By Yvan Marston
No one disputes that a high functioning healthcare system is one that improves clinical outcomes while lowering costs. But how we get there and whether we are close to implementing one are areas rife with debate.
A new report studying health systems around the world is the latest attempt to give the conversation some form. It says Canada is ‘moderately aligned’ with the core components of value-based healthcare, though its implementation remains a few steps from certain.
Designed to set a global standard of evaluation and to establish the core components of what it calls “an enabling environment for value-based healthcare,” the 30-page report from The Economist’s Intelligence Unit, released in September, examines the health systems of 25 countries scoring them on a number of key metrics.
It defines a value-based healthcare system (VBHC) as one that explicitly prioritizes health outcomes that matter to patients relative to the cost of achieving those outcomes. VBHC is an idea popularized by Michael Porter and Elizabeth Teisberg in their 2006 book Redefining Healthcare, but it has long existed as a focus for health systems worldwide.
For the study, researchers sought to determine the level of alignment for each of the 25 countries selected. They organized their enquiry around four key components, namely: Is there an enabling context where policies and institutions champion value in healthcare? Are outcomes and costs measured? Is there integrated and patient-focused care? And is there an outcome-based payment approach?
Value-based approaches, according to the study, are being implemented incrementally and at varying speeds across the world’s healthcare systems. And in some places it is further along than in others.
Sweden, for example, emerged as the only country in the report with very high alignment. Not that it has comprehensively implemented a VBHC system, but there are important components already in place. Its healthcare workforce, for example, is largely salaried and therefore not incentivized as they might be in a fee-for-service model.
The U.K, whose National Health Service has been experimenting with new team-based healthcare delivery models and forms of payment also scored well and was the only country with high alignment.
Canada gets its rating of ‘moderate alignment’ from the fact that it has all four of the key elements, but it only scored ‘high’ on two: having an enabling context and having an outcome-based payment approach.
Areas to work on include providing health professionals with training on how to practice in a value-based healthcare setting, and creating a national and provincial level registry where patient reported outcome measures can be more successfully integrated with existing government data.
Recent evidence suggests Canada has gained ground on the use of interoperable Electronic Health Records.
The peer-reviewed journal BMC Medical Informatics and Decision Making reported that healthcare providers in Canada were active users of at least two iEHR components such as accessing diagnostic images and drug information outside of their organization. Twelve months after the initial assessment, that figure jumped by an additional 50 per cent, bringing the number to approximately 139,000. More than 250,000 clinicians from across Canada use at least one component of the iEHR.
A second article in the same journal revealed that iEHR users reported improved quality of care and improved access to patient information.
“Better data and more data is one key to system improvements and to understanding outcomes,” says Janet Davidson, board chair at the Canadian Institute for Health Information and most recently the deputy minister of Health in Alberta.
“There are a lot of data, but is it organized in a way that is easily understood? Can it be accessed? Is it timely? There’s no point in having access to outcomes that are three years old if your organization is, for example, talking to physicians about performance,” says Davidson.
Better information can also contribute to better quality discussions on health spending explains Davidson. “We have the components of a good system but when there’s a suggestion that things should be done differently, the reaction by whatever stakeholder group is impacted is to say: You’re destroying medicare. But it’s the opposite, we’re trying to improve it,” she adds. “Talk is often about costs, because based on the evidence of how much we spend on healthcare there is no reason we cannot have far better outcomes.”
While a focus on outcomes seems like an obvious goal, it is not an easy thing to realize in a system that puts volume before value, explains Dr. Gabriela Prada, a Conference Board of Canada health policy expert who has studied health innovation and procurement.
“The problem with value is that it can be defined differently by patients, providers and suppliers, but outcomes are what links them all,” says Prada. “People working in healthcare want the best for patients. When you focus on outcomes, rather than cost or volume, the conversation becomes much more collaborative.”
Spending more on care is not always effective, as is evidenced by the overuse of some medical tests, Canada’s high rate of caesarian sections and the misuse of antibiotics, but cutting back in service-based areas is complex and often met with skepticism from users.
“Procurement is a tangible place to start,” says Prada, explaining that moving the transaction from a cost conversation to one focused on outcome can yield value.
She cites the example of a hospital in Norway that bought catheters in the usual manner using key criteria and selecting the lowest cost solution. But patients complained the catheters weren’t comfortable, and providers said they often needed to be replaced. The hospital went back to market with a new procurement process that included a pain test and a one-month trial period for potential solutions. The catheter that was eventually selected was not the cheapest one but the one that would contribute best to outcomes and yield the most value.
Pacemakers with longer battery life serve as another example.
“These purchasing decisions are made in the context of annual budgets,” Prada says, explaining the challenge. “They aren’t decisions made about the greater value to the system but rather what is of a lower cost today.”
“We are currently operating in a system where our ability to measure value is less than our ability to measure cost,” says Prada. “Cost, she explains, is tangible. When you follow a patient through the continuum of care, from acute care to chronic care, measuring outcomes becomes more complicated. But it remains an important focus.”
“When you talk about change in a particular healthcare program with hospitals and providers and you talk about it in terms of patient outcomes, people will focus on working together,” says Prada.
Yvan Marston is a freelance writer in Toronto.