Value-Based Healthcare: A Revolution for the Healthcare System and its Implementation in France

The healthcare landscape is undergoing a profound transformation. Faced with increasing pressures related to optimizing limited resources, the costs associated with technological advancements, the rise in patients suffering from multiple chronic diseases, and evolving clinical practices, a new approach is gaining ground: Value-Based Healthcare (VBHC). Although its English name is still relatively unknown, even abstract, this concept promises to revolutionize the way healthcare is evaluated and financed. The goal is to shift from viewing the healthcare system as a short-term spending constraint to viewing it as a long-term investment focused on creating value.

What is Value-Based Healthcare?

Developed by economist Michael Porter and physician-researcher Elizabeth Teisberg, VBHC, or "value-based healthcare" in the closest translation, is a framework for restructuring healthcare systems with the primary objective of creating value for patients. Value, in this context, is defined as health outcomes divided by the costs required to achieve those outcomes. This fundamental definition, introduced by Porter and Teisberg in their book "Redefining Health Care," characterizes value-based healthcare. It is important to differentiate this notion of "value" from simple economic value or ethical and moral values; VBHC specifically addresses value creation. It involves measuring outcomes, not just expenses or processes. Improving health outcomes is essential to value creation in a holistic and systemic approach. Simply reducing costs is not considered an appropriate strategy if it is not accompanied by improved patient outcomes. However, the definition of value is not monolithic and can be subjective, varying among patients, clinicians, healthcare providers, policymakers, or industry stakeholders. While some use the term for its humanistic principles, others associate it with cost reduction and process efficiency. To meet this challenge, a broader perspective, particularly proposed at the European level, enriches the concept with four pillars of value:

1. Allocative Value: Equitable distribution of resources among all patient groups.
2. Technical Value: Achieving the best possible results with available resources.
3. Personal Value: Appropriate care to achieve patients' personal goals.
4. Societal Value: Contribution of healthcare to social participation and connection.

This comprehensive vision goes beyond a purely monetary interpretation of value, integrating the fundamental dimensions of solidarity-based healthcare systems, such as European systems.

Why is VBHC necessary?

Current healthcare systems, particularly in Europe, are heavily focused on process measures. Despite efforts to standardize guidelines, checklists, and quality measures, wide variations remain in processes and outcomes. Striking examples include disparities in surgical revision rates after hip replacement in Sweden or variations in incontinence rates after prostate surgery in Germany, even though survival rates may be similar. These variations have a considerable impact not only on patients' quality of life but also on the associated costs to the healthcare system and society. Currently, few healthcare systems assess the impact on quality of life from the patient's perspective. Performance measures tend to focus on inputs and outputs. While life expectancy is important, measures of outcomes that truly matter to patients, such as pain, functionality, and quality of life, are often lacking. The VBHC aims to fill this gap by focusing on the specific outcomes that matter most to patients, such as functional recovery and quality of life, throughout the entire care pathway.

Furthermore, the current funding model, often based on fee-for-service, compensates healthcare professionals for what they do, not for what they achieve. The VBHC proposes a reversal of this logic, by linking funding to the actual impact of care on the patient's health. The objective is to ensure the economic and financial sustainability of healthcare systems in the face of increased spending due to population aging and the chronicity of diseases.

The fundamental principles of value-based evaluation

The implementation of VBHC is based on several key principles:

1. The Patient at the Center of Evaluation: The VBHC approach places the patient as an active participant in the system, rather than a passive one. The idea is to include them at the center and evaluate the benefits they derive from their care pathway. This involves focusing on the quality of their care, how they experience it in the long term, and introducing the concept of the "patient partner". The objectives of care must be defined in agreement with the patient, as expectations and the concept of success can differ considerably from one person to another. This approach strengthens the dialogue between caregiver and patient and the patient's involvement in shared decision-making. Patient experience is recognized as an integral component of quality of care, particularly related to treatment adherence. Measuring the Outcomes That Matter: This is a fundamental principle of VBHC. Evaluation is based on indicators that capture improvements in health status and quality of life. Two types of indicators are essential: PROMs (Patient Reported Outcome Measures): Measures of the effects on the patient's health as reported by the patient themselves. These are quality-of-life questionnaires, measuring, for example, how long the patient spent in the hospital, when they were able to resume physical activity, pain levels, and functionality. This data reflects what truly matters to patients. CROMs (Clinical Reported Outcome Measures): Clinical elements measured by healthcare teams. These are objective patient data, with a clinical aspect, such as surgical scores or imaging.
2. (Note that some sources also mention PREMs - Patient Reported Experience Measures - which are based on the patient's experience: how they experienced the delays, the diagnosis announcement, the support, the pain, etc.)
3. Measuring Costs Across the Entire Care Pathway: The value is calculated by relating the beneficial outcomes to the costs per patient. The denominator applies to the total expenditure for the complete cycle of care relating to a condition, including post-hospital care.
4. Reorganization of Care: The effectiveness of VBHC increases by reorganizing care, for example into Integrated Practice Units (IPUs). The idea is to plan and coordinate the entire care pathway from the outset, particularly for chronic diseases that extend over long periods. Data Use and Digitalization: The collection, structuring, analysis, and comparison of data (PROMs, PREMs, CROMs, adherence, complications, etc.) are the foundation of a virtuous system. Digitalization is a major undertaking for implementing a robust data management strategy. Digital solutions enable, in particular, the measurement and comparison of data. Quality of life questionnaires (PROMs) can be online and completed remotely, facilitating the collection of longitudinal information. The development of AI and the use of real-world evidence are also mentioned.
5. Collaboration and Learning: Implementing VBHC requires a collaborative approach involving all stakeholders: institutions, healthcare professionals, patients, payers, and industry. Learning communities are encouraged to share best practices and learn collectively.
6. Cultural Change and Governance: VBHC represents a profound cultural shift. It requires healthcare professionals to question the meaning of their work and rethink how they work. A long-term strategy with strong governance is recommended for this gradual change.

The application of VBHC in France: the example of AP-HP

AP-HP (Assistance Publique – Hôpitaux de Paris) is part of this approach by adopting Value Based Healthcare as an innovative concept for evaluating the quality of care. Its main objective, in line with the definition of VBHC, is to measure the improvement in patients' health status after their care in the hospital.

At AP-HP, this evaluation is based on the collection of two types of indicators:

• Clinical Reported Outcome Measures (CROMs): clinical data measured by medical and nursing teams.
• Patient Reported Outcome Measures (PROMs): quality of life questionnaires completed by the patients themselves.

Evaluations are carried out at different key points in the patient's journey: before treatment, shortly after, and sometimes continue for up to ten years, generally once a year. An important aspect of the implementation at AP-HP is the digitalization of PROMs collection: the quality of life questionnaires are online and can be completed by the patient at home after receiving an email or SMS notification containing an access link.

The information thus collected has a dual purpose at AP-HP:

1. It allows healthcare teams to better care for each patient individually.
2. By combining data from numerous patients, it contributes to improving care for all patients.

This AP-HP initiative demonstrates the progressive adoption of the VBHC in France, aligning with approaches already well advanced in other European countries. The National Health Plan also seems to adopt this terminology, indicating political recognition of the concept.

France has several strategic advantages for the deployment of Value-Based Healthcare:

• Medical excellence, despite structural challenges.
• A lead in digital health facilities compared to most European countries (excluding Nordic countries), estimated at 2 to 4 years. The ability to collect, structure, analyze, and compare the right data (PROMs/PREMs, etc.) is the foundation of a virtuous system fostered by Value-Based Healthcare (VBHC).
• Momentum to evolve the system, generated in particular by recent crises.
• A healthcare system with fewer payers than elsewhere (the CPAM), which could theoretically facilitate the validation of eligible patient/pathology categories and shift from a cost-focused approach to an outcomes-based approach.

However, the transition to value-based financing, as opposed to the current fee-for-service system, is complex and cannot happen overnight. VBHC is more of an approach that is added "on top of the cake" to an existing system, rather than a model that replaces everything. Major projects, such as implementing a robust data management strategy, are necessary.

Benefits and Perspectives

Adopting VBHC promises numerous benefits:

• Improved Patient Outcomes: By focusing on what matters most to patients (functional recovery, quality of life, pain reduction), the system can aim for tangible improvements in individuals' daily lives.
• Increased Efficiency: By measuring outcomes against costs, VBHC makes it possible to identify "low-value care" practices and reallocate resources to "high-value care." This can help combat waste, fraud, and unjustified variations.
• System Sustainability: By linking funding to actual results, VBHC offers a way to ensure the long-term economic viability of healthcare systems.
• Stimulation of Innovation and Research: By measuring the long-term effects of treatments and care pathways, VBHC provides valuable data for research, the development of new treatments, and personalized medicine.
• Improved Quality of Working Life for Healthcare Professionals: By giving meaning to work and enabling the measurement of the real impact of care, VBHC can help counteract the distress experienced by some healthcare professionals.
• Strengthening of the Healthcare Professional-Patient Dialogue: Patient involvement in defining objectives and evaluating outcomes fosters better communication and a relationship of trust.

Full implementation of VBHC is a gradual process requiring cultural and systemic transformation. It involves training change agents (leaders) and developing learning communities. This is a matter of health democracy and an opportunity for France and Europe to exert a positive influence globally. Successfully completing flagship pilot projects is a key step in demonstrating the potential of this approach.

Conclusion

Value-Based Healthcare is much more than a simple management concept; it is a fundamental paradigm shift for healthcare systems. By shifting the focus from processes and raw costs to the outcomes that truly matter to patients, and by measuring these outcomes against costs across the entire care pathway, Value-Based Healthcare (VBHC) offers a promising avenue for improving the quality, efficiency, and sustainability of care. AP-HP, through its PROM and CROM data collection initiative, concretely illustrates this application in France. While the transition is complex and requires collaboration from all stakeholders and a robust data management strategy, VBHC is emerging as a crucial direction for building the healthcare systems of tomorrow, more patient-centered and focused on creating sustainable value for individuals and society.