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 to optimize 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 cost center 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," as it is most commonly translated—is a framework for restructuring healthcare systems with the primary objective of creating value for patients. In this context, value 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 distinguish this concept 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 within 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: Fair distribution of resources among all patient groups.
2. Technical Value: Achieving the best possible results with available resources.
3. Personal Value: Providing appropriate care to help patients achieve their personal goals.
4. Societal Value: The Role of Healthcare in Promoting Social Participation and Connection.

This comprehensive vision goes beyond a purely monetary interpretation of value, incorporating the fundamental aspects of solidarity-based healthcare systems, such as those found in Europe.

Why is VBHC necessary?

Current healthcare systems, particularly in Europe, place a heavy emphasis on process measures. Despite efforts to standardize guidelines, checklists, and quality measures, significant variations persist in both processes and outcomes. Striking examples include disparities in surgical revision rates following hip replacement in Sweden or variations in incontinence rates following 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, which is often based on fee-for-service, compensates healthcare professionals for the services they provide, not for the outcomes they achieve. VBHC proposes reversing this approach by linking funding to the actual impact of care on patients' health. The goal is to ensure the economic and financial sustainability of healthcare systems in the face of rising costs driven by an aging population and the increasing prevalence of chronic 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 positions the patient as an active participant in the system, rather than a passive one. The idea is to place them at the center and assess the benefits they derive from their care pathway. This involves focusing on the quality of their care, how they experience it over 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 vary 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 regarding 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 (Clinician-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, the support, the pain, etc.)
3. Measuring Costs Across the Entire Care Pathway: The value is calculated by comparing the beneficial outcomes to the costs per patient. The denominator represents the total expenditure for the entire care cycle related to a condition, including post-hospital care.
4. Reorganization of Care: The effectiveness of VBHC is enhanced 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.) form 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 completed online and remotely, facilitating the collection of longitudinal data. The development of AI and the use of real-world evidence are also highlighted.
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 together.
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 to facilitate 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 initiative by adopting Value-Based Healthcare as an innovative approach to evaluating the quality of care. Its primary objective, in line with the definition of VBHC, is to measure the improvement in patients' health status following their hospital care.

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

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

Assessments are conducted at various key points in the patient’s care journey: before treatment, shortly after, and sometimes for up to ten years, typically once a year. A key aspect of the implementation at AP-HP is the digitization of PROM collection: the quality-of-life questionnaires are available online and can be completed by the patient at home after receiving an email or text message containing an access link.

The information collected in this way serves two purposes at AP-HP:

1. It enables healthcare teams to provide better, more personalized care for each patient.
2. By combining data from numerous patients, it helps improve care for all patients.

This AP-HP initiative demonstrates the gradual adoption of VBHC in France, in line with approaches that are already well established in other European countries. The National Health Plan also appears to adopt this terminology, indicating political recognition of the concept.

France has several strategic advantages for the implementation of value-based healthcare:

• Medical excellence, despite structural challenges.
• A lead in digital health infrastructure compared to most European countries (excluding the Nordic countries), estimated at 2 to 4 years. The ability to collect, organize, analyze, and compare the right data (PROMs/PREMs, etc.) is the foundation of a virtuous cycle fostered by Value-Based Healthcare (VBHC).
• Momentum to evolve the system, driven in particular by recent crises.
• A healthcare system with fewer payers than elsewhere (the CPAM), which could theoretically facilitate the identification of eligible patient and disease 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 existing system," rather than a model that replaces everything. Major projects, such as implementing a robust data management strategy, are necessary.

Benefits and Outlook

Adopting VBHC offers numerous benefits:

• Improved Patient Outcomes: By focusing on what matters most to patients (functional recovery, quality of life, pain reduction), the system can aim to achieve tangible improvements in patients' 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 provides 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 Working Life for Healthcare Professionals: By giving meaning to work and enabling the measurement of the actual impact of care, VBHC can help alleviate the stress experienced by some healthcare professionals.
• Strengthening the Dialogue Between Healthcare Professionals and Patients: Patient involvement in setting goals and evaluating outcomes promotes better communication and a relationship of trust.

The full implementation of VBHC is a gradual process that requires 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, provides a concrete example of this approach 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—systems that are more patient-centered and focused on creating sustainable value for individuals and society.