Value-Based HealthCare: A Revolution for the Healthcare System and Its Application in France

The healthcare landscape is changing rapidly. Faced with increasing pressures related to the optimization of limited resources, the costs associated with technological advances, the increase in patients suffering from multiple chronic diseases, and the evolution of clinical practices, a new approach is gaining ground: Value-Based HealthCare (VBHC). Although its English name is still relatively unknown, or even abstract, this concept promises to revolutionize the way healthcare is evaluated and financed. The goal is to shift from a view of the healthcare system as a short-term spending constraint to a long-term investment focused on value creation.

What is Value-Based HealthCare?

Developed by economist Michael Porter and medical researcher Elizabeth Teisberg, VBHC, or "value-based healthcare" in the closest translation, is a framework aimed at 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 refers to value creation. It is about measuring results, and not just expenses or processes. Improving health outcomes is essential to creating value in a comprehensive and systemic approach. A simple reduction in costs is not considered an appropriate strategy if it is not accompanied by an improvement in patient outcomes.

However, the definition of value is not monolithic and can be subjective, varying between patients, clinicians, care providers, policymakers, or industry stakeholders. While some use the term for its humanistic principles, others associate it with cost reduction and process efficiency. To address this challenge, a broader perspective, notably 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 the resources available.
3. Personal Value: Appropriate care to achieve patients' personal goals.
4. Societal Value: Contribution of healthcare to participation and social connection.

This comprehensive vision goes beyond a purely monetary interpretation of value, integrating the fundamental dimensions of healthcare systems based on solidarity, 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 persist 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 the quality of life of patients, but also on the associated costs for 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 on outcomes that really matter to patients, such as pain, functionality, and quality of life, are often lacking. 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, across the entire care pathway.

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

Fundamental principles of value-based assessment

The implementation of VBHC is based on several key principles:

1. The Patient at the Center of the Evaluation: The VBHC approach places the patient as a stakeholder in the system, and no longer just passive. The idea is to include them at the center and evaluate the benefits they derive from their care pathway. This implies focusing on the quality of their care, how they experience it in the long term, and introducing the notion of "patient partner". The objectives of care must be defined in agreement with the patient, as the expectation and the notion of success can differ considerably from one person to another. This approach strengthens the dialogue between caregiver and patient and the patient's engagement in shared decision-making. Patient experience is recognized as an integral component of the quality of care, linked in particular to adherence to treatment.
2. Measuring Results That Matter: This is a fundamental principle of VBHC. The assessment is based on indicators that capture the improvement of health status and quality of life. Two types of indicators are essential:
   • PROMs (Patient Reported Outcome Measures): Measures of patient health outcomes as reported by the patient him/herself. These are quality-of-life questionnaires, measuring, for example, how long the patient spent in hospital, when they were able to resume physical activity, pain and functionality. These data reflect what really matters to patients.
   • CROMs (Clinical Reported Outcome Measures): Clinical elements measured by healthcare professional teams. These are objective data on patients, with a clinical aspect, such as surgical scores or imaging.
   • (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 Pathway: Value is calculated by relating beneficial outcomes to 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 in Integrated Practice Units (IPU). The idea is to plan and coordinate the entire care pathway from the outset, especially for chronic diseases that extend over long periods.
5. Use of Data and Digitalization: The collection, structuring, analysis, and comparison of data (PROMs, PREMs, CROMs, compliance, complications, etc.) are the basis of a virtuous system. Digitalization is a major undertaking to implement a strong 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 data (Real World Evidence) are also mentioned.
6. Collaboration and Learning: The implementation of VBHC requires a collaborative approach involving all stakeholders: hospitals, healthcare professionals, patients, payers, and industry. Learning communities are encouraged to share best practices and learn collectively.
7. 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 progressive change.

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

The 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 specifically based on the collection of two types of indicators:

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

Assessments are carried out at different key moments of the patient journey: before care, shortly after, and sometimes extend up to ten years, generally once a year. An important point of implementation at AP-HP is the digitization of PROMs collection: quality of life questionnaires are online and can be completed by the patient at home after receiving a notification by email or SMS containing an access link.

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

1. They enable healthcare professional teams to better manage each patient individually.
2. By combining data from numerous patients, they contribute to improving care for all patients.

This AP-HP initiative demonstrates the progressive adoption of VBHC in France, aligning with the already well-advanced approaches in other European neighbors. The national health plan also seems to be adopting this terminology, indicating a political recognition of the concept.

France has several strategic assets for the deployment of VBHC:

• Medical excellence, despite structural challenges.
• A lead in the digital health of facilities compared with most European countries (excluding the Nordic countries), estimated at 2 to 4 years. The ability to collect, structure, analyze and compare the right data (PROMs/PREMs, etc.) is the basis of a virtuous system promoted by VBHC.
• Momentum to change the system, generated in particular by recent crises.
• A healthcare system with fewer payers than elsewhere (the CPAM), which could theoretically make it easier to validate eligible patient/pathology categories and move from a focus on costs to a results-based approach.

However, the transition to value-based financing, as opposed to the current fee-for-service payment model, is complex and cannot happen overnight. VBHC is more of an approach that comes "on top of the cake" of a system, rather than a model that replaces everything. Major projects, such as the implementation of 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 unwarranted variations.
• System Sustainability: By conditioning funding on actual results, VBHC offers a way to ensure the long-term economic viability of healthcare systems.
• Stimulating 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 Life at Work for Healthcare Professionals: By giving meaning to work and allowing the real impact of care to be measured, VBHC can help counteract the malaise of certain health professions.
• Strengthening the Healthcare Professional-Patient Dialogue: Involving the patient in defining objectives and evaluating results promotes better communication and a relationship of trust.

The full implementation of VBHC is a progressive process that requires a cultural and systemic transformation. It involves the training of "change agents" (leaders) and the development of learning communities. It is an issue of "health democracy" and an opportunity for France and Europe to exert a positive influence on a global scale. Successfully completing emblematic pilot projects is a key step in demonstrating the potential of this approach.

Conclusion

Value-Based HealthCare is more than just a managerial concept; it is a fundamental paradigm shift for healthcare systems. By shifting the focus from processes and gross costs to the outcomes that really matter to patients and by measuring these outcomes against costs across the entire care pathway, VBHC offers a promising way to improve the quality, efficiency, and sustainability of care. AP-HP, through its PROMs and CROMs collection approach, concretely illustrates this application in France. Although the transition is complex and requires collaboration from all stakeholders and a strong data management strategy, VBHC is emerging as an essential direction for building the healthcare systems of tomorrow, more patient-centered and focused on creating sustainable value for the individual and society.