The adoption, adaptation, and abandonment of value-based health care

Abstract

Introduction: Value-based health care (VBHC) is a strategic framework designed to improve care in parallel with lowered or sustained costs. It was soon touted as “the strategy that will fix health care”, garnering increased attention in different countries. The contextual differences between and within health systems, in addition to the wide range of strategies employed by organizations adopting VBHC, create an opportunity for developing empirical evidence on the adoption, adaptation and potentially abandonment of VBHC.

Aim: To explore the adoption, adaptation, and potential abandonment of VBHC.

Methods: The empirical data has been collected from the contexts of the Karolinska University Hospital and the Hospital Israelita Albert Einstein. Study I is an observational, cross-section survey exploring physicians’ awareness on core concepts of VBHC in the context of Latin America. Study II is a mixedmethods study investigating how healthcare providers in Latin America are implementing VBHC. Study III is a comparative case-study of how VBHC was adopted in two contextually different hospitals – Karolinska and Einstein - and how its application was influenced by contextual factors at the system and organizational levels. Study IV is a longitudinal case-study exploring how VBHC management innovations were adopted, adapted, and abandoned at Karolinska. The Complex Innovation Framework was used to analyze the findings and suggest potential feedback loops driving adoption, adaptation, and abandonment of VBHC.

Findings: Study I found that high cost of healthcare was identified as the key driver for VBHC discussions in Brazil, and that awareness on VBHC amongst clinical staff was low. Study II showed that healthcare organizations adopting VBHC failed to conceptually define it and adopt it as an integrative strategy – instead they identified management practices unrelated with the Value Agenda as VBHC. Study III showed that organizations adapted VBHC to emphasize components that best translated into their system, e.g. Karolinska focused on health outcomes and Einstein on costs. VBHC adoption challenged established business models - Karolinska had difficulties matching the new organizational model with the research and education missions; Einstein with aligning the new financing models with their independent physician staff. Study IV further shows that VBHC adoption was driven by a coalition of interests at Karolinska; adaptation was required early in the adoption process due to several misfit examples - between the specialization mandate and delivery of multidisciplinary care; the decentralization of management and the organization’s IT and data systems, financial model and cultural values; and the models of patient participation. In the end, abandonment was characterized by a return to previous practices – merger of flows resulting in larger units; re-center of outcomes improvement narrative around NQRs; - and the “silent death” of VBHC artifacts, such as the PFCs or outcomes steering cards.

Discussion: VBHC adoption is largely influenced by contextual factors at the health system level, leading to a phenomenon of piece-meal adoption. Since systemic and organizational business model alignment with the components of VBHC is generally low, organizations emphasize those that are most aligned with their health system goals and contextual circumstances.

Conclusion: If adopters of VBHC are able to focus attention on integrated understanding of both outcomes and costs (the hard core of VBHC), we may start to unpack the specific care-related processes that contribute to value creation for different patient populations.