives might be on their way to VBHC yet are still far from the finish line regarding the implementation of the value agenda.
However, there is a clear need for the implementation of a fuller picture as especially the mostly forgotten component, enabling IT, appeared of importance in the studies. The need for enabling IT was mentioned in five studies and four studies expressed the encounter of a lack of enabling IT as barrier to change. However, the creation of such an enabling IT system was barely addressed and was never part of the planned content of the change. While the need for enabling IT was confirmed within this study, not one study’s initiative showed the intent to ensure an enabling IT system.
Observing that none of the VBHC initiatives in the studies are implementing the full concept, this raises the question why health care organisations fall short in doing so. Several factors might explain this shortcoming. Firstly, it might be caused by a lack of understanding of VBHC. When health care professionals perceive ambiguity regarding the VBHC concept, it is hard to change the work patterns accordingly. Accordingly, Gorman et al. (2019) reported a lack of understanding within the discipline they analysed. Furthermore, Nilsson et al. (2017b) stated that “there were multiple understandings of
the value concept” (p. 1). These findings add to prior research from Fredriksson et al. (2015), who
concluded that the understanding of the VBHC concept in literature is rather low and might even be undergoing a process of dilution by pointing to a similar lack of understanding in health care practice. This lack of understanding of the authentic concept can also enable managerial pragmatism. Attempts to change can result in business as usual through three stages in translation, namely framing, localising, and normalising (Wright & Nyberg, 2017). Nilsson et al. (2017b) observed such translation of the concept and concluded that “it is therefore debatable whether or not VBHC was really
implemented or whether it was just an inspiring concept” (p. 9). Furthermore, Colldén & Helmströng
(2018) argue that the value concept that VBHC is built upon is ambiguous, which makes it highly adaptable. Consequently, the label of VBHC could be adapted to any quality improvement projects when a manager would choose to, in light of subsidies or possibly a good image. The own interpretation of the VBHC concept leads to other improvement initiatives within the VBHC umbrella. While these initiatives might be beneficial for health care, these are not part of the VBHC concept. Hence, the managerial pragmatism through translation of the concept and labelling other improvement initiatives as VBHC could lead to no true change to VBHC.
