It is time to reshape the health system from the rubble, aligning efforts to value

A blog by Giovanni Gorgoni, Chair at EUREGHA & CEO at AReSS Puglia

It is pretty easy to say “value” in healthcare and quite hard to actually practice it in processes and services. This is why we often see so many conferences on VBHC and less long-lasting experiences. There are many reasons to explain this gap between theory and practice and one of these can be the wrong allocation of value decisions through governance levels, or the missing coordination among them.

Value has different decision places. From Michael Porter, to Muir Gray and the EU Expert Panel on effective ways to invest in health, we learned that value has got at least four dimensions: technical, personalized, allocative, and societal. But we often forget that any dimension has different decision and acting venues. The case studies reported in a recent EAVH policy paper demonstrate that value initiatives need at least meso-level commitment to be successful and long-lasting. By meso-level, I mean regional and local authorities, a kind of crossing point and a bridge between national level and healthcare provider level; between strategy side and service side.

The four dimensions of value require the vertical distribution of value tasks through governance levels and the horizontal joining of other stakeholders: the value challenge, even more for driving a transformative resilience, relies on alliances and ecosystems because value lives in different places and has multiple meanings depending on who expresses it (policy-makers, health administrations, providers, patients, industries, municipalities, volunteers, research organizations and so on).

The mentioned EAVH paper highlights how a value-based approach can foster a better direction for post COVID recovery with some cautious tricks.

We can start the new value-based “normal” on so many patterns starting from the 5+1 value agenda by Porter to many other frameworks but the access keys remain outcome based contracts and payments. Bundle reimbursement is the concrete balance point among policy, administration, providers, patients, industry and – to some extent – research for innovation: fee for service, global capitation and global provider budget are at all incompatible, dangerous and make only episodic the best project.

How can we improve this critical corner-stone? Once again, with the right distribution of value tasks:

• The role of the EU, member States and European networks is strategic for scouting, evaluating and fostering the best practices of bundle reimbursement.
• Renovation of health price regulations would be needed, but too slow to start and too delayed to be upgraded further on. In the meantime, outcome based contracting and public-private partnerships could already substitute at regional authorities and health providers.

I do not like the word “resilience” because it could conceal a passive adaptation to outer change. Much better is the term “transformation” or “transformative resilience”.

But digital transformation requires specific knowledge, skills, literacy and numeracy both for patients and for professionals. In the value approach, it means to raise the quality of human capital through education and training, and through new professions.

And since we talk about education, another cornerstone of value facility is to educate patients to understand what an outcome is, how to use it to choose a provider and how to pretend it. Without this brick we have only technical value for what a fee and a bill are enough.

Value according to patients can be measured using PROMS and PREMS. Let’s not expect better tools to start. We have been using the obsolete DRG’s system to bill healthcare services for so many decades, but PROMS and PREMS could be the first European standards. There’s enough authoritative evidence about their efficacy.

Let’s come back to prevention and promotion, do we ever make it a backbone item? We need to make disease prevention and health promotion a starting point, but with a methodological shift using more communication and data technology.

COVID-19 showed the key role of communication to drive and move social habits, so we need new professions and skills for health communication and fast fingers on posts are not enough.

During the pandemic we learnt to handle – not yet to manage – big data, machine learning and people allocation to cope, and for the immediate future we could further use them to effectively focus targeted interventions with limited resources, for instance to avoid health inequalities leveraging societal value.

Digital health and telemedicine can provide health processes closer to patient existence and to patient value, but they should be simple and sustainable, not complex and expensive. The risk to be technological at all costs and to enhance health inequalities through inappropriate investments in technology is dangerously close around the corner. I will  make an example: during the pandemic I received an offer to buy amazing systems to keep COVID patients monitored at home but – almost always – a pulse oximeter, a self-evaluation questionnaire and a web call were enough.

Innovation for value needs trust, and never like now with vaccines have we had the demonstration that innovation sometimes can have a fast pace if we respect some conditions in terms of novel forms of data collection and sharing among many actors. So, we must not lose this novel dynamism in research and innovation.

This is the time to reshape the system from the rubble, aligning efforts to value. Before now it would have been too difficult.

I want to close this post with an effect warning: the real danger is the comeback to the status quo, not the comeback of another pandemic.