Value-based health care : challenges in moving forward

Background. Value-based health care (VBHC), a strategic framework launched in 2006, suggests restructuring health care to maximize health outcomes in relation to societal costs. The framework builds upon a tradition of outcome assessment in clinical work and health economic evaluation. In suggesting maximization of outcomes in relation to costs, the framework makes assumptions about what constitute a valuable outcome to persons with a disease, and how this should be operationalized. The framework, for example, assumes: (A) only outcomes matter to patients; (B) outcomes that matter to patients are separable into three categories: health status achieved, time to health status achieved, and sustainability of health; and (C) standardized instruments are preferable when operationalizing a certain outcome. Critique has been raised towards VBHC as being ill adapted to the chronic care setting. Aim. The aim of this thesis is to assess assumptions (A-C) of VBHC in a chronic care setting. Methods. This thesis uses a mixed-methods approach. First, the current understanding and application of VBHC in the research literature is assessed using literature citation data. Secondly, empirical consequences of the assumptions (A-C) are assessed in the setting of rheumatology, using a randomized controlled trial (A) and semi-structured interviews (B-C). The research participants had rheumatoid arthritis (RA). Findings. This thesis shows that the literature has not assessed assumptions of VBHC empirically; non-outcomes can have intrinsic value to persons with RA (A); outcomes not found in the outcome categories can have intrinsic value to persons with RA (B); and a common functional measurement in rheumatology, Stanford’s Health Assessment Questionnaire-Disability Index, is not aligned with the perspective of persons with RA (C). Discussion. The framework assumptions did not find support in the setting of rheumatology. This thesis does not address settings other than rheumatology and not all aspects of the assumptions. However, the findings show that the assumptions are not universally applicable. There are several possible reasons for the disagreement between the assumptions and the findings. The most reasonable is that VBHC addresses care from the perspective of the provider. Although the needs and challenges of the provider might be fully addressed by VBHC, the perspective of patients with RA is not. The disagreement between the assumptions and the findings, in combination with the lack of assessment in the scientific literature, raises the question whether VBHC is a scientific or a non-scientific framework. Conclusion. The thesis shows limitations of VBHC in one specific setting, using data from persons with RA. Those specific limitations can most likely be avoided if VBHC were adjusted and implemented in patient-professional partnership