Moving from Principles to Practice: A scoping Review of Value-Based Healthcare (VBHC) Implementation Strategies

1. Introduction

The escalating concern about the sustainability of healthcare systems, driven by the ever-increasing demand for healthcare services and the challenges posed by resource limitations, has mandated a profound shift in priorities. This calls for innovative approaches to healthcare delivery, as more than mere cost containment is needed to address the mounting pressure on healthcare systems, particularly where costs are not aligned with outcomes [1]. In response, Value-Based Healthcare (VBHC), a model introduced by Porter and Teisberg [2], represents a paradigm shift in healthcare management. Unlike models prioritizing service volume, VBHC is a tool used to enhance health organizations' reorientation towards person-centred care [3]. A patient-centred approach necessitates a departure from the conventional discipline-based organizational model, by aligning hospital activities around the needs of care processes (and patients) [4]. This approach aims to address the needs of each patient holistically, ensuring seamless coordination and continuity of care throughout their entire treatment journey. Since their introduction, the principles underlying VBHC have proven to be compelling and widely embraced by academics and professionals alike, to the extent that healthcare organizations in various countries are adjusting their strategies toward VBHC [5]. However, proposals for healthcare improvement have typically focused only on changes to individual system components, thereby diverting attention from the overarching goal: improving patient care [6]. In their scoping review, Van Staalduinen et al. [5] observed that hospitals tend to implement only one or two components of VBHC rather than adopting it as an integrative management strategy. However, an effective transition to value-based care models necessitates a more strategic and coordinated approach. Indeed, although hospitals are at the core of this change, VBHC is a complex concept, and its implementation necessitates a range of actions and practices across multiple domains within the healthcare system, extending beyond the hospital's boundaries [7,8,9]. Larson et al. [10] emphasize that a VBHC system requires the development of a governance and regulatory context. This necessitates the development of coordinated public policies, regulations, and shared infrastructure to encourage multi-stakeholder cooperation and value-based innovation across all healthcare sectors [10]. However, while existing literature primarily concerns providing guidelines for implementing value-based care in hospital settings [5,11,12], limited research has explored how to create such comprehensive and multilevel strategies for implementing VBHC, which are necessary to implement the principles underlying this theory. Within this context, this study attempts to take a step forward. We aim to conduct a scoping review to identify studies that address the implementation of VBHC at different levels (healthcare policymakers, hospital management, and healthcare providers), focusing on each level’s relative strategy. This review addresses the following research questions: How can healthcare systems effectively transition to VBHC through strategic engagement, governance, and integrated care models at both system and hospital levels? What managerial strategies should hospitals consider when transitioning to VBHC? These questions will guide our analysis and provide insights into the strategies for transitioning to VBHC.

2. Materials and Methods

We conducted and reported a scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist [13] (online supplemental file 1). No published protocol is available for this scoping review. This scoping review was conducted using Arksey and O'Malley's methodological framework [14], which consists of five stages: identifying the research question, identifying relevant studies, study selection, charting the data, collating, summarizing, and reporting the results. The decision to conduct a scoping review, instead of a systematic review, was made to identify the various types of evidence related to the implementation strategies of VBHC theory. To attain this objective, it is imperative to analyze papers that employ a range of diverse methodologies [15].

2.1. Search Strategy

The electronic databases of Web of Science, PubMed, MEDLINE and Scopus, and the following keywords and synonyms, linked by Boolean operators, were used: “value-based care”, “VBHC”, “value-based”, “policy”, “strategy”, “intervention”, “organizational change”, “change management”, “redesign”, “transformation”, “implementation”. Search strategies for the four scientific electronic databases are provided in the online supplemental file 2. The investigation was conducted in September 2023 and the articles retrieved were screened according to the inclusion/exclusion criteria previously stated and listed in the following paragraph.

2.2. Study Eligibility

The inclusion criteria for this study encompassed both qualitative and quantitative studies published in English from January 2006, when Porter and Teisberg coined VBHC, to 31 July 2023 that describe the implementation of VBHC in a hospital setting or healthcare system, provided they adhered to the following predefined criteria:

• They examined how government policies, network structures, and regulatory frameworks can support the transition to VBHC.
• They focused on hospital management strategies before implementation and throughout the process of adopting and sustaining VBHC practices.
• We have excluded studies:
• Solely focusing on implementing individual components of VBHC.
• Describing different methodologies for designing and implementing bundled payments/value-based repayment program reimbursement.
• Reporting the evolution of VBHC theory.
• Not reporting on any managerial implementation strategies of VBHC theory.

2.3. Study Selection

The identified articles were uploaded to the Rayyan website for deduplication and screening. Two reviewers (dME and CA) independently assessed titles and abstracts for eligibility, resolving discrepancies through reviewers’ discussion or consulting a third party (DM). Articles meeting eligibility criteria underwent full-text review and data extraction. To ensure comprehensive coverage, reviewers also checked reference lists of included studies.

Additionally, reference lists were manually checked and searched for additional relevant publications. An Excel list containing potentially eligible documents was created, and subsequently, the full texts of these documents were independently assessed by two researchers (dME and DM) against our inclusion criteria.

2.4. Quality Appraisal

Based on the current methodological guidelines for scoping studies [15] [13], no Critical Appraisal of the strength and quality of the included papers was performed.

2.5. Data Extraction, Analysis and Reporting

From the included studies, two reviewers (dME, DM) extracted the following information on a dedicated data extraction form built with Excel:

• Study identification (first author, title, publication year).
• Study characteristics (country, study design).
• Level of analysis (system level, hospital level).
• Disease area (if relevant).
• Dimensions analyzed.
• Barriers and/or success factors.

3. Results

The screening and study selection is presented in Figure 1. The scientific and grey literature search produced 7790 records, which were then screened for duplicates, resulting in 3543 eligible records for title/abstract screening. Following this, the full text of 117 articles was carefully reviewed. Ultimately, 30 articles were included in the scoping review, consisting of a systematic literature review study (n= 1), a scoping review (n= 1), qualitative studies (n= 5), case studies (n= 12), mixed (explorative and qualitative) studies design (n= 3), a conceptual framework and case examples (n= 1), an observational cohort study design (n= 1), a comparative multiple case study (n= 2), explorative design studies (n= 3), and a descriptive qualitative study (n= 1). The articles selected for this research were published between 2013 and 2023 and originated from three countries, namely the Netherlands (n=12), the United States (n=9), and Sweden (n=5).

Literature Synthesis

The data extraction is shown in Table 1. Subsequently, the data extraction results were translated into a framework (Table 2). This framework serves as a comprehensive roadmap to guide policymakers, healthcare providers and hospital managers during their transition toward VBHC. It comprises four strategic levels: government commitment in policy definition, Organizational Vision and cultural integration, Operational Excellence, and VBHC assessment. Each strategic level is associated with specific dimensions and operational strategies that should be implemented.

4.1. Government Commitment in Policies Definition

Eight articles [17,18,20,21,23,26,32,42] described the role of government commitment in implementing the principles of the VBHC model, especially during the introduction of value-based payment reforms. These studies have identified several operational strategies. Four studies [17,21,23,42] suggested establishing state legislation to encourage state and regional initiatives for VBHC, involving key stakeholders (such as policy makers, government agencies, public and private healthcare providers, patients private organizations) in this change process [17,23]. Four studies [18,20,24,26] suggested that the government may need to provide further guidance or assistance for payment reform, adopt a long-term vision, provide information on implementation and the potential impact of payment reforms, as well as create a sense of urgency for the change [18,21,23,26,42]. Lastly, other studies have recommended allocating significant resources (financial/human resources) to support the transition, including external resources (e.g., grants) [21]. Regarding value-based agreements (VBAs), adopting legal and regulatory policies that enable innovative contracting, such as net price confidentiality, was recommended [20]. Policies that facilitate acquiring and using appropriate data to support contracting have also been suggested [20]. Finally, collaboration and engagement with the medical device industry is believed to be beneficial [42].

4.2. Organizational Vision and Cultural Integration

In the hospital setting, the need for an official commitment to value-based redesign from higher organizational levels was emphasized in seven studies [11,16,24,30,34,35,38]. This is consistent with the findings of other two included studies [19,33] suggesting that it is important to incorporate the implementation of the VBHC concept into hospital strategy, policy documents, planning, and control. Several papers suggested to attribute formal responsibility and mandate upon a steering group with hospital representatives for the implementation of VBHC [5,16,19,24,25,27,29,30,31,33,34,35,39]. Other studies suggested to empower service line leadership with direct accountability and authority over programs and budgets [19,33]. Another frequently employed operational strategy entails developing tailored business plans to provide a structured, clear and goal-oriented process, adaptable to each situation [9,24,33,34,39]. Furthermore, starting with "experiments", "pilots" [11,22,25,34,39], planning and preparation before beginning the implementation process [35,38,39] was also regarded as essential in transforming to VBHC. Five studies [5,22,34,35,39] described the support from consultancy since the early stages of the transition process as a success factor.

Once the vision and strategy are defined, the principles of VBHC need to be anchored in the hospital's organizational culture. To achieve this, various operational strategies have been proposed in the literature. One commonly cited was the education and training of clinical staff about the VBHC concept [5,11,19,24,31,33,35,36], to improve communication and information sharing with staff regarding the change [5,22,25,33,35,36,37], to entail time for healthcare professionals to work on the project and anchor changes in their daily work [22,24,30,34,35]. Some studies underscored the importance of continued recognition of the usefulness of VBHC implementation [30,35,38], with initial positive results [22,24,30,34], and the motivation of individuals to get involved at each step of the developmental process [11,22,33]. Establishing and maintaining a positive atmosphere [33,34,38], trust building, and pursuing a common goal [16,33] were proposed multiple times. Finally, seven studies suggested to involve patients and their representatives in the implementation process [9,24,30,35,37,39,41].

4.3. Operational Excellence

To improve regional networking models and promote cooperation between hospital and local communities, four studies [9,26,27,29] stressed the importance of establishing transmural care standards. The term “transmural care standard” refers to a healthcare approach that integrates various care settings to ensure seamless patient management throughout the entire care delivery value chain. At the same time, four studies [17,26,32,36] highlighted the value of hiring additional staff dedicated to care coordination (such as nurses, navigators and community health workers) to expand care teams in the hospital setting. Participating in peer-to-peer learning collaboration on implementing new delivery models or enhancing care coordination [32], planning and attending periodic networking meetings [26,29] were other strategies mentioned. In the hospital setting, process optimization and coordination can be achieved through the definition and optimization of Critical Pathways (CPs) [9,11,26,27,37,41] , the utilization of liaison positions (such as 'intermediary managers') to enhance coordination between functional units [5,9,11,36,38] and the application of a lean methodology [24]. Regarding developing a multidisciplinary team, the following strategies were identified as effective means in the included studies in this study: engaging all professionals involved in the care of the same patient at different levels [9,19,34,38,41], planning and attending regular institutionalized meetings ('standing committees')[5,11,24], sharing workspace [24], and creating multidisciplinary meetings to discuss complex patients [9,27]. The terms “standing committees” referring to institutionalized meetings that take place regularly and enable interunit communication [11]. To improve the data collection throughout patients’ clinical pathways and to support clinical decision making, six studies recommended to setup innovative data-sharing mechanisms to provide real-time data to providers [17,18,20,21,26,42], or/and a care and information technology platform with the objective of facilitating communication between patients and healthcare professionals [22,24,35,36]. Furthermore, three articles recommended the creation of dashboards containing outcome measurements, PROMS/PREMS, and costs [12, 29, 31]. Finally, other articles emphasized the need for additional support staff such as data analysts, project leaders, and care managers [9,24,35] to assist the healthcare workforce.

4.4. VBHC Assessment

Seventeen studies described clinical outcome measurements [9,11,22,24,26,27,28,29,30,31,33,35,36,37,39,40,41] as crucial component of VBHC. The main operational strategies employed to measure clinical outcomes include the identification and collection of relevant clinical outcome measurements [9,11,22,24,26,27,28,29,30,31,33,35,36,37,39,40], the mapping of the care processes for each respective group of patients [22,39], and the acquisition, processing, and dissemination of data in a time-efficient manner for internal reflection [11,28,30,31,33,40,41]. In order to enhance their comprehension from a clinical standpoint, two additional operational strategies were proposed in one included article. These strategies involve elucidating the rationale behind clinical outcome measurements in a more pedagogical manner and simplifying PowerPoint presentations of measured outcomes [43]. Additionally, the articles highlighted the importance of benchmarking outcome data between hospitals [11,24,28,31,39]. In addition to clinical outcome measurements, the collection of data on patient-reported measures (PREMs and PROMs) [24,26,27,30,37,40], the measurement of costs, and the implementation of 'Audit and Feedback' (A&F) mechanism [27,29] were reported as part of the VBHC components.

4. Discussion

Our study aimed to conduct a scoping review to identify studies that address the implementation of VBHC at different levels (hospital and system variables), focusing on each relative defined strategy. This comprehensive perspective emphasizes the importance of multilevel strategies and stakeholder engagement, which provides a more systemic view of VBHC implementation beyond the single hospital focus. Findings are organized into four strategic levels, namely, Government commitment in policy definition, Organizational Vision and cultural integration, Operational Excellence, and VBHC assessment. Each strategic level is associated with specific dimensions and operational strategies that should be implemented.

Our results highlight how critical government involvement is in promoting and implementing VBHC. The studies reviewed have demonstrated various combinations of state legislation and reimbursement strategies. However, almost all have underscored three fundamental aspects: the importance of strong governmental leadership, enhancing cooperation among key stakeholders involved in the healthcare delivery process, and the development of IT platforms to support service delivery and payment models. De Vries E.F. et al. [18] and Kissam SM et al. [32] emphasize the role of strong governmental leadership in stimulating value-based payment reform. This can be achieved by providing a long-term vision, supporting knowledge development, and creating a sense of urgency for implementing payment reforms. In this context, establishing state/regional legislation to encourage VBHC initiatives needs to be considered [17,21,23,42]. Only a few countries have regulated this matter recently, with the United States (US) being one of the most notable examples. The Medicare Shared Savings Program, established by the Affordable Care Act in the US, promotes the formation of Accountable Care Organizations (ACOs) and several types of bundled payment models as part of public health system reform [44]. In the Netherlands, the extent of the government's intervention to accelerate reform is unclear, as its role in payment reform is less defined [18] [45]. Douglas C. et al. [17] reported that shifting towards value-based payments requires extensive cooperation among private healthcare plans, providers, purchasers, and public programs. However, this demands time and resources.

In the context of hospital organizations, our study indicates that it would be beneficial for the higher organizational levels to make official commitments to value-based redesign. Daniels et al. [24] suggested that a more formal commitment is needed to move the organization towards VBHC, and that implementation will only be successful if it is embedded in hospital strategy, policy documents and planning and control. Preliminary experiments, pilot testing [11,22,26,34,39] and adequate planning and preparation before implementation [35,38,39] are also highly advisable. In their study, Zipfel et al. [34] identified personal and professional involvement in the design of the intervention as an important role in successful implementation, as well as clinical leadership and a positive climate.

As mentioned before, VBHC models represent a paradigm shift in healthcare management. In the hospital setting, two distinct approaches to reshaping hospital organizational design for implementing VBHC principles from the papers included: one more incremental and the other more radical. As described by Steinmann et al. [11], the incremental hospital redesign approach employs linking mechanisms, such as middle managers and regular meetings of multidisciplinary teams, to facilitate coordination while preserving the original functional units. On the other hand, the radical approach was described by Ramos et al. [9] in which the traditional medical organization was replaced by a matrix organizational structure with vertical functions and horizontal medical themes, allowing patient flows to cross departmental boundaries. However, as reported in several studies, this shift from a traditional departmental structure to a disease-oriented organization is not a foregone conclusion. Several strategies that could overcome this gap emerged from our study [19] [22] [24] 25] [9] [11], ranging from the definition of Critical Pathways, to anchoring the VBHC principles in the hospital's organizational culture through various initiatives, to planning regular institutionalized meetings ('standing committees').

However, in today's healthcare environment, the vision is limited to considering the patients' care as exclusively hospital-based. This calls for the development of integrated care models, which involve efforts to coordinate and join fragmented and disjointed healthcare providers [46]. Van Veghel H. P. A. et al. [29] stressed the importance of defining transmural care standards within the context of a Dutch regional networking to provide patients with care tailored to their individual needs. Our results suggest that cooperation can be enhanced by equipping healthcare providers with advanced health information technology (IT) systems and dashboard to capture the state of a patient across time and then sharing this information with various stakeholders who interact with the patient at different level. However, as highlighted by several articles in our review [17,21,22,31,39], many healthcare providers lack the necessary IT support. This structural deficit can hinder achieving another important goal of VBHC, which is to measure outcomes and costs for each patient [2,3,7]. This led us to the fourth level of our analysis, known as “VBHC assessment”. This section covers all the main approaches and resources needed to improve the quality of care according to the VBHC theory. The most commonly cited dimension is the ”identification and collection of relevant clinical outcome measures” [9,11,22,24,26,27,28,29,30,31,33,35,36,37,39,40,41]. However, only few papers have methodologically described the methods used to make this a routine part of hospital practice. The same applies to the “collection of patient-reported measures (PREMs and PROMs)”. With regard to cost measurement, although Time-Driven Activity-Based Costing (TDABC) is the predominant choice for cost accounting in this context [47,48], its practical adoption in hospitals proves to be extremely challenging. Numerous studies highlight how measuring costs was particularly difficult to establish as the hospital accounting system only allowed data capture on an aggregated level [11,22]. Additionally, hospital care is still paid according to pay-for-volume contracts, and budget responsibility still lies with the traditional functional departments [9,24,25,35].

Our findings should be interpreted in the light of some limitations. Firstly, scoping reviews, though, come with their own limitations. They typically don't assess the quality of the included studies as rigorously as systematic reviews do [15] [13]. This can affect the reliability and validity of the findings, as lower-quality studies might be included without proper scrutiny. Additionally, scoping reviews may not always provide a comprehensive analysis of the evidence due to their broader focus on identifying and mapping existing literature rather than synthesizing findings in depth [15]. Secondly, another limitation of this study is related to the eligibility criteria. Although payment models are a cornerstone of VBHC, papers describing different methodologies for designing and implementing value-based payments (VBPs) were not included because it is impractical to develop a uniform and scalable strategy globally, given the diversity of healthcare systems in different countries. Thus, we have focused on papers that examine governmental role as an active participant in this transition process. We decided to exclude from our review all articles describing the implementation of VBHC methodologies, such as the collection of Patient-Reported Experience Measures (PREMs) and Patient-Reported Outcome Measures (PROMs), or the adoption of TDABC, if such applications were related to isolated case studies and not integrated into daily hospital practice. Lastly, we only included articles written in English, which may have introduced a country bias.

5. Conclusions

The study underscored the necessity of a comprehensive approach to successfully implement VBHC. While hospitals are recognized as key players in this transition, requiring organizational and attitudinal changes among healthcare professionals, a complete shift to VBHC necessitates government involvement in state legislation, reimbursement strategies, and hospital networking to ensure seamless patient management throughout the entire care delivery value chain. Furthermore, the review highlighted the limited number of studies that evaluate the role of state committees in VBHC implementation, indicating a need for a more comprehensive examination of the state's role in implementing VBHC.