24-25 - VALUE-BASED HEALTHCARE - The importance of value when treating patients

We all know that feeling of dread: hearing your car begin to rattle as you drive it. It doesn’t have to be loud to indicate that something has gone wrong.

What would you do? As much as we might want to apply a quick fix and hope that solves the problem (like using sealant on a blown head gasket, for the car fanatics), I doubt many of us would willingly let the noise continue unchecked until the car breaks down completely – costing us far more in repairs than if we had visited the mechanic immediately. We choose to maintain our cars before they break down because it inevitably saves us time, stress and money.

Why then don’t we do the same in health? Healthcare models around the world face rising costs, and so are tempted to focus on short-term cost-savings. Due to this, many treatment protocols recommend ‘step therapy’ policies – where the cheapest treatments are prescribed first, and if these fail, are often followed by treatments that doctors do not necessarily want to prescribe, and which can be equally ineffective. It’s the same as the quick fix that keeps your car running but does not solve the underlying issue – and over time costs more than an initial thorough repair.

Healthcare models have urgently needed to save costs for a while now. The COVID-19 pandemic has only exacerbated this: simultaneously reducing the available funds to spend on long-term health, while delaying access to medicine for millions. This meant healthcare faced a massive demand for service, without the budget to fulfil it. This in turn can lead to poorer patient quality of life, and the continuous treatment of the symptoms, as opposed to the underlying causes, thereby exacerbating long-term issues.

For example, cost restrictions can heavily affect people with immunological issues, with newer treatment advances often restricted by insurance companies in favour of these ‘step therapy’ policies. Almost half of surveyed rheumatology patients reported that they were on a step therapy insurance policy. These cost restrictions have significant effects: people living with rheumatoid arthritis or psoriatic arthritis saw reduced treatment effectiveness and therapy adherence while on a step therapy programme compared with those without.

The VBHC model is based on the equation ‘value = patient health outcomes divided by health system cost’. This means giving the patient the best possible care from the start, while doing what we can to maximise efficiency and reduce long-term expenditure.

Fundamental to this approach is treating patients with the most effective treatments first. This is a clear example of the long-term benefits of VBHC: while initial short-term costs may be higher than simply providing the patient with less effective, cheaper treatments, in the long term the benefits far outweigh the costs. When patients return to better health faster, clinical benefits include avoiding the additional care and guidance costs of patients needing to switch treatment regimens, as well as less bed capacity used in hospital-care scenarios; additionally fewer days are taken off work, providing personal and societal benefits; and patient satisfaction is increased given faster and more efficient treatment.

Perhaps this sounds fantastical, but VBHC really is the first step towards these benefits. And what’s more, it has already been implemented in several healthcare systems – with promising results.

While still limited, VBHC uptake has been largely positive where reported: eg, the UK’s King’s Health Partners Science Centre, which implemented a number of VBHC practices into its methodology (such as optimising drug therapy by reducing high dose inhaled steroid use, and increasing referrals of patients to pulmonary rehabilitation) reported numerous improvements to care – including a 17% reduction in length of chronic obstructive pulmonary disease (COPD) patient stay, predicted savings of more than £2m in its Three Dimensions for Diabetes care and up to £2m in annual net savings in its orthopaedics care pathway.

In Europe, the Santeon group of private teaching hospitals in the Netherlands employed several value-based strategies starting in 2016 (adopting the same VBHC model in all seven of its hospitals to enable benchmarking and leverage combined expertise). In the 18 months after implementing its VBHC plan for breast cancer, Santeon saw re-operations due to complications reduced by up to 74% at some locations. Similarly, at the Netherlands Heart Registry, a non-profit organisation facilitating a VBHC programme for cardiac diseases from 2015-2017, the 120-day mortality for combined aortic valve disease and coronary artery disease dropped by 38% by creating a data registry that enabled a learning ecosystem and transparency across different providers. This has a significant impact on patients’ experience.
The Swedish healthcare system, which places a strong emphasis on value, uses bundled payments (paying healthcare facilities a single payment for one patient’s entire treatment episode of care), health registries and telemedicine to improve patients’ care experiences. An example of this is the Orthochoice programme for hip and knee replacements, which was, at launch in 2002, one of the first examples of a bundled payment system and was found to have improved both access to care and quality of care, while keeping costs down.

As individual case studies of VBHC multiply, it is time to think about the framework we need for further implementation. Much of the change we need to create requires a change of mindset in current thinking. For example, the first step on the road to VBHC is reaching a social consensus about the meaning of ‘value’ – and how important it should be to healthcare – and establishing a common language around high-value care.

Greater patient-centricity is another milestone we must reach on the road to achieving VBHC. To better provide value to patients while conserving costs, we need greater dialogue between patients and clinicians so that there will be clear understanding of patients’ needs, wants and priorities. This will help address the current discrepancies we see between the outcomes reported by clinics and those reported by patients. Different patients have unique, varied needs, and only by better understanding this can we truly create a VBHC system.

Immune-mediated inflammatory diseases (IMIDs) provide a good example here. Due to the nature of some chronic diseases, and people’s varying capacity to adapt to them, the impact of an IMID is unique for each patient. Because of this, and the need of many healthcare systems to prioritise cost over value, often the easiest symptoms to measure and track are treated – not necessarily those that matter most to a patient, or that treat the underlying disease. By better understanding how chronic diseases affect different patients and treating each patient as effectively and quickly as possible, we will create a healthcare system based on value, that works for the patient, not for the cost.

Finally, the measurement of best value must be taken into consideration. Healthcare organisations need to work together more in multidisciplinary teams, or continue to evolve their procedures where these teams exist already in order to measure how meaningful certain outcomes are, and create comprehensive solutions that fit individual patient needs. Teams must learn from the information they receive based on these value judgments, and use the learnings to continue driving efficiencies in healthcare.

If implemented intelligently and efficiently, VBHC could revolutionise healthcare. But challenges remain before we do this. These issues are often systemic, and it is impossible to deny that to some extent short-term savings are needed to ensure patients can receive vital treatments and health systems can continue to function. If we want to create systems that will continue to deliver into the future, however, we must look beyond the short term and focus on better patient outcomes, longer-term savings and an improved healthcare model for patients over the course of their chronic disease and healthcare operations.

Coming back to our earlier metaphor on fixing a broken car, if our mechanic kept trying the same fixes to no avail, we would change mechanics. Healthcare stakeholders, policymakers, we all need to work together to change our healthcare system to one that is fast, effective and safeguards the most important thing to us all – our health.

The importance of value
when treating patients

What is value-based healthcare?

Where VBHC has worked

How can we implement VBHC in other locations?